Anesthesia For The Child With A Recent Upper Respiratory Infection - UpToDate

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Anesthesia for the child with a recent upper respiratory

infection
AUTHOR: Philipp Houck, MD
S E C T I O N E D I TO R : Lena S Sun, MD
D E P U T Y E D I TO R : Marianna Crowley, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2023.

This topic last updated: Sep 19, 2022.
INTRODUCTION
Upper respiratory infection (URI) is the most frequent human illness and the most common
infection in childhood; infants and preschoolers have six to eight URIs per year [1]. Thus,
children commonly present for surgery and anesthesia with a current or recent URI, with
potential for increased risk for perioperative respiratory adverse events.
This topic will discuss the preoperative assessment of children with a current or recent URI,
as well as intraoperative anesthesia management. Diagnosis, treatment, prevention, and
complications of URIs in children are discussed separately. (See "The common cold in
children: Clinical features and diagnosis" and "The common cold in children: Management
and prevention".)
TERMINOLOGY
The term "upper respiratory infection" (URI) may be used to describe a variety of infections.
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For the purposes of this topic, URI is meant to refer to a constellation of signs and symptoms
otherwise called "the common cold," an acute viral infection of the upper respiratory tract
involving, to variable degrees, sneezing, nasal congestion and discharge (rhinorrhea), sore
throat, cough, low-grade fever, headache, and malaise.
RISKS OF ANESTHESIA FOR THE CHILD WITH AN UPPER RESPIRATORY

INFECTION
Multiple studies have shown that children who undergo general anesthesia with a current or
recent URI are at increased risk of perioperative respiratory adverse events (PRAEs), mostly
related to airway hyperreactivity, though most of these events are mild and easily managed
[2-8]. Perioperative respiratory events increase admission rates and costs and prolong
hospitalizations [9], but long-term consequences of brief oxygen desaturations have not be
demonstrated [10].
PRAEs include laryngospasm, bronchospasm, atelectasis, coughing, airway obstruction,

hypoxia, stridor, and breathholding. Though most PRAEs are easily managed, more
significant events can occur. According to data from the Pediatric Perioperative Cardiac
Arrest Registry, after cardiovascular causes, respiratory events were the second-most
common cause of perioperative cardiac arrests in children, with laryngospasm being the
most likely cause for respiratory-induced cardiac arrests [11,12].
Time course of PRAE risk — Airway hyperreactivity, which increases the risk of
laryngospasm and bronchospasm, decreases over time with a URI, though the literature on
the time course of resolution is inconsistent. While some studies have shown increased
airway reactivity for up to four weeks after the URI [2,3,6,8], one study found no increase in
PRAEs in children with rhinorrhea two to four weeks prior to anesthesia [13], and one large
study reported a decrease in PRAEs in patients who had a URI two to four weeks prior to a
procedure [2].
Evidence for risk of PRAEs — Evidence for increased risk of PRAEs in children with URIs
comes from prospective and retrospective observational studies, most of which excluded
patients who were obviously ill with purulent rhinitis, productive cough, fever, and malaise.
Examples include the following:
● A prospective observational study included approximately 9300 children who

underwent general anesthesia for elective, urgent, and emergent procedures in one
institution, including those with active URIs [2]. The relative risk for a PRAE doubled in
patients who had an active URI or had a URI in the two weeks preceding the anesthetic.
A URI two to four weeks prior lowered the risk for PRAEs.
● A prospective study of approximately 400 children who underwent general anesthesia

reported a higher incidence of minor oxygen desaturations (ie, SpO2 ≤95 percent for
≥60 seconds) in children with a mild URI and a higher incidence of bronchospasm in
patients with a URI who were intubated, but no increase in major oxygen desaturations
(ie, SpO2 ≤85 percent for ≥30 seconds or laryngospasm [5]. In this study, patients were
excluded if they had purulent URIs, fever >101°F, or at the anesthesiologist's discretion.

for elective surgical procedures reported higher incidence of breath-holding, oxygen
desaturations to <90 percent, and overall adverse respiratory events in children with
active or recent (ie, within four weeks preoperatively) URIs, but none was associated
with long-term adverse sequelae [3]. Other risk factors that increased the incidence of
PRAEs in children with active URIs include a history of reactive airway disease, surgical
procedure on the airway, a history of prematurity, exposure to second-hand cigarette
smoke, nasal congestion or copious secretions, and endotracheal intubation. Patients
were excluded if they had severe URIs, lower respiratory infection, evidence of bacterial
infection, and at the discretion of the anesthesiologist.
● A prospective study of approximately 2000 children who presented for anesthesia at

