Respiratory Complications In Children Research Articles

Respiratory Complications in Children with Cerebral Palsy

Respiratory Complications in Children with Cerebral Palsy

Adenotonsillectomy for obstructive sleep apnea in children with cerebral palsy: Risks and benefits.

To determine outcomes following adenotonsillectomy for obstructive sleep apnea (OSA) and the impact of motor and swallowing impairment on respiratory complications in children with Cerebral Palsy (CP). A retrospective review of children with CP and sleep disordered breathing (SDB) who underwent adenotonsillectomy (2003-2021) was performed. Children with CP were age-matched to children without CP. Motor and swallowing function was assessed using the Gross Motor Functional Classification System (GMFCS) and the Eating and Drinking Ability Classification System (EDACS). The primary outcome was postoperative obstructive apnea-hypopnea index (OAHI). Secondary outcomes were cure rate, complications, and need for additional interventions. Ninety-seven children with CP were assessed for SDB, and 74 underwent polysomnography. Moderate or severe OSA was found in 49% (36/74). Adenotonsillectomy was performed in 30% (29/97). All children who underwent adenotonsillectomy experienced an initial reduction in OAHI (31.7/h to 2.9/h, p<0.0001). Children with CP were less likely to achieve an OAHI<1 compared with children without CP (62.5% vs 81.8%, p=0.23). Children with CP had more postoperative complications (43.5% vs. 8.7%) and greater odds of respiratory complications compared with children without CP (OR 8.9 95% CI 2.1-37.9). Children with CP and a GMFCS score of 5 and EDACS score between 3 and 5 had more respiratory complications post-adenotonsillectomy compared to those with GMFCS<5 (p=0.002) and EDACS<3 (p=0.031). Children with CP had an improved OAHI initially following adenotonsillectomy but had higher rates of post-adenotonsillectomy complications. Respiratory complications after adenotonsillectomy were more common in children with motor and swallowing impairment. Findings may provide better preoperative planning for caregivers.

Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty.

Postoperative respiratory complications (PORCs) can occur following supraglottoplasty (SGP) for obstructive sleep apnea. However, there are very limited data on risk factors associated with these complications. This study aims to evaluate the occurrence of PORC in children undergoing SGP and to assess clinical factors and polysomnographic parameters predicting these complications. A retrospective study was performed in children with laryngomalacia who underwent SGP with preoperative polysomnography. 400 children who underwent SGP met the criteria for entry into the analysis with a total of 416 surgeries with corresponding preoperative polysomnography. The median age (interquartile range) at the time of polysomnography was 0.4 (0.2, 1.5) years. A total of 96 (23.1%) PORCs were noted. Compared with those without complications, children with PORCs had a higher proportion of congenital heart disease (P < .05), higher median obstructive apnea-hypopnea index (obstructive AHI; median 16.0 vs 11.4 events/h; P < .01), and lower median oxygen saturation (SpO2) (P < .001). The unadjusted odd ratio indicated an increased risk of PORCs in children with congenital heart disease (odds ratio 1.66; P < .05) and those with an obstructive AHI > 10 events/h (odds ratio 2.06; P < .01). Multiple regression analysis demonstrated that an obstructive AHI > 10 events/h was the only independent risk factor for PORCs (P < .05). In our cohort of children with laryngomalacia undergoing SGP, those with underlying congenital heart disease, higher obstructive AHI, and lower SpO2 were more likely to develop PORCs. Only children with an obstructive AHI > 10 events/h were at significantly increased risk for PORCs following SGP. Preoperative polysomnography is useful in preoperative planning in children undergoing SGP. Kanavitoon S, Ngamprasertwong P, Gurbani N, etal. Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty. J Clin Sleep Med. 2024;20(1):9-16.

The Effect of Parental Smoking Exposure on Perioperative Respiratory Complications in Children

The Effect of Parental Smoking Exposure on Perioperative Respiratory Complications in Children

Predictive risk score of respiratory complications in children with mediastinal tumors: A case-control study.

