Obstructive sleep apnoea syndrome in children

Update on the safety of anesthesia in young children presenting for adenotonsillectomy

Tonsillectomy with and without adenoidectomy is a frequently performed surgical procedure in children. Although a common procedure, it is not without significant risk. It is critical for anesthesiologists to consider preoperative, intraoperative, and postoperative patient factors and events to optimize safety, especially in young children. In the majority of cases, the indication for adenotonsillectomy in young children is obstructive breathing. Preoperative evaluation for patient comorbidities, especially obstructive sleep apnea, risk factors for a difficult airway, and history of recent illness are crucial to prepare the patient for surgery and develop an anesthetic plan. Communication and collaboration with the otolaryngologist is key to prevent and treat intraoperative events such as airway fires or hemorrhage. Postoperative analgesia planning is critical for safe pain control especially for those patients with a history of obstructive sleep apnea and opioid sensitivity. In young children, it is important to also consider the impact of anesthetic medications on the developing brain. This is an area of continuing research but needs to be weighed when planning for surgical treatment and when discussing risks and benefits with patients' families.

The comparison of ketamine with tramadol for postoperative pain relief on children following adenotonsillectomy or tonsillectomy: A meta-analysis of randomized controlled trials

INTRODUCTION

The comparison of ketamine with tramadol for pain control remains controversial in pediatric adenotonsillectomy or tonsillectomy. We conduct a systematic review and meta-analysis to explore the efficacy of ketamine vs tramadol for pain relief in children following adenotonsillectomy or tonsillectomy.

METHODS

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through October 2019 for randomized controlled trials (RCTs) assessing the effect of ketamine vs tramadol for pediatric adenotonsillectomy or tonsillectomy. This meta-analysis is performed using the random-effects model.

RESULTS

Six RCTs are included in the meta-analysis. Overall, compared to ketamine group for pediatric adenotonsillectomy or tonsillectomy, tramadol is associated with substantially lower CHEOPS at 1 h (SMD = 1.56; 95% CI = 0.20-2.92; P = .02; low quality) and longer first time of additional pain medication (SMD = -0.47; 95% CI = -0.74 to -0.19; P = .0008; low quality), but demonstrates no obvious effect on CHEOPS at 6 h (SMD = 0.51; 95% CI = -1.17 to 2.19; P = .55; low quality), sedation scale at 1 h (SMD = -0.80; 95% CI = -3.07 to 1.48; P = .49; low quality) or additional pain medication (RR = 1.31; 95% CI = 0.85-2.02; P = .23; moderate quality).

CONCLUSIONS

Tramadol may be better to alleviate the postoperative pain after pediatric adenotonsillectomy or tonsillectomy.

Outpatient Anesthetic Safety Considerations for Obstructive Sleep Apnea

Most patients with obstructive sleep apnea (OSA) are not diagnosed preoperatively. The STOP-Bang questionnaire may identify patients at risk of OSA, especially those with severe OSA. Patients with mild to moderate OSA, with optimized comorbidities, can usually safely undergo outpatient surgery. Patients with severe OSA, who are not optimized medically, should avoid outpatient surgery.

Anaesthesia for adenotonsillectomy: An update

Adenotonsillectomy remains one of the most common surgical procedures carried out in children. Though a commonly performed procedure, it poses a great challenge to the surgeon as well as the anaesthesiologist and is associated with a substantially increased risk of morbidity and mortality. In the post-operative period, it poses threats such as post-tonsillectomy bleeding and airway obstruction if not diagnosed and treated promptly. Various recent advances in airway management and early detection of post-operative complications have been made to reduce the sequelae associated with tonsillectomy. In this article, we have reviewed the various techniques, complications and recent advances, which have evolved in the anaesthetic technique related to adenotonsillectomy.

Comparison of different administration of ketamine and intravenous tramadol hydrochloride for postoperative pain relief and sedation after pediatric tonsillectomy

OBJECTIVES

Tonsillectomy is the oldest and most frequently performed surgical procedure practiced by ear, nose, and throat physicians. In this study, our aim was to compare the analgesic effects of peritonsillar, rectal, as well as intravenous infiltration of ketamine and intravenous tramadol hydrochloride infiltration for postoperative pain relief and sedation after tonsillectomy in children.