one institution reported that the parent's statement that the child had a cold, sputum
production, and nasal congestion increased the risk of PRAEs, along with other, non-URI
related variables [8]. In this study, a URI in the six weeks prior to anesthesia did not
increase the risk of complications. Infants with URIs; patients with fever, malaise, or
wheezing; and others at the discretion of the anesthesiologist were excluded.
for elective surgery reported that the risk of PRAEs was increased in patients with an
active or recent (ie, within two weeks of surgery) respiratory infection (odds ratio [OR]
3.72) [4]. Patients with active purulent rhinitis, active bronchitis, or fever >38°C were
excluded.
● A study of the relationship between preoperative URI symptoms and adverse events
during emergence from anesthesia included the amalgamated data on 335 patients
from several prospective studies [6]. Adverse respiratory event outcomes included
oxygen desaturation, coughing, laryngospasm, time in the recovery room, and time of
postoperative oxygen supplementation. There was a tendency toward adverse events if
peak URI symptoms had occurred in the four weeks prior to anesthesia. A low-grade
fever was associated with a lower rate of postoperative respiratory complications.
Anesthesia was postponed at the discretion of the anesthesiologist, such that exclusion
criteria with regard to URI symptoms are unclear.
● A retrospective case-control study including 130 children who had laryngospasm under
general anesthesia reported an association between laryngospasm and intercurrent
URI (OR 2.03) [7].
● URI may increase the risk of PRAEs during procedural sedation as well. In a prospective
multicenter database study including approximately 83,500 children who underwent
procedural sedation reported increases in the incidence of airway-related adverse
events and airway interventions in children with recent URIs, and further increases in
children with current URIs [14]. An airway adverse event (eg, cough, laryngospasm,
desaturation, apnea >15 seconds) occurred in approximately 6 percent of children
without a URI, 9 percent of children with a recent URI, 15 percent of children with a
current URI with clear secretions, and 22 percent of children with a current URI with
thick secretions.
Other risk factors for PRAEs — A number of patient, surgical, and anesthetic factors have
been shown to increase the risk for PRAEs in patients with and without a URI ( table 1). The
following risk factors increase the risk for PRAEs in patients with and without URI and should
be considered in assessing the risk of anesthesia for a specific child:
● Ear, nose, and throat (ENT) procedures [2,13]
● Airway anomalies such as subglottic stenosis, cleft palate, Pierre-Robin sequence, and
laryngomalacia [7]
● Absence of a pediatric anesthesiologist [2,15]
● Passive exposure to smoke [16,17]
● Patient or family history of asthma or atopy [18]
● Young age, with infants at highest risk [3,13,15,19,20]
Choice of airway device — The choice of airway device may affect the risk of PRAEs in
children without a URI. In general, increasing airway stimulation is associated with higher
risk of at least some PRAEs (ie, mask ventilation < supraglottic airway < endotracheal
intubation). A meta-analysis of 16 randomized controlled studies including 1240 children <12
years of age that compared laryngeal mask airways (LMAs) with ETT for anesthesia reported
increased cough and postoperative sore throat with ETT, but no difference in the incidence of
bronchospasm or laryngospasm on emergence [21].
The effect of the choice of airway device on the risk of PRAEs in small infants is unclear; many
studies comparing LMAs with ETT have either excluded infants or did not specify patient
ages. In one single center study, 180 infants <1 year of age were randomly assigned to LMA
or ETT for airway management for general anesthesia [22]. LMAs were associated with a
lower risk of all perioperative PRAEs than ETTs (18 versus 53 percent) and a lower risk of
laryngospasm and bronchospasm (4 versus 19 percent). However, it may not be possible to
generalize the results of this study, as the incidence of PRAE was unusually high, criteria for
extubation were not specified, the anesthetic techniques were not standardized, and all
patients were cared for by attending pediatric anesthesia specialists. Therefore, further study
is required before basing the choice of airway device for infants on the risk of PRAEs.
Many pediatric anesthesiologists, including this author, routinely use an ETT rather than a
supraglottic airway for small infants. SGAs may not seal well in infants, and tend to become
dislodged. Infants desaturate quickly, and there is less time to react to problems with the
airway device. In addition, the infant's airway may not be easily accessible, and it can be
difficult to rescue a malpositioned SGA or replace it with an endotracheal tube. We extubate

most patients with ETT awake, to avoid the chance of laryngospasm on emergence. (See
"General anesthesia in neonates and children: Agents and techniques", section on
'Emergence and extubation'.)
The COLDS score — A decision-making tool, "COLDS" ("Current signs/symptoms, Onset,

Lung disease, airway Device, Surgery"), incorporates most risk factors for the child with a
URI, with the notable exception of age ( table 2) [23,24]. The COLDS score does not
designate a cutoff that would indicate a safe anesthetic; it can serve as a reminder of all
factors one should consider. It helps in identifying where on the spectrum of perioperative
risk a particular patient lies. If this risk is acceptable, the decision to proceed or postpone still
needs to be made based on local resources and individual experience.
PREOPERATIVE EVALUATION
History — Most decisions regarding the anesthetic plan for children with a URI can be made
based on history and physical examination, if not by history alone. Signs and symptoms that
should be elicited include fever, clear or green nasal secretions, wet or dry cough, wheezing,
changes in respiratory pattern, shortness of breath, anorexia, malaise, and/or changes in
playfulness and physical activity. The disease course of sick contacts in the patient's family
can help predict the course of the illness.
Simply asking the parents or caregivers whether a child is sick is an important part of
preoperative evaluation. A case-control study of 123 children who developed perioperative
laryngospasm found that laryngospasm was twice as likely in patients with an active URI, as
defined by the parents, compared with those without an active URI [25].
Most often, a patient with a significant URI who is scheduled for an elective procedure can be
advised to postpone the procedure during a preoperative screening phone call the day
before the anesthetic. Postponement before the patient even reaches the healthcare facility
avoids unnecessary fasting, interruption of the operating room schedule, economic
hardship, and inconvenience for the patient and family. At our institution, the nurses who
make the preoperative phone calls are authorized to cancel elective cases at the time of the
phone call if symptoms of URI are present.
Physical examination — Patients should be examined for obvious signs of a URI such as
nasal discharge, repeated coughing, a sick appearance, and/or fever. The chest should be
auscultated for wheezing, crackles, or rhonchi as signs of lower respiratory infection.
Inspection of the throat can help in making a more specific diagnosis (eg, patients with
coxsackie infections who present with herpangina).
Laboratory and radiologic examination — Preoperative laboratory and radiologic

