Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

doi:10.1007/s00134-024-07578-2

. 2024 Oct;50(10):1563-1579.

doi: 10.1007/s00134-024-07578-2. Epub 2024 Aug 20.

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

Kunal Karamchandani¹, Prashant Nasa^{2

3}, Mary Jarzebowski⁴, David J Brewster^{5

6}, Audrey De Jong⁷, Philippe R Bauer⁸, Lauren Berkow⁹, Calvin A Brown 3rd¹⁰, Luca Cabrini¹¹, Jonathan Casey¹², Tim Cook¹³, Jigeeshu Vasishtha Divatia¹⁴, Laura V Duggan¹⁵, Louise Ellard¹⁶, Begum Ergan¹⁷, Malin Jonsson Fagerlund¹⁸, Jonathan Gatward^{19

20}, Robert Greif^{21

22}, Andy Higgs²³, Samir Jaber⁷, David Janz²⁴, Aaron M Joffe²⁵, Boris Jung²⁶, George Kovacs²⁷, Arthur Kwizera²⁸, John G Laffey^{29

30}, Jean-Baptiste Lascarrou³¹, J Adam Law³², Stuart Marshall^{33

34}, Brendan A McGrath³⁵, Jarrod M Mosier³⁶, Daniel Perin³⁷, Oriol Roca^{38

39

40}, Amélie Rollé⁴¹, Vincenzo Russotto⁴², John C Sakles⁴³, Gentle S Shrestha⁴⁴, Nathan J Smischney⁴⁵, Massimiliano Sorbello^{46

47}, Avery Tung⁴⁸, Craig S Jabaley^{49

50}, Sheila Nainan Myatra¹⁴; Society of Critical Care Anesthesiologists (SOCCA) Physiologically Difficult Airway Task Force

Collaborators, Affiliations

Collaborators

Society of Critical Care Anesthesiologists (SOCCA) Physiologically Difficult Airway Task Force:
Kariem El-Boghdadly, Anna Budde, Stephen Estime, Kristina Goff, Rachel Kadar, Ashish K Khanna, Crystal Manohar, Gerald Matchett, Ronald G Pearl, Robert D Stevens, Habib Srour

Affiliations

¹ Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA. kunal.karamchandani@utsouthwestern.edu.
² Critical Care Medicine, NMC Specialty Hospital, Al Nahda, Dubai, UAE.
³ Internal Medicine, College of Medicine and Health Sciences, Al Ain, Abu Dhabi, UAE.
⁴ Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, MI, USA.
⁵ Intensive Care Unit, Cabrini Hospital, Melbourne, Australia.
⁶ School of Translational Medicine, Monash University, Melbourne, Australia.
⁷ Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France.
⁸ Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA.
⁹ Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
¹⁰ Department of Emergency Medicine, Lahey Hospital and Medical Center, UMass Chan - Lahey School of Medicine, Burlington, MA, USA.
¹¹ Department of Biotechnology and Life Sciences, Insubria University, Ospedale di Circolo, Varese, Italy.
¹² Division of Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA.
¹³ Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.
¹⁴ Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
¹⁵ Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada.
¹⁶ Department of Critical Care, University of Melbourne, Department of Anaesthesia, Austin Health, Victoria, Australia.
¹⁷ Division of Critical Care Medicine, Department of Pulmonary and Critical Care, Dokuz Eylul University, Izmir, Turkey.
¹⁸ Department of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden.
¹⁹ Intensive Care Unit, Royal North Shore Hospital, Sydney, Australia.
²⁰ Sydney Medical School, University of Sydney, Sydney, Australia.
²¹ University of Bern, Bern, Switzerland.
²² Department of Surgical Sciences, University of Turin, Turin, Italy.
²³ Department of Critical Care Medicine, Warrington Teaching Hospitals, Cheshire, UK.
²⁴ Section of Pulmonary and Critical Care Medicine, Tulane School of Medicine, University Medical Center New Orleans, LSU School of Medicine of New Orleans, New Orleans, LA, USA.
²⁵ Department of Anesthesiology, Creighton University School of Medicine, Valleywise Health Medical Center, Phoenix, AZ, USA.
²⁶ Medical Intensive Care Unit, INSERM PhyMedexp, Montpellier University, Montpellier, France.
²⁷ Departments of Emergency Medicine, Anaesthesia, Medical Neurosciences & Continuing Professional Development and Medical Education, Charles V. Keating Emergency and Trauma Centre, Dalhousie University, Halifax, NS, Canada.
²⁸ Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Mulago Hospital Complex, Kampala, Uganda.
²⁹ Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland.
³⁰ Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland.
³¹ Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, Médecine Intensive Réanimation, UR 4334, 44000, Nantes, France.
³² Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
³³ Department of Critical Care, University of Melbourne, Melbourne, Australia.
³⁴ Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia.
³⁵ Anaesthesia and Intensive Care Medicine, Manchester University Hospital, NHS Foundation Trust, Manchester, UK.
³⁶ Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, University of Arizona College of Medicine, Tucson, AZ, USA.
³⁷ Albert Einstein Hospital, São Paulo, Brazil.
³⁸ Servei de Medicina Intensiva, Institut de Recerca Part Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Sabadell, Spain.
³⁹ Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain.
⁴⁰ Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain.
⁴¹ Anesthesia and Intensive Care, University Hospital of La Guadeloupe, University of Les Antilles, Abymes, France.
⁴² Anesthesia and Intensive Care, University Hospital San Luigi Gonzaga, Orbassano (TO), University of Turin, Turin, Italy.
⁴³ Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
⁴⁴ Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
⁴⁵ Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
⁴⁶ UOC Anesthesia and Intensive Care PO Giovanni Paolo II, Ragusa, Italy.
⁴⁷ Anaesthesia and Intensive Care, Kore University, Enna, Italy.
⁴⁸ Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA.
⁴⁹ Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA.
⁵⁰ Emory Critical Care Center, Atlanta, GA, USA.

