Problem Based Learning Discussion:

Perioperative management of the child with obstructive sleep apnea

Moderators: Allison Fernandez MBA MD and Deborah Schwengel MD
Institution: Johns Hopkins School of Medicine
Objectives: At the completion of this session, learners will be able to:
1. Describe the clinical features of pediatric OSA
2. Discuss the anesthetic options for the outpatient tonsillectomy patient
3. Discuss criteria for ambulatory surgery vs. post-operative admission for pediatric
OSA patients
4. Discuss future research in the area of OSA
Case History:
37 month female, weight 13 kg, scheduled for an adenotonsillectomy and bilateral ear
tubes in an outpatient facility. The child has a history of loud snoring, hyperactivity and
multiple ear infections. Parents state that they have not witnessed apnea while she is
sleeping but are impressed by her snoring and that it has been getting worse over the past
year. She has no other medical problems and no drug allergies. The childs older sibling
also had snoring that was treated with T&A. A sleep study was not obtained prior to
surgery.
What is Obstructive Sleep Apnea (OSA)? What are the systemic considerations for OSA?
How to diagnose OSA?
OSA is a disorder characterized by periodic, partial or complete obstruction of the upper
airway during sleep. The patient usually arouses during sleep to improve the patency of
the airway. This repetitive sleep disruption is especially common during REM sleep in
children and can produce hypoxemia, hypercarbia, disruption of sleep architecture and
long term may result in pulmonary hypertension. The gold standard test for diagnosis of
OSA is overnight polysomnography (PSG). PSG is expensive, inconvenient, not readily
available in all communities and not always scored appropriately for pediatric patients; an
alternative method of screening is nocturnal oximetry. PSG is utilized to make a
diagnosis and judge severity by scoring the number of events per hour and by
measuring severity of hypoxemia and hypercarbia. (For more discussion of measurement
parameters and PSG scoring please read in Schwengel3) It does not predict which
patients will have adverse outcomes postoperatively, but severity is linked to adverse
perioperative events. Numerous studies including a recent study by Jaryszak4 attempts to
use PSG to predict postoperative outcomes and found that a high apnea-hypopnea index,
high hypopnea index, low nadir oxygen saturation and high BMI were associated with
adverse events. There are questionnaires that might be useful screening tools for
pediatric patients, however none are validated as a diagnostic tool. An OSA identification
and assessment to determine perioperative risk was developed by the ASA Task Force on
OSA and was published in 20062. This questionnaire focuses on identification and
stratification of OSA in patients to improve perioperative care. Some of the signs and
symptoms to identify OSA include physical characteristics such as BMI, neck

circumference, craniofacial abnormalities, anatomical nasal obstruction, hypertrophic

tonsils and history of snoring, apnea during sleep, frequent arousal, somnolence during
daytime. Although this is a useful tool it only correlates clinically to PSG 55% of the
time1, and it is a tool designed to estimate risk in both adult and pediatric patients.
Diagnostic criteria are different in adults and children and OSA in non-obese children
should be considered a different disorder than in adults or obese children.
Childhood vs. adult obstructive sleep apnea syndrome features3
Children

Adults

Age

26-year peak

Increased elderly

Gender

Male = female

Males > females

Obesity

Few

Most

Tonsils & adenoids

Often enlarged

Rarely enlarged

Daytime sleepiness

Less common than in adults but

Common

Presentation

can be seen
Sleep
Obstruction

Obstructive apnea or

Obstructive apnea

hypoventilation
Sleep architecture

Usually normal

Decreased delta and REM

Arousals with obstruction

May not be seen

At end of each apnea

Definitive therapy in most

Minority of cases with

patients

inconsistent results

Selected patients

Most common therapy

Treatment
Surgical

Medical (positive airway pressure)

REM, rapid eye movement. Adapted from Sterni LM, Tunkel DE. Obstructive sleep apnea in children: An
update. Pediatr Clin North Am 2003;50(2):42743.

