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Brennan MP, Webber AM, Patel CV, Chin WA, Butz SF, Rajan N. Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg 2024; 139:509-520. [PMID: 38517763 DOI: 10.1213/ane.0000000000006645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.
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Affiliation(s)
- Marjorie P Brennan
- From the Department of Anesthesiology, Pain and Perioperative Medicine, The George Washington University School of Medicine, Children's National Hospital, Washington, DC
| | - Audra M Webber
- University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Chhaya V Patel
- Department of Anesthesiology and Pediatrics, Emory School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Wanda A Chin
- Department of Anesthesiology and Perioperative Medicine, New York University Grossman School of Medicine, NYU Lagone Health, New York, New York
| | - Steven F Butz
- Department of Anesthesiology, Medical College of Wisconsin, Children's Wisconsin Surgicenter
| | - Niraja Rajan
- Department of Anesthesiology, Penn State Milton S Hershey Medical Center, Hershey Outpatient Surgery Center, Hershey, Pennsylvania
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Park AC, Billings K, Maddalozzo J, Dsida R, Benzon HA, Lavin J, Hazkani I. Perioperative opioids in high-risk children undergoing tonsillectomy - A single institution experience. Am J Otolaryngol 2024; 45:104453. [PMID: 39151380 DOI: 10.1016/j.amjoto.2024.104453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/29/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Patients undergoing tonsillectomy/ adenotonsillectomy (T/AT) can experience substantial postoperative pain. The aims of this study are to assess perioperative pain management in high-risk children (children with severe obstructive sleep apnea and other complex medical comorbidities or age younger than 2 years) undergoing T/AT, and the impact on oxygen levels and pain during extended Post-Anesthesia Care Unit (PACU) admission. METHODS A retrospective case series study at a tertiary care children's hospital. RESULTS There were 278 children enrolled in the study. The Apnea-Hypopnea index and mean oxygen nadir on preoperative polysomnography were 31.3 ± 25.76/h and 79.5 ± 9.5 % respectively. Overall, 246 (89 %) patients received intraoperative opioids alone (n = 35, 13 %) or in combination with non-opioid analgesia (n = 209, 75 %). While the median dose of opioid-free medications (acetaminophen, ibuprofen) ranged from 93 to 100 % of standard maximal dosing by weight and age, the median dose of opioids was significantly lower and ranged from 54 to 63 % of standard maximal dosing by weight and age, with 43 % of the patients receiving less than half the recommended maximum dose. Oxygen desaturation was charted in 21 patients (8 %) during their PACU admission. Patients who received opioid-free analgesia were as likely to develop oxygen desaturations (n = 17 (81 %) vs. n = 228 (89.4 %), p = 0.27) and to receive rescue pain medication during their PACU stay as patients who received opioids intraoperatively (n = 18 (56 %) vs. n = 167 (68 %), p = 0.23). CONCLUSIONS Intraoperative pain management varies across high-risk pediatric tonsillectomies. Opioid-free analgesia was not associated with an increased need for pain medications during PACU admission, or with a decreased likelihood of oxygen desaturations compared to intra-operative opioid analgesia use.
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Affiliation(s)
- Asher C Park
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kathleen Billings
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - John Maddalozzo
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Richard Dsida
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Hubert A Benzon
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jennifer Lavin
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Inbal Hazkani
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Efune PN, Pinales P, Park J, Poppino KF, Mitchell RB, Szmuk P. Pediatric obstructive sleep apnea: a prospective observational study of respiratory events in the immediate recovery period after adenotonsillectomy. Anaesth Crit Care Pain Med 2024; 43:101385. [PMID: 38705239 DOI: 10.1016/j.accpm.2024.101385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Adenotonsillectomy is often curative for pediatric obstructive sleep apnea, yet children remain at high risk of respiratory complications in the postoperative period. We sought to determine the incidence and risk factors for respiratory depression and airway obstruction, as well as clinically apparent respiratory events in the post-anesthesia care unit (PACU) in high-risk children after adenotonsillectomy. METHODS In this prospective cohort study, we enrolled 60 high-risk children having adenotonsillectomy. Our primary outcome was respiratory depression and airway obstruction in the PACU measured using a noninvasive respiratory volume monitor (RVM) and defined by episodes of predicted minute ventilation less than 40% for at least 2 min. We measured clinically apparent respiratory events using continuous observation by trained study staff. RESULTS The median (range) age of our sample was 4 years (1, 16) and 27 (45%) were female. Black and Hispanic race children comprised 80% (n = 48) of our cohort. Thirty-nine (65%) had at least one episode of PACU respiratory depression or airway obstruction measured using the RVM, while only 21 (35%) had clinically apparent respiratory events. Poisson regression demonstrated the following associations with an increase in episodes of respiratory depression and airway obstruction: BMI Z-score less than -1 (estimate 3.91; [95%CI 1.49-10.23]), BMI Z-score 1-2 (estimate 2.04; [1.20-3.48]), and two or more comorbidities (estimate 1.96; [1.11-3.46]). CONCLUSIONS Respiratory volume monitoring in the immediate postoperative period after pediatric high-risk adenotonsillectomy identifies impaired ventilation more frequently than is clinically apparent.
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Affiliation(s)
- Proshad N Efune
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States; Outcomes Research Consortium, 9500 Euclid Avenue Cleveland, OH 44195, United States.
| | - Pedro Pinales
- University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-8876, United States.
| | - Jenny Park
- Southern Methodist University, Department of Biostatistics, 6425 Boaz Lane, Dallas TX 75205, United States.
| | - Kiley F Poppino
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States
| | - Ron B Mitchell
- University of Texas Southwestern Medical Center, Department of Otolaryngology, Head and Neck Surgery, 2001 Inwood Road, Dallas, TX 75390-9035, United States.
| | - Peter Szmuk
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States; Outcomes Research Consortium, 9500 Euclid Avenue Cleveland, OH 44195, United States.
