Abstract
The All India Difficult Airway Association (AIDAA) methodology document describes the guideline development process and methodology employed for the AIDAA 2025 Guidelines for the management of unanticipated difficult airway in adults, obstetrics, and paediatrics and the management of at-risk extubations. The process for constituting the Steering Committee and Guideline Subcommittees and managing conflicts is described. Patients or Population-Intervention-Comparison-Outcome (PICO) questions were formulated for the respective guidelines. A systematic literature search was performed by a librarian from January 2000 to December 2024. A PRISMA flowchart describing the search process was prepared for each research question. The evidence was summarised and recommendations categorised according to the American Heart Association (AHA) Class of Recommendations and Level of Evidence for clinical strategies, interventions, treatments, or diagnostic testing in patient care. In addition, a Delphi process was conducted by the Steering Committee and a Delphi methodologist to achieve consensus among 24 airway experts for the clinical research questions using Delphi methodology, where the evidence was either lacking or weak. The Steering Committee coordinated the iterative Delphi rounds and refrained from participating in the voting process to prevent potential bias. The Delphi survey results were reported based on the Accurate Consensus Reporting Document (ACCORD) Guidelines. Consensus was established when 75% or more of panellists selected the same option(s) in multiple-choice statements and the seven-point Likert scale statements. Expert consensus statements were drafted from the survey statements that achieved consensus. A plan for guideline dissemination, promotion, integration into clinical practice and revision has also been included.
Keywords: AIDAA guidelines, airway, guideline development process, guidelines, methodology, Delphi methodology
BACKGROUND
Difficult airway management requires a timely and coordinated team response to prevent complications.[1] Managing an unanticipated difficult airway is one of the most critical and stressful situations, testing an airway operator’s technical and non-technical skills. This scenario can often become life-threatening if not managed effectively. The fourth National Audit Project (NAP4) conducted in the UK strongly recommended the adoption of airway algorithms and proposed that their utilisation might lead to improved patient outcomes.[1] Several international airway societies have published new or updated guidelines for managing these situations in the past decade.[1,2,3,4,5,6,7,8,9] While these guidelines are exemplary, it would be naïve to directly adopt them into the Indian context and expect them to work equally well. There was a long-felt need to develop Indian guidelines to meet our needs and situation. In 2016, the All-India Difficult Airway Association (AIDAA), through a 14-member committee of airway experts, developed evidence-based national guidelines for the management of unanticipated difficult airway in adults, obstetrics, and paediatrics, difficult extubation, and tracheal intubation in intensive care unit.[10,11,12,13,14] These were the first Indian guidelines for difficult airway management published by the national airway society. The AIDAA has updated the 2016 guidelines. In this article, we describe the guideline development process and the methodology employed by the Steering Committee and the Guideline Subcommittees of the AIDAA 2025 Guidelines for the management of unanticipated difficult airway in adults, obstetrics, and paediatrics and the management of at-risk extubations.
THE AIDAA 2016 GUIDELINES
The unique features of the AIDAA Guidelines include the emphasis on peri-intubation oxygenation including apnoeic oxygenation, an oxygen saturation (SpO2) threshold of ≥95% to proceed to the next attempt at securing the airway, confirmation of tracheal intubation following six sustained capnograph traces without any decline in the detected carbon dioxide levels, use of a new terminology, complete ventilation failure as a trigger for performing cricothyroidotomy, call for additional help during complete ventilation failure, and adoption of a cricothyroidotomy technique based on familiarity and availability of the equipment.[10,15] Though the penetration and acceptability of the AIDAA guidelines were initially low, a survey conducted among practising anaesthesiologists in 2020 showed high awareness (81%) of the guidelines.[16] While most of the recommendations were followed, there was wide variation in their adherence by anaesthesiologists, primarily related to the use of apnoeic oxygenation, capnography, debriefing after an airway event, and issuing an airway alert card.[16] The acceptability and adherence of the AIDAA guidelines have increased since. These guidelines are highly cited nationally and internationally. In addition, certain unique features of the guidelines have been acknowledged internationally and adopted into recent guidelines.[2,17]
NEED FOR DEVELOPMENT OF THE AIDAA 2025 GUIDELINES
The evolution of technology, additional published evidence, and resulting changes in clinical practices in airway management over the past few years have necessitated the revision of the AIDAA guidelines. While the adult, obstetric, and paediatric guidelines provide an algorithmic approach for a failed tracheal intubation, they do not provide guidance for a failed supraglottic airway insertion, face mask ventilation, or other strategies commonly used as part of a primary airway management plan. This important limitation makes these guidelines incomplete for addressing unanticipated difficult airway scenarios, where tracheal intubation has not been a part of the primary or initial airway management plan. Though the obstetric and paediatric guidelines were drafted by airway experts, a need was felt for the involvement of obstetric and paediatric airway experts this time in drafting the respective guidelines. The AIDAA extubation guidelines provide a three-limb format with a step-wise approach to managing group-specific high-risk extubations. The recognition that all patients cannot transition from “tube dependency to normalcy” in a single step and the need for risk evaluation prior to extubation (identify “at-risk” extubations) justify further improvement in the extubation guidelines. Risk assessment is important for the airway operator to assess the possibility of encountering challenges during extubation, rather than just having a strategy for management. In addition, the increasing role of ultrasound in airway management and the use of sugammadex in the last decade required inclusion across all the guidelines. The AIDAA leadership recognises the need to take into consideration the wide variation in resource availability across health care settings and therefore, the AIDAA guideline recommendations regarding the use of specific resources apply where there is access to these resources and should be viewed as aspirational when this is not the case. Against this background, the AIDAA leadership planned an update to the existing guidelines.