Which OSA patients are at increased risk for respiratory complications in the post
operative period? Are specific anesthetic techniques associated with poor outcomes in
patients with OSA?
Current data indicate that children with OSA are at increased risk for post operative
respiratory complications especially if it is severe OSA. In a review of medical
malpractice cases, Morris found that children had more fatal respiratory failure events
after T &A than adults (25 fatalities in children vs 11 in adults)5. Most authors agree that
children less than 3 years of age are at particular risk and are not candidates for outpatient
surgery. Don et al published that children < 2 years of age are more likely to be
diagnosed with severe OSA therefore are at increased risk for postoperative respiratory
failure. Children with other comorbidities such as former prematurity, asthma, obesity,
trisomy 21, craniofacial and neurological abnormalities are also at increased risk for
complications in the postoperative period and have an increased risk of ongoing OSA
despite treatment with T&A. Brown et al studied post-operative complications of urgent
tonsillectomies and found that comorbid conditions and severe OSA defined as SaO2
nadir <80% are associated with increased respiratory complications in the post operative
period. This study also found a 20% incidence of major respiratory complications in the
study group with 11% requiring reintubation and 9.3% post operative pneumonia10.
Finally, obesity is another comorbidity frequently related to or causing OSA. In the US
the definition for overweight children is BMI >85% th percentile and childhood obesity is
BMI > 95%th percentile9 and 32% of children in the US are overweight9. According to
Verhulst 13-59% of obese children are diagnosed with OSA by PGS7. Obese children
with snoring or OSA have increased inflammation of their airway8. However, obese
children without OSA did not have an increase in airway inflammation8.
Specific anesthetic techniques have not been correlated with poor outcomes in the
postoperative period. However, OSA patients are known to be sensitive to opioids and
more likely to become apneic with higher doses. In fact, Brown et al have shown that
children with severe OSA dont even need the same opioid doses post-operatively11.
Despite the significant pain of the operation, these children are more comfortable with
lower opioid doses. Brown et al. found that among patients with OSA, young age and
lower oxygen nadir correlated with the requirement of lower opioid dose in the post
operative period11. In a follow up prospective study Brown found that children with an
oxygen saturation nadir <85% required half the amount of analgesic as those with an
oxygen saturation nadir >85%12. This study assigned patients to receive standard
morphine dose (0.1 mg/kg) or a calculated dose based on patients age and nadir oxygen
desaturation 50% of (0.0007 * age (months))+ (0.0021 * saturation nadir (%)) -0.1138
mg/kg12. From this study one can infer that the standard morphine dose in severe OSA
patients is an overdose.
Another important teaching point is that codeine requires metabolism to morphine by the
CYP2D system in the liver in order to be effective. The genetics of the CYP2D enzyme
system is known. We know that some patients are homozygotes or heterozygotes for
enzyme deficiencies resulting in slow or absent metabolism of codeine to morphine.
Additionally, some patients are rapid metabolizers, resulting in rapid conversion to

morphine and higher than normal blood levels after administration. We do not
recommend the use of codeine because of this inter-individual variation. Oxycodone is
preferable alternative.
Dexamethasone is routinely used to reduce incidence of post-operative nausea and
vomiting. In one study the use of high doses was incidentally related to bleeding in
tonsillectomy patients16. However, high doses are not required to produce an anti-emetic
effect15. Dexamethasone might additionally provide an analgesic effect but more
research is needed to determine the effective dose and mechanism of effect.
Finally, Nixon et al looked at the sleep and breathing patterns with PSG of OSA patients
who had undergone a tonsillectomy that day. The results of this small study demonstrated
that all patients had obstructive events that night. The severe OSA group had a
desaturation index of 9.3 and an AHI of 21 compared to 1.8 and 6.9 respectively in the
mild OSA group13. Interestingly, in all children the post operative AHI was higher
during REM sleep. These findings suggest that patients with severe OSA warrant an
overnight hospital stay.

