Management of the Difficult Airway: An Appraisal of Clinical Practice Guidelines

Objective: Management of the difficult airway can be a challenging process, which necessitates actionable recommendations from well-established guidelines. Herein, clinical practice guideline (CPG) quality is evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Study Design: A systematic literature search was performed using Scopus, EMBASE, and MEDLINE via PubMed. Setting: Literature database. Methods: Data were abstracted from relevant guidelines and appraised by 4 expert reviewers in the 6 domains of quality defined by AGREE II. Intraclass correlation coefficients (ICC) were calculated across domains to quantify interrater reliability. Results: Twelve guidelines met the inclusion criteria. With a mean quality score of 83.1%, the highest quality guideline was authored by the American Society of Anesthesiologists (ASA). Low-quality content was observed in CPGs authored by the Japanese Society of Anesthesiologists (JSA) and the Chinese Collaboration Group for Emergency Airway Management (CCGEAM). Overall, deficits were most pronounced in domains describing the involvement of stakeholders, developmental rigor, and editorial independence. These findings were consistent among the panel of independent reviewers, with high ICC inter-rater reliability scores of 58.0% to 70.0% for the referenced domains. Conclusion: By providing a comprehensive appraisal of guidelines, this report may serve as a reference for clinicians seeking to understand and improve upon the developmental quality of difficult airway management resources. According to AGREE II criteria for the quality of the guideline creation process, the 2022 ASA guideline outperforms its predecessors.