(1042) Management of a Physiologically Difficult Airway: Expert Consensus Statements Using a Delphi Method

Introduction: Physiologic alterations in critically ill adults may increase the risk for peri-intubation cardiorespiratory and other complications during tracheal intubation and the initiation of positive pressure ventilation, which has been termed the physiologically difficult airway (PDA). While some strategies and interventions have been studied and adopted to mitigate such complications, robust evidence is lacking for many. We aimed to review the existing literature and generate expert consensus on the various aspects of managing patients with a PDA.

Methods: Using a Delphi process, an international panel of 35 international Experts developed clinical practice statements on airway management in patients with a PDA for areas where evidence is absent or limited. Consensus was achieved when there was >70% agreement among Experts on a statement with a 7-point Likert scale, or when > 80% of Experts selected a specific option in multiple-choice questions. Stability was evaluated between consecutive rounds, starting from the second, for each statement using the non‐parametric Kruskal–Wallis H-test or Chi‐square (χ2) test (with p < 0.05 considered unstable).

Results: The Delphi process included seven survey rounds, Consensus was achieved for 54 (89%) of 61 statements. All the consensus statements were statistically stable. These statements include guidance on the definition and risk factors for poor outcomes in patients with PDA, optimizing the procedural team and patient for success, performance of tracheal intubation, as well as post-intubation care. Consensus was not reached on the definition of an experienced airway operator, use of cricoid pressure during airway management in a patient with PDA, and the preferred video laryngoscope.

Conclusions: Through a Delphi method, we reached Expert consensus on 54 statements, culminating in 35 clinical practice statements for managing patients with PDA. These address important treatment decisions where current evidence is either lacking or limited, offering clinicians actionable guidance for safe tracheal intubation in the critically ill, with the aim of improving clinical outcomes. Well-designed studies are needed to evaluate the impact of these practice statements and address the remaining uncertainties.