MATERIALS AND METHODS

This randomized controlled study evaluated the effects of peritonsillar, intravenous, and rectal infiltration of ketamine in children undergoing adenotonsillectomy. One hundred twenty children who were categorized under American Society of Anesthesiologists classes I to II were randomized to 4 groups of 30 members each. Group 1 received intravenous (IV) ketamine (0.5 mg/kg), group 2 received rectal ketamine (0.5 mg/kg), group 3 received local peritonsillar ketamine (2 mg/kg), and the control group received IV tramadol hydrochloride infiltration (2 mg/kg). Children's Hospital of Eastern Ontario Pain Scale scores and Wilson sedation scale were recorded at minutes 1, 15, 30, 60 as well as hours 2, 12, and 24 postoperatively. The patients were interviewed on the day after the surgery to assess the postoperative pain and sedation.

RESULTS

All the routes of infiltration of ketamine were as effective as those of tramadol hydrochloride (P > 0.05). A statistically significant difference was observed between IV infiltrations and all groups during the assessments at hours 6 and 24. The analgesic efficacy of IV ketamine was found especially higher at hours 6 and 24 (P(6) = 0.045, P(24) = 0.011).

CONCLUSIONS

Perioperative, low-dose IV, rectal, or peritonsillar ketamine infiltration provides efficient pain relief without any adverse effects in children who would undergo adenotonsillectomy.

Predictors of complications following adenotonsillectomy in children with severe obstructive sleep apnea

OBJECTIVE

To identify pre-operative risk factors predicting complications following adenotonsillectomy in children with severe OSA.

METHODS

Retrospective chart review in an academic tertiary care center. Children with symptoms of OSA with overnight polysomnography (PSG) revealing apnea-hypopnea index (AHI) >10, who underwent adenotonsillectomy with overnight postoperative observation between 2008 and 2012. Univariate logistic regression was used to assess odds ratio (OR) of individual risk factors versus postoperative complications such as overnight desaturations <90%, length of stay (LOS)>24 h, supplemental oxygen requirement, and transfer to a higher level of care.

RESULTS

All patients (n=157) with severe OSA were observed overnight. Mean age was 5.3±3.7 years. Twenty-five (15.9%) patients had LOS>24 h. Forty-two (26.8%) had overnight desaturations <90%. AHI ≥15 and O2 saturation nadir <80% on preop polysomnography (PSG) were independent predictors of post-op O2 saturation <90% and LOS>24 h. (p<0.05). PSG minimum saturation <80% was the strongest predictor of all variables examined with an OR of 6.98 (3.15-15.48, 95% CI) for desaturation <90% and 5.19 (2.11-12.75, 95% CI) for LOS>24 h. Preop PSG O2 saturation<90% predicted overnight post op oxygen requirement with an OR of 3.38 (1.39-8.25, 95%CI).

CONCLUSIONS

Preoperative polysomnography yields significant independent predictors of post-op complications in children with OSA. While AHI is a significant independent predictor, minimum O2 saturation on preop PSG appeared the strongest predictor when <80%. Patients with these risk factors, especially low O2 on PSG, warrant overnight observation with continuous pulse oximetry.

Comparison of Postoperative Pain in Children with Two Intracapsular Tonsillotomy Techniques and a Standard Tonsillectomy: Microdebrider and radiofrequency tonsillotomies versus standard tonsillectomies

OBJECTIVES

The aim of this study was to compare the duration and severity of postoperative pain for two different tonsillotomy techniques (radiofrequency [RF] and microdebrider [MD]) with the standard tonsillectomy.

METHODS

This non-randomised retrospective study, carried out from February 2011 to September 2012, investigated 128 children in two independent centres: Heim Pál Children's Hospital in Budapest, Hungary, and Muscat Private Hospital in Muscat, Oman. Those undergoing conventional tonsillectomies acted as the control group. One centre tested the MD technique (n = 28) while the other centre tested the RF technique (n = 31).

RESULTS

The pain-free period after the tonsillotomies was similar between the two techniques and ranged up to three days. Other indicators of pain resolution, like the use of a single analgesic, reduced night-time waking and the time taken to resume a normal diet, were also similar for the two groups. However, patients benefited significantly from having a tonsillotomy rather than a tonsillectomy.

CONCLUSION

The partial resectioning of tonsillar tissue using the MD and RF techniques showed promising outcomes for a better postoperative quality of life when compared to a traditional tonsillectomy. In this study, the results of both the MD and RF tonsillotomy methods were almost identical in terms of the duration of postoperative pain and recovery time.