The aim of this study was to examine risk factors of respiratory complications at the diagnosis and establish an algorithm of clinical management in children and adolescents with mediastinal tumors. We retrospectively collected clinical information of all children and adolescents who presented with mediastinal tumors at Saitama Children's Medical Center from 1999 to 2019, including age, sex, pathological diagnosis, eight major clinical symptoms (cough, dyspnea, hypoxia, orthopnea, chest pain, wheeze, superior vena cava syndrome, and stridor), chest computed tomography (CT) findings (tumor location, mediastinal mass ratio, pleural fluid, pericardial effusion, and compression of trachea and bronchi), types of diagnostic procedure and anesthesia, respiratory complications (severe hypoxia, difficult ventilation, respiratory failure, and cardiopulmonary arrest), and clinical outcome. Subsequently, we calculated the risk score for predicting respiratory complications by combining clinical and radiological findings. Of the 57 patients, 7 (12%) developed respiratory complications. Cough, dyspnea, hypoxia, and orthopnea were significantly more common in patients with complications (p=0.02, p=0.02, p < 0.01, p=0.03, respectively). The reduction of percentage of tracheal cross-sectional area (%TCA) and compression of the carina in chest CT were also significantly more common in patients with complications (p < 0.01 and <0.01, respectively). We calculated the risk score of respiratory complications by combining cough, wheeze, stridor, orthopnea, dyspnea, hypoxia, %TCA < 0.5, and compression of the carina. A risk score≥ 7 showed high predictive accuracy for complications (sensitivity: 100%, specificity: 97.7%, positive likelihood ratio: 43.0). The risk score combining clinical symptoms with radiological findings is a promising predictive tool for respiratory complications in children with mediastinal tumors.

Postoperative respiratory complications in children with obstructive sleep apnoea syndrome.

SUMMARYObjectiveWe aimed to prospectively assess the effect of comorbidities on the occurrence of postoperative respiratory complications (PoRCs) after adenotonsillectomy in children with obstructive sleep apnoea syndrome (OSA) and whether otherwise healthy children need a higher level of postoperative monitoring.Methods577 children who had OSA and underwent adenotonsillectomy were enrolled. The effects of demographics, comorbidities and OSA on PoRCs were investigated with logistic regression analysis.ResultsThe PoRC rate was 4.3%. Postoperative oxygen desaturations were more marked in patients with comorbidities (p = 0.005). The presence of comorbidity increased the risk of PoRCs (odds ratio 4.234/3.226-5.241, 95% confidence intervals, p < 0.001). There was no difference in apnoea-hypopnoea index (AHI) values between comorbid patients with and without PoRCs [8.2 (3.8-50.2) vs 14.3 (11.7-23.3)]. (p = 0.37). In the group of patients without comorbidities, PoRCs were associated with a higher AHI [14.7 (3.4-51.3) vs 3.9 (2.0-8.0), p < 0.001].ConclusionsComorbidities are more closely linked with PoRCs than OSA severity. In patients without comorbidity, PoRCs are associated with OSA severity and usually occur within the first 2 hours after the intervention.

Can pediatric sleep questions be incorporated into a risk model to predict respiratory complications following adenotonsillectomy?

BackgroundAdenotonsillectomy, one of the most frequent surgical procedures in children, is usually performed for sleep-disordered breathing, a disease spectrum from primary snoring to obstructive sleep apnea. Children undergoing an adenotonsillectomy may be at risk for perioperative respiratory complications, necessitating intervention or escalation of care. However, there is no effective preoperative screening or risk-stratification model for perioperative respiratory complications that incorporates not only clinical history and physical examination but also sleep question responses for children as there is for adults. ObjectivesThe aim of this prospective observational study was to develop a risk-stratification model for perioperative respiratory complications in children undergoing an adenotonsillectomy incorporating not only clinical history and physical examination but also sleep question responses. MethodsA 25-question sleep questionnaire was prospectively administered preoperatively for 1895 children undergoing an adenotonsillectomy from November 2015 to December 2017. The primary outcome measure was overall perioperative respiratory complications, collected prospectively and defined as having at least one major or minor complication intraoperatively or postoperatively. ResultsThe incidence of overall perioperative respiratory complications was 20.4%. Preoperative factors associated with perioperative respiratory complications in the multiple regression model were age, race, preoperative tonsil size, the presence of a syndrome, and the presence of a pulmonary disease. None of the sleep questionnaire responses remained in the multivariable analysis. The area under the ROC curve for the risk stratification model incorporating sleep question responses was only 0.6114% (95% CI: 0.60, 0.67). ConclusionPreoperative sleep question responses may be unable to predict overall perioperative respiratory complications in children undergoing an adenotonsillectomy. A robust risk stratification model incorporating sleep question responses with clinical history and physical examination was unable to discriminate or predict perioperative respiratory complications in our population undergoing an adenotonsillectomy.

