Professional Documents
Culture Documents
): 19-26
1
Department of Anesthesiology, Sapienza University of Rome, Rome, Italy
2
Department of Sense Organs, Sapienza University of Rome, Rome, Italy
3
Department of Clinical Sciences and Translational Medicine, Tor Vergata University, Rome, Italy
4
Department of Medicine, Surgery and Neuroscience, ENT Clinic, University of Siena, Siena, Italy
5
Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Rome, Italy
Table I. Severity ranking system based on polysomnography. plaints are snoring and difficulty to breath during
Apnea- Oxygen sleep; some children may also present difficult
Hypopnea saturation and noisy breathing during the day.
index nadir The etiology of pediatric OSAS is multifacto-
Normal 0-1 > 92 rial and is specially associated to adenotonsillar
Mild OSA 2-4 hypertrophy. Actually, tonsillectomy with ade-
Moderate OSA 5-9 noidectomy (adenotonsillectomy) is the first treat-
Severe OSA >10 < 80 ment line in many pediatric OSAS patients6.
Erickson et al7 investigated epidemiological
OSAS = obstructive sleep apnea syndrome
trends in tonsillectomy and adenotonsillectomy
and reported that the indication to perform a ton-
sillectomy and adenotonsillectomy have sub-
In this review, we examine the most recent stantially shifted in the last years: whereas in
literature on pediatric OSAS and discuss the role 1970 infections represented the main indication
of the anesthesiologist before, during and after for tonsillectomy and adenotonsillectomy (88%),
adenoidectomy and tonsillectomy surgery. today the main indication is a pharyngeal ob-
struction (77%).
Preoperative investigations
Materials and Methods The correct identification of OSAS patients
is important for the anesthesiologist because it
A literature review has been performed on changes the perioperative and postoperative man-
articles retrieved from PubMed and Scopus from agement as children with OSAS are at higher risk
the last 30 years on the following topics: clinical for perioperative airway obstruction8.
aspects of pediatric OSAS, preoperative inves- Preoperative evaluation of a patient for po-
tigations including questionnaires, clinical pa- tential identification of OSAS includes medical
rameters and laboratory polysomnography and record review, patient and family interview and
home sleep apnea testing, anesthesiologic preop- questionnaires, physical examination, laboratory
erative management, anesthesiologic periopera- polysomnography (PSG) and home sleep apnea
tive management, anesthesiologic postoperative testing. The diagnosis has historically been based
management including postoperative analgesia, on patient history and physical exam; however,
postoperative nausea and vomiting (PONV) and it is important to underline that the hypertrophy
post-tonsillectomy bleeding. of tonsils and adenoids is not correlated with the
severity of OSAS. The in-laboratory PSG is the
gold standard for the diagnosis of OSAS, but
guidelines recommend this exam for definitive
Results diagnosis only in specific cases. Actually, consid-
ering the cost of in-laboratory PSG and the incon-
Clinical aspects of pediatric OSAS venience to the patient and caregiver, this is often
OSAS is defined by the American Thoracic not a reasonable option. When it is not possible
Society5 as “a disorder of breathing during sleep to execute PSG, many children with symptoms
characterized by prolonged partial upper airway of OSAS go unrecognized and thus may be at
obstruction and/or intermittent complete ob- risk for perioperative respiratory adverse events.