Anaesthetic Management in Obstructive Sleep Apnoea Syndrome for Adenotonsillectomy

The anaesthetic management of adenotonsillectomy in children with obstructive sleep apnoea syndrome is characteristic due to respiratory and cardiac side effects. A detailed physical examination in the preoperative period should be performed, including children's respiratory and cardiac systems. If they have an active infection, surgery should be postponed until the end of medical treatment. Preparation for difficult airway management should be done in the preoperative period. In this case, we presented a report of two children who had obstructive sleep apnoea syndrome, with airway management performed at the right lateral position to prevent the pharyngeal collapse and rapid sequence intubation performed using a short-acting muscle relaxant.

A 2013 updated systematic review & meta-analysis of 36 randomized controlled trials; no apparent effects of non steroidal anti-inflammatory agents on the risk of bleeding after tonsillectomy

BACKGROUND

Although the literature suggests that non-steroidal anti-inflammatory drugs (NSAIDs) are effective in controlling post-operative pain in the paediatric population, physicians have been reluctant to utilise these medications after tonsillectomy due to concerns of increased bleeding rates. While many surgeons prescribe opioid analgesics postoperatively, these are associated with a number of potential adverse side-effects including nausea, vomiting, constipation, excessive sedation and respiratory compromise.

OBJECTIVE OF REVIEW

To compare bleeding rates and severity between recipients of NSAIDs versus placebo or opioid analgesics for tonsillectomy.

SEARCH STRATEGY

Two authors independently searched electronic databases including PubMed, OVID, EMBASE and Cochrane Review from inception to July 2012. The keywords used included: Adenotonsillectomy, Tonsillectomy, Analgesia, Bleeding, Perioperative and Postoperative. These were then combined in various combinations with specific NSAIDs.

EVALUATION METHOD

A systematic review and meta-analysis of all randomised control trials comparing bleeding rates and severity between NSAIDs versus placebo or opioids post-tonsillectomy.

RESULTS

A total of 36 studies met our inclusion criteria including 1747 children and 1446 adults. When all of the studies were combined in a meta-analysis using the most severe outcome, there was no increased risk of bleeding in those using NSAIDs after tonsillectomy. Use of NSAIDs in general [1.30 (0.90-1.88)] or in children [1.06 (0.65-1.74)] was not associated with increased risk of bleeding in general, most severe bleeding, secondary haemorrhage, readmission or need of reoperation due to bleeding. Similarly, there was no increased bleeding risk for specific NSAIDs in adults. In the studies looking at paediatric subjects, the overall odds ratio of bleeding was even lower than in the general population and not significant. This result is based on 18 studies, six of which had zero outcomes in either treatment arm. Similar to the general population analysis, there was no significant difference in any of the subanalyses: bleeds treated with reoperation, readmission or bleeds in children that could be managed conservatively. There were also no significant differences in the subanalyses of individual NSAIDs. Similarly, there was no significant difference in rates of bleeding in the subanalysis of studies that gave NSAIDs multiple times, for instance, both before and after surgery.

CONCLUSIONS

These results suggest that NSAIDs can be considered as a safe method of analgesia among children undergoing tonsillectomy.

Apnea and oxygen desaturations in children treated with opioids after adenotonsillectomy for obstructive sleep apnea syndrome: a prospective pilot study

BACKGROUND

Recent case reports have alerted the medical community of fatality in children receiving codeine after tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome.

OBJECTIVE

The objective of this study was to compare the rates of oxygen desaturation before and after adenotonsillectomy in children with obstructive sleep apnea syndrome (OSAS), and to examine the relationship between cytochrome P450 2D6 (CYP2D6) genotype and respiratory events.

STUDY DESIGN

This was a prospective observational study.

METHODS

Twenty-six children with OSAS (mean age 78 months, range 1.8-17 years) who underwent adenotonsillectomy were studied. CYP2D6 genotype was characterized in 21 of these children. The primary endpoints of the study were the change in the rate of desaturation and in the nadir oxygen saturation values before and in the first 24 hours after surgery as measured by pulse oximetry.