Apnea-hypopnea index severity as an independent predictor of post-tonsillectomy respiratory complications in pediatric patients: A retrospective study.

Despite the presence of clinical practice guidelines for overnight admission of pediatric patients following adenotonsillectomy, variance in practice patterns exists between pediatric otolaryngologists. The purpose of this study is to examine severity of apnea-hypopnea index (AHI) as an independent predictor of postoperative respiratory complications in children undergoing adenotonsillectomy. Retrospective chart review of all children undergoing adenotonsillectomy at a large tertiary referral center between January 2015 and December 2019 who underwent preoperative polysomnography and were admitted for overnight observation. Charts were reviewed for total adverse events and respiratory events occurring during admission. Overall, respiratory events were seen in 50.6% of patients with AHI ≥10 and in 39.6% of patients with AHI <10. The overall mean AHI was 19.2, with a mean of 28.1 in the AHI ≥10 subgroup vs 4.6 in the AHI <10 subgroup. There was no statistical correlation or increased risk between an AHI ≥10 and having a pure respiratory event, with a relative risk of 1.19 (.77-1.83, P = .43). There was a statistically significant difference between the mean AHI of those with any adverse event and those without (21.6 vs 13.4, P = .008). There is additionally an increased risk of any event with an AHI over 10, with a relative risk of 1.51 (1.22-1.88, P < .0001). Preoperative AHI of 10 events per hour was not a predictor of postoperative respiratory complications. However, there was a trend for those with a higher AHI requiring additional supportive measures or a prolonged stay. Practitioners should always use their best judgment in deciding whether a child warrants postoperative admission following adenotonsillectomy.

Peri operative airway and respiratory complications in children undergoing cleft lip and palate repair at a tertiary institute: An observational study

Introduction: Airway related problems have always been a major concern in paediatric patients more so in patients presenting with cleft lip/palate. Objective: Our aim was to determine the incidence of various types of perioperative airway and respiratory complications in children undergoing cleft lip and palate repair and their management at our tertiary care centre. Methodology: This prospective observational study was conducted over a period of 18 months in 50 ASA I and II paediatric patients (age group new born to 12 years) undergoing cleft lip/palate surgery. Complications during induction, intubation and postoperative period were noted. Results: Difficult laryngoscopy in 10% (n=5) patients & difficult intubation in 4% (n=2) patients were noted. No incidences of failed intubation were seen. Tube disconnection (n=1) and tube repositioning (n=2) after mouth gag placement. Desaturation occurred in 4% (n=2) patients, one during difficult intubation and one after mouth gag placement. One patient had laryngospasm during intubation. One patient had an episode of post extubation breath holding spell. One patient had tongue fall postoperatively. Conclusion: Airway and respiratory complications can be encountered during cleft lip and palate surgeries. Preoperative assessment and identifying any airway problems, congenital anomalies and comorbid conditions is important. Adequate preparation for difficult airway should be done before induction of anaesthesia to avoid morbidity and mortality. Intraoperative airway complications due to the shared airway have to be anticipated. Postoperative airway obstruction may be encountered and has to be treated prophylactically.

Surgical Techniques for Tonsillectomy and Perioperative Respiratory Complications in Children.

The aim of this study was to determine the incidence of perioperative respiratory complications in children following tonsillectomy with cold and hot dissection surgical techniques. The study was a retrospective cohort study. Retrospective chart review was performed for all children presenting for a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. Pre- and intraoperative patient factors, including surgical technique with cold or hot dissection (electrocautery or radiofrequency ablation), and perioperative anesthetic factors were collected to determine the incidence of perioperative respiratory complications. A total of 2437 patients underwent a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. The incidence of perioperative respiratory complications was 20.0% (n = 487). Sickle cell disease, cardiac disease, reactive airway disease, pulmonary disease, age >2 and <3 years, and obesity, defined as a body mass index >95th percentile for age, were significant for overall perioperative respiratory complications. There was no difference in the incidence of perioperative respiratory complications in children undergoing tonsillectomy by cold or hot dissection. Perioperative respiratory complications following tonsillectomy are more affected by patient factors than surgical technique.