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So V, Radhakrishnan D, MacCormick J, Webster RJ, Tsampalieros A, Zitikyte G, Ripley A, Murto K. Does Celecoxib Prescription for Pain Management Affect Post-tonsillectomy Hemorrhage Requiring Surgery? A Retrospective Observational Cohort Study. Anesthesiology 2024; 141:313-325. [PMID: 38684054 DOI: 10.1097/aln.0000000000005032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Adenotonsillectomy and tonsillectomy (referred to as tonsillectomy hereafter) are common pediatric surgeries. Postoperative complications include hemorrhage requiring surgery (2 to 3% of cases) and pain. Although nonsteroidal anti-inflammatory drugs are commonly administered for postsurgical pain, controversy exists regarding bleeding risk with cyclooxygenase-1 inhibition and associated platelet dysfunction. Preliminary evidence suggests selective cyclooxygenase-2 inhibitors, for example celecoxib, effectively manage pain without adverse events including bleeding. Given the paucity of data for routine celecoxib use after tonsillectomy, this study was designed to investigate the association between postoperative celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery using chart-review data from the Children's Hospital of Eastern Ontario. METHODS After ethics approval, a retrospective single-center observational cohort study was performed in children less than 18 yr of age undergoing tonsillectomy from January 2007 to December 2017. Cases of adenoidectomy alone were excluded due to low bleed rates. The primary outcome was the proportion of patients with post-tonsillectomy hemorrhage requiring surgery. The association between a celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery was estimated using inverse probability of treatment weighting based on propensity scores and using generalized estimating equations to accommodate clustering by surgeon. RESULTS An initial patient cohort of 6,468 was identified, and 5,846 children with complete data were included in analyses. Median (interquartile range) age was 6.10 (4.40, 9.00) yr, and 46% were female. In the cohort, 28.1% (n = 1,644) were prescribed celecoxib. Among the 4,996 tonsillectomy patients, 1.7% (n = 86) experienced post-tonsillectomy hemorrhage requiring surgery. The proportion with post-tonsillectomy hemorrhage requiring surgery among patients who had a tonsillectomy and were or were not prescribed celecoxib was 1.94% (30 of 1,548; 95% CI, 1.36 to 2.75) and 1.62% (56 of 3,448; 95% CI, 1.25 to 2.10), respectively. Modeling did not identify an association between celecoxib prescription and increased odds of post-tonsillectomy hemorrhage requiring surgery (odds ratio = 1.4; 95% CI, 0.85 to 2.31; P = 0.20). CONCLUSIONS Celecoxib does not significantly increase the odds of post-tonsillectomy hemorrhage requiring surgery, after adjusting for covariates. This large pediatric cohort study of celecoxib administered after tonsillectomy provides compelling evidence for safety but requires confirmation with a multisite randomized controlled trial. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Vincent So
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dhenuka Radhakrishnan
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Johnna MacCormick
- Department of Otolaryngology Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard J Webster
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Gabriele Zitikyte
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Allyson Ripley
- University of Western Ontario, Faculty of Medicine, London, Ontario, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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Rossi NA, Spaude J, Ohlstein JF, Pine HS, Daram S, McKinnon BJ, Szeremeta W. Apnea-hypopnea index severity as an independent predictor of post-tonsillectomy respiratory complications in pediatric patients: A retrospective study. EAR, NOSE & THROAT JOURNAL 2024; 103:424-429. [PMID: 34851765 DOI: 10.1177/01455613211059468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Despite the presence of clinical practice guidelines for overnight admission of pediatric patients following adenotonsillectomy, variance in practice patterns exists between pediatric otolaryngologists. The purpose of this study is to examine severity of apnea-hypopnea index (AHI) as an independent predictor of postoperative respiratory complications in children undergoing adenotonsillectomy. METHODS Retrospective chart review of all children undergoing adenotonsillectomy at a large tertiary referral center between January 2015 and December 2019 who underwent preoperative polysomnography and were admitted for overnight observation. Charts were reviewed for total adverse events and respiratory events occurring during admission. RESULTS Overall, respiratory events were seen in 50.6% of patients with AHI ≥10 and in 39.6% of patients with AHI <10. The overall mean AHI was 19.2, with a mean of 28.1 in the AHI ≥10 subgroup vs 4.6 in the AHI <10 subgroup. There was no statistical correlation or increased risk between an AHI ≥10 and having a pure respiratory event, with a relative risk of 1.19 (.77-1.83, P = .43). There was a statistically significant difference between the mean AHI of those with any adverse event and those without (21.6 vs 13.4, P = .008). There is additionally an increased risk of any event with an AHI over 10, with a relative risk of 1.51 (1.22-1.88, P < .0001). CONCLUSION Preoperative AHI of 10 events per hour was not a predictor of postoperative respiratory complications. However, there was a trend for those with a higher AHI requiring additional supportive measures or a prolonged stay. Practitioners should always use their best judgment in deciding whether a child warrants postoperative admission following adenotonsillectomy.
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Affiliation(s)
- Nicholas A Rossi
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jordan Spaude
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jason F Ohlstein
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Harold S Pine
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Shiva Daram
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Brian J McKinnon
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Wasyl Szeremeta
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
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Moroco AE, Friedman N, Jabbour C, Roy S, Schmidt R, Nardone HC. Current Pediatric Tertiary Care Practices Following Adenotonsillectomy: An Update. Laryngoscope 2024; 134:2931-2936. [PMID: 38073113 DOI: 10.1002/lary.31216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/08/2023] [Accepted: 11/17/2023] [Indexed: 05/09/2024]
Abstract
OBJECTIVE Adenotonsillectomy is a common procedure performed in children, and the practice patterns at academic centers have been evolving with the publication of updated societal guidelines. In this study, we assess perioperative practice patterns at tertiary care children's hospitals for children undergoing adenotonsillectomy. METHODS A cross-sectional 18-question survey distributed in July of 2022 recruited responses through August 25, 2022. The division chiefs of 70 pediatric otolaryngology groups at tertiary care children's hospitals across the United States and Canada were surveyed. Division chiefs submitted survey responses on behalf of the group practice patterns for children undergoing adenotonsillectomy. The main measure was survey responses from the division chiefs of pediatric otolaryngology reporting group practice. RESULTS The survey response rate was 46%. Eighty-eight percent of groups reported an official adenotonsillectomy admission policy. Commonly reported admission criteria included age (93%) and obesity (59%). Eighty-eight percent of groups defined severe obstructive sleep apnea as apnea-hypopnea index ≥10. Only 41% of groups required a child to be observed sleeping on room air prior to ambulatory discharge. Ninety-seven percent of groups reported routinely obtaining preoperative polysomnography in a variety of clinical settings. CONCLUSIONS Many children's hospitals report an official admission policy following adenotonsillectomy. Despite a decade passing since the initial publication of the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines, there remains great variability in the practice patterns for both preoperative polysomnography and postoperative monitoring and admission. These results highlight an opportunity for an improved unified approach to perioperative pediatric adenotonsillectomy practice. LEVEL OF EVIDENCE 5 Laryngoscope, 134:2931-2936, 2024.
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Affiliation(s)
- Annie E Moroco
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Norman Friedman
- Division of Pediatric Otolaryngology, Colorado Children's Hospital, Aurora, Colorado, U.S.A
| | - Christopher Jabbour
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Nemours Children's Health, Wilmington, Delaware, U.S.A
| | - Soham Roy
- Division of Pediatric Otolaryngology, Colorado Children's Hospital, Aurora, Colorado, U.S.A
| | - Richard Schmidt
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Nemours Children's Health, Wilmington, Delaware, U.S.A
| | - Heather C Nardone
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Nemours Children's Health, Wilmington, Delaware, U.S.A
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Martin E, Frank M, Nguyen C, Bhatt J, Huoh K, Ahuja G, Pham N. Supplemental oxygen requirement after tonsillectomy in children >3 years of age. Int J Pediatr Otorhinolaryngol 2024; 178:111893. [PMID: 38382259 DOI: 10.1016/j.ijporl.2024.111893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION The indications for postoperative admission after tonsillectomy in children >3 years of age are less well defined than for children <3 years old, and typically include severe obstructive sleep apnea (OSA), obesity, comorbidities, or behavioral factors. Inpatient care after tonsillectomy typically consists of respiratory monitoring and support, as respiratory compromise is the most common complication after pediatric tonsillectomy. We aim to evaluate risk factors associated with postoperative oxygen supplementation and to identify high risk populations within the admitted population who use additional resources or require additional interventions. METHODS Retrospective chart review of patients between the ages of 3 and 18 years old who underwent tonsillectomy by four surgeons at a tertiary care children's hospital was performed. Data including demographics, comorbidities, surgical intervention, pre- and postoperative AHI, admission, postoperative oxygen requirement, and postoperative complications was collected and analyzed. RESULTS There were 401 patients included in the analysis. Of the patients in this study, 65.59% were male, 43.39% were Latino, and 53.87% were ages 3 to 7. Of the 397 patients with a record for supplemental oxygen, 36 (9.07%) received supplemental oxygen. The LASSO regression odds ratios (OR) found to be important for modeling supplemental oxygen use (in decreasing order of magnitude) are BMI ≥35 (OR = 2.30), pre-op AHI >30 (OR = 2.28), gastrointestinal comorbidities (OR = 2.20), musculoskeletal comorbidities (OR = 1.91), cardiac comorbidities (OR = 1.20), pulmonary comorbidities (OR = 1.14), and BMI 30 to <35 (OR = 1.07). Female gender was found to be negatively associated with risk of supplemental oxygen use (OR = 0.84). Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement. CONCLUSION BMI ≥30, pre-op AHI >30, male gender, and gastrointestinal, musculoskeletal, cardiac, and pulmonary comorbidities are all associated with postoperative supplemental oxygen use. Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement.
