Guidelines for the Management of the Unpredicted Difficult Airway in Children

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Guidelines for the Management of the Unpredicted
Difficult Airway in Children
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Background

• Difficult Laryngoscopy 1 in 10
• Difficult Intubation 1 in 100
• Failed Intubation 1 in 2000
• Obstetric Failed Intubation 1 in 300
• Cant Ventilate 1-3 in
  10,000
• ASA adult guidelines 1993/2003
• CAFG unanticipated adult guidelines 1998
• DAS unanticipated adult guidelines 2004
• Also SFAR, DGAI, SIAARTI adult guidelines

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DAS Plan
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DAS Scenarios
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• Lack of data on paediatric difficult airway
  incidence
• Childrens Hospital of Philadelphia registry of
  8800 children in 2006
• Overall difficult intubation 0.42
• Unanticipated difficult intubation 0.08
• Unanticipated difficult ventilation 0.02
• RCoA 4th National Anaesthesia Audit Project

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Working Group

• Established November 2006
• Members
• Dr Ann Black (Chair)
• Dr Kathy Wilkinson (APA)
• Dr Mansukh Popat (DAS)
• Dr Mark Thomas
• Dr Helen Smith
• Dr Paul Flynn
• Dr Rob Walker (RCoA Link)

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Initial Stated Aims

• To focus on management of the unpredicted/unantici
  pated difficult airway in children
• Focusing on specific scenarios
• Difficult intubation - grade passage
• Difficult facemask ventilation
• CICV

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• To determine the need/desire for guidance
• To investigate the existence of any current
  guidelines nationally/internationally
• If therefore appropriate, to develop paediatric
  guidelines based on best evidence available and
  expert opinion
• Main target population non-specialist
  paediatric consultant anaesthetists and trainees

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International Survey 2007

• Investigated ..
• the existence of paediatric specific guidelines
  for
• the unanticipated difficult airway locally,
  nationally
• internationally
• the prevalence of application of adult
  guidelines
• in the paediatric setting
• To review submitted paediatric airway guidelines

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Targeted Groups

• SA Australasia - SASA
• SPANZA
• Asia - ASPA
• SAHK (Hong Kong)
• JSPA (Japan)
• ISA (India)
• Other - WFSA
• ISA (Israel)

• UK - Linkmen
• Regional Network Group leads
• APAGBI Member list
• APA website visitors
• Anaesthetic College Tutors
• Europe FEAPA
• North America - SPA
• CAS

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• 31 respondents used some form of specific
  paediatric airway guideline
• 11 UK respondents use some form of specific
  paediatric airway guideline
• 54 UK respondents base their paediatric practice
  on personally adapted adult guidelines

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Adult based Paediatric Guidelines

• 40 of respondents using some form of specific
  paediatric airway guideline report that it is
  based on adult guidelines
• ASA 59
• DAS 21
  
  
• SIAARTI 12
• SFAR 6
• DGAI 6

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New Guidelines Useful ?

• YES - 86
• NO - 4

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UK College Tutors View

• 24 response
• 70 thought specific paediatric guidelines would
  be useful for trainees
• 12 thought existing adult guidelines were
  sufficient in the paediatric setting

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Submitted Guidelines

• Sheffield CH
• Birmingham CH
• Norfolk Norwich
• Leeds CH PICU Paediatric
  
• India
• SCARE
• SARNePI
• ASA
• DAS
• SFAR Adult
• DGAI
• SIAARTI

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Appraisal of SARNePI
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• An international collaboration of researchers and
  policy makers.
• Denmark, Finland, France, Germany, Italy, the
  Netherlands, Spain, Switzerland and the United
  Kingdom, Canada, New Zealand and the USA
• Assesses the quality of clinical practice
  guidelines

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• AGREE tool consists of 23 key items organised in
  six domains
• Scope and purpose
• Stakeholder involvement
• Rigour of development
• Clarity and presentation
• Applicability
• Editorial independence

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Result of SARNePI Appraisal
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Systematic Literature Review

• EMBASE 1974 onwards Medline 1950 onwards
• 624 references restricted to infant/child/adole
  scent
• References assigned into scenario(s)
  directional
• statements/evidence linkages approach used
  to review
• Relevent articles
• Difficult Ventilation 133
• Difficult Intubation 246
• CICV 34

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• Recommendation methodology based on dual process
  as available paediatric evidence in literature
  known to be poor-
• SIGN
• A systematic review conducted to identify and
  critically appraise the evidence Grade
• 1 to 4
• Recommendations explicitly linked to supporting
  evidence - Grades A to D
• Modified Delphi
• Questionnaire of selected interventions
  synthesized from literature
• Expert panel - lack of group interaction
  assured anonymity reducing bias
• Series of rounds to determine average rating per
  intervention on scale from strongly disagree to
  strongly agree controlled opinion feedback

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Our Delphi

• 27 member panel
• All consultant anaesthetists with declared
  paediatric interest
• 3 Delphi rounds each consisting of 3 online
  questionnaires
• Each question response graded along 1 to 9 Likert
  scale
• Panel asked to consider target user group
  (SpRgt3/STgt5/Non Paediatric Consultants) when
  answering
• Accepting 70 consensus level
• Round 2 comments median response s quoted
• Round 3 as per Round 2 but evidence quoted

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Questionnaires

• 3 per round questions subdivided by age
• group
• Scenario 1 - unanticipated difficulty in
• ventilation following
  induction
• of anaesthesia 45
  Questions
• Scenario 2 unanticipated difficulty in tracheal
  
• intubation 46
  Questions
• Scenario 3 CICV 16 Questions

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Overall Delphi Outcomes

• Difficult Ventilation Scenario
• 66 consensus
• Difficult Intubation Scenario
• 47 consensus
• CICV Scenario
• 70 consensus

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Next Steps

• Update literature search
• Formulate recommendations/algorithms based on
  Delphi
• consensus and available evidence
  independent expert
• panel opinion where Delphi evidence lacking
• Apply AGREE tool to resulting guideline to test
  quality
• Review of guideline by independent expert panel
• Present draft guidelines at National meetings
• encourage feedback
• Trial in simulator training scenarios