Monitoring and Nursing for Children with Obstructive Sleep Apnea Syndrome in the Recovery Room After General Anesthesia

Background: Preschool children with obstructive sleep apnea-hypopnea syndrome (OSAHS) experience a potentially lethal sleep disorder disease. Early surgical resection of OSAHS is critical for children’s growth and development. Tonsil adenoidectomy is an essential treatment technique for OSAHS. However, laryngeal trauma caused by surgery leads to agitation due to pain during recovery, accompanied by other symptoms such as unstable vital signs and postoperative anxiety. Little research has been done on the treatment and care of postoperative agitation and respiratory complications in children with OSAHS. Therefore, exploring a better-personalized care method is essential for reducing the incidence of respiratory complications during anesthesia recovery in children with OSAHS and the smooth recovery of the child. Objectives: The study aimed to investigate the respiratory complications and agitation of childhood OSAHS in the anesthesia recovery period after surgery and suitable nursing care methods. Methods: A total of 200 children with OSAHS were randomly divided into the routine care group (Group A, n = 100) and the personalized nursing group (Group B, n = 100). Personalized nursing included postoperative bleeding care, psychological care, infusion care, and pain care. Patients’ demographic and clinical data were collected. A CO2 laser-assisted modified uvulopalatopharyngoplasty (UPPP) was performed after the induction of general anesthesia. Children were extubated and transferred to the recovery room after the surgery. The nurses closely monitored the children’s agitation, oxygen saturation, and spontaneous breathing every 15 min within one hour in the recovery room. The respiratory frequency and amplitude, ECG changes, blood pressure, hospitalization time, and economic costs were recorded. Results: The incidences of agitation and respiratory obstruction were significantly lower in Group B than in Group A in the recovery room (P &lt; 0.05). Blood pressure and heart rates were significantly higher, and oxygen saturation was lower in Group A at 15 min, 30 min, and 45 min (all P &lt; 0.05), but the difference disappeared 60 min after surgery (P &gt; 0.05). The hospitalization time and expenses of Group B were significantly lower than those of Group A (P &lt; 0.05). Conclusions: Personalized nursing care during postoperative anesthesia recovery can reduce the incidence of agitation and respiratory obstruction, lower blood pressure and heart rate, and accelerate postoperative recovery in children with OSAHS. Our study discovered a suitable nursing method for OSAHS children after general anesthesia to improve patients’ recovery and reduce economic costs.

Management of chronic respiratory complications in children and adolescents with sickle cell disease.

Sickle cell disease (SCD) is a life-threatening hereditary blood disorder that affects millions of people worldwide, especially in sub-Saharan Africa. This condition has a multi-organ involvement and highly vascularised organs, such as the lungs, are particularly affected. Chronic respiratory complications of SCD involve pulmonary vascular, parenchymal and airways alterations. A progressive decline of lung function often begins in childhood. Asthma, sleep-disordered breathing and chronic hypoxaemia are common and associated with increased morbidity. Pulmonary hypertension is a serious complication, more common in adults than in children. Although there is a growing attention towards respiratory care of patients with SCD, evidence regarding the prognostic meaning and optimal management of pulmonary issues in children with this condition is limited.This narrative review presents state-of-the-art evidence regarding the epidemiology, pathophysiology and therapeutic options for chronic respiratory complications commonly seen in paediatric patients with SCD. Furthermore, it highlights the gaps in the current knowledge and indicates future directions for studies that aim to improve our understanding of chronic respiratory complications in children with SCD.

Polysomnography variables associated with postoperative respiratory issues in children

