POSTOPERATIVE RESPIRATORY COMPROMISE IN CHILDREN WITH OBSTRUCTIVE SLEEP-APNEA SYNDROME - CAN IT BE ANTICIPATED

Objective. The aim of this research was to describe the postoperative respiratory complications after tonsillectomy and/or adenoidectomy (T and/or A) in children with obstructive sleep apnea syndrome (OSAS), to define which children are at risk for these complications, and to det ermine whether continuous positive airway pressure (CPAP) is an effect ive strategy for dealing with these complications. Methods. The data f or this study were gathered through a retrospective chart review of al l children 15 years of age or younger with polysomnographically (PSG) proven OSAS who had a T and/or A at Hennepin County Medical Center bet ween January 1985 and September 1992. Particular attention was paid to factors that contributed to the OSAS, postoperative respiratory compl ications, and intervention strategies for dealing with these complicat ions. Results. The charts of 37 children with OSAS documented by preop erative PSG who later had a T and/or A were reviewed retrospectively. Ten of these children had significant postoperative respiratory compro mise secondary to OSAS that prolonged their hospital stay from 1 to 30 days and caused symptoms ranging from 0(2) desaturation < 80% to resp iratory failure. These children were younger and had significant assoc iated medical problems that contributed to or resulted from their OSAS in addition to large tonsils and adenoids. The associated medical pro blems included craniofacial anomalies, hypotonia, morbid obesity, prev ious upper airway trauma, cor pulmonale, and failure to thrive. The ch ildren with postoperative respiratory complications also had more seve re apnea on their preoperative PSG. One child had a uvulopalatopharyng oplasty (UPPP) in addition to the T and A. Taken together, the history , physical and neurological examination, and the PSG were able to iden tify successfully the children who subsequently developed respiratory compromise secondary to OSAS after a T and/or A. Nasal continuous posi tive airway pressure (CPAP) and bilevel CPAP was used successfully to manage the preoperative and/or postoperative upper airway obstruction in five of these children. Conclusions. Based on these findings, overn ight observation is recommended with an apnea monitor and oximeter for patients undergoing a T and/or A who have OSAS and meet any of the fo llowing high-risk clinical criteria: (1) < 2 years of age, (2) craniof acial anomalies affecting the pharyngeal airway particularly midfacial hypoplasia or micro/retrognathia, (3) failure to thrive, (4) hypotoni a, (5) cor pulmonale, (6) morbid obesity, and (7) previous upper airwa y trauma; or high-risk PSG criteria: (1) respiratory distress index (R DI) > 40 and (2) SaO(2) nadir < 70%; or undergoing a UPPP in addition to the T and/or A. Nasal CPAP/bilevel CPAP can be used to manage the p reoperative and/or postoperative upper airway obstruction in patients with OSAS undergoing a T and/or A.