METHODS
Formation of the Steering Committee and the guideline sub-committees
At the 2022 AIDAA annual general body meeting (AGM), the AIDAA leadership put up the proposal to update the 2016 AIDAA Guidelines. After approval in the AGM, the AIDAA leadership appointed a Steering Committee consisting of nine airway experts (SMA, JVD, JRD, RG, PK, SNM, APS, SRS, and RV) involved in the development of the AIDAA 2016 guidelines to lead the development of the AIDAA 2025 guidelines. PK served as the Chair of the AIDAA Guidelines Steering Committee. The Steering Committee constituted the AIDAA 2025 adult, obstetric, paediatric, and extubation guideline sub-committees. SNM, RV, JRD, and PK served as Leads for the AIDAA 2025 adult, obstetric, paediatric, and extubation guidelines, respectively. A methodologist PN was included to design, conduct, and ensure methodological rigour for the Delphi process. A librarian was included to perform the literature search and prepare PRISMA flowcharts for each research question.
Selection of experts for the guideline sub-committees
The experts for the guideline sub-committees included the respective sub-committee lead, a few Steering Committee members, airway experts who served on the previous AIDAA guidelines, and other airway experts from the AIDAA members. The criteria used for selection of airway experts from the AIDAA members for the guideline sub-committees included clinical expertise in airway management, active involvement in teaching and training in airway management, and publications in airway management. In addition, three members were nominated by the leadership of the Association of Obstetric Anaesthesiologists (AOA) and the Indian Association of Paediatric Anaesthesiologists (IAPA) to be a part of the AIDAA obstetric and paediatric guideline sub-committees, respectively. Thereby, the AIDAA guideline committees included multi-disciplinary expertise. However, neither patients nor the public were included in the guideline development process due to the complexities involved in integrating their perspective into the highly technical aspects of difficult airway management.
Conflicts of interest
A declaration of conflicts of interest was obtained from all members of the Steering Committee and each guideline sub-committee before initiation of the guideline development process. Members having conflicts related to a specific topic were not involved in drafting or voting on the respective statements on the subject to prevent potential bias.
Clinical research question selection and literature search
The respective guideline sub-committee members formulated questions according to the Patients or Population-Intervention-Comparison-Outcome (PICO) format. Each PICO question was discussed and agreed upon by the guideline sub-committee members. A librarian assigned by AIDAA performed the literature search, data extraction, and evidence synthesis for the PICO questions for each guideline. A concept table and search string were prepared for each PICO question. A systematic literature search was performed from January 2000 to December 2024 using the search string for the respective PICO in PubMed and Scopus, with no restriction on publication type. Non-English language articles were excluded. Additional articles were retrieved by cross-referencing and hand searching. The complete search strategy used for each research question is provided in the Appendix of the respective guideline.
All retrieved articles were entered into the Rayyan software (Rayyan Systems Inc., Cambridge, Massachusetts, USA. http://rayyan.qcri.org) for initial screening of abstracts and titles using a semi-automated process, while incorporating a high level of usability. Use of the Rayyan software enhanced the quality of the search results by the use of artificial intelligence-powered screening, duplicate detection, and customisable filters to streamline the review process.[18] Following the literature search, two reviewers from the respective guideline sub-committee independently screened each article using the titles and abstracts and selected the final list of full-text studies to be included. Any difference of opinion was resolved through discussion, with disagreements adjudicated by a third reviewer. A PRISMA flowchart describing the search process prepared for each research question is provided in the Appendix of the respective guideline.