evaluation are rarely necessary or helpful for otherwise healthy children with a URI. The need
for testing should be individualized based on patient comorbidities and the surgical
procedure. For example, for ex-premature infants who need elective procedures, it may be
helpful to rule out a respiratory syncytial virus (RSV) infection, as RSV infection at the time of
anesthesia has been associated with increased risk of unplanned postoperative intensive
care unit (ICU) admission and increased length of hospital stay [26].
Blood tests for immunologic markers of allergic sensitization and systemic inflammation are
not useful predictors of perioperative respiratory adverse events (PRAEs) [18].
Concerns during the COVID-19 pandemic — During the COVID-19 pandemic, preoperative
evaluation should include COVID-19 screening or testing for patients who are not known to
have COVID-19, and for all patients, risk assessment related to COVID-19. Risk assessment
includes both the likelihood of perioperative morbidity and mortality, and also the risk of
spread of the virus to care providers and other patients. This is discussed in detail separately.
(See "COVID-19: Perioperative risk assessment, preoperative screening and testing, and
timing of surgery after infection", section on 'Preoperative evaluation'.)
Timing of elective procedures — Timing of elective surgery for a child with current or
recent URI symptoms remains controversial. Although clinical practice varies widely, a survey
of approximately 200 pediatric anesthesiologists reported that those with more clinical
experience were more conservative compared with anesthesiologists with less experience
[27]. While each situation must be individualized, taking into account both medical and
practical concerns, our approach is generally as follows:
● URI found on preoperative screening – For children who are found during
preoperative screening prior to an elective procedure to have or have had a URI, we

postpone the procedure until two to four weeks after symptoms subside. (See 'Time
course of PRAE risk' above.)
● Patients who present with an ACTIVE URI the day of an elective procedure – When
patients present the day of surgery with symptoms of a URI, we decide whether to
postpone the procedure on an individual basis, taking into account the severity of URI
symptoms, the patient's risk factors, the planned procedure, and the medical and
practical disadvantages of postponement.
• For patients with only mild rhinorrhea and mild symptoms at the time of a minor
procedure, we do not postpone anesthesia.
• For patients who present with fever ≥38°C or a wet cough, we postpone elective
procedures until two to four weeks after symptoms subside.
• For patients with moderate symptoms, we make an individualized decision.
● Patients who present with a RECENT URI the day of an elective procedure – For
patients who are currently asymptomatic but are found to have had a recent URI, we
use the following approach:
• URI within two weeks – When patients present on the day of surgery with a history
of URI in the preceding two weeks, we decide whether to postpone the procedure
on an individual basis, taking into account the patient's risk factors, the planned
procedure, and the medical and practical disadvantages of postponement. In
general, we proceed with elective procedures for older children who have been
asymptomatic for more than one week. We often postpone the procedure for two to
four weeks for younger, higher-risk patients who are to undergo higher-risk
procedures.
• URI two to four weeks ago – We do not usually postpone a procedure when a
patient has been asymptomatic for two to four weeks after a URI, recognizing that
airway hyperreactivity may persist for up to six weeks.
● Urgent procedures – For patients who present with a URI for urgent or semiurgent
procedures, the risks and benefits of postponement should be weighed in a discussion

between the anesthesiologist, the surgeon, and the other care providers. When we
proceed, we medically optimize as time allows. For urgent procedures, we administer
inhaled beta2 agonists and a nasal decongestant, as needed. Truly emergent
procedures that cannot wait until an inhaled beta2 agonist or a nasal decongestant is
administered are rare. (See 'Preoperative optimization' below.)
PREOPERATIVE OPTIMIZATION
Inhaled short-acting beta-2 agonist — Patients with asthma or recurrent wheezing who
present with a (URI) are treated preoperatively with an inhaled short-acting beta2 agonist
(SABA) such as albuterol. We routinely administer a SABA 20 to 30 minutes prior to induction
of anesthesia (albuterol via nebulizer 2.5 mg if <20 kg, 5 mg if >20 kg, or via metered dose
inhaler [MDI] with spacer, two to eight puffs). (See "Anesthesia for the child with asthma or
recurrent wheezing", section on 'Premedication'.)
In most cases, there is little disadvantage to premedication with an inhaled beta2 agonist for
children without asthma who present with current or recent URI symptoms, though
literature on the benefits is conflicting. A prospective observational study of 400 children with
a recent URI reported a 35 percent decrease in perioperative respiratory events in children
who were premedicated with an inhaled beta2 agonist compared with those who were not
treated [28]. In contrast, in a randomized trial of school age children with risk factors for
PRAEs who underwent general anesthesia with an LMA, the rates of perioperative PRAEs
were similar in children who were premedicated with salbutamol and those who received
placebo [29]. However, in this study, only 23 percent of children had a URI in the two weeks
prior to anesthesia.
Antisialagogue — Once intravenous (IV) access is established, an antisialagogue should be

administered (eg, glycopyrrolate 4 mcg/kg IV) in order to minimize secretions and to
decrease the chance of laryngospasm. (See 'Laryngospasm' below.)
Nasal decongestant — For patients ≥6 years of age with significant rhinorrhea who require
urgent procedures, we administer topical nasal decongestant spray (eg, oxymetazoline nasal
spray 0.05%, not more than two to three sprays per nostril) before induction of anesthesia in
order to decrease laryngeal and tracheal irritation from secretions. We also suction the nose
prior to induction. For toddlers and children up to six years of age, we may administer topical
nasal decongestant, limiting the dose to one gentle half-spray per nostril. We do not
administer nasal decongestant spray to infants.
Chest physical therapy — Whenever significant bronchial secretions are present, we clap
the chest with a cupped hand or a facemask to loosen secretions, and we encourage the
patient to cough them up. Use of incentive spirometry is encouraged postoperatively in all
patients with a URI who are hospitalized and old enough to use it.
Glucocorticoids — Perioperative systemic glucocorticoids should be reserved for patients