RESULTS

Twenty-two children received codeine and four were managed with hydrocodone. There was no post-operative improvement in the mean rate of desaturation (1.84 ± 1.45/hour pre-operative vs 2.97 ± 3.3/hour post-operative; p = 0.119; 95% CI -2.56, 0.313), or the post-operative nadir of oxygen saturation (85.2 ± 5.8% pre-operative vs 84.0 ± 6.8% post-operative; p = 0.632; 95% CI -3.00, 4.84) on the night after surgery. Prior to surgery, six children had an oxygen saturation nadir <80%, while post-surgery, the number increased to eight children. Ten children improved their parameters after surgery. CYP2D6 genotype by itself did not predict the changes in desaturation or nadir.

CONCLUSION

Post-operative use of opioids following OSAS may not be safe for all children. It is conceivable that if the child is among the significant proportion that experiences increased oxygen desaturations, the CNS depressing effects of codeine or hydrocodone and their respectively potent morphine or hydromorphone metabolites can further compromise respiratory drive. Larger studies are needed to investigate the potential contribution of CYP2D6 genotype.

Persistent snoring under conscious sedation during colonoscopy is a predictor of obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by cessation of breathing during sleep. Conscious sedation (CS) induces sleep and may uncover sleep-related breathing disorders.

OBJECTIVE

To determine whether snoring during CS is a sensitive predictor of OSA.

DESIGN

Matched cohort study.

SETTING

University-based ambulatory endoscopy center.

PATIENTS

Consecutive patients undergoing colonoscopy completed a detailed sleep questionnaire and physical examination geared toward detecting OSA (body mass index [BMI], neck circumference, and the presence of craniofacial abnormalities). The endoscopist was blinded to the information.

INTERVENTIONS

Portable nocturnal polysomnography.

MAIN OUTCOME MEASUREMENTS

Patients who snored during CS in the left lateral decubitus position for 10 seconds or longer were referred for polysomnography. Sex- and BMI-matched patients who did not snore served as control subjects.

RESULTS

A total of 131 patients were enrolled, and 24 (18.3%) of them snored. These patients (22 men, 2 women) had a predominance of Mallampati grade III/IV, higher Stanford and Epworth scale scores, and greater BMI and neck circumference and were more likely to report daytime sleepiness, decreased vigilance, and personality and mood changes (all P values <.05). All investigated patients who snored during CS had evidence of OSA versus 4 of 18 control subjects (mean apnea-hypopnea index: 40 events vs 5 events; P < .0001) (100% positive predictive value; 77.8% negative predictive value). Moderate or severe OSA was detected in 14 of 20 patients versus 1 of 18 control subjects (P < .001; 70% positive predictive value; 94.4% negative predictive value, 93% sensitivity, 74% specificity). Data obtained from sleep questionnaires and physical examination failed to accurately predict OSA.

LIMITATIONS

Single-center nature and relatively small number of patients developing the outcome variable.

CONCLUSIONS

Snoring during CS is a strong predictor of OSA. Given the medical and financial burden of undiagnosed OSA, these patients should be carefully identified and referred for sleep medication evaluation.

Anesthetic and postoperative management of the obstructive sleep apnea patient

Sleep apnea patients pose a challenge for surgeons, anesthesiologists, and surgical facilities as there is increased risk for anesthetic and postoperative complications. Precautions before and after surgery minimize these risks. Screening for sleep apnea should be done for all surgical patients. Safe perioperative management requires judicious use of narcotics and sedating medications, reducing upper airway edema, prevention of aspiration and deep vein thrombosis, blood pressure control, use of positive airway pressure, and proper postoperative monitoring. Although the literature lacks specific recommendations, the guidelines presented in this article are based on more than 20 years of experience and supported by peer-reviewed medical literature.

Not just a patient that snores. Obstructive sleep apnoea: the perioperative concerns through the eye of the anaesthetist

Obstructive sleep apnoea (OSA) has life threatening perioperative cardiorespiratory implications. As patients present to hospital for incidental surgery unaware of their condition, perioperative practitioners need a thorough knowledge of OSA to allow optimisation before theatre. Elective cases should be delayed for investigation and treatment if OSA is suspected. In theatre cardiorespiratory problems should be managed by a senior anaesthetist and a perioperative team alert to the risk of post-operative hypoxia.

A disquisition on sleep-disordered breathing in children

Sleep-disordered breathing (SDB) is a continuum of breathing abnormalities that affects children and adults. This disorder has been continuously evolving, particularly in children, with new insights in its pathogenesis, clinical manifestations, diagnosis, treatments, and outcomes. The purpose of this review is to provide a current framework for pediatric anesthesiologists to address the perioperative needs of these children to ensure their safe conduct through anesthesia.