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Affiliation(s)
- Elaine Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA.
| | - Madelyn Frank
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Cecilia Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Jay Bhatt
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Kevin Huoh
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Gurpreet Ahuja
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Nguyen Pham
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
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Age criteria for polysomnography and inpatient management for adenotonsillectomy. Am J Otolaryngol 2023; 44:103670. [DOI: 10.1016/j.amjoto.2022.103670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/15/2022] [Indexed: 11/05/2022]
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Kukkala S, Vazifedan T, Baldassari CM. Association of Apnea vs Hypopnea Predominance With Pediatric Sleep Apnea Outcomes: A Secondary Analysis of the Childhood Adenotonsillectomy Trial. JAMA Otolaryngol Head Neck Surg 2022; 148:1038-1043. [PMID: 36201186 PMCID: PMC9539728 DOI: 10.1001/jamaoto.2022.3031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/20/2022] [Indexed: 12/13/2022]
Abstract
Importance Children with apnea-predominant obstructive sleep apnea (OSA) are hypothesized to have a more severe form of the disease. However, research is lacking as to whether there is a significant difference in outcomes between children with apnea-predominant vs hypopnea-predominant OSA. Objective To assess the association between baseline apnea-predominant or hypopnea-predominant OSA on polysomnography and quality of life (QOL) outcomes in children with obstructive sleep apnea managed by watchful waiting with supportive care (WWSC) or adenotonsillectomy (AT). Design, Setting, and Participants This case-control study is a secondary analysis of a randomized clinical trial, the Childhood Adenotonsillectomy Trial, which was conducted at multiple tertiary children's hospitals from October 2007 to June 2012. Children aged 5.0 to 9.9 years with OSA were randomized to WWSC or AT and underwent polysomnography and completed validated QOL and symptom assessments at baseline and 7 months. The current data analysis was performed from October 2020 to February 2022. Main Outcomes and Measures Apnea-predominant OSA was defined as an apnea hypopnea index (AHI) greater than 2 with more than 50% of the obstructive events being apneas. Patients were considered to have hypopnea-predominant OSA if they had an AHI greater than 2 and more than 50% of the obstructive events were hypopneas. Results A total of 386 children (185 boys [48%]; mean [SD] age, 6.56 [1.4] years) were analyzed. The mean (SD) obstructive AHI for patients was 6.98 (5.62), with 198 patients (51%) having mild disease. Thirty-seven children (10%) had apnea-predominant OSA at baseline. Black children were at increased risk for apnea-predominant OSA vs White children (odds ratio [OR], 13.40; 95% CI, 5.70-33.90). Children with apnea predominance were more likely to have severe OSA (AHI >10) compared with children with hypopnea predominance (OR, 2.30; 95% CI, 1.03-5.03); baseline Pediatric Sleep Questionnaire and OSA-18 QOL scores were similar between the 2 groups. Among children undergoing AT, those with baseline apnea predominance were more likely to have a Pediatric Sleep Questionnaire score greater than 0.33 at follow-up (OR, 3.30; 95% CI, 1.01-10.80). Rates of OSA resolution and improvements in QOL scores following AT or WWSC were similar between the apnea-predominant and hypopnea-predominant groups. Conclusions and Relevance In children with OSA, apnea-predominant disease is uncommon. Apnea predominance was not associated with symptom resolution and cure rates in children undergoing AT or WWSC for OSA. Further research is needed to assess how apnea predominance affects AT outcomes in children with more severe disease.
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Affiliation(s)
| | - Turaj Vazifedan
- Department of Pediatrics, Children’s Hospital of the King’s Daughters, Norfolk, Virginia
| | - Cristina M. Baldassari
- Department of Otolaryngology Head and Neck Surgery, Eastern Virginia Medical School, Norfolk
- Division of Sleep Medicine, Children’s Hospital of the King’s Daughters, Norfolk, Virginia
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Rollins JT, Wajsberg B, Bitners AC, Burton WB, Hametz PA, Chambers TA, Yang CJ. Admission practices following pediatric tonsillectomy: A survey of ASPO members. Int J Pediatr Otorhinolaryngol 2022; 162:111286. [PMID: 36206700 PMCID: PMC11232560 DOI: 10.1016/j.ijporl.2022.111286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/08/2022] [Accepted: 08/12/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Although evidence-based Clinical Practice Guidelines (CPGs) have specified postoperative admission criteria for pediatric tonsillectomy, there is substantial variation in guideline implementation and adherence among otolaryngologists in practice. We aimed to assess pediatric otolaryngologists' post-tonsillectomy admission practices and to examine patient and surgeon factors associated with differences in admission practices. METHODS An electronic cross-sectional survey was distributed to members of the American Society of Pediatric Otolaryngology (ASPO) to determine current practices regarding admission practices following pediatric tonsillectomy. Chi-square and Fisher's exact tests were performed to compare differences in adherence to tonsillectomy CPGs by respondent characteristics. RESULTS The survey was sent to 644 pediatric otolaryngologists with a response rate of 19.1%. 37% of respondents reported "always" and 60% "often" using the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) CPG to guide decision for admission. Years in practice was the factor most strongly associated with admission practices, with 10 or fewer years in practice significantly correlated with stricter adherence to the AAO-HNS CPG of overnight observation when Apnea-Hypopnea Index (AHI) ≥10, age <3 years, or O2 nadir <80%) (OR 4.2, p <0.001), as well as specific individual criteria such as an AHI ≥10 (OR 4.1, p = 0.03). Respondents in an academic practice setting were more likely to admit children <3 years of age than those in private practice (OR 5.0, p = 0.01). CONCLUSION Admission practices varied among pediatric otolaryngologist survey respondents, and strict AAO-HNS CPG adherence was associated with fewer years in practice and academic practice setting. These results suggest that further study investigating factors influencing guideline adherence and post-tonsillectomy admission practices is warranted.
