Difficult airway in children with trisomy 18: prevalence, outcomes, and complications in a single center retrospective observational study

Abstract

Difficult airway in children with trisomy 18: prevalence, outcomes, and complications in a single center retrospective observational study Introduction: Trisomy 18 (T18) is the second most common autosomal trisomy disorder after Down syndrome, with a prevalence of 1/6000-8000(1). It is characterized by multiple congenital malformations including craniofacial anomalies, congenital heart disease, multilevel airway obstruction, gastrointestinal and genitourinary defects, orthopedic anomalies, and severe neurocognitive disability. Airway management of children withT18 can be challenging due to characteristic craniofacial features(2)(3). This study examined the frequency of difficult airway including difficult mask ventilation and difficult intubation, adverse events of airway management, and related outcomes in a large children’s hospital. Methods: We performed a retrospective medical record review of children <18 years with T18 undergoing general anesthesia, 01/2010 - 06/2021. All diagnoses were identified using ICD 9 and 10 codes and confirmed by a chart review. Only anesthetics with airway intervention were included. The primary outcome was difficult airway defined as difficult facemask ventilation, difficult intubation, or both. Difficult intubation was defined as Cormack and Lehane grade ≥ 3 during direct laryngoscopy, ≥ 3 intubation attempts, and/or intubation achieved with an advanced airway device. Secondary outcomes were immediate outcomes of intubation and the prevalence of adverse airway events. Preliminary exploratory data analysis techniques, such as frequencies and standardized differences (SD) were used to assess the distributions of outcome measures. SD > 0.2 considered unbalanced distribution. Results: Of 165 anesthetics from 48 children, the adjusted prevalence of difficult mask ventilation was 2.9% (95% confidence interval [CI] (0.92%- 7.61%), 4/140), the prevalence of difficult intubation was 41.4% (95% CI (33.4%- 49.9%), 60/145), and the prevalence of difficult airway among airway interventions was 36.4% (95% CI (29.1%- 44.3%), 60/165). Among difficult intubations performed by anesthesiologists, video laryngoscope (VL) was utilized in 48.3% and a fiberoptic (FOI) -only or combined technique used in 15%; 21.7% of intubations were performed by an otolaryngologist who most often used the rigid bronchoscope (70%). Difficult intubation was most likely in infants (55%, SD 0.35), and children ≤ 10kg (78%, SD 0.77). Difficult intubation also was more common during otolaryngology procedures (45%) and when the child had an anatomical feature known to be associated with difficult intubation (67%, SD 0.61). Hypoxemia occurred in 45.5% of airway interventions. Critical cardiopulmonary events requiring treatment with at least one vasoactive medication occurred in 7% of inductions. Discussion: Difficult airway and difficult intubation were common in children with T18, especially in those with micrognathia/ retrognathia, young age or weight ≤10kg, and undergoing otolaryngology procedures. Difficult intubations were frequently managed using non-conventional airway devices. Conclusion: Children with T18 require special perioperative care for a potential difficult airway. References 1. Mai CT, et al. Birth Defects Res A Clin Mol Teratol. 2015;103(11):972-93. 2. Bansal T, et al. Egypt J Anaesth. 2016;32(2):227-+. 3. Birmingham EE, et al. Paediatr Anaesth. 2021;31(4):419-28.