with poorly controlled asthma (see "Anesthesia for the child with asthma or recurrent
wheezing" and "Anesthesia for the child with asthma or recurrent wheezing", section on
'Supplemental glucocorticoids'). Limited data suggest that inhaled glucocorticoids may
reduce the incidence of perioperative oxygen desaturation in children with URI [30]. Further
study is required before recommending routine use of inhaled glucocorticoids in this setting.
ANESTHESIA MANAGEMENT
Premedication — We prefer to use distraction techniques (eg, toys, video games, stickers) or
parental presence prior to anesthesia for patients with a URI, rather than administration of
sedatives. Multiple studies have shown that premedication of a patient with a URI with
benzodiazepines increases the risk for respiratory complications [2,6,7,13]. Premedication
with midazolam not only invites respiratory complications by delaying awakening and
prolonging the excitatory phase of emergence from anesthesia, but it can also lead to
decreased functional residual capacity (FRC) and an alteration in respiratory mechanics [31].
In a small observational study including 164 children who were premedicated with
midazolam for strabismus surgery, antagonism of midazolam with flumazenil during
emergence from anesthesia was associated with a decrease in respiratory complications in
the post-anesthesia care unit [32].
Airway management — When possible, we minimize airway instrumentation for patients
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with current or recent URI in order to decrease the risk of laryngospasm and bronchospasm.
A number of studies have compared the risks associated with various anesthesia airway
management devices for children with URIs.
● A retrospective review of a pediatric anesthesia database included approximately

22,300 children, including approximately 1300 with a URI [33]. Children who had a URI
and endotracheal intubation had an 11-fold higher incidence of adverse respiratory
events than children without a URI, compared with a ninefold increase in perioperative
respiratory adverse events (PRAEs) without intubation.
● A prospective study of 82 children who presented for elective surgery randomized

patients to airway management with an endotracheal tube (ETT) or a laryngeal mask
airway (LMA) [34]. Compared with the use of an LMA, endotracheal intubation increased
the risks of mild bronchospasm (12 versus 0 percent), major oxygen desaturation
during airway placement (12.5 versus 0 percent), and the total number of adverse
airway events (35 versus 19 percent). All respiratory complications were easily managed
without sequelae.
● A prospective observational study that included approximately 750 children who

presented for anesthesia with a recent or current URI found that use of an ETT
increased the incidence of breath-holding, severe cough, oxygen desaturation, and
overall PRAEs compared with the use of a facemask or LMA [3]. The majority of adverse
events associated with an ETT occurred during removal of the ETT or in the recovery
room.
● An observational study including approximately 900 children with a current or recent

URI who underwent anesthesia reported an increase in respiratory complications with
endotracheal intubation compared with LMA or mask ventilation [8].
● A prospective observational study of 831 children who underwent anesthesia with an

LMA reported a higher incidence of laryngospasm, cough, and oxygen desaturation in
children with a URI compared with healthy children [13]. This study did not compare the
LMA with alternative airway devices.
Induction and maintenance of anesthesia — Management of induction and maintenance
of anesthesia for the child with a URI are similar to such management for children with
asthma, which are discussed separately. (See "Anesthesia for the child with asthma or
recurrent wheezing", section on 'Induction of anesthesia' and "Anesthesia for the child with
asthma or recurrent wheezing", section on 'Maintenance of anesthesia'.)
Ventilation during anesthesia — Ventilatory strategy for children with URIs during
anesthesia should be designed to avoid atelectasis. Ciliary clearance of bronchial and
tracheal secretions is impaired under general anesthesia (more so with sevoflurane
compared with propofol) [35], which can lead to a decrement of pulmonary function and
increased risk of atelectasis in patients with URIs.
We usually use lung-protective mechanical ventilation principles (ie, low tidal volumes;
positive end-expiratory pressure [PEEP]; if necessary, prolonged inspiratory to expiratory
ratio) for children with URIs.
If bronchospasm develops during anesthesia, the ventilatory strategy should be designed to

reduce air trapping via reduction in minute ventilation and inspiratory to expiratory ratio.
(See "Anesthesia for the child with asthma or recurrent wheezing", section on 'Ventilation
during anesthesia'.)
Intraoperative airway events — Laryngospasm, bronchospasm, coughing, and breath-

holding are more likely to occur in patients with a current or recent URI. Management can
include deepening the level of anesthesia, as well other specific maneuvers.
Laryngospasm — Laryngospasm is the sustained closure of the vocal cords by constriction

of the intrinsic muscles of the larynx. It can make ventilation difficult or impossible and can
quickly lead to hypoxemia and bradycardia, as well as significant morbidity or mortality. The
risk of laryngospasm increases with airway instrumentation and/or unnecessary stimulation
during a light level of anesthesia, as well as with copious airway secretions. Blood and
secretions should be suctioned from the airway before lightening the level of anesthesia.
Diagnosis — Signs of laryngospasm under anesthesia include:
● Inspiratory stridor or airway obstruction

● Increased inspiratory effort/retractions
● Paradoxical chest and abdominal movements