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Affiliation(s)
| | | | - Anna C Bitners
- Johns Hopkins Hospital, Department of Pediatrics, Baltimore, MD, USA
| | | | - Patricia A Hametz
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Pediatrics, Bronx, NY, USA
| | - Terry-Ann Chambers
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Anesthesiology, Bronx, NY, USA
| | - Christina J Yang
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Pediatrics, Bronx, NY, USA; Montefiore Medical Center, Department of Otorhinolaryngology-Head and Neck Surgery, Bronx, NY, USA.
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11
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Predictors of overnight postoperative respiratory complications in obese children undergoing adenotonsillectomy for obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2022; 162:111334. [PMID: 36209625 DOI: 10.1016/j.ijporl.2022.111334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/24/2022] [Accepted: 10/01/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Current clinical guidelines from the American Academy of Otolaryngology Head & Neck Surgery (AAO-HNS) recommend a preoperative polysomnogram (PSG) for obese patients prior to adenotonsillectomy (T&A). An overnight admission is recommended for children with severe (AHI >10) obstructive sleep apnea (OSA), citing a higher incidence of post-operative respiratory complications (PRCs) and need for respiratory support. Routine admission of obese children based on AHI >10 alone after T&A may place undue strain on hospital resources and increase healthcare costs, especially considering that many of these children have uncomplicated postoperative courses. In this study, we sought to identify variables from the pre-operative PSG and post-anesthesia care unit (PACU) that could more accurately predict overnight PRCs and indicate the need for a post-surgical admission after T&A. METHODS A single-center retrospective chart review was performed on a cohort of 155 obese children who underwent adenotonsillectomy for OSA. Inclusion criteria included patients 17 years of age and younger who had BMI 95th percentile or greater, underwent preoperative polysomnography, and were admitted overnight after T&A. Overnight respiratory complications were defined as an O2 desaturation under 92%, the need for overnight airway support, a respiratory support regression, respiratory depression, and bronchospasm/laryngospasm. Multivariable binary logistic regression analysis, point-biserial correlation, and Chi-square tests were performed to assess relationship of BMI z-score, polysomnography parameters, and PACU events with overnight respiratory complications. RESULTS Lower O2 saturation nadirs on polysomnography were an independent predictor of respiratory complications overnight (OR = 0.953, 95% CI = 0.91-0.99, P = 0.021), as was sleep time with O2 saturation less than 90% (OR = 1.04, 95% CI = 1.00-1.07, P = 0.048). A prediction model with preoperative and postoperative variables significant on simple logistic regression yielded a ROC curve with AUC 0.89 (95% CI 0.82, 0.96). At a cutoff point of O2 saturation nadir less than 80%, overnight PRCs were predicted with 70.8% sensitivity and 75.2% specificity. At a cutoff point of greater than 0.5% of sleep time spent with O2 < 90% on PSG, overnight PRCs were predicted with 82.6% sensitivity and 62% specificity. Obstructive apneas (OAI) was not predictive of PRCs. BMI percentile was not significantly correlated with overnight respiratory complications, but BMI z-score was significantly correlated with overnight respiratory depression and an overnight airway event. CONCLUSIONS O2 saturation nadir on PSG and time spent with oxygen saturation <90% (TST90) on PSG were found to be independent predictors of overnight postoperative respiratory complications after adenotonsillectomy in obese children. In addition to reaffirming existing guidelines for postoperative admission of patients with O2 saturation nadir on PSG <80%, these findings also suggest considering postoperative admission for obese patients who experience >0.5% sleep time with O2 sat <90% during PSG due to increased risk of overnight postoperative respiratory complications.
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12
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Clinical Characteristics and Post-Operative Outcomes in Children with Very Severe Obstructive Sleep Apnea. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9091396. [PMID: 36138705 PMCID: PMC9498166 DOI: 10.3390/children9091396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/06/2022] [Accepted: 09/10/2022] [Indexed: 11/17/2022]
Abstract
Available information on clinical characteristics and post-operative outcomes in children with very severe obstructive sleep apnea (OSA) is limited. Our study evaluates the clinical features and polysomnographic (PSG) variables that predict post-operative outcomes in children with an obstructive apneal hypopnea index (AHI) of more than 25 events/hr. In this study from a single tertiary care center, we performed a retrospective chart review of patients with an AHI > 25/hr, who underwent tonsillectomy and adenoidectomy (T&A) between January 2016 and September 2021. In total, 50 children were included in the study: 26.0% (13/50) of children experienced post-operative respiratory events and four children needed intubation and ventilator support. Compared with children without respiratory events, children requiring post-operative respiratory interventions were younger (4.4 ± 5.2 vs. 8.0 ± 5.2 years; p = 0.04), had higher pre-operative AHI (73.6 ± 27.4 vs. 44.8 ± 24.9; p < 0.01), lower oxygen nadirs (70.0 ± 13.0% vs. 83.0 ± 7.0%; p < 0.01), and had lower body metabolic index Z-scores (−0.51 ± 2.1 vs. 0.66 ± 1.5; p < 0.04). Moderate to severe residual OSA was identified in 70% (24/34) of children with available post-operative PSG; younger children had better PSG outcomes. Our study shows that post-operative respiratory events are frequent in children with very severe OSA, particularly with an AHI > 40/h, younger children (<2 years of age), lower oxygen saturation (SpO2), and poor nutritional status, necessitating close monitoring.
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13
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Lim J, Garigipati P, Liu K, Johnson RF, Liu C. Risk Factors for Post-Tonsillectomy Respiratory Events in Children With Severe Obstructive Sleep Apnea. Laryngoscope 2022; 133:1251-1256. [PMID: 35932233 DOI: 10.1002/lary.30317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/26/2022] [Accepted: 07/01/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS To identify risk factors for postoperative respiratory events in pediatric patients with severe obstructive sleep apnea (OSA). METHODS Retrospective single-institution retrospective cohort study of pediatric patients with severe OSA who were admitted postoperatively after tonsillectomy. Patients who experienced respiratory events after surgery were identified and differences between the respiratory event and no event groups were compared. RESULTS There were 887 patients included in this study. 14.8% (n = 131) experienced a documented respiratory event. The following risk factors were found to be most significant: %sleep time with O2 < 90% (tb90) (95% CI = 1.07-1.14, OR = 1.10, p < 0.001), Black race (95% CI = 1.53-3.58, OR = 2.34, p < 0.001), primary neurologic co-morbidity (1.67-6.32, OR = 3.27, p < 0.001), Down syndrome (1.25-5.94, OR = 2.72, p = 0.01), and age (0.84-0.94, OR = 0.88, p < 0.001). Regression modeling demonstrated that the rate of respiratory events increased with tb90. CONCLUSIONS Our results demonstrate that there are other potential risk factors outside of AHI and O2 nadir that are associated with respiratory events after tonsillectomy. Black race and prolonged desaturations during polysomnography (PSG) are independent risk factors. Measures of abnormal gas exchange on PSG may be better at identifying at risk patients. LEVEL OF EVIDENCE 4 Laryngoscope, 2022.
