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International Journal of Pediatric Otorhinolaryngology 73 (2009) 10951099

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International Journal of Pediatric Otorhinolaryngology


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Complications in children who electively remain intubated after adenotonsillectomy for severe Obstructive Sleep Apnea
James W. Schroeder Jr.a,*, Amy S. Anstead b, Hausin Wong c
a

Childrens Memorial Hospital, Chicago, Pediatric Otolaryngology, 2300 Childrens Plaza, Box 25, Chicago, IL 60614, USA University of Illinois, Chicago, Medical Center, Otolaryngology Division, 1740 West Taylor Street, Chicago, IL 60612, USA c University of California, Irvine, Division of Otolaryngology, Irvine, CA 92697, USA
b

A R T I C L E I N F O

S U M M A R Y

Article history: Received 31 January 2009 Received in revised form 5 April 2009 Accepted 7 April 2009 Available online 20 May 2009 Keywords: Obstructive Sleep Apnea Adenotonsillectomy Intubation

Objective: To compare the indications for and the postoperative course of children who are electively left intubated postoperatively vs. those who are not after urgent adenotonsillectomy (T&A) for severe Obstructive Sleep Apnea (OSA). Methods: A retrospective study of children with severe OSA diagnosed by polysomnogram (PSG) who were admitted to the Pediatric Intensive Care Unit (PICU) after urgent adenotonsellectomy between January 2002 and June 2006. Those who were electively left intubated after surgery were compared to those who were extubated. Results: n = 70. Fifty-three were extubated postoperatively. Seventeen remained intubated. All were admitted to the PICU postoperatively. Method of tonsillectomy and PSG indices were not signicantly different between the two groups. Children who remained intubated had a higher complication rate (47%) than those who did not (2%). Children who remained intubated were younger and had a higher ASA (American Society of Anesthesiologist) physician status classication and had a longer PICU and hospital stay. Children under three who were extubated did not require reintubation. Conclusions: Children who electively remain intubated after urgent adenotonsellectomy for severe OSA have a higher complication rate and require a longer hospital stay than those who are extubated. None of the extubated children required reintubation. We recommend a trial of extubation in these patients. 2009 Elsevier Ireland Ltd. All rights reserved.

1. Background Children with severe Obstructive Sleep Apnea (OSA) who require adenotonsillectomy (T&A) may require additional airway support postoperatively [13]. The rate of postoperative respiratory compromise requiring medical intervention in children undergoing T&A for OSA ranges from 2136% [1,2]. Most of these children are extubated in the operating room following T&A and can be managed conservatively postoperatively with blow by oxygen, nasal cannula oxygen and/or continuous or bi-level positive airway pressure (CPAP or BiPAP). In some cases, patients are electively left intubated in the operating room and sent to Pediatric Intensive Care Unit (PICU) for further care and extubation. There are no clear guidelines to determine which children should remain intubated and which children should undergo a trial of extubation in the operating room at the completion of the procedure. The risk of postoperative airway compromise after T&A for severe OSA in children younger than 3 years of age and in

children with concurrent comorbidities is well documented [47]. Some physicians choose to keep these high-risk children intubated postoperatively to minimize the risk of postoperative airway obstruction and respiratory failure. Unfortunately, there remains inherent risk in electively leaving a child intubated after adenotonsillectomy. The aim of this study was to determine the potential consequence of electively leaving children with severe OSA intubated after urgent adenotonsillectomy for severe OSA and to determine the utility of this practice. 2. Methods Approval was obtained from the Childrens Memorial Hospital (Chicago, IL) IRB. The charts for all children admitted to the PICU from January 2002June 2006 with the primary admitting diagnosis of OSA were reviewed. Children who meet the following criteria were included in this study: (1) they were admitted directly to the PICU from the sleep lab due the severity of OSA, (2) the nal polysomnogram (PSG) report veried severe OSA, (3) an urgent adenotonsillectomy was performed during the same admission, and (4) the patient received postoperative care in the PICU. Severe OSA was dened by a respiratory distress index (RDI)

* Corresponding author. Tel.: +1 773 883 6181 fax: +1 773 880 4110. E-mail address: jschroeder@childrensmemorial.org (J.W. Schroeder Jr.). 0165-5876/$ see front matter 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.04.007

