|EVIDENCE BASED DATA
|Year : 2008 | Volume
| Issue : 6 | Page : 870
The Child with Sleep Apnea for Adenotonsillectomy
Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India
|Date of Web Publication||19-Mar-2010|
25, Polo Ground, Udaipur (Raj.)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bajaj P. The Child with Sleep Apnea for Adenotonsillectomy. Indian J Anaesth 2008;52:870
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  . 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  . 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  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
Recent respiratory infection
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  . 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  . 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  .
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  . 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  . 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  . 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  . 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  . Drugs for pain management to decrease opioid use include ketamine 0.1 mg.kg-1  and dexamethasone 0.5-1mg. kg -1 (maximum 25 mg) , . 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  . It is important to realize that these children may have increased anaesthetic risk if they return for other surgeries.
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