Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study

doi:10.1097/PCC.0000000000003418

. 2024 Apr 1;25(4):335-343.

doi: 10.1097/PCC.0000000000003418. Epub 2023 Dec 7.

Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study

Eric J Wilsterman Jr¹, Marianne E Nellis¹, Josep Panisello², Awni Al-Subu³, Ryan Breuer⁴, Dai Kimura⁵, Conrad Krawiec⁶, Palen P Mallory⁷, Sholeen Nett⁸, Erin Owen⁹, Simon J Parsons¹⁰, Ronald C Sanders Jr¹¹, Annery Garcia-Marcinkiewicz¹², Natalie Napolitano¹³, Justine Shults¹⁴, Vinay M Nadkarni¹⁵, Akira Nishisaki^{16

17}; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

Affiliations

¹ Pediatric Critical Care, Department of Pediatrics, New York Presbyterian Weill Cornell Medical Center, New York, NY.
² Critical Care, Department of Pediatrics, Yale Medical School, New Haven, CT.
³ Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.
⁴ Critical Care Medicine, Department of Pediatrics, Oishei Children's Hospital University at Buffalo, Buffalo, NY.
⁵ Critical Care Medicine, Department of Pediatrics, Le Bonheur Children's Hospital, Heart Institute, University of Tennessee Health Science Center, Memphis, TN.
⁶ Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA.
⁷ Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC.
⁸ Pediatric Critical Care, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH.
⁹ Pediatric Critical Care Medicine, Department of Pediatrics, Norton Children's Hospital, University of Louisville, Louisville, KY.
¹⁰ Critical Care, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada.
¹¹ Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR.
¹² General Anesthesiology, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA.
¹³ Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA.
¹⁴ Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
¹⁵ Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
¹⁶ Critical Care, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
¹⁷ Department of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

PMID: 38059735
PMCID: PMC10994735 (available on 2025-04-01)
DOI: 10.1097/PCC.0000000000003418

Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study

Eric J Wilsterman Jr et al. Pediatr Crit Care Med. 2024.

. 2024 Apr 1;25(4):335-343.

doi: 10.1097/PCC.0000000000003418. Epub 2023 Dec 7.

Authors

Affiliations

¹ Pediatric Critical Care, Department of Pediatrics, New York Presbyterian Weill Cornell Medical Center, New York, NY.
² Critical Care, Department of Pediatrics, Yale Medical School, New Haven, CT.
³ Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.
⁴ Critical Care Medicine, Department of Pediatrics, Oishei Children's Hospital University at Buffalo, Buffalo, NY.
⁵ Critical Care Medicine, Department of Pediatrics, Le Bonheur Children's Hospital, Heart Institute, University of Tennessee Health Science Center, Memphis, TN.
⁶ Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA.
⁷ Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC.
⁸ Pediatric Critical Care, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH.
⁹ Pediatric Critical Care Medicine, Department of Pediatrics, Norton Children's Hospital, University of Louisville, Louisville, KY.
¹⁰ Critical Care, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada.
¹¹ Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR.
¹² General Anesthesiology, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA.
¹³ Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA.
¹⁴ Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
¹⁵ Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
¹⁶ Critical Care, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
¹⁷ Department of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

PMID: 38059735
PMCID: PMC10994735 (available on 2025-04-01)
DOI: 10.1097/PCC.0000000000003418

Abstract

Objectives: Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]).

Design: Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS).

Setting: Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020.

Patients: A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry.

Interventions: None.

Measurements and main results: We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822).

Conclusions: Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.

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Conflict of interest statement

Drs. Nishisaki and Nadkarni and Ms. Napolitano’s institution received funding from the National Institute of Child Health and Development, Agency for Healthcare Research and Quality (AHRQ), and Chiesi, USA. They received support for article research from the AHRQ. Dr. Nadkarni serves as President of the Society of Critical Care Medicine (SCCM) 2023–2024. The views presented in this article are his own, and are not intended to represent the views of the SCCM. Dr. Al-Subu received funding from the American Physician Institute. Dr. Krawiec received funding from NEJM Healer Cases and Elsevier Osmosis. Dr. Napolitano received funding from Drager Medical; their institution received funding from Drager, Timpel, Actuated Medical, and Vero-Biotech. Dr. Shults’ institution received funding from the National Institutes of Health (NIH) (R18HS024511); they received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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Miller AG, Mallory PM, Rotta AT. Miller AG, et al. Respir Care. 2024 Aug 24;69(9):1165-1181. doi: 10.4187/respcare.12014. Respir Care. 2024. PMID: 38744479 Review.

References

1. Parker MM, Nuthall G, Brown C 3rd, et al.: Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes. Pediatr Crit Care Med 2017; 18:310–318 - PMC - PubMed
1. Mai CT, Isenburg JL, Canfield MA, et al.: National population-based estimates for major birth defects, 2010–2014. Birth Defects Res 2019; 111:1420–1435 - PMC - PubMed
1. de Graaf G, Buckley F, Dever J, et al.: Estimation of live birth and population prevalence of Down syndrome in nine U.S. states. Am J Med Genet A 2017; 173:2710–2719 - PubMed
1. Shott SR: Down syndrome: analysis of airway size and a guide for appropriate intubation. Laryngoscope 2000; 110:585–592 - PubMed
1. Bertolizio G, Saint-Martin C, Ingelmo P: Cervical instability in patients with Trisomy 21: The eternal gamble. Paediatr Anaesth 2018; 28:830–833 - PubMed

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[1] Parker MM, Nuthall G, Brown C 3rd, et al.: Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes. Pediatr Crit Care Med 2017; 18:310–318 - PMC - PubMed

[2] Parker MM, Nuthall G, Brown C 3rd, et al.: Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes. Pediatr Crit Care Med 2017; 18:310–318 - PMC - PubMed

[3] Mai CT, Isenburg JL, Canfield MA, et al.: National population-based estimates for major birth defects, 2010–2014. Birth Defects Res 2019; 111:1420–1435 - PMC - PubMed

[4] Mai CT, Isenburg JL, Canfield MA, et al.: National population-based estimates for major birth defects, 2010–2014. Birth Defects Res 2019; 111:1420–1435 - PMC - PubMed

[5] de Graaf G, Buckley F, Dever J, et al.: Estimation of live birth and population prevalence of Down syndrome in nine U.S. states. Am J Med Genet A 2017; 173:2710–2719 - PubMed

[6] de Graaf G, Buckley F, Dever J, et al.: Estimation of live birth and population prevalence of Down syndrome in nine U.S. states. Am J Med Genet A 2017; 173:2710–2719 - PubMed

[7] Shott SR: Down syndrome: analysis of airway size and a guide for appropriate intubation. Laryngoscope 2000; 110:585–592 - PubMed

[8] Shott SR: Down syndrome: analysis of airway size and a guide for appropriate intubation. Laryngoscope 2000; 110:585–592 - PubMed

[9] Bertolizio G, Saint-Martin C, Ingelmo P: Cervical instability in patients with Trisomy 21: The eternal gamble. Paediatr Anaesth 2018; 28:830–833 - PubMed

[10] Bertolizio G, Saint-Martin C, Ingelmo P: Cervical instability in patients with Trisomy 21: The eternal gamble. Paediatr Anaesth 2018; 28:830–833 - PubMed

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Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study

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Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study

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