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Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated?
G M Rosen1, R P Muckle, M W Mahowald
1Department of Pediatrics, University of Minnesota Medical School, Minneapolis.
Insights
Children with obstructive sleep apnea syndrome (OSAS) undergoing tonsillectomy and/or adenoidectomy (T and/or A) face risks of postoperative respiratory complications. Younger age, craniofacial anomalies, and severe apnea increase these risks, necessitating careful monitoring and potential CPAP use.
Area of Science:
- Pediatric Otolaryngology
- Sleep Medicine
- Respiratory Medicine
Background:
- Obstructive sleep apnea syndrome (OSAS) is a common condition in children.
- Tonsillectomy and/or adenoidectomy (T and/or A) are frequent surgical interventions for pediatric OSAS.
- Postoperative respiratory complications following T and/or A in children with OSAS require careful assessment.
Purpose of the Study:
- To describe postoperative respiratory complications in children with OSAS after T and/or A.
- To identify risk factors for these complications.
- To evaluate the efficacy of continuous positive airway pressure (CPAP) in managing these complications.
Main Methods:
- Retrospective chart review of children aged 15 or younger with polysomnographically (PSG) proven OSAS undergoing T and/or A.
- Analysis of factors contributing to OSAS, postoperative complications, and interventions.
- Inclusion of data on patient age, associated medical conditions, and PSG findings.
Main Results:
- Ten out of 37 children experienced significant postoperative respiratory compromise.
- High-risk children were younger and had associated medical problems (e.g., craniofacial anomalies, hypotonia, morbid obesity).
- Severe preoperative apnea (RDI > 40, SaO2 nadir < 70%) and concurrent uvulopalatopharyngoplasty (UPPP) were also risk factors. CPAP was successfully used in five children.
Conclusions:
- Overnight observation with apnea monitoring and oximetry is recommended for high-risk OSAS patients undergoing T and/or A.
- High-risk clinical criteria include age < 2 years, craniofacial anomalies, failure to thrive, hypotonia, cor pulmonale, morbid obesity, or previous upper airway trauma.
- High-risk PSG criteria (RDI > 40, SaO2 nadir < 70%) or concurrent UPPP also warrant caution. CPAP is an effective management strategy.
Objective:
The aim of this research was to describe the postoperative respiratory complications after tonsillectomy and/or adenoidectomy (T and/or A) in children with obstructive sleep apnea syndrome (OSAS), to define which children are at risk for these complications, and to determine whether continuous positive airway pressure (CPAP) is an effective strategy for dealing with these complications.
Methods:
The data for this study were gathered through a retrospective chart review of all children 15 years of age or younger with polysomnographically (PSG) proven OSAS who had a T and/or A at Hennepin County Medical Center between January 1985 and September 1992. Particular attention was paid to factors that contributed to the OSAS, postoperative respiratory complications, and intervention strategies for dealing with these complications.
Results:
The charts of 37 children with OSAS documented by preoperative PSG who later had a T and/or A were reviewed retrospectively. Ten of these children had significant postoperative respiratory compromise secondary to OSAS that prolonged their hospital stay from 1 to 30 days and caused symptoms ranging from O2 desaturation < 80% to respiratory failure. These children were younger and had significant associated medical problems that contributed to or resulted from their OSAS in addition to large tonsils and adenoids. The associated medical problems included craniofacial anomalies, hypotonia, morbid obesity, previous upper airway trauma, cor pulmonale, and failure to thrive. The children with postoperative respiratory complications also had more severe apnea on their preoperative PSG. One child had a uvulopalatopharyngoplasty (UPPP) in addition to the T & A. Taken together, the history, physical and neurological examination, and the PSG were able to identify successfully the children who subsequently developed respiratory compromise secondary to OSAS after a T and/or A. Nasal continuous positive airway pressure (CPAP) and bilevel CPAP was used successfully to manage the preoperative and/or postoperative upper airway obstruction in five of these children.
Conclusions:
Based on these findings, overnight observation is recommended with an apnea monitor and oximeter for patients undergoing a T and/or A who have OSAS and meet any of the following high-risk clinical criteria: (1) < 2 years of age, (2) craniofacial anomalies affecting the pharyngeal airway particularly midfacial hypoplasia or micro/retrognathia, (3) failure to thrive, (4) hypotonia, (5) cor pulmonale, (6) morbid obesity, and (7) previous upper airway trauma; or high-risk PSG criteria: (1) respiratory distress index (RDI) > 40 and (2) SaO2 nadir < 70%; or undergoing a UPPP in addition to the T and/or A. Nasal CPAP/bilevel CPAP can be used to manage the preoperative and/or postoperative upper airway obstruction in patients with OSAS undergoing a T and/or A.