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Affiliation(s)
- Jorena Lim
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
| | - Priyanka Garigipati
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
| | - Katie Liu
- Department of Anesthesiology, Pediatric Anesthesiology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
| | - Christopher Liu
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
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14
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Xiao L, Barrowman N, Momoli F, Murto K, Bromwich M, Katz SL. Risk factors for respiratory adverse events after adenoidectomy and tonsillectomy in children with down syndrome: a retrospective cohort study. Eur J Pediatr 2022; 181:2399-2408. [PMID: 35278117 DOI: 10.1007/s00431-022-04438-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/03/2022] [Accepted: 03/05/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Obstructive sleep apnea syndrome is a major cause of morbidity in the Down syndrome population and is commonly treated with adenoidectomy and/or tonsillectomy (AT). However, these children are at increased risk for perioperative respiratory adverse events (PRAEs). The objective of this study was to examine risk factors for major PRAEs requiring intervention in children with Down syndrome undergoing AT and to describe their postoperative monitoring environment. This retrospective study included all children with Down syndrome aged 0-18 years who underwent a preoperative polysomnogram followed by AT at a tertiary pediatric institution. Descriptive statistics were used to summarize baseline demographic and clinical characteristics. A multivariable model for prediction of PRAEs was constructed. A priori, it was decided that minimum oxygen saturation, apnea-hypopnea index, and average oxygen saturation asleep would be included, along with medical comorbidities associated with PRAEs at p < 0.2 in univariable analyses. Fifty-eight children were included in this study; twelve had a PRAE. Cardiac disease was associated with PRAEs on univariable analysis (p = 0.03). In multivariable analysis, average oxygen saturation asleep was associated with PRAEs (OR 1.50; 95% confidence interval 1.00, 2.41; p = 0.05). For all of the remaining variables, p > 0.15. Fifty-six children were admitted for monitoring overnight; four were admitted to the intensive care unit and fifty-two were admitted to the ward. CONCLUSIONS A multivariable model found evidence that lower average oxygen saturation while asleep was associated with PRAEs requiring intervention in children with Down syndrome. This study highlights the difficulty in predicting complications in this population. WHAT IS KNOWN • Obstructive sleep apnea syndrome is a major cause of morbidity in the Down syndrome population and is commonly treated with adenoidectomy and/or tonsillectomy. • However, children with Down syndrome are at increased risk for perioperative respiratory adverse events (PRAEs) following adenoidectomy and/or tonsillectomy. WHAT IS NEW • We found that a lower average oxygen saturation asleep is associated with increased odds of PRAEs, adjusting for age, total apnea-hypopnea index, cardiac comorbidity, and minimum oxygen saturation. • This study highlights the difficulty in predicting complications in this population.
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Affiliation(s)
- Lena Xiao
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada.,University of Ottawa, Ottawa, Canada
| | - Nicholas Barrowman
- University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Franco Momoli
- University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kimmo Murto
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada.,University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Matthew Bromwich
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada.,University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Sherri L Katz
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada. .,University of Ottawa, Ottawa, Canada. .,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
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15
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Mills TG, Bhattacharjee R, Nation J, Ewing E, Lesser DJ. Management and outcome of extreme pediatric obstructive sleep apnea. Sleep Med 2021; 87:138-142. [PMID: 34607111 DOI: 10.1016/j.sleep.2021.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Classify post-adenotonsillectomy (AT) respiratory support, identify variables that predict these interventions, and evaluate outcomes in children with extreme obstructive sleep apnea (OSA). METHODS Retrospective chart analysis was performed on patients found to have apnea/hypopnea index (AHI) > 100 events/h. Patients with chronic diseases other than obesity were excluded. RESULTS Forty-one subjects were studied, average age of 11.4 ± 4.3 years, majority (73.1%) were Hispanic, with a mean total AHI (TAHI) of 128.1 ± 22.9/h. Twenty-eight (68.3%) patients underwent AT. Lower age (P < 0.001), lower BMI Z-score (P < 0.01), higher OAHI (P < 0.05) were associated with having surgery. Eleven out of 28 (39.3%) surgical patients required respiratory support (oxygen or positive airway pressure) postoperatively. Longer % total sleep time SpO2 <90% during PSG (P < 0.05) and lower SpO2 nadir (P < 0.05) were associated with requiring airway support. No patients experienced mortality, reintubation, or hospital readmission following AT, with majority (71.4%) discharged 1 day post-operatively. Eleven (57.9%) of the 19 patients who had a postoperative PSG had residual OSA, defined as AHI >5 events/h, but there was a significant improvement in TAHI (P < 0.01). CONCLUSION Our findings confirm the need for postoperative observation in a controlled setting for patients with extreme OSA undergoing AT. Although at higher risk of needing respiratory support, those patients undergoing AT for extreme OSA did not require re-intubation post-operatively or suffer serious harm. Barring contraindications to AT, surgery may still be a first-line therapy for some children with extreme OSA.
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Affiliation(s)
- Tatyana G Mills
- Department of Pediatrics, University of California San Diego, Rady Children's Hospital San Diego, 3030 Children's Way, San Diego, CA, 92123, USA.
| | - Rakesh Bhattacharjee
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University of California San Diego, Rady Children's Hospital San Diego, 3030 Children's Way, San Diego, CA, 92123, USA
| | - Javan Nation
- Division of Pediatric Otolaryngology, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, 3030 Children's Way, San Diego, CA, 92123, USA
| | - Emily Ewing
- Department of Pediatrics, University of California San Diego, Rady Children's Hospital San Diego, 3030 Children's Way, San Diego, CA, 92123, USA
| | - Daniel J Lesser
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University of California San Diego, Rady Children's Hospital San Diego, 3030 Children's Way, San Diego, CA, 92123, USA
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16
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Caetta A, Timashpolsky A, Tominaga SM, D'Souza N, Goldstein NA. Postoperative respiratory complications after adenotonsillectomy in children with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2021; 148:110835. [PMID: 34280801 DOI: 10.1016/j.ijporl.2021.110835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/20/2021] [Accepted: 07/11/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Children with obstructive sleep apnea are considered high risk for postoperative respiratory complications, but opinions differ regarding the polysomnography (PSG) criteria that suggest the need for postoperative admission. Our objective was to determine if otherwise healthy children age ≥3 years with an apnea-hypopnea index (AHI) < 24 on overnight PSG can be safely discharged on the same day of surgery. METHODS Case series with chart review of children age <18 years with positive PSG (AHI > 2) who underwent adenotonsillectomy (T&A) between January 2013 and August 2019. Data collected included patient demographics, medical history, comorbidities, PSG results, operative details, length of stay, intraoperative and postoperative respiratory complications and management. Potential predictors of respiratory complications were evaluated using chi-square/Fisher's exact test and 2-tailed unpaired t tests with the Bonferroni adjustment for multiple comparison artifact. The percentages of healthy children age ≥3 years who were discharged on the day of surgery at various PSG cutoffs were calculated. RESULTS Of the 560 children, mean (SD) age was 6.4 (3.7) years, 318 (56.8%) were male, 438 (78.2%) were African American, 243 (43.4%) were obese, 16 (2.9%) had Down Syndrome and 12 (2.1%) had sickle cell disease. Median (range) AHI was 12.3 (2-145). Fifteen children (2.7% [95% CI 1.3, 4.0]) had an intraoperative or postoperative respiratory complication. Minor complications including mild desaturation, stridor, croupy cough, and laryngospasm occurred in 9 patients and did not prolong the planned ambulatory or hospital stay. Of the 6 children with more severe complications including prolonged desaturation, tachypnea, atelectasis, intercostal retraction and obstructive apnea requiring continuous positive airway pressure, all were planned admissions based on age, severe sleep study indices (AHI ≥ 24 or oxygen saturation nadir < 80%) or underlying medical condition. Of the 165 children age ≥3 without medical comorbidities known to be predictive of postoperative complications with an AHI ≥10 but <24, 113 (68.5%) were discharged home on the same day of surgery without additional respiratory sequelae. CONCLUSIONS This study demonstrates a low risk of respiratory complications after T&A. Otherwise healthy children age ≥3 years with AHI <24 may be considered for ambulatory discharge.