ObjectivesTo determine the polysomnogram (PSG) variables associated with increased incidence of postoperative respiratory complications in children <3 years of age undergoing adenotonsillectomy (T&A) for the management of obstructive sleep apnea (OSA). MethodsRetrospective case series of children <3 years of age who underwent T&A for the management of OSA at a tertiary care children's hospital from 1/1/08–6/1/2018. Postoperative hospital courses were analyzed to determine if certain clinical or PSG variables might have predicted an increased rate of respiratory complications. ResultsA total of 195 children <3 years of age with OSA on preoperative PSGs underwent T&A. The mean age of patients was 25.8 months (range 9–35 months). Seventeen patients (16.2%) had mild OSA, 35 (17.9%) had moderate, and 141 (72.3%) had severe OSA. Most patients (n = 155, 79.5%) required no respiratory intervention postoperatively. Those with severe OSA were more likely to require oxygen support (n = 25, 17.7%) when compared to those with mild-moderate OSA (n = 3, 5.6%). Patients admitted directly to the pediatric intensive care unit (PICU) from the sleep lab (n = 7) had a mean apnea-hypopnea index (AHI) of 63.6 events/hour (range 23–146/hr.), and a mean SpO2 nadir of 56.3% (range 46–68%). Four of these patients required CPAP after T&A. Of the 7 patients (3.6%) who required intubation after their procedure, only 1 did not have severe OSA, and 2 were intubated to manage post-obstructive pulmonary edema (POPE). Only 4 patients (4.2%) had unplanned PICU admissions. An AHI >12.7 events/hour, >18.5 obstructive apneas, and SpO2 nadir <72.5% were associated with a greater likelihood of requiring postoperative respiratory interventions. ConclusionsMost children <3 years of age, even with severe OSA, had no respiratory issues postoperatively. Those with severe OSA and hypoxemia admitted directly from the sleep lab were more likely to require CPAP postoperatively. All but one patient who developed POPE or who required intubation had severe OSA with associated hypoxemia on their preoperative PSGs.

Assessing Frequency of Respiratory Complications in Children Undergoing Adenotonsillectomy.

To determine the frequency of respiratory complications in children admitted to the ICU after adenotonsillectomy and to identify factors associated with the risk of respiratory complications in this cohort. Retrospective observational study. PICU. All children admitted to the ICU following adenotonsillectomy from September 30, 2009, to March 30, 2014. Of the 165 children included in the study, 150 (91%) received no respiratory support other than oxygen in the first 2 hours postoperatively. Of the 15 who required support following 2 hours, 14 required nasopharyngeal airways, one required invasive mechanical ventilation, and seven required supplemental oxygen for more than 2 hours. None of the children who received respiratory support for less than 2 hours required subsequent ICU level care. When comparing those who received support for more than 2 hours to those who did not, there were no differences in clinical characteristics except that those who received support were more likely to have chronic neurologic disease including autism, seizures, or cerebral palsy (odds ratio, 3.7; 95% CI, 1.1-11.9; p = 0.04). Intraoperative events were not predictive of need for respiratory support. Most of the children (n = 117/165 or 71%) had sleep studies preoperatively. Abnormal sleep studies (apnea-hypopnea index > 20 [n = 68] or oxygen saturation nadir < 80% [n = 48]) were not associated with need for postoperative respiratory support. Most children admitted to the ICU following adenotonsillectomy in this population required no support after 2 hours. Preoperative factors such as obesity and abnormal sleep studies were not predictive of need for postoperative respiratory support. Need for respiratory support at 2 hours may be a useful criterion for need for ICU level care in this population.

Complicações respiratórias na criança com mucopolissacaridose

Complicações respiratórias na criança com mucopolissacaridose

Respiratory Complications in Children Hospitalized with Respiratory Syncytial Virus Infection.

The goal of this study was to define the prevalence of respiratory complications, other than bronchiolitis, such as pneumonia, acute otitis media, and conjunctivitis in children treated in a hospital due to respiratory syncytial virus (RSV) infection, with reference to the plausible risk factors. The study included 111 children, aged up to 22months (median 3months). Complications were observed in 68 (61%) children, with 32 (29%) children presenting more than one. The most frequent complication was acute otitis media in 53 (48%), pneumonia in 37 (33%), and conjunctivitis in 12 (11%) out of the 111 children. Children with complications were older than those without complications and had fever that lasted for a significantly longer time, both before and during hospitalization, and the fever was stronger. They also presented a significantly lower breathing rate at admission. The age over 3months was a single risk factor associated with the development of otitis media (OR=9.8, 95%CI: 3.6-26.7) and pneumonia (OR=2.8, 95%CI: 1.1-7.3). Other factors such as prematurity, birth weight below 2500g, exposure to tobacco smoke during pregnancy, and the cessation of breastfeeding below age 6months were statistically irrelevant to this end. We conclude that complications are very frequent in hospitalized children with RSV infection and their risk increases with the infant age.

