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Overnight Monitoring Criteria for Children with Obstructive Sleep-Disordered Breathing After Tonsillectomy: Revisited
Emmanuel J Jáuregui1, Obinna Diala2, Kyle O Rove3
1Department of Pediatric Otolaryngology-Head & Neck Surgery, Mary Bridge Children's Hospital, Tacoma, Washington, U.S.A.
Insights
Revised overnight monitoring criteria for adenotonsillectomy (T&A) did not increase same-day surgery (SDS) return visits or readmissions. More children with Class I obesity safely underwent SDS T&A following the criteria update.
Area of Science:
- Pediatric Otolaryngology
- Sleep Medicine
- Surgical Outcomes Research
Background:
- Previous studies suggest children passing an Asleep Room Air Challenge (AsRAC) have minimal postoperative respiratory events after adenotonsillectomy (T&A).
- Modified overnight monitoring (OM) criteria were implemented, allowing patients with an obstructive apnea/hypopnea index (OAHI) ≤20 or Class I obesity to be considered for same-day surgery (SDS) if they passed an AsRAC.
Purpose of the Study:
- To evaluate if revised OM criteria for T&A increase return visits or readmission rates within 48 hours or 15 days for SDS patients.
- To assess the impact of modified OM criteria on the rate of SDS for children with Class I obesity and those undergoing polysomnography.
Main Methods:
- Retrospective review of T&A cases in children aged 3 to <21 years from January 2017 to September 2022.
- Comparison of descriptive statistics and outcome measures using a 3% margin noninferiority test before and after the new criteria implementation.
- Analysis of emergency department (ED) revisit rates, readmissions, and perioperative respiratory events for SDS patients.
Main Results:
- The rate of T&A performed as SDS increased significantly from 58% to 74% after the criteria revision (p<0.05).
- There was no significant difference in ED revisit rates for SDS within the 3% noninferiority margin.
- SDS T&A increased by 29% for children with Class I obesity (62% vs. 33%, p<0.001) and by 19% for children with polysomnography (39% vs. 20%, p<0.001).
- Post-intervention, 0.9% of SDS patients had revisits for bleeding and 1.2% for vomiting within 48 hours; no perioperative respiratory events occurred.
Conclusions:
- Revised OM criteria for T&A are safe, as they did not lead to an increase in ED visits or readmissions within 48 hours or 15 days.
- The updated criteria facilitated a significant increase in SDS T&A for children with Class I obesity.
- The study supports the use of modified OM criteria to safely expand same-day surgery options for select pediatric T&A patients.
Objectives:
Previous studies indicate children who pass an Asleep Room Air Challenge (AsRAC) do not have significant postoperative adverse respiratory events after adenotonsillectomy (T&A). Subsequently, we revised our overnight monitoring (OM) criteria, allowing patients with an obstructive apnea/hypopnea index (OAHI) ≤20 or nonsevere obesity (Class I) to be considered for same-day surgery (SDS) if they passed an AsRAC. Our hypothesis is that our modified OM criteria would not increase the return visits or readmission rates for patients undergoing SDS within 48 h or 15 days of T&A.
Methods:
A retrospective review of all children aged ≥3 and <21 years who underwent T&A at a tertiary children's hospital and its satellite locations was performed from January 2017 to September 2022. Descriptive statistics and outcome measures were compared using a 3% margin noninferiority test before and after the new criteria implementation.
Results:
Before intervention, 3,266 (58%) T&As were performed as SDS. Afterward, 74% of T&As were performed as SDS (p-value <0.05). There was no difference in the ED revisit rate for SDS within the 3% noninferiority margin. Following intervention, 29% more children with Class I obesity (62% vs. 33%) underwent SDS (p-value <0.001). Afterward, 19% more children with polysomnography underwent SDS (39% vs. 20%), p-value <0.001. After intervention, within 48 h of SDS, six (0.9%) children had revisits for bleeding and seven (1.2%) for vomiting. There were no perioperative respiratory events.
Conclusion:
Our revised monitoring criteria did not demonstrate an increase in ED visit or readmissions rates within 48 h or 15 days of T&A. Additionally, we found a 29% increase in Class I obese children undergoing SDS T&A.
Level Of Evidence:
3 Laryngoscope, 134:5223-5230, 2024.
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