PMID: 39162823
DOI: 10.1007/s00134-024-07578-2

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

Kunal Karamchandani et al. Intensive Care Med. 2024 Oct.

. 2024 Oct;50(10):1563-1579.

doi: 10.1007/s00134-024-07578-2. Epub 2024 Aug 20.

Authors

Collaborators

Society of Critical Care Anesthesiologists (SOCCA) Physiologically Difficult Airway Task Force:
Kariem El-Boghdadly, Anna Budde, Stephen Estime, Kristina Goff, Rachel Kadar, Ashish K Khanna, Crystal Manohar, Gerald Matchett, Ronald G Pearl, Robert D Stevens, Habib Srour

Affiliations

¹ Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA. kunal.karamchandani@utsouthwestern.edu.
² Critical Care Medicine, NMC Specialty Hospital, Al Nahda, Dubai, UAE.
³ Internal Medicine, College of Medicine and Health Sciences, Al Ain, Abu Dhabi, UAE.
⁴ Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, MI, USA.
⁵ Intensive Care Unit, Cabrini Hospital, Melbourne, Australia.
⁶ School of Translational Medicine, Monash University, Melbourne, Australia.
⁷ Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France.
⁸ Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA.
⁹ Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
¹⁰ Department of Emergency Medicine, Lahey Hospital and Medical Center, UMass Chan - Lahey School of Medicine, Burlington, MA, USA.
¹¹ Department of Biotechnology and Life Sciences, Insubria University, Ospedale di Circolo, Varese, Italy.
¹² Division of Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA.
¹³ Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.
¹⁴ Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
¹⁵ Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada.
¹⁶ Department of Critical Care, University of Melbourne, Department of Anaesthesia, Austin Health, Victoria, Australia.
¹⁷ Division of Critical Care Medicine, Department of Pulmonary and Critical Care, Dokuz Eylul University, Izmir, Turkey.
¹⁸ Department of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden.
¹⁹ Intensive Care Unit, Royal North Shore Hospital, Sydney, Australia.
²⁰ Sydney Medical School, University of Sydney, Sydney, Australia.
²¹ University of Bern, Bern, Switzerland.
²² Department of Surgical Sciences, University of Turin, Turin, Italy.
²³ Department of Critical Care Medicine, Warrington Teaching Hospitals, Cheshire, UK.
²⁴ Section of Pulmonary and Critical Care Medicine, Tulane School of Medicine, University Medical Center New Orleans, LSU School of Medicine of New Orleans, New Orleans, LA, USA.
²⁵ Department of Anesthesiology, Creighton University School of Medicine, Valleywise Health Medical Center, Phoenix, AZ, USA.
²⁶ Medical Intensive Care Unit, INSERM PhyMedexp, Montpellier University, Montpellier, France.
²⁷ Departments of Emergency Medicine, Anaesthesia, Medical Neurosciences & Continuing Professional Development and Medical Education, Charles V. Keating Emergency and Trauma Centre, Dalhousie University, Halifax, NS, Canada.
²⁸ Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Mulago Hospital Complex, Kampala, Uganda.
²⁹ Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland.
³⁰ Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland.
³¹ Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, Médecine Intensive Réanimation, UR 4334, 44000, Nantes, France.
³² Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
³³ Department of Critical Care, University of Melbourne, Melbourne, Australia.
³⁴ Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia.
³⁵ Anaesthesia and Intensive Care Medicine, Manchester University Hospital, NHS Foundation Trust, Manchester, UK.
³⁶ Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, University of Arizona College of Medicine, Tucson, AZ, USA.
³⁷ Albert Einstein Hospital, São Paulo, Brazil.
³⁸ Servei de Medicina Intensiva, Institut de Recerca Part Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Sabadell, Spain.
³⁹ Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain.
⁴⁰ Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain.
⁴¹ Anesthesia and Intensive Care, University Hospital of La Guadeloupe, University of Les Antilles, Abymes, France.
⁴² Anesthesia and Intensive Care, University Hospital San Luigi Gonzaga, Orbassano (TO), University of Turin, Turin, Italy.
⁴³ Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
⁴⁴ Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
⁴⁵ Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
⁴⁶ UOC Anesthesia and Intensive Care PO Giovanni Paolo II, Ragusa, Italy.
⁴⁷ Anaesthesia and Intensive Care, Kore University, Enna, Italy.
⁴⁸ Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA.
⁴⁹ Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA.
⁵⁰ Emory Critical Care Center, Atlanta, GA, USA.

