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EVIDENCE BASED DATA
Year : 2008  |  Volume : 52  |  Issue : 6  |  Page : 870 Table of Contents     

The Child with Sleep Apnea for Adenotonsillectomy


Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India

Date of Web Publication19-Mar-2010

Correspondence Address:
Pramila Bajaj
25, Polo Ground, Udaipur (Raj.)
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Bajaj P. The Child with Sleep Apnea for Adenotonsillectomy. Indian J Anaesth 2008;52:870

How to cite this URL:
Bajaj P. The Child with Sleep Apnea for Adenotonsillectomy. Indian J Anaesth [serial online] 2008 [cited 2020 Sep 25];52:870. Available from: http://www.ijaweb.org/text.asp?2008/52/6/870/60705

Sleep apnea is a sleep-related breathing disorder in children characterized by a periodic cessation of air exchange, with apnea episodes lasting>10 s and an apnea / hypopnea index (AHI, total number of obstruc­tive episodes per hour of sleep) >5 [1] . Air flow cessation is confirmed by auscultation or oxygen desaturation <92%. Types of sleep apnea include central (absent gas flow, upper airway obstuction, and paradoxical movement of rib cage and abdominal muscles) and mixed (due to both CNS defect and obstructive prob­lems). Diagnosis is made by clinical assessment (a his­tory of snoring and restless sleep), nocturnal pulse oxim­etry, or polysomnography studies (PSG).

Obstructive sleep apnea syndrome (OSAS) is manifested by episodes that disturb sleep and ventila­tion. These episodes occur more frequently during REM sleep and increase in frequency as more time is spent in REM sleep periods as the night progresses. OSAS occurs in children of all ages (about 2% of all children) but more commonly in children 3-7 yr of age. It occurs equally among boys and girls, but the prevalence may be higher in African American individualsv [2] . Signs of OSAS as sleep disturbances include daytime sleepi­ness, failure to thrive from poor intake due to tonsillar hypertrophy, speech disorders, and decreased size (de­creased growth hormone release during disturbed REM sleep.) This syndrome can cause significant car­diac, pulmonary, and CNS impairment due to chronic oxygen desaturation. Pulmonary vasoconstriction can increase pulmonary vascular resistance with resultant decrease in cardiac output due to cor pulmonale. Relief of the tonsillar / adenoidal obstruction can reverse many of these problems and prevent progression of others (pulmonary hypertension and cor pulmonale)

The American Academy of Pediatrics Clinical Practice Guidelines [2] give the following, recommenda­tions for inpatient monitoring in patients at high risk for postoperative complications that have OSAS and are undergoing adenotonsillectomy. These include

Age younger than 3 yr

Severe OSAS on polysomnography

Cardiac complications of OSAS (e.g., right ventricu lar hypertrophy)

Failure to thrive

Obesity

Prematurity

Recent respiratory infection

Craniofacial disorders

Neuromuscular disorders

Cerebral palsy

Down syndrome

Sickle cell disease

Central hypoventilation syndromes

Genetic / metabolic / storage disease

Chronic lung disease

As far as outpatient surgery for adenoto­nsillectomy in patients with OSAS, children age 1-18 yr without underlying medical conditions, neuromuscu­lar disease, or craniofacial abnormalities with mild sleep apnea (<15 obstructive events per hour) will have im­provement of their airway obstruction documented by polysomnography the night of surgery and do not need to be monitored intensively. In these patients the num­ber of obstructive events and fewer severe oxygen deasaturations occurred on the operative night [3] . Based on this and other studies it is possible to consider dis­charge to home for children age 3-12 yr if they meet these criteria.

However, patients with preoperative nocturnal oximetry with an oxygen saturation of 80% or less had an increase from 20% to 50% in postoperative respi­ratory complications. Frequently these children were younger (<2 yr) and had an associated medical condi­tion [4] . Sixty percent of OSAS patients requiring urgent adenotonsillectomy had postoperative respiratory com­plications. Risk factors for respiratory complications were again an associated medical condition and pre­operative nocturnal oxygen saturarion nadir <80%. Atropine administration at induction decreased the risk of postoperative respiratory complications. There was an 11.1% incidence of reintubation and a 9.3% inci­dence of postoperative pneumonia in this urgent adenotonsillectomy group [5] .