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Affiliation(s)
- Alfonso Caetta
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA.
| | - Alisa Timashpolsky
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA.
| | - Stephanie M Tominaga
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA.
| | - Neeta D'Souza
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA. neeta.d'
| | - Nira A Goldstein
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA.
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17
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Xiao L, Barrowman N, Momoli F, Murto K, Bromwich M, Proulx F, Katz SL. Polysomnography parameters as predictors of respiratory adverse events following adenotonsillectomy in children. J Clin Sleep Med 2021; 17:2215-2223. [PMID: 34019475 DOI: 10.5664/jcsm.9420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The first line treatment of obstructive sleep apnea syndrome in children is adenotonsillectomy but this may result in perioperative respiratory adverse events (PRAEs). The primary aim of this study is to examine whether the McGill oximetry score (MOS) and other polysomnography parameters can predict major PRAEs following adenotonsillectomy. We secondarily evaluated the MOS inter-rater reliability and correlation with other polysomnography parameters. METHODS This retrospective study included all children aged 0-18 years who underwent preoperative polysomnography between June 2010 and January 2016 prior to adenotonsillectomy at a tertiary pediatric institution. Oximetries from polysomnograms were assigned a MOS. Univariable and multivariable models for prediction of major PRAEs were constructed. MOS was correlated with polysomnography parameters and inter-rater reliability was evaluated. RESULTS This study included 106 children; 15 had a major PRAE. A multivariable prediction model that combined MOS and age showed evidence for the ability to predict major PRAEs with an area under the receiver operating characteristic curve of 0.68 (95% confidence interval 0.52, 0.84), whereby increased MOS and younger age were associated with PRAEs, but apnea-hypopnea index was not. MOS had excellent inter-rater reliability (Kappa=0.95) and was highly correlated with oxygen saturation nadir and cumulative time percentage with oxygen saturation less than 90%. CONCLUSIONS A prediction model including MOS and age may predict PRAEs following adenotonsillectomy. This suggests that nocturnal oximetry provides the most essential information of polysomnography measures to direct postoperative monitoring following adenotonsillectomy.
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Affiliation(s)
- Lena Xiao
- Children's Hospital of Eastern Ontario, Ottawa, Canada.,University of Ottawa, Ottawa, Canada
| | - Nicholas Barrowman
- University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Franco Momoli
- University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kimmo Murto
- Children's Hospital of Eastern Ontario, Ottawa, Canada.,University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Matthew Bromwich
- Children's Hospital of Eastern Ontario, Ottawa, Canada.,University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Frédéric Proulx
- Centre Hospitalier de l'Université Laval, Québec City, Canada.,Université Laval, Québec City, Canada
| | - Sherri L Katz
- Children's Hospital of Eastern Ontario, Ottawa, Canada.,University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
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18
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Chandrakantan A, Mehta D, Adler AC. Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist. Int J Pediatr Otorhinolaryngol 2020; 139:110420. [PMID: 33035805 DOI: 10.1016/j.ijporl.2020.110420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/10/2023]
Abstract
Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.
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Affiliation(s)
| | - Deepak Mehta
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Adam C Adler
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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19
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Moroco AE, Saadi RA, Wilson MN. Post-tonsillectomy respiratory complications in children with sleep disordered breathing. Int J Pediatr Otorhinolaryngol 2020; 131:109852. [PMID: 31901486 DOI: 10.1016/j.ijporl.2019.109852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/20/2019] [Accepted: 12/22/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE A common indication for tonsillectomy in children is clinically diagnosed sleep disordered breathing (SDB) without confirmation of obstructive sleep apnea (OSA) by polysomnography (PSG). Our goal was to review rates of post-tonsillectomy respiratory complications in children with SDB without prior PSG in order to develop recommendations for postoperative monitoring and safe hospital discharge in this population. METHODS Following Institutional Review Board (IRB) approval at Penn State Milton S. Hershey Medical Center, a database query using Current Procedural Terminology (CPT) codes for tonsillectomy with or without adenoidectomy (42820, 42821, 42825, 42826) between January 1, 2012 and December 31, 2017 was performed. International Classification of Diseases (ICD) codes for sleep disordered breathing (G47.30), snoring (R06.83), and obstructive sleep apnea (G47.33) were applied for further selection. Charts were individually reviewed to confirm the inclusion criteria of pediatric patients (≤18 years) who underwent tonsillectomy without prior PSG and were monitored overnight. Demographic, operative, and relevant postoperative hospital course data (including desaturations, supplemental oxygen requirements, and upgraded level of care) were collected. RESULTS A total of 1874 unique patient encounters were identified by our database search and 364 children met inclusion criteria. The average age of the patient population was 6.5 ± 3.1 years and 52.2% of children were female. Mean z-score for the population was 0.6. The rate of overnight oxygen desaturation events (<95%) was 2.2%, with no severe complications found in this population. Children with desaturation events were supplemented with oxygen and resolved prior to hospital discharge. Only race was found to be significantly related to risk of mild overnight desaturations (P = 0.023). CONCLUSION A lack of significant postoperative respiratory complications or alterations in the clinical management of children with SDB without prior PSG supports the idea that such patients may safely be discharged from the hospital following tonsillectomy without overnight oxygen monitoring.
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Affiliation(s)
- Annie E Moroco
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Robert A Saadi
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.
| | - Meghan N Wilson
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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20
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Allen DZ, Worobetz N, Lukens J, Sheehan C, Onwuka A, Dopirak RM, Chiang T, Elmaraghy C. Outcomes intensive care unit placement following pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2020; 129:109736. [PMID: 31704575 DOI: 10.1016/j.ijporl.2019.109736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care. METHODS This is a retrospective chart review from the years of 2009-2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU. RESULTS There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p < 0.0001), and more severe classifications of OSA (p < 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p < 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement. CONCLUSIONS This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.
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Affiliation(s)
- David Z Allen
- The Ohio State College of Medicine, Columbus, OH, USA
| | - Noah Worobetz
- The Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Cameron Sheehan
- The Department of Otolaryngology, Baylor College of Medicine, Houston, TX, USA
| | - Amanda Onwuka
- The Center for Surgical Outcomes and Research, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Tendy Chiang
- The Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles Elmaraghy
- The Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA.
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Roberts C, Al Sayegh R, Ellison PR, Sedeek K, Carr MM. How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy. Ann Otol Rhinol Laryngol 2019; 129:55-62. [PMID: 31801377 DOI: 10.1177/0003489419874371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA). STUDY DESIGN Online survey. METHOD A sample of pediatric anesthesiologists received the survey by email. RESULTS 110 respondents were included. 46.4% worked in a free-standing children's hospital and 32.7% worked in a children's facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children's hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA (P < 0.05). CONCLUSION Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.
