Training Curriculum For Physicians Involved With Airway Management In Critically Ill Patients: A Delphi Study
Conditions: Airway Management, Tracheal Intubation, Critical Illness, Training
Sponsor: University of Texas Southwestern Medical Center

 
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RESEARCH PROTOCOL 
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STUDY TITLE: Curriculum for Airway Skills in Critically Ill Adults: a Delphi 
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Evaluation (CASCADE) 
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Training Curriculum for Physicians Involved with Airway Management in 
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Critically Ill Patients: a Delphi Study 
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Clinicaltrials.gov: NCT06689748 
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Dated: February 20, 2025 
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INVESTIGATORS (Steering committee members) 
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Sheila Nainan Myatra MD, Mumbai, India 
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Andy Higgs, Warrington, UK 
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Robert Greif, Bern, Switzerland 
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Prashant Nasa MD, Wolverhampton, UK 
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George Kovacs, Halifax, Canada 
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Aaron Joffe, Phoenix, AZ, USA 
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Massimiliano Sorbello, Enna, Italy 
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Wade Brown MD, Nashville, TN, USA 
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Craig S. Jabaley MD, Atlanta, GA, USA 
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Mary Jarzebowski MD, Ann Arbor, MI, USA 
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Kunal Karamchandani MD, Dallas, TX, USA   
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Need and Scope of the Project 
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Airway management in critically ill patients is associated with significant morbidity and 
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mortality.1,2 In an international Delphi study, the need for a training curriculum for 
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airway management in critically Ill patients was identified.3 While attempts have been 
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made to collaborate and define the training, and learning requirements in this field4, 
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significant discrepancies remain between different countries and even between different 
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specialities in the same jurisdiction. Further clarity is needed. In order to define the 
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essential components of the training curriculum for airway management in critically ill 
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patients, we plan to conduct a Delphi study involving a diverse group of international 
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experts from various specialities involved with airway management in critically ill adults. 
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The stakeholders include physicians involved with airway management in critically ill 
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patients, including (but not limited to) the specialities of Emergency, and Acute  
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Medicine, Pulmonology (or Respiratory Medicine), Critical Care Medicine, Internal 
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Medicine, and Anaesthesiology. The proposed components of this Delphi include, 
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identifying the scope of such training, description of the training methods, and detailing 
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the specifics of training requirements for patient preparation and optimisation. The 
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Delphi will also include domains defining mandatory (core practice) and desirable 
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(advanced practice) components of training requirements for airway management, and 
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airway monitoring, as well as assessment of training, and future research priorities. 
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OBJECTIVES 
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1. To generate consensus on different components of curriculum for physicians 
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involved with airway management in critically ill patients.  
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2. To generate consensus on the teaching and training methods and assessment of 
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both for physicians involved with airway management in critically ill patients.  
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3. To generate consensus statements on the mandatory (core practice) and desirable 
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(advanced practice) components of training requirements for physicians involved 
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with airway management in critically ill patients.  
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4. To generate consensus on educational requirements pertaining to physiologic 
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monitoring of critically ill patients during airway management. 
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5. To identify research priorities for future of training and learning curricula 
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regarding airway management in critically ill patients. 
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METHODOLOGY  
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Steering Committee 
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A Steering Committee (SC) comprised of physicians with experience in airway 
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management in critically ill patients was formed including a Delphi methodologist. The 
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Steering Committee selected Experts from across the globe based on pre-defined criteria. 
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Selection of Experts  
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A diverse (specialty, geography, sex, country, resource setting) group of physicians 
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meeting ALL the following inclusion criteria: 
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1. Clinical expertise in airway management of critically ill patients 
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2. Educators with expertise in teaching and training in airway management of critically ill 
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patients. 
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3. At least one publication and/or research project related to airway management in 
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critically ill patients.  
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We will include 3-5 learners, for whom these criteria will  be liberalized,. As they 
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represent the group to whom training curricula apply. 
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The Delphi process 
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The Delphi process is a well-established methodology to generate consensus on a 
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particular topic using the “collective intelligence” of panel members.5,6 The steering 
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committee members will perform a literature search on the available evidence, including 
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existing curriculum for airway management, draft the initial statements, and will conduct 
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iterative Delphi rounds to generate consensus among the experts. The Steering 
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Committee members will not participate in the Delphi surveys. The study findings will be 
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reported according to the ACCORD criteria.7  
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Steps of the Delphi process 
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Step 1: Establishing a preliminary list of broad domains 
