Postoperative bilevel positive airway pressure ventilation after tonsillectomy and adenoidectomy in children - a preliminary report

Obstructive sleep apnea (OSA) in children, characterized by hypoventilation secondary to upper airway obstruction, often results from tonsil and adeno id hypertrophy. Adenotonsillectomy is the standard therapy in this patient population. The immediate postoperative period is complicated occasionally by respiratory difficulties that may require intubation and mechanical vent ilation. Recently, physicians have provided temporary airway support using continuous and bilevel positive airway pressure (BiPAP) devices. Reported c omplications of positive airway pressure devices include local abrasions to the nose and mouth; dryness of the nose, eyes, and mouth; sneezing; nasal drip, bleeds, and congestion; sinusitis; increased intraoccular pressure; n on-compliance; and pneumocephalus. Subcutaneous emphysema following facial trauma, dental extractions, adenotonsillectomy, and sinus surgery has been reported. There is also a hypothetically increased risk of subcutaneous emp hysema following the use of positive airway pressure ventilation in the ton sillectomy patient. Between January 1997 and July 1998, 1321 patients under went tonsillectomy and/or adenoidectomy at our institution. In reviewing th e records of all pediatric intensive care unit admissions during that time period, we identified nine patients, of the 1321, who required BiPAP postop eratively. Of these, four children were obese, four had preexisting neurolo gical disorders, and one underwent endoscopic sinus surgery and adenoidecto my. Three children were asthmatic, and three were less than 3 years of age. Two obese children were discharged with home BiPAP, one of whom had been o n BiPAP prior to surgery. All patients tolerated BiPAP without complication s. This]preliminary report suggests that BiPAP is a safe and effective meth od of respiratory assistance in the adenotonsillectomy patient with preexis ting conditions who is predisposed to postoperative airway obstruction. Fur thermore, with BiPAP, the risks of intubation and ventilator dependence are avoided. (C) 1999 Elsevier Science Ireland Ltd. All rights reserved.