● Inability to ventilate via mask or LMA
Treatment — Laryngospasm must be treated immediately. Management of

laryngospasm starts with application of continuous positive airway pressure with 100
percent oxygen and deepened anesthesia. If ventilation is not possible, a neuromuscular
blocking agent (NMBA) should be administered to relax the laryngeal muscles and allow
mask ventilation. Risk factors, prevention, and management of intraoperative laryngospasm
in children are discussed more fully separately ( algorithm 1). (See "General anesthesia in
neonates and children: Agents and techniques", section on 'Laryngospasm'.)
Bronchospasm — Intraoperative bronchospasm may be suspected in the patient with

wheezing on chest auscultation, slow or incomplete expiration on inspection, change in the
end-tidal carbon dioxide waveform, decreased tidal volume, high inspiratory pressure, or
decreasing oxygen saturation. The evaluation and management of intraoperative
bronchospasm in the child with a recent URI is similar to that in the child with asthma. This is
discussed in more detail separately. (See "Anesthesia for the child with asthma or recurrent
wheezing", section on 'Intraoperative bronchospasm'.)
EMERGENCE
Laryngospasm and other perioperative respiratory adverse events (PRAEs) can occur during
emergence from anesthesia and at extubation. In many cases, the airway device can be
removed either "deep," while the patient is still deeply anesthetized, or awake. Deep
extubation can result in smoother emergence without the irritation of the airway device in
place. We usually extubate patients with upper respiratory tract infections (URIs) deep unless
there is a contraindication, such as blood or secretions in the airway (eg, during ear, nose,
and throat procedures) or previous difficulty with mask ventilation or intubation.
Literature on the risk of PRAEs related to the timing of extubation is inconsistent. One
prospective study of approximately 1100 anesthetized children with and without current or
recent URIs found that the depth of anesthesia at the time of removal of either an
endotracheal tube (ETT) or a laryngeal mask airway (LMA) had no effect on the incidence of
PRAEs [3]. Another prospective study of approximately 9300 children with and without URIs
reported a lower incidence of PRAEs when an LMA was removed deep, but a lower incidence
of PRAEs if an ETT was removed awake [2].
POSTOPERATIVE CONCERNS
Adverse respiratory events can occur intraoperatively or during the postoperative period.
Laryngospasm is almost exclusively an intraoperative event and rarely occurs once the
patient completely regains consciousness. However, oxygen desaturation, bronchospasm,
and cough can occur in the recovery room and later in the postoperative course. (See
"Respiratory problems in the post-anesthesia care unit (PACU)".)
Most otherwise healthy children with URIs have an uncomplicated postoperative course and
rarely require unplanned admission to the hospital [3]. If the intraoperative course is
uneventful and pain and nausea are well controlled, postoperative management may be
similar to that of children without URIs [3].
Children with asthma or recurrent wheezing are at increased risk for postoperative
respiratory complications. Other groups of patients with URIs at higher risk of significant
postoperative respiratory complications include those with documented influenza or
respiratory syncytial virus (RSV) infection and those with congenital heart disease.
● A retrospective case-control study of 24 children with documented influenza and RSV

infection who underwent anesthesia prior to the viral diagnosis reported an increase in
unplanned intensive care unit (ICU) admission and hospital length of stay compared
with controls [26]. Half of the infected patients had no preoperative URI symptoms, and
there was no increase in overall perioperative complications, need for positive pressure
ventilation, or mortality in the patients with RSV or influenza.
● Children with congenital heart disease who undergo cardiac surgery with a URI may be
at increased risk for PRAEs and other postoperative complications. A prospective study
of 713 children who presented for open heart surgery, 96 of whom had an active URI,
reported that those with a URI were at increased risk of respiratory complications,
postoperative infections, multiple complications, and increased length of ICU stay [36].
There was no increase in major morbidity or mortality or hospital length of stay in

patients with a URI.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Pediatric
anesthesia".)
SUMMARY AND RECOMMENDATIONS
● Risks of anesthesia – Upper respiratory infection (URI) is a common illness, and

children often present for anesthesia with a current or recent URI. Children with current
or recent URIs are at increased risk for perioperative respiratory adverse events (PRAEs)
including laryngospasm, bronchospasm, oxygen desaturation, cough, and breath-
holding, though most of these events are mild and easily treated. (See 'Risks of
anesthesia for the child with an upper respiratory infection' above.)
● Timing of anesthesia – Our approach to the timing of anesthesia for children with
current or recent URI is as follows (see 'Timing of elective procedures' above):
• URI found on preoperative screening – For children who are found during
preoperative screening for elective surgery to have a current or recent URI, we
postpone the procedure until two to four weeks after symptoms subside.
• ACTIVE URI the day of an elective procedure – For patients with an active URI on
the day of an elective procedure, our decision to postpone surgery is individualized,
taking into account the severity of URI symptoms, the patient's risk factors, the
planned procedure, and the medical and practical disadvantages of postponement:
- For patients with only mild rhinorrhea and mild symptoms at the time of a
minor procedure, we do not postpone anesthesia.
- For patients who present with fever ≥38°C or a wet cough, or who are obviously
ill, we postpone elective procedures until two to four weeks after symptoms
subside.
- For patients with moderate symptoms, we make an individualized decision.
• RECENT URI discovered the day of an elective procedure – For patients who are
currently asymptomatic but are found to have had a recent URI, we use the
following approach:
- URI within two weeks – In general, we proceed with elective procedures for
older children who have been asymptomatic for more than one week. We often
postpone the procedure for two to four weeks for younger, higher-risk patients
who are to undergo higher-risk procedures.
- URI two to four weeks ago – We do not usually postpone a procedure when a
patient has been asymptomatic for two to four weeks after a URI, recognizing
that airway hyperreactivity may persist for up to six weeks.
• Urgent procedures – For patients who present with a URI for urgent or semiurgent
procedures, the risks and benefits of postponement should be weighed in a
discussion between the anesthesiologist, the surgeon, and the other care providers.
● Premedication – For children with symptoms of a URI, we usually premedicate as

follows:
• We administer a short-acting beta2 agonist (eg, albuterol via nebulizer 2.5 mg if <20
kg, 5 mg if >20 kg, or via metered dose inhaler [MDI] with spacer, two to eight puffs).
• For children ≥6 years of age with rhinorrhea, we administer topical nasal