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A focused literature review was performed by the members of the SC and based on their 
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findings, the steering committee identified the following broad domains, which were used 
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to draft statements for Round one of the Delphi process. 
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List of domains: 
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1. Educational need and scope 
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2. Teaching and Training methods in Airway Management 
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3. Patient preparation for Airway Management 
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4. Mandatory or Core teaching and training requirements in Airway Management 
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5. Desirable or Advanced teaching and training requirements in Airway 
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Management  
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6. Training in patient monitoring modalities during Airway Management 
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7. Assessment of teaching and training progress, and evaluation of the curriculum 
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Step 2: Preparation of the Delphi Round One Survey 
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The list of questions related to the domains outlined above will be sent to the Experts as a 
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Delphi questionnaire. The anonymity of the Experts will be maintained until the end of 
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the Delphi rounds. The Experts will be asked to answer questions related to the 
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curriculum based on their experience and knowledge of the subject. The questions will 
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either be multiple choice or a 7-point Likert scale (strongly agree, agree, somewhat 
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agree, neither agree nor disagree, somewhat disagree, disagree, strongly disagree). The 
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experts can also provide their opinion regarding  additional questions, deletion of 
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questions or modification using free-text. The responses of experts will be collated during 
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the analysis of results and shared in the following survey as controlled feedback.  
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Step 3: Subsequent Delphi Rounds 
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The steering committee will review the results of round one. The statements listed will be 
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modified, deleted, or added if found ambiguous based on the feedback and comments of 
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the experts. The remaining statements will be continued in the subsequent rounds until 
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the stability of the responses is achieved. The cumulative results of round two will be 
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presented to experts along with anonymized comments, and the survey process will be 
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repeated with the modified questionnaire. The Delphi rounds will be continued until the 
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desired consensus and stability is achieved for statements. . 
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Step 4: Final Consensus 
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Only the statements that achieved consensus and stability will be used develop consensus 
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statements. The results of the last stable round will be used to issue the consensus 
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statements related to the above-mentioned domains. The results of the final survey, 
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consensus statements, and the manuscript will be circulated among the experts for 
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approval before submission for publication. 
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Statistical analysis  
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A descriptive analysis of the preliminary survey will be performed. For the Delphi 
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process, stability will be checked by non-parametric chi-square (χ2) tests or Kruskal-
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Wallis test from round two onwards. A statement is said to be stable if p-value is > 0.05 
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for two consecutive rounds Consensus will be considered reached when a statement 
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achieves >=75% of votes for multiple-choice questions and likert-scale statements. A 
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statement will be continued in the questionnaire round until response stability is 
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achieved. Consensus statements will be considered as those that generate both consensus 
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and stability. 
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PROPOSED TIMELINE 
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10/2025: Preliminary survey development, dissemination, and analysis  
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03/2025: Development and dissemination of the Round one Delphi survey 
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04/2025: Subsequent Delphi rounds 
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07/2025: Analysis of Delphi survey results and preparation of statements  
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10/2025: Manuscript writing and submission for publication  
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Excurse on medical education terms: 
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Education is in the broader context a lifelong comprehensive process of learning and 
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acquiring knowledge, skills, values, and beliefs (attitudes). It aims to develop critical 
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thinking, problem-solving, and creativity. Education includes the learning of abstract 
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concepts and theories. This encompasses a curriculum, which provides the specific 
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content and methods used to achieve educational goals to achieve during specialist 
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training (in this case for airway management in critical ill patients – very specific). 
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Curriculum is a roadmap, a planned course of study or instruction, outlining the goals, 
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objectives, content, and methods of teaching. This provides a tailored framework and the 
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structure within which education, teaching, and training takes place for each objective. 
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Teaching is the delivery mechanism or method of imparting knowledge and skills to 
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others, within a structured curriculum. It facilitates learning, using various methods (e.g. 
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lectures, discussions, and hands-on activities, tutoring, etc.) to help learners to understand 
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and to apply the content of the curriculum. It must be adapted to the learner’s' needs. 
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Training is skill-focused learning, a targeted approach to developing specific skills and 
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competencies as part of a curriculum. Training emphasizes hands-on practice, application 
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of knowledge, and interaction of health care providers within the team, often in a 
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simulated or real-world setting. 
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Relationships: 
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Feature 
Education 
 
