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Guidelines for the Management of the Unpredicted Difficult Airway in Children . Background. Difficult Laryngoscopy 1 in 10 Difficult Intubation 1 in 100 Failed Intubation 1 in 2000 Obstetric Failed Intubation 1 in 300

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background
Background
  • Difficult Laryngoscopy 1 in 10
  • Difficult Intubation 1 in 100
  • Failed Intubation 1 in 2000
  • Obstetric Failed Intubation 1 in 300
  • Can’t 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
slide6

Lack of data on paediatric difficult airway incidence

  • Children’s 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
working group
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)

initial stated aims
Initial Stated Aims
  • To focus on management of the unpredicted/unanticipated difficult airway in children
  • Focusing on specific scenarios :

Difficult intubation - grade & passage

Difficult facemask ventilation

CICV

slide9
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
international survey 2007
International Survey2007
  • 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
targeted groups
Targeted Groups
  • UK - Linkmen

Regional Network Group leads

APAGBI Member list

APA website visitors

Anaesthetic College Tutors

  • Europe – FEAPA
  • North America - SPA

CAS

  • SA + Australasia - SASA

SPANZA

  • Asia - ASPA

SAHK (Hong Kong)

JSPA (Japan)

ISA (India)

  • Other - WFSA

ISA (Israel)

slide12
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
adult based paediatric guidelines
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%
new guidelines useful
New Guidelines Useful ?
  • YES - 86%
  • NO - 4%
uk college tutors view
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
submitted guidelines
Sheffield CH

Birmingham CH

Norfolk & Norwich

Leeds CH PICU Paediatric

India

SCARE

SARNePI

ASA

DAS

SFAR Adult

DGAI

SIAARTI

Submitted Guidelines
slide21

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
slide22

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
systematic literature review
Systematic Literature Review
  • EMBASE 1974 onwards & Medline 1950 onwards
  • 624 references – restricted to ‘infant/child/adolescent’
  • References assigned into scenario(s) & ‘directional

statements/evidence linkages’ approach used to review

  • ‘Relevent’ articles :

Difficult Ventilation 133

Difficult Intubation 246

CICV 34

slide27
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
  • Determination of average rating range consistent with consensus
our delphi
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 (SpR>3/ST>5/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
questionnaires
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
overall delphi outcomes
Overall Delphi Outcomes
  • Difficult Ventilation Scenario
              • ≈ 66% consensus
  • Difficult Intubation Scenario
              • ≈ 47% consensus
  • CICV Scenario
              • ≈ 70% consensus
next steps
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