struction (obstructive apnea) that disrupts nor- Questionnaires are a simple practical tool to
mal ventilation during sleep and normal sleep identify children with symptoms consistent with
patterns”. OSAS and SDB; the most common are the OSA-
OSAS in children is a distinct disorder from 189, the Pediatric Sleep Questionnaire Sleep-Re-
the condition that occurs in adults, such that the lated Breathing Disorder10 and the Snoring, Trou-
clinical manifestations, diagnostic criteria and, ble Breathing, Un-Refreshed scales11. Schnoor et
more important, treatment approaches need to be al12 reported that the use of three core-questions
considered in an age-specific manner. (Does your child regularly snore at night? Does
OSAS affects 1-3% of children1; the most your child demonstrate labored breathing during
prevalent age group is in pre-school age children sleep? Does your child have breathing pauses
between 3 and 5 years. The most common com- during sleep?) may facilitate the detection of pe-
20
OSAS in children: the role of the anesthesiologist
diatric OSAS within the scope of the anesthesia with complex medical conditions such as obesi-
survey. Unfortunately, given the subjectivity of ty, Down syndrome, craniofacial abnormalities,
questionnaires as a form of data collection, they neuromuscular disorders, sickle cell disease, or
failed to reach statistically significant results in mucopolysaccharidoses and in patients for whom
detecting OSAS. the diagnosis is unclear or discordant with the
History and physical examination aimed to history or physical exam. Overall, it is estimated
investigate typical symptoms such as snoring and that only 10% of children undergo a PSG prior
apneas and excessive daytime sleepiness are cru- to adenotonsillectomy for SDB18. Actually, PSG
cial in the preoperative investigation; however, is expensive, time consuming, and labor inten-
they have limitations in the ability to determine sive. For this reason, the researchers are studying
the severity of SDB. Actually, it is important to home sleep apnea testing. Some individuals use
underline that presumptive diagnosis based on overnight oximetry as a screening tool for OSAS,
history and physical exam agrees with objective but compared with PSG, it has limited sensitivi-
data obtained from PSG in about 30-50% of chil- ty and specificity19. Unattended monitoring with
dren13 and neither tonsil size nor palate positions 4-7 channels (Type three studies) has sparse and
are reliable indicators of disease severity. Nolan conflicting data regarding utility in the pediatric
et al14 reviewed the biomedical literature for data population20.
comparing clinical and subjective tonsil size to
objectively measured OSAS using PSG, and they Preoperative management
found that the association between subjective pe- Accessing the operating room is a cause of
diatric tonsil size and objective OSAS severity is anxiety, especially for young patients and the
weak at best. presence of parents during induction of anesthe-
In the last decade, research15,16 efforts have sia may be helpful in reducing patient anxiety.
been made to identify laboratory biomarkers for The anesthesiologists must consider the in-
pediatric OSAS. Gozal et al17 assess that high-sen- creased complications expected in OSAS patients
sitivity C-reactive protein are higher in children and anxiolytics and sedatives must be carefully
with OSAS, and particularly in those who devel- administrated in these patients (Table II). Pre-
op neurocognitive deficits as OSAS in children is medication in children is performed with oral
associated with substantial neurobehavioral and midazolam (0.5 mg/kg) or clonidine; both drugs
cognitive dysfunction. However, more studies have been shown to be effective and safe. Dex-
are needed to demonstrate the clinical utility in medetomidine and ketamine have also been pro-
the use of serum biomarkers as screening tools posed although the safety of their use in pediatric
for pediatric OSAS. Laboratory PSG and home patients with OSAS is still being studied.
sleep apnea testing are necessary before surgery.
The American Academy of Sleep Medicine, the Perioperative management
American Academy of Otolaryngology – Head Perioperative respiratory adverse events may
and Neck Surgery, and the American Academy of be more frequent in children with symptoms
Pediatrics published the guidelines8 regarding the of SDB and OSAS. Although many of these
appropriate use of laboratory PSG for the diagno- events can be easily recognized and treated, some
sis of OSAS in children. These guidelines recom- can be life-threatening and preventing measures
mend performing in-laboratory PSG in patients must be taken in these patients.
21
R. Bellucci, F. Campo, M. Ralli, C. Buonopane, S. Di Girolamo, et al
22
OSAS in children: the role of the anesthesiologist
disease27,28. Down’s syndrome patients have cal technique and may have serious complications
predisposing factors to OSAS including large including death34,35. The bleeding is most likely to
tongue, narrow nasopharynx, hypoplastic man- occur within the first 24 hours after surgery and
dibula, muscular hypotonia, obesity, tracheal 6-10 days after tonsillectomy. The main factors
abnormalities, and lymphoid hyperplasia 29. For to be considered in post-tonsillectomy bleeding
their anatomical features of head and neck are potential hypovolemic shock, pulmonary as-
anatomy, these patients often require an ade- piration, and potential difficult intubation due to
notonsillectomy29-31. bleeding obscuring the view and oedema from
The majority of children undergoing adenoid- the previous surgery3,36.
ectomy and tonsillectomy are discharged the day Most clinicians perform preoperative investi-
of the surgery. The 2011 Academy of Otolar- gations such as clotting profile, full blood count,
yngology - Head and Neck Surgery guidelines grouping and cross-matching of blood, to reduce the
suggested inpatient postoperative care for chil- incidence of bleeding during and after tonsillecto-
dren with severe OSAS (AHI ≥10/h), SpO2 nadir my. However, although these exams may be useful
<80%, and/or age <3. In 2012, the American in patients who have a history suggestive of a major
Academy of Pediatrics also published guidelines8 bleeding disorder, routine preoperative coagulation
recommending postoperative admission for chil- studies are not recommended in all patients37,38.
dren with OSAS aged <3 years, obese, or with
SpO2 nadir <80%, or peak PCO2 ≥60 mm Hg.