Formulation of recommendations and best practice statements
A table of the shortlisted articles for each PICO question was prepared by two members of the respective guideline sub-committee, comprising of the inclusion and exclusion criteria, primary and secondary objectives, intervention and remarks, or conclusions for the relevant research questions. This was approved by the guideline sub-committee members before submission to the Steering Committee for drafting the final recommendations and best practice statements. The evidence was summarised and recommendations categorised according to the American Heart Association (AHA) Class of Recommendations and Level of Evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care,[19] rather than systematic Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessments.[20]
The AHA classification system grades the evidence into class (strength) of recommendation as Class 1: Strong (Benefit >>> Risk), 2a: Moderate (Benefit >> Risk), 2b: Weak (Benefit > Risk), 3: No Benefit (Benefit = Risk) and 3: Harm (Risk > Benefit) and level (quality) of evidence as Level A: High-quality evidence (High-quality evidence more than one RCT/Meta-analyses of high-quality RCTs/One or more RCTs corroborated by high-quality registry studies), B-R: Randomised studies (Moderate-quality evidence from one or more RCTs/Meta-analyses of moderate quality RCTs), B-NR: Nonrandomised studies (Moderate-quality evidence from one or more well-designed, well-executed nonrandomised studies, observational studies or registry studies/Meta-analyses of such studies), C-LD: Limited data (Randomised or non-randomised observational or registry studies with limitations of design or execution/Meta-analyses of such studies/Physiological or mechanistic studies in human subjects) and C-EO: Expert opinion (Consensus of expert opinion based on clinical experience). A recommendation was given for the research question if the level (quality) of evidence was Level A. A best practice statement was given when high-quality evidence was lacking (B-R, B-NR, C-LD and C-EO). The final recommendations and best practice statements were drafted by the Steering Committee after reviewing the strength of the recommendations and the quality of evidence for the clinical research questions. A model structure of the table used to summarise the recommendations and best practice statements is presented in Table 1.
Table 1.
Model Structure of the Table Used to Summarise the Recommendations or Best Practice Statements for the Clinical Research Questions
| Clinical Research Question | Recommendation / Best Practice Statement | Type of Guidance | Class (Strength) of Recommendation | Level (Quality) of Evidence |
|---|---|---|---|---|
| Should neuromuscular monitoring be performed before extubation? | Quantitative neuromuscular monitoring (TOF ratio >0.9) is recommended whenever equipment and expertise are available. | Recommendation | Class 1 | A |
| Should a cuff leak test be performed before extubation? | A quantitative cuff leak test may be considered before extubation in clinical situations where airway oedema is suspected | Best Practice Statement | Class 2b | C-LD |
Delphi process for consensus among experts
The Delphi process was initiated by the Steering Committee and a Delphi methodologist to achieve consensus among experts for the clinical research questions using Delphi methodology, where the evidence was either lacking or weak. A preliminary list of statements for the Delphi rounds was prepared based on the literature reviewed and published difficult airway guidelines. The Delphi survey was divided into five guideline sections: adult, obstetrics, paediatric, paediatric surgical airway and extubation. The Steering Committee coordinated the iterative Delphi rounds, prepared the anonymised Delphi reports, revised the statements for subsequent Delphi rounds as required, and provided controlled feedback. The Steering Committee refrained from participating in the voting process during the Delphi rounds to maintain objectivity and prevent potential bias.[21,22] The Delphi survey results were reported based on the Accurate Consensus Reporting Document (ACCORD) Guidelines.[23]
Selection of experts
The Steering Committee constituted a panel of 24 airway experts to participate in the Delphi process. The criteria used for the selection of airway experts from the AIDAA members as panellists for the Delphi process included clinical expertise in airway management, active involvement in teaching and training in airway management, and publications in airway management. After confirming their acceptance, the experts were actively engaged in the Delphi process. Periodic reminders were sent during the Delphi rounds to minimise attrition. Anonymity of the experts was maintained until the end of the Delphi process to avoid any group pressure or bias.
Delphi rounds
The Delphi surveys prepared using Google FormsTM included statements formatted as either multiple-choice questions or 7-point Likert scales. The surveys were shared with the experts via a unique online link. Experts were encouraged to provide feedback during each round through an open text field at the end of the survey. The questions were modified or deleted in the subsequent rounds based on the responses and feedback. Responses from the experts were anonymised. A cumulative report was shared with the experts following each Delphi round. Statements were included in the Delphi rounds until the criteria for stability were reached, thereby eliminating the need for further iterative rounds.