Future research: Risk stratification of patients based on PSG studies. Development of

protocols to decrease respiratory complications in patients with severe OSA
Raghavendran et al compared OSA patients undergoing tonsillectomy following the
anesthetic standard practice in 2001 to tonsillectomy patients after an anesthetic protocol
was implemented to risk stratify severe OSA patients. Patients were stratified into OSA
2, 3 or 4 based on the McGill Oximetry Score of SaO2 <90%, 85% and 80% respectively.
If the patient did not meet these requirements they underwent PSG to determine if the
patient had mixed/ obstructive apnea /hypopnea > 1 event per hour. If the child had an
event <1 per hour they were assigned to the OSA 1 group. Their revised guidelines
include: admission of OSA 4 patients to the PICU, administration of atropine after
induction, dexamethasone (0.3 mg/kg), codeine (1 mg/kg) PRN for pain and reduced
opioid doses intraoperatively and postoperatively. The authors found 29.6% of patients
required a major respiratory medical intervention in the historical group compared to
11.3% in the revised guidelines group14. Additionally, the OSA 4 group in the revised
guidelines received lower total opioid dosing and still achieved optimal pain control as
assessed by the Childrens Hospital Eastern Ontario Pain Scale (CHEOPS). In addition
54% of the OSA 4 group patients received dexamethasone under the revised guidelines;
they were discharged on postoperative day 1.
As of now we can identify patients who are at increased risk of complications after a
tonsillectomy. Several studies have identified age, comorbidities, opioid doses, severe
OSA and obesity as risk factors for complications in the postoperative period after
tonsillectomy. However, are there other ways to identify risk factors? Jaryszak attempted
to identify risk factors for postoperative respiratory complications in patients undergoing
tonsillectomy using their preoperative PSG. In this study there was a 15% respiratory
complication rate following tonsillectomy. A regression analysis of the data revealed that
patients who suffered a postoperative respiratory complication had the following risk

factors: BMI greater than 95%, 31.8 apnea hypopnea index, 22.6 hypopnea index and a
nadir oxygen saturation of 74%4. Further research is necessary to identify patients at risk
of developing postoperative respiratory complications. PSG in the preoperative period
may be a useful tool to help identify these patients. However, most patients do not
receive a PSG because of expense, inconvenience of the study and length of study. Other
techniques to identify high risk patients undergoing tonsillectomy will further improve
patient safety in the post operative period.
We must also mention that neither an uncomplicated intraoperative course nor an
uncomplicated PACU stay can prove that a child with OSA is safe for discharge1.
Although the mortality for T&A is low, it is not zero. Perioperative respiratory
complications for children with OSA pose real risk. Children with severe OSA,
comorbidities, age < 3 or morbid obesity must not be discharged on the day of surgery.

References
1. Brown K. Outcomes, risk, and error and the child with obstructive sleep apnea.
Pediatic Anesthesia 2011; 21:771-780.
2. Practice Guidelines for the perioperative Management of patients with obstructive
sleep apnea: A report by the American Society of Anesthesiologists Task Force
Perioperative Management of Patients with Obstructive Sleep Apnea.
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3. Schwengel DA, Sterni LM, Tunkel DE and Heitmiller ES. Perioperative
management of children with obstructive sleep apnea. Anesthesia and Analgesia
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4. Jaryszak E, Shah R, Vanison C, Lander L, Choi S. Polysomnographic variables
predicitive of adverse respiratory events after pediatric adenotonsillectomy.
Archives of Otolaryngology Head and Neck Surgery 2011;137(1):15-18.
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malpractice claims after tonsillectomy. Otolaryngology Head and Neck Surgery
2008;138:315-320.
6. Don Dm, Geller KA, Koempel JA Age specific differences in pediatric
obstructive sleep apnea. International Journal of Otorhinolaryngol 2009;73:10251028.
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treatment of sleep-disordered breathing in obese children and adolescents. Sleep
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11. Brown K, Laferriere A and Moss I. Recurrent hypoxemia in young children with
obstructive sleep apnea is associated with reduced opioid requirement for
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Brouillette RT. Sleep and breathing on the first night after adenotonsillectomy for
obstructive sleep apnea. Pediatirc Pulmonology 2005;39(4):332-338.
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2010;110(4):1093-1101.
15. Kim MS, Cot CJ, Cristoloveanu C, Roth AG, Vornov P, Jennings MA,
Maddalozzo JP, Sullivan C. There is no dose-escalation response to
dexamethasone (0.0625-1.0 mg/kg) in pediatric tonsillectomy or
adenotonsillectomy patients for preventing vomiting, reducing pain, shortening
time to first liquid intake, or the incidence of voice change. Anesthesia
&Analgesia 2007;104(5):1052-8.
16. Czarnetzki C, Elia N, Lysakowski C, Dumont L, Landis BN, Giger R, Dulguerov
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