Abstract
This chapter presents one of the most common pediatric surgeries, adenotonsillectomy. The author reviews in the indications for adenotonsillectomy in the setting of a child with obstructive sleep apnea (OSA). The perioperative considerations for this extremely high risk population of children with OSA is considered with respect to the anesthetic considerations.
A four-year-old child presents over winter break for a tonsillectomy, adenoidectomy, and bilateral ear tubes. When interviewing the patient, mom reports her child “snores all night long, sometimes stops breathing, and has fallen asleep in her preschool class.” She has no neurologic or developmental delays.
She has had a series of ear infections, with the most recent infection last month. A hearing test was performed, showing diminished hearing which is causing her to fall behind her peers with regard to speech development.
In the preoperative area, she had clear rhinorrhea, non-productive cough. She complains of left ear pain. Her temperature is 38.0°C and the perioperative nurse discusses case cancellation with you. Lung auscultation is clear bilaterally.
How Common Is Pediatric Obstructive Sleep Apnea (OSA) Syndrome?
Currently 1–4% of children carry a diagnosis of OSA and with improved diagnostic techniques, the prevalence will continue to increase.
What Is the Difference Between Sleep Disordered Breathing and OSA?
Sleep disordered breathing is a generalized term that encompasses all abnormalities associated with breathing during sleep, ranging from snoring to obstructive sleep apnea.
Obstructive sleep apnea is a form of sleep disordered breathing with specific criteria including the symptoms of snoring, increased respiratory effort, periodic obstructive apnea, and oxygen desaturation.
What Is the Gold Standard for Diagnosing OSA?
The most reliable and validated way to diagnose OSA is by an overnight polysomnogram.
The diagnostic criteria for OSA in children include a child with an apnea duration of two breaths, hypopnea desaturation >3%, hypopnea duration of two breaths and hypopnea nasal pressure drop >50%.
How Do You Determine the Severity of OSA?
The severity of OSA is based on four criteria:
Apnea-hypopnea index (AHI), number of hypopnea/apnea events secondary to obstructive events during sleep for 60 min as observed during polysomnography
Nadir of oxygen saturation
Percentage of sleep time with a PETCO2 > 50 mmHg
Respiratory arousal index (RAI): the number of respiratory arousals per hour of sleep
Severe obstructive sleep apnea has an AHI >10, nadir SpO2 <80%, PETCO2 >50 mm Hg >20% of the total sleep time, and RAI >8 per hour of total sleep time.
Commonly used severity classifications are the indices from the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea and the McGill Oximetry scoring system (Tables 31.1 and 31.2). In the absence of a sleep study, the clinical questionnaire OSA 18 can be used to determine the presence and severity of pediatric OSA.
Table 31.1 OSA severity scale by AHI between children and adults from the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. AHI, apnea hypopnea index; OSA, obstructive sleep apnea
| OSA severity | AHI in children | AHI in adults |
|---|---|---|
| None | 0 | 0–5 |
| Mild | 1–5 | 6–20 |
| Moderate | 6–10 | 21–40 |
| Severe | >10 | >40 |
Table 31.2 The McGill Oximetry Scoring System. The severity of OSA is determined by the SpO2 nadir and by the number of desaturation events during nocturnal oximetry. OSA, obstructive sleep apnea
| Oximetry score | OSA classification | No. of desaturation events <90% SpO2 | No. of desaturation events <85% SpO2 | No. of desaturation events <80% SpO2 |
|---|---|---|---|---|
| 1 | Normal | <3 | None | None |
| 2 | Mild | ≥3 | ≤3 | None |
| 3 | Moderate | ≥3 | >3 | ≤3 |
| 4 | Severe | ≥3 | >3 | >3 |
What Are the Most Common Indications for Tonsillectomy in Children?
The most common indications for tonsillectomy include sleep-disordered breathing in younger age–group children and recurrent throat infections in older children. Both of these conditions can negatively impact the quality of a child’s health. In the United States, tonsillectomy is one of the most common surgical procedures. There are more than 530,000 cases performed annually in children younger than 15 years. Most cases of tonsillectomy for sleep disordered breathing or OSA are performed in conjunction with an adenoidectomy.
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