Consensus and stability
Consensus was established when 75% or more of panellists selected the same option(s) in multiple-choice statements and indicated agreement (scores 5–7) or disagreement (scores 1–3) with a statement on the seven-point Likert scale. The stability (absence of variation in responses between two consecutive rounds) of responses was assessed from round 2 onwards, employing statistical tools such as the Kruskal–Wallis test for Likert-scale statements and Chi-squared tests for multiple-choice statements. When comparing statements between consecutive Delphi rounds, stability was defined as a P value of 0.05 or greater. Microsoft Excel (MS Office 2019, Microsoft Corp, WA, USA) was used for statistical analysis.
Expert consensus statements
The Steering Committee drafted expert consensus statements from the survey statements that achieved consensus. If a survey statement required for specific guidance in any of the guideline algorithms (e.g., number of attempts at tracheal intubation) did not achieve consensus through the Delphi process, it was taken to the Steering Committee for an anonymised voting process to make a decision using the majority vote, and thereafter included as an expert consensus statement. The results of the Delphi process and the expert consensus statements drafted were circulated among the experts before publication of the Delphi process to generate expert consensus for the AIDAA guidelines.
Manuscript writing and publication
The respective lead of the guideline sub-committee and the members led the manuscript writing. The results of the Delphi process, recommendations, best practice statements, expert consensus statements, and the manuscript were circulated among the sub-committee members for feedback and approval. Thereafter, each guideline underwent external review by national and international airway experts before submission for publication.
GUIDELINE DISSEMINATION, PROMOTION, AND INTEGRATION INTO CLINICAL PRACTICE
The AIDAA guidelines will be available as open-access articles on PubMed, thereby making them easily accessible for readers across the globe. The AIDAA guidelines will be presented in regional, national, and international academic meetings.[24,25,26,27,28] The AIDAA guidelines will also be promoted globally through webinars, workshops, and the use of social media. In addition, a pocket card bearing all four guideline algorithms will be made available for airway operators for easy integration of the guidance into clinical practice during airway management.
REVISION AND UPDATING OF THE AIDAA 2025 GUIDELINES
A revised version of the AIDAA 2025 guidelines is planned in 2030, 5 years after the publication of the current guidelines, which will incorporate the updated evidence and existing practices in the field. In addition, feedback on the AIDAA 2025 guidelines collected from airway experts and clinicians will be considered. A committee will be formed by the AIDAA leadership 3 years after the publication of the AIDAA 2025 guidelines to facilitate this.
DISCLAIMER
These guidelines have been developed to help clinicians manage unanticipated difficult airways in patients using evidence-based recommendations or Delphi consensus opinions from airway experts, wherever evidence was lacking or weak. These guidelines do not represent the minimum standard of practice, nor are they a substitute for good clinical judgement. The recommendations in the guidelines assume that the airway operator has adequate experience with the devices and techniques described and that these are applied within the scope of their practice. Recommendations regarding the use of specific resources (devices, medications, or workforce) apply where these resources are available. These recommendations should be viewed as aspirational when this is not the case. While careful attention has been paid to provide accurate and updated information, the authors acknowledge that the literature related to airway management is rapidly changing, altering our attitudes and clinical practice. It is important to note that the application of these recommendations in specific settings remains the responsibility of the clinician.
Presentation at conferences/CMEs and abstract publication
Nil.
Study data availability
De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared upon request.
Disclosure of use of artificial intelligence (AI)-assistive or generative tools
The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.
Declaration of use of permitted tools
The tables and figures are self-made and not copyrighted.
Authors contributions
SNM served as the lead for the AIDAA 2025 guideline methodology. APS served as the project administrator. SNM, APS, SMA, JVD, JRD, RG, VR, SRS and PK provided specialised inputs in drafting the methodology, drafting and editing the manuscript, and critical review and approved the final version of the manuscript. All authors contributed to reviewing and editing of the manuscript for intellectual content and are responsible for the content of this guideline.
Supplementary material
None.
Conflicts of interest
Dr Amit Shah- inventor of Patwashahi video laryngoscope (non-commercial), designer of HFNO device HuFlo2. Dr Rakesh Garg, Dr Pankaj Kundra, Dr Sheila Nainan Myatra, Dr Syed Moied Ahmed, and Dr Jeson R Doctor, who are co-authors of this manuscript, are editors of this journal. They were not involved in the decision-making process, and an independent editor handled this manuscript. Other authors declare that they have no conflicts of interest.
Acknowledgement
The authors acknowledge the contribution of Dr. Prashant Nasa, Senior Clinical Fellow, New Cross Hospital, the Royal Wolverhampton NHS Trust, Wolverhampton, the United Kingdom for his inputs in drafting the Delphi methodology.
Funding Statement
All India Difficult Airway Association (AIDAA) has supported the expenses for the guideline meetings (including travel and stay of the committee members), payment for the librarian, artwork and use of the Rayyan software.
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