While the American Society of Anesthesiologists
did not issue specific guidelines for postoperative Discussion
admission for children with OSAS, it recom-
mended monitoring these patients until they can Children with OSAS are at higher risk for
maintain their oxygen saturation on room air at perioperative airway obstruction; therefore, the
rest, and preferably while sleeping22. correct identification of OSAS patients is import-
Children with severe OSAS and those with ant for the anesthesiologist because it changes
comorbidities may also require postoperative in- the perioperative and post-operative management.
tensive care unit admission. Preoperative evaluation of a patient for potential
identification of OSAS includes medical record
Postoperative nausea review, patient and family interview and question-
and vomiting naires, physical examination, laboratory PSG and
A major problem in pediatric patients under- home sleep apnea testing. The in-laboratory PSG
going tonsillectomy and adenotonsillectomy is is the gold standard for the diagnosis of OSAS,
the high incidence of PONV. Antiemetic drugs but guidelines recommend this exam for definitive
can reduce PONV; however, their use is not diagnosis only in specific cases; however, when it
always safe. The combination of paracetamol, is not possible to execute PSG, many children with
NSAIDs, and fentanyl provide excellent analgesia OSAS are unrecognized and may be at risk for
with minimal PONV after elective tonsillectomy perioperative respiratory adverse events.
and adenotonsillectomy32. Preoperative management is mainly aimed at
Dexamethasone is widely used to prevent reducing anxiety and agitation and is often per-
PONV in pediatric tonsillectomy. In one study formed using oral midazolam.
from Czarnetzki et al33 the use of high doses of Perioperative respiratory adverse events are
dexamethasone was associated to bleeding after more frequent in children with OSAS and some
tonsillectomy; however, high doses were not re- of these events can be life-threatening. The use
quired to produce an anti-emetic effect. Accord- of perioperative opioid in children with OSAS
ing to recent studies, dexamethasone could also should be carefully evaluated as chronic inter-
have an analgesic effect although further research mittent hypoxia, typical in patients with SDB,
is needed. upregulates the expression of opioid receptors
and therefore increases the effects of these drugs.
Post-tonsillectomy bleeding Other phases that deserve attention are the in-
Post-tonsillectomy bleeding is an emergency duction of anesthesia, ventilation and intubation,
and can lead to rapid deterioration of hemody- as the relaxation of musculature can lead to the
namics34,35. The incidence of bleeding following collapse of the upper airways causing a difficult
tonsillectomy is 0.5-2% depending on the surgi- mask ventilation.
23
R. Bellucci, F. Campo, M. Ralli, C. Buonopane, S. Di Girolamo, et al
It is important to monitor postoperative ther- before, during and after surgery, as pediatric pa-
apy especially in children with OSAS, because tients are at higher risk of preoperative, perioper-
postoperative respiratory adverse events can be ative and postoperative adverse events including
life-threatening. The use of opioids in OSAS airway obstruction, PONV, and bleeding.
children is not safe as they can have a stronger
depressing effect on the central nervous system.
NSAIDs are instead recommended to control
postoperative paid. Sources of Funding
A major problem in pediatric patients under- This work was supported by the Italian Society of Rhi-
going tonsillectomy and adenotonsillectomy is nology. The sponsor provided financial support for costs
the high incidence of PONV; dexamethasone is related to the publication of this article. The sponsor was
not involved in the study design, in the collection and in-
currently used to prevent this complication and terpretation of data, in the writing of the study, or in the
may have a significant role especially in children decision to submit the article for publication.
with SDB and OSAS.
Post-tonsillectomy bleeding is an emergency
and could lead to rapid death34,35,36. Unfortunately,
preoperative coagulation studies in all pediat- Conflict of Interests
ric patients undergoing tonsillectomy have not The authors declare that they have no conflict of interest.
shown to be cost-effective and their role seems
to be limited to patients who have a history sug-
gestive of a major bleeding disorder.
Further studies to understand preoperatively References
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