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

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Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study
Intensive Care Medicine ( IF 27.1 ) Pub Date : 2024-08-20 , DOI: 10.1007/s00134-024-07578-2
Kunal Karamchandani ₁ , Prashant Nasa _{2,

3} , Mary Jarzebowski ₄ , David J Brewster _{5,

6} , Audrey De Jong ₇ , Philippe R Bauer ₈ , Lauren Berkow ₉ , Calvin A Brown ₁₀ , Luca Cabrini ₁₁ , Jonathan Casey ₁₂ , Tim Cook ₁₃ , Jigeeshu Vasishtha Divatia ₁₄ , Laura V Duggan ₁₅ , Louise Ellard ₁₆ , Begum Ergan ₁₇ , Malin Jonsson Fagerlund ₁₈ , Jonathan Gatward _{19,

20} , Robert Greif _{21,

22} , Andy Higgs ₂₃ , Samir Jaber ₇ , David Janz ₂₄ , Aaron M Joffe ₂₅ , Boris Jung ₂₆ , George Kovacs ₂₇ , Arthur Kwizera ₂₈ , John G Laffey _{29,

30} , Jean-Baptiste Lascarrou ₃₁ , J Adam Law ₃₂ , Stuart Marshall _{33,

34} , Brendan A McGrath ₃₅ , Jarrod M Mosier ₃₆ , Daniel Perin ₃₇ , Oriol Roca _{38,

39,

40} , Amélie Rollé ₄₁ , Vincenzo Russotto ₄₂ , John C Sakles ₄₃ , Gentle S Shrestha ₄₄ , Nathan J Smischney ₄₅ , Massimiliano Sorbello _{46,

47} , Avery Tung ₄₈ , Craig S Jabaley _{49,

50} , Sheila Nainan Myatra ₁₄ ,

Affiliation

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Critical Care Medicine, NMC Specialty Hospital, Al Nahda, Dubai, UAE.
Internal Medicine, College of Medicine and Health Sciences, Al Ain, Abu Dhabi, UAE.
Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, MI, USA.
Intensive Care Unit, Cabrini Hospital, Melbourne, Australia.
School of Translational Medicine, Monash University, Melbourne, Australia.
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.
Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA.
Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
Department of Emergency Medicine, Lahey Hospital and Medical Center, UMass Chan - Lahey School of Medicine, Burlington, MA, USA.
Department of Biotechnology and Life Sciences, Insubria University, Ospedale di Circolo, Varese, Italy.
Division of Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA.
Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada.
Department of Critical Care, University of Melbourne, Department of Anaesthesia, Austin Health, Victoria, Australia.
Division of Critical Care Medicine, Department of Pulmonary and Critical Care, Dokuz Eylul University, Izmir, Turkey.
Department of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden.
Intensive Care Unit, Royal North Shore Hospital, Sydney, Australia.
Sydney Medical School, University of Sydney, Sydney, Australia.
University of Bern, Bern, Switzerland.
Department of Surgical Sciences, University of Turin, Turin, Italy.
Department of Critical Care Medicine, Warrington Teaching Hospitals, Cheshire, UK.
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.
Department of Anesthesiology, Creighton University School of Medicine, Valleywise Health Medical Center, Phoenix, AZ, USA.
Medical Intensive Care Unit, INSERM PhyMedexp, Montpellier University, Montpellier, France.
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.
Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Mulago Hospital Complex, Kampala, Uganda.
Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland.
Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland.
Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, Médecine Intensive Réanimation, UR 4334, 44000, Nantes, France.
Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
Department of Critical Care, University of Melbourne, Melbourne, Australia.
Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia.
Anaesthesia and Intensive Care Medicine, Manchester University Hospital, NHS Foundation Trust, Manchester, UK.
Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, University of Arizona College of Medicine, Tucson, AZ, USA.
Albert Einstein Hospital, São Paulo, Brazil.
Servei de Medicina Intensiva, Institut de Recerca Part Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Sabadell, Spain.
Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain.
Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain.
Anesthesia and Intensive Care, University Hospital of La Guadeloupe, University of Les Antilles, Abymes, France.
Anesthesia and Intensive Care, University Hospital San Luigi Gonzaga, Orbassano (TO), University of Turin, Turin, Italy.
Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
UOC Anesthesia and Intensive Care PO Giovanni Paolo II, Ragusa, Italy.
Anaesthesia and Intensive Care, Kore University, Enna, Italy.
Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA.
Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA.
Emory Critical Care Center, Atlanta, GA, USA.

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.

中文翻译：

生理困难气道的危重成人的气管插管。一项国际 Delphi 研究

目的

我们的研究旨在提供与患有生理困难气道（PDA）的危重成人患者的气道管理相关的共识和专家临床实践声明。

方法

重症监护麻醉医师协会（SOCCA）生理困难气道工作组召集了一个由 7 名重症监护医师和 1 名 Delphi 方法专家组成的国际指导委员会。该委员会选择了一个由 35 名临床专家研究人员组成的国际小组，他们在危重症成人气道管理方面具有专业知识。使用基于迭代方法的 Delphi 过程来获得最终的共识声明。

结果

Delphi 流程包括七轮调查。在 61 个陈述中，有 53 个（87%）达成了稳定的共识。专家们一致认为，除了病理生理状况外，与怀孕和肥胖相关的生理变化也构成了生理上困难的气道。他们建议组建一个由至少三名医疗保健提供者组成的插管团队，包括两名气道操作员，实施适当设计的检查表，并在气管插管前优化血流动力学。同样，专家们就头部抬高喉镜位置、第一次尝试时常规使用电子喉镜检查、无创通气预充氧、呼吸暂停期仔细面罩通气以及注意心肺状态以进行插管后护理达成一致。