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greater than 25, end tidal CO2 >50 mm Hg, O2 saturation <90% for greater than 10 s or the persistence of desaturation and apneas despite O2 therapy [8]. Two groups were identied and compared: Group one comprised those children who electively remained intubated after surgery without a trial of extubation and Group two comprised those who were extubated in the operating room but were managed with alternative airway interventions including: positioning, oxygen supplementation and/or CPAP or BiPAP. Postoperative complications, technique of adenotonsillectomy, length of stay in the PICU, length of total hospital stay, age, comorbidities, American Society of Anesthesiologists (ASA) physician status classication, PSG ndings including: apnea index (AI), respiratory depression index (RDI), peak end tidal carbon dioxide level (ETCO2), and oxygen saturation (nadir O2) were compared. All sleep studies were performed at the Childrens Memorial Hospital Sleep Lab in a standardized fashion. All sleep studies were read and interpreted by the same attending Sleep Medicine physician. Only patients whose preoperative PSG was available and read as severe sleep apnea were included in the study. Chi-square, T-tests, negative bimodal regressions and Fishers exact tests were then completed and statistical signicance noted. 3. Results A total of 70 children with PSG veried severe OSA were urgently admitted to the PICU for urgent T&A from January 2002 June 2006. All underwent T&A and the technique used was not signicantly different between the two groups (Table 1). A similar anesthetic technique was used in all cases. Mask induction was achieved with nitrous oxide and sevoourane. Dexamethasone (0.5 mg/kg IV) was given intraoperatively. Morphine at 0.1 mg/kg IV was also used. No intraoperative antibiotics were given. Fiftythree (53) children were extubated in the operating room immediately following the T&A and were not reintubated. Fortythree percent (43%) of these children required postoperative oxygen supplementation, BiPAP and/or CPAP. Seventeen (17) children electively remained intubated postoperatively. There was no trial of extubation. The average duration of the intubation was 3.4 days. The intubated children remained in the PICU 3.79 days longer than their non-intubated counterparts (<0.0001). The average total length of an intubated childs hospital stay was 7 days longer than the non-intubated child (p < 0.0001) (Fig. 1). None of the PSG indices were signicantly different between groups (Table 2). The average age of the children in the intubated group was younger, (2.7 years of age), than in the non-intubated group, 4.6 years old (p = 0.002). The ASA physician status classication was higher for the intubated group (3.06) than the non-intubated group (2.4) (p < 0.0001). Eighty-two percent of the children who were electively left intubated had some comorbidity other than OSA. This was in contrast to 34% of the extubated children. This difference was statistically signicant (p < 0.001). When comorbidities were separated into type, i.e., aspiration, hypertension, history of prematurity and craniofacial disorder, they all were signicantly

Fig. 1. Length of stay.

Table 2 Polysomnogram indices. Intubated (n = 17 RDI AI O2 nadir ET CO2 max 56.18 22.66 57.66 53.36 Extubated (n = 53) 46.29 22.38 63.74 55.59 p value 0.31 0.97 0.15 0.2746

more prevalent in the intubated group. However, the presence of asthma/chronic lung disease, chromosomal abnormality, neurologic disorder, Down syndrome, development delay, and cardiac disease were not signicantly different across groups (Table 3). Body Mass Index (BMI) was recorded for 38 of the extubated children and 11 of the intubated children. Height was not available for the remaining children so BMI could not be calculated. BMI was categorized into four groups: Underweight (BMI <18.5), Normal (BMI 18.524.9), Overweight (BMI 2529.9) and Obese (BMI >30). In the intubated group, 33% were underweight, 33% were normal weight, 11% were overweight and 22% were obese. In the nonintubated group 34% were underweight, 12.5% were normal weight, 15% were overweight and 37% were obese (Fig. 2). Postoperative complication rates among children who remained intubated after adenotonsillectomy were much higher (47%) when compared to children who were extubated (2%) (p < 0.0001). (Table 4 and Fig. 3). Two children suffered cardiopulmonary arrest. The rst occurred in a child after a selfextubation on postoperative day 3 and the second was due to opioid toxicity on postoperative day 1. One child suffered postobstructive pulmonary edema after a self-extubation on postoperative day 3. This was in a child with a history of severe asthma.

Table 3 Comorbidities. Intubated Comorbidity Aspiration Hypertension History of prematurity Craniofacial Abnormality Developmental delay Asthma/CLD Chromosomal abnormality Neurologic disorder Down syndrome Cardiac disease 82% 2 2 3 5 5 4 4 3 1 55 Extubated 34% 0 0 1 1 6 9 4 6 2 2 p value p < 0.0001 p = 0.011 p = 0.011 p = 0.015 p = 0.019 p = 0.075 p = 0.546 p = 0.072 p = 0.50 p = 0.709 p = 0.217

Table 1 Style of tonsillectomy. Intubated Bovie electrocautery dissection Bovie setting average (Watts) Cold dissection Coblater dissection Microderidder 13 12.74 13 1 0 Extubated 33 13.5 3 0 1 Value p = 0.62 p = 0.74 p = 0.24 p = 0.99