Post-tonsillectomy respiratory complications in children with sleep disordered breathing

ObjectiveA common indication for tonsillectomy in children is clinically diagnosed sleep disordered breathing (SDB) without confirmation of obstructive sleep apnea (OSA) by polysomnography (PSG). Our goal was to review rates of post-tonsillectomy respiratory complications in children with SDB without prior PSG in order to develop recommendations for postoperative monitoring and safe hospital discharge in this population. MethodsFollowing Institutional Review Board (IRB) approval at Penn State Milton S. Hershey Medical Center, a database query using Current Procedural Terminology (CPT) codes for tonsillectomy with or without adenoidectomy (42820, 42821, 42825, 42826) between January 1, 2012 and December 31, 2017 was performed. International Classification of Diseases (ICD) codes for sleep disordered breathing (G47.30), snoring (R06.83), and obstructive sleep apnea (G47.33) were applied for further selection. Charts were individually reviewed to confirm the inclusion criteria of pediatric patients (≤18 years) who underwent tonsillectomy without prior PSG and were monitored overnight. Demographic, operative, and relevant postoperative hospital course data (including desaturations, supplemental oxygen requirements, and upgraded level of care) were collected. ResultsA total of 1874 unique patient encounters were identified by our database search and 364 children met inclusion criteria. The average age of the patient population was 6.5 ± 3.1 years and 52.2% of children were female. Mean z-score for the population was 0.6. The rate of overnight oxygen desaturation events (<95%) was 2.2%, with no severe complications found in this population. Children with desaturation events were supplemented with oxygen and resolved prior to hospital discharge. Only race was found to be significantly related to risk of mild overnight desaturations (P = 0.023). ConclusionA lack of significant postoperative respiratory complications or alterations in the clinical management of children with SDB without prior PSG supports the idea that such patients may safely be discharged from the hospital following tonsillectomy without overnight oxygen monitoring.

Adenotonsillectomy for pediatric obstructive sleep apnea: how to predict those at risk for postoperative complications.

