Management and outcome of extreme pediatric obstructive sleep apnea

ObjectivesClassify post-adenotonsillectomy (AT) respiratory support, identify variables that predict these interventions, and evaluate outcomes in children with extreme obstructive sleep apnea (OSA).MethodsRetrospective chart analysis was performed on patients found to have apnea/hypopnea index (AHI) > 100 events/h. Patients with chronic diseases other than obesity were excluded.ResultsForty-one subjects were studied, average age of 11.4 ± 4.3 years, majority (73.1%) were Hispanic, with a mean total AHI (TAHI) of 128.1 ± 22.9/h. Twenty-eight (68.3%) patients underwent AT. Lower age (P < 0.001), lower BMI Z-score (P < 0.01), higher OAHI (P < 0.05) were associated with having surgery. Eleven out of 28 (39.3%) surgical patients required respiratory support (oxygen or positive airway pressure) postoperatively. Longer % total sleep time S_pO₂ <90% during PSG (P < 0.05) and lower S_pO₂ nadir (P < 0.05) were associated with requiring airway support. No patients experienced mortality, reintubation, or hospital readmission following AT, with majority (71.4%) discharged 1 day post-operatively. Eleven (57.9%) of the 19 patients who had a postoperative PSG had residual OSA, defined as AHI >5 events/h, but there was a significant improvement in TAHI (P < 0.01).ConclusionOur findings confirm the need for postoperative observation in a controlled setting for patients with extreme OSA undergoing AT. Although at higher risk of needing respiratory support, those patients undergoing AT for extreme OSA did not require re-intubation post-operatively or suffer serious harm. Barring contraindications to AT, surgery may still be a first-line therapy for some children with extreme OSA.     

重视阻塞性睡眠呼吸暂停低通气综合征儿童腺样体

儿童阻塞性睡眠呼吸暂停低通气综合征(OSAS)是常见的儿童睡眠呼吸疾病。OSAS对儿童体格、神经认知发育、心血管系统以及内分泌代谢水平都可能产生危害。腺样体、扁桃体肥大是儿童OSAS的主要病因,腺样体、扁桃体切除术(T&A)因而是治疗儿童OSAS的一线治疗方法。多数接受T&A治疗的儿童睡眠呼吸障碍有显著改善,但按照研究定义的不同,儿童T&A术后OSAS残留的发生率在21.6%~49.0%之间。一些儿童存在术后OSAS残留的危险因素,对这些患儿后续的监测和管理有助于纠正残留疾病导致的病理生理危害及并发症。就腺样体、扁桃体切除术后残留的危险因素以及后续检查、治疗做一综述,旨在加强对儿童OSAS术后随访和管理的重视,提高儿童睡眠疾病的整体诊断和治疗水平。     

Assessment of Operative Blood Loss and the Factors Affecting it in Tonsillectomy and Adenotonsillectomy

To estimate the average operative blood loss in tonsillectomy and adenotonsillectomy and the various factors affecting it. A prospective study of estimation of blood loss in 100 patients who underwent tonsillectomy and adenotonsillectomy. Data collected included the age, sex, operative indication, clotting time, Hb levels and usage of pre-operative antibiotics. Cold knife dissection method for tonsillectomy and curettage method for adenoidectomy were used. Measurement by calorimetric method of estimation being simple and accurate was used for estimation. Study undertaken at a tertiary referral hospital catering to an urban, semi-urban and rural populace. Blood loss was more in males and increases as age advances both in adenotonsillectomy and tonsillectomy. Blood loss was more in fibrosed tonsils, at lower hemoglobin levels and at higher clotting times. It was less in cases who received pre-operative antibiotics. The average blood losses in males and females during tonsillectomy were 106.91 and 96.26 ml respectively. In adenotonsillectomy, the average blood losses in males and females were 81.44 and 76.82 ml respectively. In our series we found that blood loss in tonsillectomy and adenotonsillectomy depended on various factors like age, sex, the type of tonsillitis, method of dissection, hemoglobin concentration, clotting time and the use of antibiotics. All these factors must be taken into consideration while taking up patients especially those who cannot tolerate blood loss, for surgery.     

Psychiatric disorders and symptoms severity in patients with adenotonsillar hypertrophy before and after adenotonsillectomy

Objective

The objective of this study was to compare the frequency of psychiatric disorders and the severity of psychiatric symptoms in patients with adenotonsillar hypertrophy with a healthy control group and investigate the potential improvement after adenotonsillectomy.