Teaching 
 
Training 
   Curriculum 
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Scope  
Broad  
 
Specific 
 
Specific 
   Structured 
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Focus  
Knowledge,   
Knowledge 
 
Skill   
   Content &  
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skills, values,  
& skill  
 
development    methods 
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beliefs  
 
transfer 
 
 
 
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Timeframe 
Long-term 
 
Medium-term  
Short-term 
   Varies 
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Setting 
Formal & 
 
Structured 
 
Structured or    Formal &  
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informal 
 
 
 
 
unstructured    informal  
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Role of the 
Guide & 
 
Active  
 
Facilitate 
   Design &  
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facilitator  
support  
 
instruction  
 
practice 
   implement 
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• Training enhances skills: Training programs often focus on specific skills identified 
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within a curriculum, such as technical and non-technical skills. 
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• Teaching supports learning: Effective teaching helps learners acquire the knowledge, 
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skills and attitudes outlined in the curriculum. 
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• Curriculum informs teaching: Teachers use the curriculum to plan lessons, select 
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materials, assess the learners and evaluate the learning process. 
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• Education is the ultimate goal: It is the overarching framework that encompasses 
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curriculum, teaching, and training, with the goal of fostering lifelong learning and 
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personal growth. 
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REFERENCES  
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1. 
Garnacho-Montero J, Gordillo-Escobar E, Trenado J, et al. A Nationwide, 
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Prospective Study of Tracheal Intubation in Critically Ill Adults in Spain: Management, 
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Associated Complications, and Outcomes. Crit Care Med. May 1 2024;52(5):786-797. 
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doi:10.1097/CCM.0000000000006198 
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2. 
Russotto V, Myatra SN, Laffey JG, et al. Intubation Practices and Adverse Peri-
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intubation Events in Critically Ill Patients From 29 Countries. JAMA. Mar 23 
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2021;325(12):1164-1172. doi:10.1001/jama.2021.1727 
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3. 
Karamchandani K, Nasa P, Jarzebowski M, et al. Tracheal intubation in critically 
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ill adults with a physiologically difficult airway. An international Delphi study. Intensive 
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Care Med. Oct 2024;50(10):1563-1579. doi:10.1007/s00134-024-07578-2 
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4. 
Brown W, Santhosh L, Brady AK, et al. A call for collaboration and consensus on 
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training for endotracheal intubation in the medical intensive care unit. Crit Care. Oct 22 
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2020;24(1):621. doi:10.1186/s13054-020-03317-3 
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5. 
Diamond IR, Grant RC, Feldman BM, et al. Defining consensus: a systematic 
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review recommends methodologic criteria for reporting of Delphi studies. J Clin 
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Epidemiol. Apr 2014;67(4):401-9. doi:10.1016/j.jclinepi.2013.12.002 
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6. 
Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to 
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decide its appropriateness. World J Methodol. Jul 20 2021;11(4):116-129. 
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doi:10.5662/wjm.v11.i4.116 
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7. 
Gattrell WT, Logullo P, van Zuuren EJ, et al. ACCORD (ACcurate COnsensus 
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Reporting Document): A reporting guideline for consensus methods in biomedicine 
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developed via a modified Delphi. PLoS Med. Jan 2024;21(1):e1004326. 
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doi:10.1371/journal.pmed.1004326 
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