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A Randomized Controlled Trial Comparing Learners' Decision-making, Anxiety, and Task Load During a Simulated Airway Crisis Using Two Difficult Airway Aids

Ambardekar, Aditee P., MD; Rosero, Eric B., MD; Bhoja, Ravi, MD; Green, Jerry, DO; Rebal, Brett A., MD; Minhajuddin, Abu T., PhD; Kosemund, Matthew S., NREMT; Guttman, Oren T., MD; Mercier, David W., MD

doi: 10.1097/SIH.0000000000000362
Empirical Investigations

Introduction The American Society of Anesthesiologists (ASA) difficult airway algorithm and the Vortex approach are difficult airway aids. Our objective was to demonstrate that a simpler cognitive model would facilitate improved decision-making during a process such as difficult airway management. We hypothesized the simpler Vortex approach would be associated with less anxiety and task load.

Methods Medical students were randomized to the ASA algorithm (n = 33) or Vortex approach (n = 34). All learned basic airway techniques on day 1 of their rotation. Next, they watched a video of their respective aid then managed a simulated airway crisis. We assessed decision-making using a seven-point airway management score and a completeness score. Completeness was at least one attempt at each of four techniques (mask ventilation, supraglottic airway, intubation, and cricothyrotomy). Two validated tools, the State-Trait Anxiety Inventory Form Y and the National Aeronautics and Space Administration Task Load Index, were used to assess anxiety and task load.

Results Students in the Vortex group had higher airway management scores [4.0 (interquartile range = 4.0 to 5.0) vs. 4.0 (3.0 to 4.0), P = 0.0003] and completeness (94.1% vs. 63.6%, P = 0.003). In the ASA group, the means (SD) of National Aeronautics and Space Administration Task Load Index scores of 55 or higher were observed in mental [61.4 (14.4)], temporal [62.3 (22.9)], and effort [57.1 (15.6)] domains. In the Vortex group, only the temporal load domain was 55 or higher [mean (SD) = 57.8 (25.4)]. There was no difference in anxiety.

Conclusions Medical students perform better in a simulated airway crisis after training in the simpler Vortex approach to guide decision-making. Students in the ASA group had task load scores indicative of high cognitive load.

From the Department of Anesthesiology and Pain Management (A.P.A., E.B.R., R.B., J.G., D.W.M.), University of Texas Southwestern Medical Center, Dallas; US Anesthesia Partners-Texas Central (B.A.R.), Austin; Department of Clinical Sciences (A.T.M.), University of Texas Southwestern Medical Center; Department of Surgery Center for Minimally Invasive Surgery (M.S.K.), University of Texas Southwestern Medical Center, Dallas, TX; and Department of Anesthesiology (O.T.G.), Thomas Jefferson University Medical Center, Philadelphia, PA.

Reprints: Aditee P. Ambardekar, MD, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9068 (e-mail:

The authors declare no conflict of interest.

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© 2019 Society for Simulation in Healthcare