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required a return to the operating room for a therapeutic rigid bronchoscopy for mucous plugging and subsequent mild respiratory distress. This resolved after the bronchoscopy and removal of the bronchial mucous plug. 4. Discussion It is well documented that children with severe OSA (RDI > 40, O2 saturation nadir < 70%) and adenotonsillar hypertrophy who undergo T&A are more likely to have postoperative respiratory complications than children without severe OSA; Especially if they are under the age of 2, have craniofacial abnormalities, failure to thrive, hypotonia, obesity and/or cor pulmonale [2]. It is not clear if there is an advantage to leaving these children intubated electively postoperatively as a way to avoid possible airway complications. One rational for electively leaving these children intubated is that it allows time for some of the postoperative airway swelling to resolve. Another is preventing the increased incidence of postoperative hypoventilation that is seen in these children. This appears to be related to the severity of the OSA. An RDI > 10 has been identied as a risk factor for postoperative desaturation to <70% or postoperative hypercapnia to more than 45mmHg [1]. It has also been reported that an RDI me than 40 is a signicant predictor of postoperative UAO and oxygen desaturation to <80% [2]. However, delaying the extubation may increase complications in this already high-risk group. Determining which children should electively remain intubated is a difcult question to answer. There are no published guidelines and there is not much literature on the subject. According to our IRB, it would be ethically problematic to randomize children into an extubated and electively intubated group for a prospective study to address this question; Hence, this retrospective study. Data suggest that, at our institution, children diagnosed with severe OSA with adenotonsillar hypertrophy undergoing urgent T&A are more likely to electively remain intubated after surgery if they are under 3 years old and have a higher ASA physician status grading due to comorbidities. Comorbidities that were signicantly more common in the intubated group included a history of aspiration during feeding, hypertension, history of prematurity and craniofacial disorder. However, the incidence of asthma/chronic lung disease (CLD), chromosomal abnormality, neurologic disorder, Down syndrome, developmental delay, and cardiac disease were not signicantly different across groups. Of particular interest is the fact that asthma/CLD was not more common in the intubated group as it is accepted as a risk factor for postoperative respiratory morbidity [4]. Also, there was a higher percentage of overweight or obese children in the extubated group than in the children who were left intubated. The intubated children were more likely to be of normal weight or be underweight for their age. PSG indices were not related to postoperative intubation status. Our entire patient group was diagnosed with severe OSA based on PSG ndings. As per the protocol at our institution, all children who meet the criteria for severe OSA (as outlined in Section 2) while in the sleep lab were admitted to the PICU for further observation and intervention prior to discharge home. We have therefore selected a group of children with extremes of severe OSA. This is demonstrated by the exceptionally high average RDI for each group; 56 for the intubated and 46 for the extubated group (not statistically signicantly different). It is within this group of children with severe OSA that the surgeon and anesthesiologist must decide which patients are most at risk for postoperative respiratory compromise and thus will benet from electively remaining intubated postoperatively. Technique of T&A was similar across both groups. The wattage setting was similar (12.7 vs. 13.5 W) when the tonsils were

Fig. 2. BMI. Table 4 Postoperative complications. Intubated (n = 17) Complication Cardiopulmonary Arrest Post-obstructive pulmonary edema Pneumonia Aspiration Transfusion (phlebotomy induced anemia) Left sided atelectasis Return to OR for Bronch 47% 2 2 4 1 1 0 2 Extubated (n = 53) 2% 0 0 0 0 0 1 0 p value

<0.0001 0.011 0.011 0.0002 0.075 0.075 0.568 0.011

Four children developed pneumonia postoperatively. One was diagnosed on postoperative day (POD) 3 based on endotracheal tube cultures and chest X-ray (CXR). Another was diagnosed on POD 3 based on CXR alone. This patient was extubated on POD 4. Another was diagnosed on POD 1 based on CXR. This child had a history of URI ndings the day prior to the procedure. The last case was diagnosed on POD 2 based on CXR. This patient was extubated on POD 1 and did not require reintubation despite the pneumonia diagnosis. All patients were treated with a combination of IV and oral antibiotics and all children recovered. One patient had an aspiration event at the time of a failed extubation and subsequently developed acute respiratory distress syndrome (ARDS) and was intubated for a total of 14 days. This patient recovered fully. The patient who required a transfusion for phlebotomy induced anemia was a 23-month-old ex 30-weekpreemie who had chronic lung disease. The patient who developed a left sided atelectasis had viral upper respiratory tract symptoms prior to the T&A. The atelectasis resolved with supportive care and did not require reintubation. Two children

Fig. 3. Complication rate.