Materials and methods

The study group consisted of 40 patients with adenotonsillar hypertrophy and a control group consisted of 35 healthy volunteers without adenotonsillar hypertrophy. A routine ear nose throat (ENT) examination, flexible nasopharyngoscopy and tympanometry were carried out. The same procedures were applied to the control group. The parents of all the participants were required to fill out the Early Childhood Inventory-4 form, the Strengths and Difficulties Questionnaire and a personal information form. At postoperative month six, the patients were re-examined, and their parents were required to fill out the same forms.

Results

Attention deficit hyperactivity disorders and sleep disorders determined with the Early Childhood Inventory-4 were more common in the patients with adenotonsillar hypertrophy than in the control group. There was a significant decrease in the rates of both types of disorders at postoperative month six. The total psychiatric symptom severity was higher in the patients with adenotonsillar hypertrophy and the following were more frequent: cases of attention deficit hyperactivity disorder, oppositional defiant disorder, symptom severity of anxiety disorders and sleep disorders determined with the Early Childhood Inventory-4, as well as emotional problems, attention deficit hyperactivity disorder problems, behavioural problems and peer problems determined with the Strengths and Difficulties Questionnaire parent-report form. There was a statistically significant decrease in all the other symptoms at postoperative month six, except for the severity of oppositional defiant disorder symptoms determined with the Early Childhood Inventory-4 and behavioural problems determined with the Strengths and Difficulties Questionnaire parent-report form. There were no differences in the severity of psychiatric disorders or symptoms between the adenotonsillar hypertrophy group and the control group at postoperative month six.

Conclusion

Adenotonsillar hypertrophy is associated with psychiatric disorders and symptoms. Adenotonsillectomy ameliorated the symptoms and the severity of these disorders in most cases.     

Pulse wave amplitude and heart period variability in children with upper airway obstruction

ObjectiveThe aim of this study was to assess cardiovascular autonomic modulation in children with upper airway obstruction (UAO), to compare this modulation to that of non-snoring children and to investigate the effect of adenotonsillectomy (AT).MethodsECG and finger photoplethysmographic signals obtained from overnight polysomnographic (PSG) recordings of 31 children with mild-to-moderate UAO and 34 non-snoring children were analysed. The extent of autonomic modulation was assessed by symbolic analysis of heart period (HP), pulse wave amplitude (PWA), and their joint dynamics during non–rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep.ResultsChildren with UAO showed more frequent patterns of monotonically increasing and decreasing HP in NREM sleep and monotonically increasing and decreasing joint PWA-HP patterns in REM and NREM sleep at baseline compared to controls, even when considering only periods of sleep free of discrete respiratory events. Following AT, HP, and joint PWA-HP dynamics significantly altered towards levels observed in the control group.ConclusionsIn children with mild-to-moderate UAO, cardiovascular autonomic modulation is more prevalent, even during quiet, event-free sleep. AT appears to reverse this pattern.     

Does pressure support ventilation improve the postoperative outcome of adeno-tonsillectomy patients? A prospective randomized trial

BackgroundSpontaneous ventilation (SV) is used for adeno/tonsillectomy in children. However, inhalational anesthetics produce dose dependent decrease in minute ventilation. We tested the impact of PSV on awakening time, and length of PACU stay.Methods34 patients were randomized into two groups; PS ventilation group and SV group. Premedication and induction were similar in both groups. Patients in PS group were ventilated with P_insp set to deliver 8 ml/kg V_T, keeping ETCO₂ between 35 and 45 mmHg. Any episodes of hypoventilation were recorded and corrected by manual support of ventilation.Upon completion of surgery, time-to-extubate was recorded. Length of PACU stay, agitation and CHEOPS scores, PONV and desaturation episodes were also recorded. Results are presented as mean (SD), median (interquartile range), or number of patients as appropriate. A P value < 0.05 was considered significant.ResultsExtubation time (min) [mean (SD)] was longer in SV group than PS group [7.8 (2.1) vs. 5.5(1.4), P < 0.001]. In the SV group 9 patients had episodes of hypoventilation that necessitated manual assist of ventilation. Pain scores were higher in SV group than PS group. Duration of stay in PACU [mean (SD)] in minutes was longer in SV group than PS group [44.3(7.4) vs. 39.4(5.7), P = 0.02]. All but one patient in the PS group needed postoperative rescue meperidine analgesia. The mean (SD) time needed for rescue meperidine analgesia was 27.1(8.9) in PS group and 21.8(9.4) in SV group (P = 0.04).ConclusionPSV carries the advantages of overcoming the effects of narcotics and inhaled anesthetics on spontaneously ventilated adeno-tonsillectomy patients. They suffer less pain and spend less time in the PACU.