decongestant spray (eg, oxymetazoline nasal spray 0.05%, not more than two to
three sprays per nostril) before induction.
• Once intravenous (IV) access is established, we administer an antisialagogue (eg,

glycopyrrolate 4 mcg/kg IV). (See 'Preoperative optimization' above.)
● Induction and airway management
• Principles for induction and maintenance of anesthesia for the child with a URI are
similar to those for the child with asthma or recurrent wheezing. (See 'Induction and
maintenance of anesthesia' above.)
• When possible, we minimize airway instrumentation for patients with a current or

recent URI. We prefer facemask to the use of a supraglottic airway (SGA) and SGA
placement to endotracheal intubation. (See 'Airway management' above.)
● Laryngospasm
• Intraoperative laryngospasm can quickly lead to hypoxia and bradycardia and can
result in morbidity and mortality. The risk of laryngospasm increases with airway
instrumentation, especially under light levels of anesthesia, and with the presence of
airway secretions. Treatment of laryngospasm includes continuous positive airway
pressure with 100 percent oxygen and, if necessary, administration of a
neuromuscular blocking agent (NMBA) ( algorithm 1). (See 'Laryngospasm' above.)
• Laryngospasm, bronchospasm, and other PRAEs can occur at the time of emergence
from anesthesia and extubation. We prefer to remove airway devices under deep
levels of anesthesia to minimize airway stimulation under light anesthesia. (See
'Emergence' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Monto AS. Studies of the community and family: acute respiratory illness and infection.
Epidemiol Rev 1994; 16:351.
2. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory
complications in paediatric anaesthesia: a prospective cohort study. Lancet 2010;
376:773.
3. Tait AR, Malviya S, Voepel-Lewis T, et al. Risk factors for perioperative adverse respiratory
events in children with upper respiratory tract infections. Anesthesiology 2001; 95:299.
4. Bordet F, Allaouchiche B, Lansiaux S, et al. Risk factors for airway complications during
general anaesthesia in paediatric patients. Paediatr Anaesth 2002; 12:762.

5. Rolf N, Coté CJ. Frequency and severity of desaturation events during general anesthesia
in children with and without upper respiratory infections. J Clin Anesth 1992; 4:200.
6. Rachel Homer J, Elwood T, Peterson D, Rampersad S. Risk factors for adverse events in
children with colds emerging from anesthesia: a logistic regression. Paediatr Anaesth
2007; 17:154.
7. Flick RP, Wilder RT, Pieper SF, et al. Risk factors for laryngospasm in children during
general anesthesia. Paediatr Anaesth 2008; 18:289.
8. Parnis SJ, Barker DS, Van Der Walt JH. Clinical predictors of anaesthetic complications in
children with respiratory tract infections. Paediatr Anaesth 2001; 11:29.
9. Oofuvong M, Geater AF, Chongsuvivatwong V, et al. Excess costs and length of hospital
stay attributable to perioperative respiratory events in children. Anesth Analg 2015;
120:411.
10. Oofuvong M, Geater AF, Chongsuvivatwong V, et al. Comparison of intelligence, weight

and height in children after general anesthesia with and without perioperative
desaturation in non-cardiac surgery: a historical and concurrent follow-up study.
Springerplus 2014; 3:164.
11. Bhananker SM, Ramamoorthy C, Geiduschek JM, et al. Anesthesia-related cardiac arrest
in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth
Analg 2007; 105:344.
12. Morray JP, Bhananker SM. Recent findings from the Pediatric Perioperative Cardiac
Arrest (POCA) Registry. ASA Newsletter 2005; 69:10.
13. von Ungern-Sternberg BS, Boda K, Schwab C, et al. Laryngeal mask airway is associated
with an increased incidence of adverse respiratory events in children with recent upper
respiratory tract infections. Anesthesiology 2007; 107:714.
14. Mallory MD, Travers C, McCracken CE, et al. Upper Respiratory Infections and Airway
Adverse Events in Pediatric Procedural Sedation. Pediatrics 2017; 140.
15. Mamie C, Habre W, Delhumeau C, et al. Incidence and risk factors of perioperative
respiratory adverse events in children undergoing elective surgery. Paediatr Anaesth
2004; 14:218.
16. Kim SY, Kim JM, Lee JH, et al. Perioperative respiratory adverse events in children with
active upper respiratory tract infection who received general anesthesia through an
orotracheal tube and inhalation agents. Korean J Anesthesiol 2013; 65:136.
17. Skolnick ET, Vomvolakis MA, Buck KA, et al. Exposure to environmental tobacco smoke
and the risk of adverse respiratory events in children receiving general anesthesia.
Anesthesiology 1998; 88:1144.
18. von Ungern-Sternberg BS, Ramgolam A, Hall GL, et al. Peri-operative adverse respiratory
events in children. Anaesthesia 2015; 70:440.
19. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a
closed claims analysis. Anesthesiology 1990; 72:828.
20. Morray JP, Geiduschek JM, Caplan RA, et al. A comparison of pediatric and adult
anesthesia closed malpractice claims. Anesthesiology 1993; 78:461.
21. Patki A. Laryngeal mask airway vs the endotracheal tube in paediatric airway
management: A meta-analysis of prospective randomised controlled trials. Indian J
Anaesth 2011; 55:537.
22. Drake-Brockman TF, Ramgolam A, Zhang G, et al. The effect of endotracheal tubes
versus laryngeal mask airways on perioperative respiratory adverse events in infants: a
randomised controlled trial. Lancet 2017; 389:701.
23. Lee BJ, August DA. COLDS: A heuristic preanesthetic risk score for children with upper
respiratory tract infection. Paediatr Anaesth 2014; 24:349.
24. Lee LK, Bernardo MKL, Grogan TR, et al. Perioperative respiratory adverse event risk
assessment in children with upper respiratory tract infection: Validation of the COLDS
score. Paediatr Anaesth 2018; 28:1007.
25. Schreiner MS, O'Hara I, Markakis DA, Politis GD. Do children who experience
laryngospasm have an increased risk of upper respiratory tract infection?
Anesthesiology 1996; 85:475.
26. Spaeder MC, Lockman JL, Greenberg RS, et al. Impact of perioperative RSV or influenza
infection on length of stay and risk of unplanned ICU admission in children: a case-
control study. BMC Anesthesiol 2011; 11:16.
27. Tait AR, Reynolds PI, Gutstein HB. Factors that influence an anesthesiologist's decision to
cancel elective surgery for the child with an upper respiratory tract infection. J Clin
Anesth 1995; 7:491.
28. von Ungern-Sternberg BS, Habre W, Erb TO, Heaney M. Salbutamol premedication in
children with a recent respiratory tract infection. Paediatr Anaesth 2009; 19:1064.
29. Ramgolam A, Hall GL, Sommerfield D, et al. Premedication with salbutamol prior to
surgery does not decrease the risk of perioperative respiratory adverse events in school-
aged children. Br J Anaesth 2017; 119:150.
30. Michelet D, Julien-Marsollier F, Bahaji M, Dahmani S. Potential beneficial effect of pre-