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removed with monopolar elecrocautery. Technique of tonsillectomy appears to have no correlation with whether a child remains intubated or is extubated in the operating room immediately postoperatively. Children who electively remained intubated were much more likely to have a postoperative complication and to have a longer hospital course than those who were extubated in the operating room. Intubated children were inpatients for a week longer, on average, than extubated children. Furthermore, their PICU stay was, on average, almost 4 days longer than their extubated counterparts. The most striking nding is that the major complication rate was 47% in the intubated group compared with 2% of the extubated group. Postoperative complications including cardio pulmonary arrest, pneumonia, postoperative pulmonary edema and return to the operating room for bronchoscopy where all statistically signicantly more common in the intubated group. All of these children eventually were discharged from the hospital in stable condition with no permanent sequela. Due to the nature of this study we are unable to determine whether the increased complication rate is due solely to the fact that these children remained intubated. The intubated children and those who were extubated had the same severity of sleep apnea based on the PSG indices. However, the intubated children tended to be younger and have a higher ASA. However, it is important to note that all children under 3 years of age (22 of 53) and those with comorbidities such as hypotonia and/or craniofacial anomalies (10 of 53) who were extubated immediately postoperatively did not require reintubation. Many of these children did have residual postoperative obstruction but this was adequately managed using alternative means of airway support. In fact, none of the children who were extubated postoperatively required reintubation. All children were eventually discharged home without additional support. It is unclear if the complications seen in the intubated group were related to the intubation or to other factors. They may have occurred whether the child was left intubated or not. At least two of the cases of postoperative pneumonia that occurred during the rst few days after the procedure may have been related to preoperative illness such as a mild upper respiratory tract infection. However, it is interesting to note that the one child that developed postoperative atelectasis had preoperative URI symptoms but did well despite not being left intubated postoperatively. The child that developed post-obstructive pulmonary edema may have developed this due the history of severe asthma and not due to the intubation itself. Several of the complications appear to be more directly related to the intubation itself. This includes 2 patients who developed pneumonia greater than 3 days after the procedure while still intubated and the children who developed mucous plugging due to inactivity and poor pulmonary toilette. Several of the complications are related to the medical care that an intubated child requires. This includes the sedation and inactivity associated with intubation. Sedating a child in this condition is difcult and complications can be related to undersedation (self-extubation) and oversedation (cardiopulmonary arrest). It is unclear what determined the duration of intubation in these children. The level of sedation, comorbidities, PICU attending preference and time of admission to he PICU all seemed to play a role, none more signicantly than the other. There is no clear standardized protocol to try and extudate these children promptly on the PICU. The children who developed a complication were intubated 3 days longer, on average, then the children who did not develop a complication. Based on the information and the nature of the study we were unable to determine causality.

Postoperative respiratory compromise, particularly upper airway obstruction, after T&A should be anticipated in children with severe OSA. The severity of respiratory complications ranges from minor oxygen desaturation to life threatening respiratory failure [2]. Studies show that most perioperative complications occur during induction of anesthesia or emergence from anesthesia [9]. Children with more severe OSA as measured by PSG experience more severe complications [9]. The great majority of children with postoperative upper airway obstruction causing respiratory distress can be managed with non-invasive support. In their study on perioperative compilations after T&A for OSA Saunders et al. report a 46% complication rate at emergence with one child requiring reintubation for bleeding in the recovery room [9]. The majority of patients were managed with nasal canula oxygen, CPAP or BPAP which has been shown to be well tolerated in children as young as 9 months of age [10]. Due to the demonstrated success of non-invasive airway support and the signicantly increased complication rate seen in children who are electively left intubated after T&A we recommend a trial of extubation in the immediate postoperative period following T&A for OSA. 5. Conclusions Children who were electively left intubated after T&A for severe OSA were younger, had a higher ASA grading and had more comorbidities. Children younger than 3 years old and those who had comorbidities who did not remain intubated did not require reintubation and did not have an increased stay or complication rate. PSG indices and technique of adenotonsillectomy were not signicantly different when comparing the children who remained intubated after T&A to those who do not. Children who remain intubated were more likely to have a complicated postoperative course and prolonged hospital stay. None of the children who were extubated required reintubation. Some did require additional temporary, non-invasive airway support. We cannot conclude that the children who were not promptly extubated had a more complicated course due solely to the fact that they electively remained intubated. There is a lack of published information on this topic. Due to the success rate of non-invasive airway support in managing upper airway obstruction and due to the signicantly elevated complication rate in children who remain electively intubated we recommend a trial of extubation in the immediate postoperative period in children after undergoing T&A for severe OSA. Acknowledgement Special thanks to Christine Sullivan for all her hard work, understanding and statistical analysis. References
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