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Affiliation(s)
- Christopher Roberts
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, West Virginia University, Morgantown, WV, USA
| | | | | | - Khaled Sedeek
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Michele M Carr
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, West Virginia University, Morgantown, WV, USA
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Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population. SLEEP DISORDERS 2018; 2018:1968985. [PMID: 30515336 PMCID: PMC6236928 DOI: 10.1155/2018/1968985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/28/2018] [Accepted: 09/26/2018] [Indexed: 11/17/2022]
Abstract
Objective To determine the prevalence of respiratory complications in the early postoperative period of children with sleep apnea who required adenotonsillectomy at a tertiary pediatric hospital and to establish recommendations for postoperative monitoring. Methods Retrospective cohort study of children with obstructive sleep apnea (OSA) diagnosed by polysomnogram (PSG), who underwent adenotonsillectomy for treatment of OSA. The prevalence of respiratory complications in the first 24 postoperative hours was measured. Patients with craniofacial malformations, obesity, and severe cardiovascular comorbidities were excluded. The prevalence of postoperative respiratory complications was compared with the severity of OSA according to the Apnea Hypopnea Index (AHI) and NADIR. All data were taken in patients residing in Bogotá city, Colombia, at 2.640 meters above sea level (m.a.s.l). Results Between May 2014 and February 2017, 167 patients (108 males) required adenotonsillectomy for OSA, with an age range of 1 and 15 years (mean 5.3 years +/- 2.7). The prevalence of postoperative respiratory complications was 3.59% (6/167). There was a statistically significant relationship between the presence of respiratory complication and AHI greater than 44/h (p <0.04). There was an inverse correlation between the AHI and NADIR values. Risk groups of patients younger than 3 years and NADIR less than 70% had a higher prevalence of respiratory complications; however, this correlation was not statistically significant (p <0.08 and 0.89, respectively). Conclusions The prevalence of respiratory complications in OSA patients undergoing adenotonsillectomy in high altitudes is similar to that reported in other heights. Preoperative AHI greater than 44/h could be considered a risk factor for early respiratory complication. We suggest ambulatory management after 6 hours in Postanesthetic Care Unit (PACU) observation in patients older than 3 years, with AHI less than 44/h and NADIR greater than 70% in altitudes higher than 2.500 m.a.s.l. Further research must be done to confirm this hypothesis.
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O'Brien DC, Desai Y, Swanson RT, Parekh U, Schubart J, Carr MM. Sleep study indices and early post-tonsillectomy outcomes. Am J Otolaryngol 2018; 39:623-627. [PMID: 30017372 DOI: 10.1016/j.amjoto.2018.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To investigate the relationships between preoperative sleep study findings of children undergoing adenotonsillectomy anesthesia emergence time, recovery room time, and length of stay. STUDY DESIGN Retrospective case series with chart review. SETTING Tertiary care children's hospital. SUBJECTS AND METHODS All children aged 1-17 years who had undergone adenotonsillectomy between 2013 and 2016 were included. Apnea-hypopnea index (AHI), central apnea index (CAI), oxygen saturation nadir, and end-tidal carbon dioxide were compared with the in-operating room times, recovery room time, and length of stay. RESULTS Three hundred and fourteen patients with a mean age of 6.67 (95% CI 6.25-7.09) years were included. Mean AHI was 9.14 (95% CI 7.33-10.95), mean CI was 0.88 (95% CI 0.50-1.26), mean oxygen saturation nadir was 82.9% (95% CI 81.41-84.32), mean end-tidal carbon dioxide was 50.3 (95% CI 49.39-51.15). Mean emergence time was 16 min (95% CI 15:11-17:13 min), recovery room time was 66 min (95% CI 1:00-1:11 h), and length of stay was 25.7 h (95% CI 21:43-30:00 h). When controlled for age, gender and BMI, linear regression showed that children with a higher AHI had a significantly longer operating room and operative times (p < 0.001), emergence time (p < 0.001) and length of stay (p = 0.01). CAI was related to shorter total operating room times (p = 0.03). AHI, oxygen saturation nadir, CAI and end-tidal carbon dioxide were not associated with recovery room time. CONCLUSION Preoperative sleep study indices are associated with longer in-operating room times and length of stay, and can be useful in planning operating room and hospital flow.
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Affiliation(s)
- Daniel C O'Brien
- Department of Otolaryngology-Head and Neck Surgery, 4520 Health Science Center South, PO Box 9200, West Virginia University, Morgantown, WV, USA
| | - Yuti Desai
- Drexel University, 3141 Chestnut St, Philadelphia, PA 19104, USA
| | - Robert T Swanson
- Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - Uma Parekh
- Penn State Department of Anesthesia, 500 University Drive, Hershey, PA 17033, USA
| | - Jane Schubart
- Penn State Departments of Surgery and Public Health, 500 University Drive, Hershey, PA 17033, USA
| | - Michele M Carr
- Department of Otolaryngology-Head and Neck Surgery, 4520 Health Science Center South, PO Box 9200, West Virginia University, Morgantown, WV, USA.
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Skirko JR, Jensen EL, Friedman NR. Lingual tonsillectomy in children with Down syndrome: Is it safe? Int J Pediatr Otorhinolaryngol 2018; 105:52-55. [PMID: 29447819 DOI: 10.1016/j.ijporl.2017.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/17/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Evaluate peri-operative course and morbidity in children with Down syndrome (DS) who underwent a lingual tonsillectomy (LT) for residual obstructive sleep apnea (rOSA). METHODS Retrospective case series for children with DS who underwent LT for rOSA from April 2011 to July 2016. Our primary outcomes were length of stay, readmission and complications. Surgical effectiveness was evaluated by change in the obstructive apnea-hypopnea-index(OAHI) and oxygen saturation nadir. RESULTS Thirty-nine patients underwent LT. The mean length of stay was 1.3 days with n = 21(72%) staying one night. One subject (2.6%) had a post-operative bleed that did not require operative intervention. No other major complications occurred. In terms of effectiveness of surgery, twenty-nine children had sufficient data for inclusion. Median OAHI did not appreciably change (p = 0.07) from before surgery. Five subjects (17%) were cured of OSA (OAHI < 2/hour) and a mix of improvement and worsening was identified. The lowest oxygen saturation improved from 78% (SD = 7) before surgery to 82% (SD = 6) after surgery (p = 0.003). CONCLUSION LT has a favorable post-operative course but its effectiveness at curing rOSA in the DS population has not been established/proven. Further research is indicated to determine optimal surgical management for DS children with LTH. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jonathan R Skirko
- Division of Pediatric Otolaryngology-Head & Neck Surgery, University of Utah and Primary Children's Hospital, United States.