Preoperative and postoperative management of obstructive sleep apnea patients

Safe perioperative management of patients with obstructive sleep apnea (OSA) requires special attention to preoperative and postoperative care. Patients with OSA are more likely to have comorbidities including hypertension, esophageal and laryngopharyngeal reflux disease, coronary artery disease, and obesity. Obesity may also contribute to deep vein thrombosis and pulmonary emboli. OSA increases the risk for anesthetic and postoperative complications. The recommendations for measures for preoperative and postoperative management of OSA presented in this article are based on a culmination of 20 years experience supported by the peer-reviewed medical literature.

The effects of jaw thrust and the lateral position on heart rate variability in anesthetized children with obstructive sleep apnea syndrome

BACKGROUND

Airway obstruction occurs in anesthetized children with obstructive sleep apnea syndrome (OSAS). The inspiratory attempts against the occluded airway lead to an increased sympathetic activity. Heart rate variability (HRV) analysis provides information about the autonomic nervous system. The low-frequency component/high-frequency component ratio of HRV is considered to be an index of sympatho-parasympathetic balance.

METHODS

We investigated the effects of general anesthesia, the neutral neck position, and jaw thrust in the supine and lateral positions on HRV in 20 children (aged 3-9 yr), with OSAS. HRV was recorded before and after anesthesia induction, at the neutral neck position and with jaw thrust maneuver in the supine and lateral positions with the patients breathing 5% sevoflurane.

RESULTS

General anesthesia with the patient in the neutral neck position increased airway obstruction. The patients' stridor scores improved with the airway maneuver of jaw thrust and lateral position. The low-frequency component/high-frequency component ratio and heart rate increased at the postinduction measurement and reached the highest value with the patient in the neutral neck position. The values significantly decreased with the jaw thrust maneuver and with the patient in the supine and lateral positions. Ultra-short-term entropy of HRV decreased after anesthetic induction and reached the lowest value with the patient in the neutral neck position. The values increased during jaw thrust and with patients in the supine and lateral positions.

CONCLUSIONS

Changes of HRV induced by inhaled anesthesia, jaw thrust, and lateral positioning procedures corresponded to changes in the stridor score of children with OSAS.

[Anaesthetic management of adult patients with obstructive sleep apnea syndrome]

OBJECTIVE

The purpose of this review article is to update the anaesthetic management of adult patients with obstructive sleep apnoea syndrome (OSAS).

DATA SOURCES

All references obtained from the medical database Medline related to OSAS and anaesthesia from 1963 until May 2006 were reviewed. References included original articles, observations, clinical cases, and reviews published in English or in French.

DATA SYNTHESIS

The anaesthetic literature related to OSAS and anaesthesia is poor. Understanding anatomy and pathophysiology is important for an optimal anaesthetic management. Since the diagnosis is unknown in almost 80-90% of these patients, many undergo general or regional anaesthesia every day without recognition of the main dangers associated with the condition. Recognition of these patients, especially in the preanaesthetic assessment, is an essential step to prevent perioperative complications. Patients with OSAS are very sensitive to sedatives, hypnotics and opioids. The use of these drugs must be controlled and monitored. Anticipation of difficult intubation avoids complications during induction of general anaesthesia and the use of nasal CPAP decreases the incidence of respiratory complications in the perioperative period.

CONCLUSION

Further research is needed in this field of anesthesia. Intraoperative difficulties in the control of airway and postoperative cardiac and respiratory complications may happen. The use of nasal CPAP in the perioperative period makes the anaesthetic management easier and safer.

Perioperative Complications of Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome

We evaluated the rate of complications experienced by children who undergo adenotonsillectomy for obstructive sleep apnea syndrome (OSAS), the safety of a standard anesthetic protocol for these children, and preoperative predictors of complications. Sixty-one children with OSAS, confirmed by polysomnography, and 21 children with recurrent tonsillitis were anesthetized using a standard protocol before adenotonsillectomy (ages 2-16 yr, ASA 1-3). The number of complications and medical interventions in the perioperative period were recorded and correlated with the presence and severity of OSAS. Children with OSAS had more respiratory complications per operation than non-OSAS children (5.7 vs 2.9, P < 0.0001). Supraglottic obstruction, breath holding, and desaturation on anesthetic induction and emergence were the most common complications. Increased severity of OSAS, low weight, and young age are correlated with an increased rate of complications. Medical intervention was necessary in more children with OSAS during recovery and emergence than in the non-OSAS group (17/61 vs 1/21, P < 0.05). Both groups of children had similar opioid requirements and time to discharge from the recovery room. These findings suggest that children with OSAS are at risk for respiratory complications after adenotonsillectomy, but that these complications do not prolong the time to discharge.

