Guidelines for the Management of the Unpredicted Difficult Airway in Children

1. Guidelines for the Management of the Unpredicted Difficult Airway in Children

2. 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

4. DAS Plan

5. DAS Scenarios

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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)

12. 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

13. 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%

14. New Guidelines Useful ? • YES - 86% • NO - 4%

15. 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

16. Sheffield CH Birmingham CH Norfolk & Norwich Leeds CH PICU Paediatric India SCARE SARNePI ASA DAS SFAR Adult DGAI SIAARTI Submitted Guidelines

20. Appraisal of SARNePI

21. 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

22. 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

23. Result of SARNePI Appraisal

24. 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

27. 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

28. 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

29. 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

31. Overall Delphi Outcomes • Difficult Ventilation Scenario • ≈ 66% consensus • Difficult Intubation Scenario • ≈ 47% consensus • CICV Scenario • ≈ 70% consensus

32. 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