PMID: 39162823
DOI: 10.1007/s00134-024-07578-2

Abstract

Purpose: Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA).

Methods: An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

Results: The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care.

Conclusion: Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Keywords: Airway management; Delphi; Guidelines; Intratracheal/adverse effects; Intratracheal/methods; Intubation; Physiologically difficult airway; Tracheal intubation.

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References

1. Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, Lascarrou JB, Szuldrzynski K, Camporota L, Pelosi P, Sorbello M, Higgs A, Greif R, Putensen C, Agvald-Ohman C, Chalkias A, Bokums K, Brewster D, Rossi E, Fumagalli R, Pesenti A, Foti G, Bellani G, Investigators IS (2021) Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA 325:1164–1172 - PubMed - PMC - DOI
1. Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC (2015) The physiologically difficult airway. West J Emerg Med 16:1109–1117 - PubMed - PMC - DOI
1. Myatra SN, Divatia JV, Brewster DJ (2022) The physiologically difficult airway: an emerging concept. Curr Opin Anaesthesiol 35:115–121 - PubMed - DOI
1. Mosier JM (2020) Physiologically difficult airway in critically ill patients: winning the race between haemoglobin desaturation and tracheal intubation. Br J Anaesth 125:e1–e4 - PubMed - DOI
1. Jarzebowski M, Estime S, Russotto V, Karamchandani K (2022) Challenges and outcomes in airway management outside the operating room. Curr Opin Anaesthesiol 35:109–114 - PubMed - DOI

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[1] Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, Lascarrou JB, Szuldrzynski K, Camporota L, Pelosi P, Sorbello M, Higgs A, Greif R, Putensen C, Agvald-Ohman C, Chalkias A, Bokums K, Brewster D, Rossi E, Fumagalli R, Pesenti A, Foti G, Bellani G, Investigators IS (2021) Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA 325:1164–1172 - PubMed - PMC - DOI

[2] Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, Lascarrou JB, Szuldrzynski K, Camporota L, Pelosi P, Sorbello M, Higgs A, Greif R, Putensen C, Agvald-Ohman C, Chalkias A, Bokums K, Brewster D, Rossi E, Fumagalli R, Pesenti A, Foti G, Bellani G, Investigators IS (2021) Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA 325:1164–1172 - PubMed - PMC - DOI

[3] Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC (2015) The physiologically difficult airway. West J Emerg Med 16:1109–1117 - PubMed - PMC - DOI

[4] Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC (2015) The physiologically difficult airway. West J Emerg Med 16:1109–1117 - PubMed - PMC - DOI

[5] Myatra SN, Divatia JV, Brewster DJ (2022) The physiologically difficult airway: an emerging concept. Curr Opin Anaesthesiol 35:115–121 - PubMed - DOI

[6] Myatra SN, Divatia JV, Brewster DJ (2022) The physiologically difficult airway: an emerging concept. Curr Opin Anaesthesiol 35:115–121 - PubMed - DOI

[7] Mosier JM (2020) Physiologically difficult airway in critically ill patients: winning the race between haemoglobin desaturation and tracheal intubation. Br J Anaesth 125:e1–e4 - PubMed - DOI

[8] Mosier JM (2020) Physiologically difficult airway in critically ill patients: winning the race between haemoglobin desaturation and tracheal intubation. Br J Anaesth 125:e1–e4 - PubMed - DOI

[9] Jarzebowski M, Estime S, Russotto V, Karamchandani K (2022) Challenges and outcomes in airway management outside the operating room. Curr Opin Anaesthesiol 35:109–114 - PubMed - DOI

[10] Jarzebowski M, Estime S, Russotto V, Karamchandani K (2022) Challenges and outcomes in airway management outside the operating room. Curr Opin Anaesthesiol 35:109–114 - PubMed - DOI

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Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

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Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

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