Children with severe OSAS who had adenoto­nsillectomy in the morning were less likely to have post­operative desaturation than those who were operated in the afternoon [6] . The shortened time interval between postoperative morphine dosing and bedtime may con­tribute to the incidence of postoperative desaturation because of an exaggerated respiratory depressive re­sponse to opioids which has been reported in children with severe OSAS [7] . There is a strong possibility that the combination of opioids and sleep promote desaturation in these patients.

Children with OSAS in general may have a di­minished ventilatory response to CO2 rebreathing com­pared with normal children [8] . Therefore, drugs known to cause ventilatory depression (sedative hypnotics, anxiolytics, narcotics and inhaled agents) must be used judiciously in these patients as they may be more sensi­tive to their effects. Younger aged patients or those with preoperative nocturnal oxygen saturation <85% had reduced morphine requirement possibly due to up-regu­lation of central opioid receptors consequent to recur­rent hypoxemia [9] . Children whose minimum nocturnal desaturation was <85% required one half of the dose of opioids for similar pain scores after adenotonsillectomy surgery compared with children whose minimal saturation was 85% or greater [10] . Drugs for pain management to decrease opioid use include ketamine 0.1 mg.kg-1 [11] and dexamethasone 0.5-1mg. kg -1 (maximum 25 mg) [12],[13] . In addition, a new surgical tech­nique partial intracapsular tonsillectomy for children with OSAS results in less postoperative pain and opioid use.

Although the respiratory distress index improves in children with severe sleep apneas and in obese chil­dren with OSAS after adenotonsillectomy, the OSAS may not resolve in the majority of these children and some may need a postoperative PSG and additional therapy such as uvulopalatoplasty (UPPP) or tracheo­stomy [14] . It is important to realize that these children may have increased anaesthetic risk if they return for other surgeries.

 
   References Top

1.Warwick JP, Mason DG. Obstructive sleep apnea syn­drome in children. Anaesthesia 1998;53:571-9.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Am Academy of Pediatrics Clinical practice guideline : diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109:704-12.  Back to cited text no. 2      
3.Helfaer MA, McColley SA, Pyzik PL, et al. Polysomnography after adenotonsillectomy in mild pediatric obstructive sleep apnea. Crit Care Med 1996; 24:1323-7.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Wilson K, Lakheeram I, Morielli A, et al. Can assess­ment for obstructive sleep apnea help predict postadenotonsillectomy respiratory complications? Anesthesiology 2002;96:313-22.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Brown KA, Morin I, Hickey C, et al. Urgent adenotonsillectomy : an analysis of risk factors associ­ated with postoperative respiratory morbidity. Anesthe­siology 2003;99:586-95.  Back to cited text no. 5      
6.Koomson A, Morin I, Brouillette R, Brown KA. Children with severe OSAS who have adenotonsillectomy in the morning are less likely to have postoperative desaturation than those operated in the afternoon. Can JAnaesth 2004;51:62-7  Back to cited text no. 6      
7.Waters KA, McBrien F, Stewart P, et al. Effects of OSA inhalational anesthesia and fentanyl on the airway and ventilation of children. J Appl Physiol 2002;92:1987-94.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Strauss SG, Lynn AM, Bratton SL, Nespeca MK. Venti­latory response to CO 2 in children with obstructive sleep apnea from adenotonsillar hypertrophy. Anesth Analg 1999;89:328-32.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Brown KA, Laferriere A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is asso­ciated with reduced opioids requirement for analgesia. Anesthesiology 2004;100:806-10.  Back to cited text no. 9      
10.Brown KA, Laferriere A, Lakheeram I, Moss IR. Recur­rent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology 2006;105:665-9.  Back to cited text no. 10      
11.Elhakim M, Khalafallah Z, El-Fattah HA, et al. Ketamine reduced swallowing-evoked pain after pediatric tonsil­lectomy. Acta Anaesthesiol Scand 2003;47:604-9.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Pappas AL, Sukhani R, Hotaling AJ, et al. The effect of preoperative dexamethasone on the immediate and de­layed postoperative morbidity in children undergoing adenotonsillectomy. Anesth Analg 1998;87:57-61.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Elhakim M, Ali NM, Rashed I, et al. Dexamethasone re­duces postoperative vomiting and pain after pediatric tonsillectomy. Can J Anaesth 2003;50:392-7.  Back to cited text no. 13  [PUBMED]    
14.Mitchell RB, Kelly J. Outcome of adenotonsillectomy for severe obstructive sleep apnea in children. Int J Pediatr Otorhinolaryngol 2004;68:1375-9.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  




 

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