Free AccessCommentaryAdenotonsillectomy for pediatric obstructive sleep apnea: how to predict those at risk for postoperative complications Heidi V. Connolly, MD, Laura T. Tomaselli, MD, Margo K. McKenna Benoit, MD Heidi V. Connolly, MD *Address correspondence to: Heidi V. Connolly, MD, University of Rochester Pediatric Sleep Medicine Services Center, 2180 S. Clinton Ave Suite C, Rochester NY 14618; Tel: (585) 340-8949; Fax: (585) 785-9901; Email: E-mail Address: [email protected] Department of Pediatrics, Division of Pediatric Sleep Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York; Search for more papers by this author , Laura T. Tomaselli, MD Department of Pediatrics, Division of Pediatric Sleep Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York; Search for more papers by this author , Margo K. McKenna Benoit, MD Department of Otolaryngology, University of Rochester School of Medicine and Dentistry, Rochester, New York Search for more papers by this author Published Online:January 15, 2020https://doi.org/10.5664/jcsm.8150Cited by:1SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTCITATIONConnolly HV, Tomaselli LT, McKenna Benoit MK. Adenotonsillectomy for pediatric obstructive sleep apnea: how to predict those at risk for postoperative complications. J Clin Sleep Med. 2020;16(1):3–4.INTRODUCTIONUntreated pediatric obstructive sleep apnea leads to both adverse cardiopulmonary and neurocognitive outcomes. Adenotonsillectomy is currently recommended by both the American Academy of Pediatrics1 as well as the American Academy of Otolaryngology Head and Neck Surgery2 as effective treatment for pediatric obstructive sleep apnea with a success rate of approximately 80%.3,4 The overall frequency of adenotonsillectomy has decreased in recent years as the indication for surgical intervention due to infection has dropped in both the United States5 as well as England6 whereas adenotonsillectomy performed as surgical treatment for sleep-disordered breathing has increased. Adenotonsillectomy comes with attendant risks of general anesthesia in addition to complications including postoperative respiratory compromise as well as postoperative bleeding. The potential for irreversible hypoxic-ischemic encephalopathy and even death from respiratory compromise in an unmonitored setting highlights the need for clear guidelines for inpatient admission as well as clear recommendations for intensity of monitoring during hospitalization. In the era of preferential outpatient procedures, it is imperative to identify those children at risk for perioperative respiratory compromise to ensure that they are in a monitored setting until this risk is minimized.In the current issue of the Journal of Clinical Sleep Medicine, Katz et al7 report on analysis of respiratory complications occurring anytime during hospitalization immediately following adenotonsillectomy in 374 children who were studied with preoperative polysomnography and underwent adenotonsillectomy from January 2010 through December 2016 at a tertiary children’s hospital. This study is an excellent example of the utility of a retrospective review to assess risk in specific clinical scenarios. Their patient population consisted mostly of preschool and school aged children (average age 6.1 years). More than 75% of the children had medical comorbidities and nearly 50% of the population had two or more comorbidities. Obesity was highly prevalent as approximately 35% of the study population had a body mass index (BMI) above the 95th percentile for age and sex. The apnea-hypopnea index (AHI) reported on preoperative polysomnography showed an approximately even distribution of mild (AHI 1–5 events/h), moderate (AHI 5–10 events/h) and severe (AHI > 10 events/h) obstructive sleep apnea. Nearly 20% of the children had at least one postoperative respiratory complication consisting mostly of need for supplemental oxygen for desaturation but also including intubation, bag valve mask ventilatory support or physical maneuvers to support the airway (jaw thrust, oropharyngeal airway, etc.). Their findings demonstrate that patients with comorbid craniofacial, genetic, cardiac, airway anomaly or neurologic conditions are at higher risk for airway complications. Age less than 3 years was the strongest predictor of perioperative respiratory compromise, but children aged 3–6 years had a nearly 2-fold increased risk compared to school-age children. Both severity of sleep apnea and depth of oxyhemoglobin desaturation were independent predictors of postoperative respiratory compromise.Despite the strengths of this study in assessing perioperative risk for respiratory compromise in a referral population with highly prevalent medical comorbidities, this study does not provide significant insight into the management of otherwise healthy children in a community setting who are undergoing adenotonsillectomy. This is important because a large number of adenotonsillectomies are performed outside of a tertiary referral center and many of these children may not have undergone preoperative polysomnography to stratify risk. The utility of preoperative polysomnography in the evaluation of all children undergoing adenotonsillectomy remains controversial, with the American Academy of Otolaryngology Head and Neck Surgery recommending polysomnographic evaluation only for children less than 2 years of age, those with obesity, specific medical comorbidities or in situations where there are not comorbidities but the need for tonsillectomy is uncertain or there is a discordance between the physical examination and the reported severity of sleep apnea.2 In contrast, the American Academy of Sleep Medicine guidelines recommend preoperative polysomnographic evaluation for all children undergoing adenotonsillectomy for a sleep-related breathing disorder.8The well-conducted, retrospective chart review study by Katz et al7 adds important information to the published literature about risk stratification for children in a tertiary referral population undergoing adenotonsillectomy. Their findings indicate that younger children remain at higher risk as well as those children with complex comorbid medical disease. Their results indicate that children with severe sleep apnea or significant oxyhemoglobin desaturation are likewise at higher risk of postoperative respiratory compromise—emphasizing the need for preoperative polysomnography—particularly in a tertiary setting where many patients have medical comorbidities. This study does not address the utility of polysomnography in community based populations of otherwise healthy children. It is imperative to accurately ascertain risk so perioperative planning can ensure the safety of children at higher risk following adenotonsillectomy; however, there remains a paucity of studies assessing the cost-effectiveness as well as the positive and negative predictive value of polysomnographic findings. This study highlights the need for community based studies of otherwise healthy children undergoing adenotonsillectomy to ensure that children at risk receive appropriate monitoring in an inpatient setting whereas those at lesser risk are not unnecessarily hospitalized postoperatively.DISCLOSURE STATEMENTAll of the authors above have seen and approved of this commentary. The authors report no conflicts of interest.REFERENCES1. Marcus CL, Brooks LJ, Davidson Ward S, et al.. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatr. 2012;130(3):e714–e755. https://doi.org/10.1542/peds.2012-1672 CrossrefGoogle Scholar2. Mitchell RB, Archer SM, Ishman SL, et al.. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg. 2019;160(1_suppl):S1–S42. https://doi.org/10.1177/0194599818801757 CrossrefGoogle Scholar3. Brietzke SE, Gallagher D. The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg. 2006;134(6):979–984. https://doi.org/10.1016/j.otohns.2006.02.033 CrossrefGoogle Scholar4. Marcus CL, Moore RH, Rosen CL; for the Childhood Adenotonsillectomy Trial. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366–2376. https://doi.org/10.1056/NEJMoa1215881 CrossrefGoogle Scholar5. Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. Natl Health Stat Rep. 2017;(102)1–15. Google Scholar6. Banigo A, Moinie A, Bleach N, Chand M, Chalker V, Lamagni T. Have reducing tonsillectomy rates in England led to increasing incidence of invasive Group A Streptococcus infections in children?. Clin Otolaryngol. 2018;43(3):912–919. https://doi.org/10.1111/coa.13095 CrossrefGoogle Scholar7. Katz SL, Monsour A, Barrowman N, et al.. Predictors of postoperative respiratory complications in children undergoing adenotonsillectomy. J Clin Sleep Med. 2020;16(1):41–48. https://doi.org/10.5664/jcsm.8118 LinkGoogle Scholar8. Aurora RN, Zak RS, Karippot A, et al.. Practice parameters for the respiratory indications for polysomnography in children. Sleep. 2011;34(3):379–388. https://doi.org/10.1093/sleep/34.3.379 CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited by Treatment Considerations for Obstructive Sleep Apnea in Pediatric Down SyndromeGastelum E, Cummins M, Singh A, Montoya M, Urbano G and Tablizo M Children, 10.3390/children8111074, Vol. 8, No. 11, (1074) Volume 16 • Issue 1 • January 15, 2020ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationNovember 14, 2019Submitted in final revised formNovember 14, 2019Accepted for publicationNovember 14, 2019Published onlineJanuary 15, 2020 Information© 2020 American Academy of Sleep Medicine

