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

Eric J Wilsterman Jr; Marianne E Nellis; Josep Panisello; Awni Al-Subu; Ryan Breuer; Dai Kimura; Conrad Krawiec; Palen P Mallory; Sholeen Nett; Erin Owen; Simon J Parsons; Ronald C Sanders Jr; Annery Garcia-Marcinkiewicz; Natalie Napolitano; Justine Shults; Vinay M Nadkarni; Akira Nishisaki; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

doi:10.1097/PCC.0000000000003418

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

Pediatr Crit Care Med. 2024 Apr 1;25(4):335-343. doi: 10.1097/PCC.0000000000003418. Epub 2023 Dec 7.

Authors

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

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.

MeSH terms

Adolescent
Airway Management
Child
Down Syndrome* / complications
Humans
Intensive Care Units, Pediatric
Intubation, Intratracheal / adverse effects
Laryngoscopes*
Retrospective Studies

Grants and funding

R18 HS024511/HS/AHRQ HHS/United States