[Anesthesia and sleep apnea syndrome]

The perioperative risk for patients with obstructive sleep apnea syndrome and the optimal anaesthesiological management of these patients have not been well elucidated. The prevalence of obstructive sleep apnea with significant symptoms is estimated to be 4% in men and 2% in women. However, in 80-95% of patients this syndrome is not sufficiently diagnosed. Thus identification of patients at risk and a thorough multidisciplinary diagnostic approach are essential for optimal perioperative management. The risk of perioperative complications, like cardiopulmonary compromise, and difficulties in airway management is elevated. The most important aspects of perioperative management include evaluation of intubating conditions, careful search for cardiopulmonary morbidity, permanent control of patient airways, sensible use of anaesthetics, sedatives, and narcotics, and strict monitoring of vital signs. If ambulatory nasal continuous positive airway pressure (CPAP) therapy has been established preoperatively, this should be continued in the perioperative period. Postoperative monitoring should be performed in an intensive care or intermediate care unit. Controlled clinical studies on the best perioperative management of patients with obstructive sleep apnea are urgently required.

Comparison of a combination of midazolam and diazepam and midazolam alone as oral premedication on preanesthetic and emergence condition in children

BACKGROUND

Preanesthetic anxiety and emergence agitation are major challenges for anesthesiologists in pediatric anesthesia. Thus, midazolam has been used as premedication for children. However, midazolam alone is not effective for emergence agitation. The present study tested the effect of a combination of midazolam and diazepam on the preanesthetic condition and emergence behavior in children.

METHODS

Forty-two children were allocated to one of three groups: the NoPre group received no premedication; the Mi group received midazolam 0.5 mg kg(-1) orally; and the Mi + Di group received midazolam 0.25 mg kg(-1) and diazepam 0.25 mg kg(-1) orally. When anesthesia was induced with 7% sevoflurane in 100% oxygen, qualities of mask induction and sedation were rated. Anesthesia was maintained with sevoflurane (3-5%) in 100% oxygen. During emergence from anesthesia, the score of the child's emergence behavior was rated.

RESULTS

Children in the Mi and Mi + Di groups were more sedated than those in the NoPre group. A combination of midazolam and diazepam provided a better quality of mask induction, when compared with no premedication. Also, the children in the Mi + Di group were less agitated than those in the other groups during the emergence.

CONCLUSION

Children in the Mi + Di group were significantly more sedated at induction of anesthesia and less agitated during emergence from anesthesia.

The Endoscopically Measured Effects of Airway Maneuvers and the Lateral Position on Airway Patency in Anesthetized Children with Adenotonsillar Hypertrophy

Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing children with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers such as chin lift and jaw thrust on airway patency (stridor score and upper airway dimensions by endoscopy) in anesthetized children scheduled for adenotonsillectomy. Eighteen children aged 1-11 yr were anesthetized with sevoflurane. During spontaneous breathing with 5% sevoflurane and 100% oxygen, upper airway dimensions and stridor score were recorded. After baseline recording, chin lift and jaw thrust were performed in both the supine and the lateral decubitus position. Chin lift, jaw thrust, and lateral position increased the airway dimensions and improved the stridor score. Moreover, lateral positioning enhanced the effects of these airway maneuvers on airway patency. We concluded that lateral positioning combined with airway maneuvers provided better airway patency for anesthetized children with adenotonsillar hypertrophy.

Obstructive sleep apnoea and anaesthesia

Upper airway obstruction is common during both anaesthesia and sleep, as a result of loss of muscle tone present during wakefulness. Patients with obstructive sleep apnoea (OSA) are vulnerable during anaesthesia and sedation as the effects of loss of wakefulness are compounded by drug-induced depression of muscle activity and of arousal responses, so that they cannot respond to asphyxia. Conversely, those with 'difficult' airways during anaesthesia, either because of problems with maintenance of airway patency without tracheal intubation or because intubation itself is problematic, are at increased risk of OSA. These relationships have clinical importance. On the one hand identification of patients with OSA forewarns the anaesthetist of potential difficulty with airway maintenance intra- and postoperatively, influencing choice of anaesthetic technique and postoperative nursing environment. On the other hand difficulty with airway maintenance during anaesthesia should prompt further investigation for the possibility of OSA.

