Expert consensus for difficult airway management in the absence of clear evidence using a Delphi method

The All India Difficult Airway Association developed clinical practice statements utilising the Delphi method among experts for specific interventions in the management of unanticipated difficult airways in adult, obstetric, and paediatric populations, as well as for the management of at-risk extubations, where existing evidence was either weak or absent. A Steering Committee consisting of nine airway experts and a Delphi methodologist convened a panel of 24 experts, from whom anonymous responses were collected via an online Delphi survey. Consensus was defined as at least 75% experts voting for a particular option in multiple-choice statements, and agreement (scores of 5-7) or disagreement (scores of 1-3) on a nominal 7-point Likert scale statement. The stability of responses between consecutive rounds was assessed using the Kruskal-Wallis test or Chi-square test, with a P value of greater than or equal to 0.05 indicating stability. Twenty-three experts completed four Delphi rounds conducted from 27 December 2024 to 25 January 2025. Of the 26 statements considered, 23 (88%) achieved both consensus and stability. Of note, the statement regarding the maximum number of attempts permitted for supraglottic airway insertion in adults to mitigate airway management-related complications did not achieve consensus among experts; however, the Steering Committee voted unanimously for a maximum of three attempts. From the 23 statements that achieved expert consensus and the statement that received the maximum vote during the adjudication process by the Steering Committee, 24 expert clinical statements were drafted. Future research is necessary to evaluate the impact of these clinical practice statements and to address the remaining uncertainties.