Predictors of postoperative respiratory complications in children undergoing adenotonsillectomy.

Obstructive sleep apnea (OSA) is commonly treated with adenotonsillectomy (AT), bringing risk of perioperative respiratory adverse events (PRAEs). We aimed to concurrently identify clinical and polysomnographic predictors of PRAEs in children undergoing AT. Retrospective study of children undergoing AT at a tertiary-care pediatric hospital, with prior in-hospital polysomnography, January 2010 to December 2016. PRAEs included those requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Relationships of PRAEs to preoperative comorbidities or polysomnography results were examined with univariable logistic regression. Variables with P < .1 and age were included in backward stepwise multivariable logistic regression. Predictive performance (area under the curve, AUC) was validated with bootstrap resampling. Analysis included 374 children, median age 6.1 years; 286 (76.5%) had ≥ 1 comorbidity. 344 (92.0%) had sleep-disordered breathing; 232 (62.0%) moderate-severe; 66 (17.6%) had ≥ 1 PRAE. PRAEs were more frequent in children with craniofacial, genetic, cardiac, airway anomaly, or neurological conditions, AHI ≥ 5 events/h and oxygen saturation nadir ≤ 80% on preoperative polysomnography. Prediction modeling identified cardiac comorbidity (odds ratio [OR] 2.09 [1.11, 3.89]), airway anomaly (OR 3.19 [1.33, 7.49]), and younger age (OR < 3 years: 4.10 (1.79, 9.26; 3 to 6 years: 2.21 [1.18, 4.15]) were associated with PRAEs (AUC 0.74; corrected AUC 0.68). Prediction modeling concurrently evaluating comorbidities and polysomnography metrics identified cardiac disease, airway anomaly, and young age as independent predictors of PRAEs. These findings suggest that medical comorbidity and age are more important factors in predicting PRAEs than PSG metrics in a medically complex population.

Course of lung function in children with cystic fibrosis in their first 3 years of life.

The early prevention of respiratory complications in children with cystic fibrosis is determining for a longer survival. The implementation of lung function tests in the first months of life allows to detect respiratory involvement, even in asymptomatic children. To assess the course of lung function in children with cystic fibrosis in their first 3 years of life and identify the factors affecting it. Observational, retrospective, analytical study. Children younger than 36 months with at least 2 lung function tests were included. Between 2008 and 2016, 48 patients were included; 85 % of them had been diagnosed by newborn screening. The first lung function test was done at 5 months old. The median Z-score of maximal flow at functional residual capacity was -0.05 (interquartile range: -1.09 to 1.08). The median change in the maximal flow Z-score between tests was -0.32 (interquartile range: -1.11 to 0.25), p = 0.045. Patients with Staphylococcus aureus respiratory infections, especially methicillin-resistant SA, evidenced a greater deterioration of lung function compared to those without infection. Neither sex nor the type of genetic mutation were associated with the course of lung function. Nutritional recovery throughout the study was really good. Lung function in children with cystic fibrosis worsens progressively during their first 3 years of life. These findings are associated with Staphylococcus aureus respiratory infections.