The Effects of Chin Lift and Jaw Thrust While in the Lateral Position on Stridor Score in Anesthetized Children with Adenotonsillar Hypertrophy

Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing patients, especially in pediatric anesthesia with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea and also decreases collapsibility of the pharynx in anesthetized adults with obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers, such as chin lift and jaw thrust, on airway patency (stridor score) in anesthetized children scheduled for adenotonsillectomy. Thirty children aged 1-10 yr were anesthetized with sevoflurane. During spontaneous breathing of 5% sevoflurane, stridor score was recorded. After baseline recording, chin lift and jaw thrust were performed on patients in both the supine and the lateral decubitus positions. Chin lift and jaw thrust improved the stridor score. Furthermore, lateral positioning dramatically enhanced the effects of these airway maneuvers on airway patency. Jaw thrust combined with lateral positioning provided easy airway management for the anesthesiologists. We conclude that lateral positioning combined with airway maneuvers significantly improved airway patency compared with the airway maneuvers alone for patients in the supine position.

Obstructive sleep-disordered breathing in children: new controversies, new directions

Although it may seem that confusion and uncertainty reign in the field of pediatric sleep medicine, the recent realizations that the scope of childhood SDB is wider, the symptomatology is broader, and the prevalence is higher than previously believed are major advances. Likewise, recent acknowledgment of the lack of true "gold standards" for diagnosing UARS and OSAS in children is also a major advancement in this field. Critical assessment of the current "state of the art" by the 2002 AAP Technical Report on the Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome [37] is another major advance that sets the stage for the next steps. The field needs an evidence-based definitions conference, standardization of definitions across all research studies, and much more research on clinical features, pathophysiology, diagnosis, and treatment of the "new" obstructive SDB, including the full range of morbidity caused by increased upper airway resistance. This should include further inquiry into the origins of adult morbidity that resulted from childhood SDB and how it can be prevented.

Sleep-related breathing disorders in adolescents aged 12 to 16 years : clinical and polygraphic findings

STUDY OBJECTIVES

To determine the frequency, symptoms, and polygraphic features of sleep-related breathing disorders (SRBD) in adolescents aged 12 to 16 years.

DESIGN

Cross-sectional study.

SETTING

Randomly selected secondary schools in the city of Seville, SPAIN:

PARTICIPANTS

A general population sample of adolescents (n = 101; mean [+/- SD] age, 13.2 +/- 0.8 years).

INTERVENTIONS

An 82-item questionnaire regarding anthropometric data and nocturnal and daytime symptoms suggestive of SRBD was administered. Symptoms were evaluated according to a 4-point frequency scale. Snorers answered "sometimes" or "often" in the question about snoring, and nonsnorers answered "never" or "rarely." All subjects underwent an overnight cardiorespiratory polygraphy at home.

RESULTS

Twenty-nine percent of the subjects were snorers. Excessive daytime sleepiness was present in 14% of subjects, and sleep apnea was present in 3%. Polygraphy showed a respiratory disturbance index > or = 10 in 18 subjects (17.8%), but concurrent symptoms highly suggestive of SRBD were found in only 2 subjects (1.9%). Snorers had higher waist-to-hip ratios and a higher frequency of witnessed apnea or labored breathing as well as higher values of respiratory events as compared with nonsnorers. However, oximetry data were similar in both groups.

CONCLUSIONS

In a nonselected group of adolescents aged 12 to 16 years, the frequency of symptoms potentially associated with SRBD was similar to that reported for younger children. Snoring was associated with a higher occurrence of other nocturnal symptoms, a more central pattern of body fat distribution, and a higher respiratory disturbance index as compared with nonsnorers. Although polygraphic abnormalities were mild, two cases of probable SRBD were found with a prevalence rate of 1.9%.

A prospective randomized controlled study of the efficacy of ketamine for postoperative pain relief in children after adenotonsillectomy

BACKGROUND

Adenotonsillectomy is commonly needed by children with obstructive sleep apnoea syndrome. This population is at high risk of life threatening airway obstruction in the postoperative period.