operative nebulisation of corticosteroids in children with upper respiratory tract
infection. Eur J Anaesthesiol 2019; 36:796.
31. von Ungern-Sternberg BS, Erb TO, Habre W, et al. The impact of oral premedication with
midazolam on respiratory function in children. Anesth Analg 2009; 108:1771.
32. Sun R, Wang G, Gao X, Wang S. Flumazenil reduces respiratory complications during
anesthesia emergence in children with preoperative upper respiratory tract infections.
Medicine (Baltimore) 2018; 97:e0516.
33. Cohen MM, Cameron CB. Should you cancel the operation when a child has an upper
respiratory tract infection? Anesth Analg 1991; 72:282.
34. Tait AR, Pandit UA, Voepel-Lewis T, et al. Use of the laryngeal mask airway in children
with upper respiratory tract infections: a comparison with endotracheal intubation.
Anesth Analg 1998; 86:706.
35. Ledowski T, Paech MJ, Patel B, Schug SA. Bronchial mucus transport velocity in patients
receiving propofol and remifentanil versus sevoflurane and remifentanil anesthesia.
Anesth Analg 2006; 102:1427.
36. Malviya S, Voepel-Lewis T, Siewert M, et al. Risk factors for adverse postoperative
outcomes in children presenting for cardiac surgery with upper respiratory tract
infections. Anesthesiology 2003; 98:628.
Topic 91498 Version 19.0
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GRAPHICS
Factors that have been associated with an increased risk for perioperative
respiratory adverse events in children
Patient factors
Age; younger higher risk than older
Premature birth
Upper respiratory tract infection (≤2 weeks)
Recurrent wheezing
Current/past asthma
Nocturnal dry cough
Wheezing during exercise
Hayfever
Current/past eczema
Family history of asthma, eczema, hayfever
Passive/active smoker
Other respiratory illnesses (eg, bronchopulmonary dysplasia, cystic fibrosis)
Previous history of apnea
Obstructive sleep apnea
Obesity
Syndromes associated with airway obstruction (eg, Down Syndrome)
Anemia, hematocrit level less than 30%
Unfasted patient
Surgical factors
Shared airway procedures (eg, ear, nose, and throat; dental; respiratory)
Blood, secretions in upper airway
Sudden surgical stimulation
Emergency procedure
Anesthesia-related factors
Premedication with midazolam
Topical airway lidocaine
Inhalational induction of anesthesia
Invasive airway management (endotracheal tube > laryngeal mask airway > facemask)
Less experience with airway management
Insufficient supervision ratio for trainees (eg, supervisor absent for critical periods during
anesthesia)
Desflurane administration
High-dose opioid administration, intraoperative or postoperative
Administration of neuromuscular blocking agents
Nurse-to-patient ratio in the recovery area (<1:1)
Mixed anesthetic clinical practice (adult/pediatric > solely pediatric)
Original ﬁgure modiﬁed for this publication. von Ungern-Sternberg B. Respiratory complications in the pediatric post-
anesthesia care unit. Anesthesiol Clin 2014; 32:45. Table used with the permission of Elsevier Inc. All rights reserved.
Graphic 99883 Version 7.0
The COLDS score
1 2 5
C: Current None Mild Moderate/severe

signs/symptoms
Examples: Parent Examples:

confirms URI and/or Purulence, wet
congestion, cough, abnormal
rhinorrhea, sore lung sounds,
throat, sneezing, low lethargy, "toxic"
fever, or dry cough appearance, or high
fever
O: Onset >4 weeks ago 2-4 weeks ago <2 weeks ago
L: Lung disease None Mild Moderate/severe
Examples: Hx of RSV, Examples: Moderate

mild intermittent persistent asthma,
asthma, CLD if >1 infant with CLD,
year old, loud OSA, or pulmonary
snoring, or passive HTN
smoker
D: Airway device None or facemask Laryngeal mask airway Tracheal tube

planned or supraglottic airway
S: Airway surgery Other (including ear Minor airway Major airway