| | - Emily L Jensen
- Department of Otolaryngology and Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Norman R Friedman
- Department of Otolaryngology and Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
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Sharma SD, Gupta S, Wyatt M, Albert D, Hartley B. Analysis of intensive care admissions among paediatric obstructive sleep apnoea referrals. Ann R Coll Surg Engl 2018; 100:67-71. [PMID: 29046100 PMCID: PMC5849202 DOI: 10.1308/rcsann.2017.0185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction The aim of this study was to identify the proportion of children referred to a paediatric tertiary referral centre who required admission to the paediatric intensive care unit (PICU) following surgery for obstructive sleep apnoea (OSA) and to establish risk factors for these admissions. Methods Retrospective review of case notes and the operative database was performed for all children undergoing adenotonsillectomy for sleep disordered breathing and OSA symptoms in Great Ormond Street Hospital over a 10-year period. Results Overall, 1,328 children underwent adenotonsillectomy for sleep disordered breathing and OSA. The mean age was 3.1 years (standard deviation [SD]: 1.7 years). A total of 37 (2.8%) were admitted to the PICU postoperatively (mean length of PICU stay: 1.2 days, standard deviation [SD]: 0.6 days) and 282 (21.2%) required nasopharyngeal airway (nasal prong) insertion intraoperatively. The mean length of stay on the ward following surgery was 1.4 days (SD: 0.8 days). Patients with severe OSA (apnoea-hypopnoea index [AHI] >10) and ASA (American Society of Anesthesiologists) grade ≥3 were more likely to require postoperative PICU admission (22/37 vs 381/1,291 [p<0.001] and 29/37 vs 660/1,291 [p=0.001] respectively). Severe OSA was also more common in children who required nasal prong insertion intraoperatively (186/282 vs 217/1,046, p<0.001). Conclusions Very few children referred to a paediatric tertiary referral centre actually require PICU admission following surgery. This may be in part due to the use of a nasopharyngeal airway in patients where postoperative obstruction is anticipated. In children with severe OSA (AHI >10) and an ASA grade of ≥3, nasopharyngeal airway insertion and potential admission to the PICU should be considered.
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Affiliation(s)
- S D Sharma
- Great Ormond Street Hospital for Children NHS Foundation Trust , UK
| | - S Gupta
- Great Ormond Street Hospital for Children NHS Foundation Trust , UK
| | - M Wyatt
- Great Ormond Street Hospital for Children NHS Foundation Trust , UK
| | - D Albert
- Great Ormond Street Hospital for Children NHS Foundation Trust , UK
| | - B Hartley
- Great Ormond Street Hospital for Children NHS Foundation Trust , UK
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Kandil A, Subramanyam R, Hossain MM, Ishman S, Shott S, Tewari A, Mahmoud M. Comparison of the combination of dexmedetomidine and ketamine to propofol or propofol/sevoflurane for drug-induced sleep endoscopy in children. Paediatr Anaesth 2016; 26:742-51. [PMID: 27212000 DOI: 10.1111/pan.12931] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2016] [Indexed: 11/30/2022]
Abstract
AIM Examination of dynamic airway collapse in patients with obstructive sleep apnea (OSA) during drug-induced sleep endoscopy (DISE) can help identify the anatomic causes of airway obstruction. We hypothesized that a combination of dexmedetomidine and ketamine (Group DK) would result in fewer oxygen desaturations and a higher successful completion rate during DISE in children with OSA when compared to propofol (Group P) or sevoflurane/propofol (Group SP). METHODS In this retrospective study, we reviewed the records of 59 children who presented for DISE between October 2013 and March 2015. Data analyzed included demographics, OSA severity, and hemodynamics (heart rate and blood pressure). The primary outcomes were airway desaturation during DISE to <85% and successful completion of DISE; these were compared between the three groups: DK, P, and SP. RESULTS Preoperative polysomnography was available for 49 patients. There were significantly more patients with severe OSA in Group P as compared to the other two groups. The mean (±sd) bolus dose for ketamine, dexmedetomidine, and propofol were 2.0 ± 0.6 mg·kg(-1) , 1.9 ± 0.9 mcg·kg(-1) , and 1.8 ± 1.1 mg·kg(-1) , respectively. The mean (±sd) infusion rate for dexmedetomidine was 1.6 ± 0.7 mcg·kg(-1) ·h(-1) and for propofol was 248 ± 68 mcg·kg(-1) ·min(-1) in Group P and 192 ± 48 mcg·kg(-1) ·min(-1) in Group SP. Patients in Group DK had significantly fewer desaturations to <85% during DISE compared to Group P. Patients in Group DK had significantly more successful completion of DISE (100% Group DK, 92% Group P, and 79% Group SP) as compared to Group SP. CONCLUSIONS These results suggest that the described dose regimen of propofol used alone or in combination with sevoflurane appears to be associated with more oxygen desaturations and a lower rate of successful completion than a combination of dexmedetomidine and ketamine during DISE in children with OSA.
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Affiliation(s)
- Ali Kandil
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rajeev Subramanyam
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mohamed Monir Hossain
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stacey Ishman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Pediatric Otolaryngology -Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sally Shott
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Pediatric Otolaryngology -Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Anurag Tewari
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mohamed Mahmoud
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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28
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Tang AL, Cohen AP, Benke JR, Stierer KD, Stanley J, Ishman SL. Obstructive Sleep Apnea Resolution in Hypopnea- versus Apnea-Predominant Children after Adenotonsillectomy. Otolaryngol Head Neck Surg 2016; 155:670-5. [PMID: 27301899 DOI: 10.1177/0194599816652387] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/10/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Given that 30% to 40% of children have persistent obstructive sleep apnea (OSA) after adenotonsillectomy, we evaluated whether children with hypopnea-predominant OSA were more likely to have complete disease resolution after adenotonsillectomy than those with apnea-predominant disease. We also identified risk factors that might modify the relationship between disease resolution and polysomnographic event type (ie, hypopnea vs apnea). STUDY DESIGN Case series with chart review. SETTING Tertiary pediatric hospital. SUBJECTS/METHODS Consecutive 1- to 18-year-old typically developing children diagnosed with OSA from March 2011 to December 2012 underwent adenotonsillectomy and completed pre- and postoperative polysomnography within 1 year of surgery. RESULTS Fifty-eight children were included (27 female; mean ± SD: age, 5.6 ± 3.1 years; body mass index z score, 1.1 ± 1.7). Overall, adenotonsillectomy resulted in significant improvement in obstructive apnea-hypopnea index (oAHI) from 23.3 ± 40.0 to 4.3 ± 8.2 events per hour (P < .001), obstructive apnea index (5.1 ± 7.4 to 0.4 ± 0.8, P < .001), and obstructive hypopnea index (oHI; 18.1 ± 37.5 to 3.7 ± 8.1, P < .001). There was complete response (oAHI <1.0 event/h) in 24 of 58 patients (41%) but no difference by event type (P = .11). On univariate analysis, only race, sex, oxygen saturation nadir, and oHI were predictive of response to adenotonsillectomy, while multivariate analysis found that prematurity, age, oxygen saturation nadir, oHI, obstructive apnea index, and oAHI were predictive. Event type was not significant, even in a model controlling for age, race, sex, prematurity, asthma, body mass index, and baseline polysomnographic variables. CONCLUSION This small study demonstrated no difference in disease resolution between children with hypopnea- and apnea-predominant OSA who underwent adenotonsillectomy. Additionally, adenotonsillectomy significantly improved OSA in most children, and high preoperative oAHI was associated with persistent postoperative OSA.
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Affiliation(s)
- Alice L Tang
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Aliza P Cohen
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James R Benke
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kevin D Stierer
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - James Stanley
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Stacey L Ishman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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