METHODS

Fifty children were studied to test the efficacy of an alternative analgesic to the use of opioids in providing analgesia in the immediate postoperative period. Patients were randomized to receive either 0.1 mg.kg-1 morphine or 0.5 mg.kg-1 ketamine at induction.

RESULTS

Ketamine was as effective as morphine with no additional side-effects.

CONCLUSIONS

Ketamine is a safe and effective alternative to morphine to provide analgesia in the immediate postoperative period after tonsillectomy.

Anaesthesia and sleep apnoea

Sleep disordered breathing is a common problem affecting all age groups, particularly in association with certain other medical conditions and syndromes. The pathological consequences of the disorder may be severe, with significant implications for the perioperative management of sufferers. Research into the effects of surgery and anaesthesia on sleep is very much in its infancy. Understanding of the implications of sleep disturbance and sleep disordered breathing for perioperative morbidity and mortality is limited. While several observations have led to considerable speculation in the literature, evidence of a causal relationship is still largely lacking. Anaesthetists are ideally placed to screen large numbers of people for sleep disordered breathing, a source of considerable community morbidity. Recognizing the symptoms, signs and associations of the condition during the preoperative visit is important in planning management, as is recognition of the likelihood of OSA in patients who present difficulty with tracheal intubation or airway maintenance. Particular care is required in the perioperative management of patients with diagnosed or suspected sleep apnoea.

[Obstructive sleep apnea syndrome and hypertrophic tonsils in infants]

BACKGROUND

Even if failure to thrive in infants suffering from obstructive sleep apnea syndrome (OSAS) due to hypertrophic tonsils is well documented in the literature, the surgical act is often delayed due to the lack of diagnostic evidence.

CASE REPORTS

We report three cases which share the common characteristic of age of onset, tonsillar hypertrophy, growth retardation and growth catch-up after tonsillectomy. Authors emphasize the importance of clinical diagnosis as a sufficient tool in making the decision of surgery, thus avoiding unnecessary and expensive investigations.

CONCLUSION

The diagnosis of OSAS in infants and children is essentially clinical, depending mainly on a history provided by the parents, laying stress on nocturnal symptoms and clinical examination. Growth retardation is frequent in this syndrome and should be systematically sought. Tonsillectomy, which is effective in relieving respiratory manifestations, also allows growth recovery.

Sleep disorders in children and teens. Helping patients and their families get some rest

Diagnosing sleep disorders in children and adolescents is challenging and rewarding and requires integration of medical, neurodevelopmental, and behavioral histories. Most patients can be successfully treated once a thorough evaluation has been completed and age-appropriate differential diagnosis of common sleep disorders has been considered. With appropriate knowledge and tools, physicians may find that pediatric sleep disorders are some of the most treatable problems in medicine.

Rapid sequence intubation of the pediatric patient. Fundamentals of practice

Rapid-sequence intubation and rapid sequence induction of general anesthesia are synonyms and refer to the technique of choice for tracheal intubation in many pediatric patients in the emergency department. The principles of safe practice and basic standards of care uniformly apply to all clinical situations in which the technique is performed. RSI has two basic technical components: induction of general anesthesia and direct laryngoscopy with tracheal intubation. The technique is a prescribed protocol that can be modified slightly by the clinical circumstances. RSI is designed to rapidly create ideal intubating conditions, attenuate pathophysiologic reflex responses to direct laryngoscopy and tracheal intubation, and reduce the risk for pulmonary aspiration. Optimal performance requires appropriate training and knowledge, technical skill, and sound medical judgment. Medical and airway evaluation, careful patient selection, recognition of the need for consultation or safer alternatives, thorough familiarity with appropriate drug management, and attention to detail are essential for minimizing the risk for adverse complications. RSI with a rapid injection of preselected dosages of an anesthetic induction agent and muscle relaxant is the pharmacologic technique of choice. Premedication should not be routinely used. Anticipation, recognition, and management of complications are inherent to the competent delivery of all medical care. The unanticipated difficult airway is arguably the most severe complication of RSI, and all individuals performing the technique must prepare in advance a specific plan for this scenario. As with all such skills or procedures, a quality assurance program is important to monitor care, and individuals practicing RSI need to take appropriate steps to maintain competence.