planned tubes)
Examples: T/A, NLD Examples: Cleft

probe, flexible palate, rigid
bronchoscopy, and bronchoscopy, and
dental extractions maxillofacial
Each category (column 1) is assigned 1, 2, or 5 points (columns 2-4), to obtain a total score ranging
from 5 to 25. Examples are illustrative and not intended to be all-inclusive.
URI: upper respiratory tract infection; Hx: history; RSV: respiratory syncytial virus; CLD: chronic lung
disease; OSA: obstructive sleep apnea; T/A: tonsillectomy and/or adenoidectomy; NLD: nasolacrimal
duct.
From: Lee BJ, August DA. COLDS: A heuristic preanesthetic risk score for children with upper respiratory tract infection. Paediatr
Anaesth 2014; 24:349. DOI: 10.1111/pan.12337. Copyright © 2014. Reproduced with permission of John Wiley & Sons Inc. This
image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint,
printed, shared or emailed. Please contact Wiley's permissions department either via email: permissions@wiley.com or use the
RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library
(http://onlinelibrary.wiley.com).
Management of intraoperative laryngospasm in children
CPAP: continuous positive airway pressure; IV: intravenous; IM: intramuscular.
* To apply laryngospasm notch pressure, apply pressure with the fingertips to the area between the
mastoid process, the ramus of the mandible, and the base of the skull. Laryngospasm notch pressure
is also known as "Larson's maneuver".
¶ If succinylcholine is contraindicated, administer rocuronium 1.2 mg/kg IV, or if no IV access, 1 mg/kg

IM in children <1 year of age, 1.8 mg/kg IM in children >1 year of age; expect prolonged duration of
paralysis.
Adapted from: Orliaguet GA, Gall O, Savoldelli GL, Couloigner V. Case scenario: perianesthetic management of laryngospasm
in children. Anesthesiology 2012; 116:458.
Contributor Disclosures
Philipp Houck, MD No relevant financial relationship(s) with ineligible companies to disclose. Lena S
Sun, MD Other Financial Interest: McGraw Hill [Royalties on pediatric anesthesia handbook]. All of the
relevant financial relationships listed have been mitigated. Marianna Crowley, MD No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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Anesthesia for the child with a recent upper respiratory

Literature review current through: Dec 2023.

RISKS OF ANESTHESIA FOR THE CHILD WITH AN UPPER RESPIRATORY

PRAEs include laryngospasm, bronchospasm, atelectasis, coughing, airway obstruction,

Examples include the following:

● A prospective observational study included approximately 9300 children who

● A prospective study of approximately 400 children who underwent general anesthesia

● A prospective study of approximately 1100 children who underwent general anesthesia

● A prospective study of approximately 2000 children who presented for anesthesia at

● A prospective study of approximately 2000 children who underwent general anesthesia

● Ear, nose, and throat (ENT) procedures [2,13]

● Absence of a pediatric anesthesiologist [2,15]

● Passive exposure to smoke [16,17]

● Patient or family history of asthma or atopy [18]

● Young age, with infants at highest risk [3,13,15,19,20]

difficult to rescue a malpositioned SGA or replace it with an endotracheal tube. We extubate

The COLDS score — A decision-making tool, "COLDS" ("Current signs/symptoms, Onset,

phone call if symptoms of URI are present.

Laboratory and radiologic examination — Preoperative laboratory and radiologic

preoperative screening prior to an elective procedure to have or have had a URI, we

• For patients with moderate symptoms, we make an individualized decision.

procedures, the risks and benefits of postponement should be weighed in a discussion

Antisialagogue — Once intravenous (IV) access is established, an antisialagogue should be

Glucocorticoids — Perioperative systemic glucocorticoids should be reserved for patients

Airway management — When possible, we minimize airway instrumentation for patients

● A retrospective review of a pediatric anesthesia database included approximately

● A prospective study of 82 children who presented for elective surgery randomized

● A prospective observational study that included approximately 750 children who

● An observational study including approximately 900 children with a current or recent

● A prospective observational study of 831 children who underwent anesthesia with an

Induction and maintenance of anesthesia — Management of induction and maintenance

If bronchospasm develops during anesthesia, the ventilatory strategy should be designed to

Intraoperative airway events — Laryngospasm, bronchospasm, coughing, and breath-

Laryngospasm — Laryngospasm is the sustained closure of the vocal cords by constriction

Diagnosis — Signs of laryngospasm under anesthesia include:

● Inspiratory stridor or airway obstruction

● Paradoxical chest and abdominal movements

Treatment — Laryngospasm must be treated immediately. Management of

Bronchospasm — Intraoperative bronchospasm may be suspected in the patient with

● A retrospective case-control study of 24 children with documented influenza and RSV

There was no increase in major morbidity or mortality or hospital length of stay in

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Risks of anesthesia – Upper respiratory infection (URI) is a common illness, and

- For patients with moderate symptoms, we make an individualized decision.

● Premedication – For children with symptoms of a URI, we usually premedicate as

• For children ≥6 years of age with rhinorrhea, we administer topical nasal

• Once intravenous (IV) access is established, we administer an antisialagogue (eg,

● Induction and airway management

• When possible, we minimize airway instrumentation for patients with a current or

Use of UpToDate is subject to the Terms of Use.

general anaesthesia in paediatric patients. Paediatr Anaesth 2002; 12:762.

10. Oofuvong M, Geater AF, Chongsuvivatwong V, et al. Comparison of intelligence, weight

30. Michelet D, Julien-Marsollier F, Bahaji M, Dahmani S. Potential beneficial effect of pre-

Age; younger higher risk than older

Upper respiratory tract infection (≤2 weeks)

Nocturnal dry cough

Wheezing during exercise

Family history of asthma, eczema, hayfever

Other respiratory illnesses (eg, bronchopulmonary dysplasia, cystic fibrosis)

Previous history of apnea