Paediatric Clinical Guideline
Surgical/Procedures 7.8
February 2002
Tonsillectomy and/or Adenoidectomy in Children with Obstructive Sleep
Apnoea Syndrome.
Children with Obstructive Sleep Apnoea Syndrome (OSAS) are at risk of postoperative
cardio respiratory complications following any type of surgery. Some will need to be
admitted to PICU postoperatively.
1. What is OSAS in children?
85% of sleep apnoeas in children are obstructive (ref. 1). About 10% are central and 5%
mixed. In OSAS apnoeas are associated with cycles of arousal from sleep and airway
obstruction leading to hypoxemia. It is commonest between the ages of 3-7 years although it
can occur at any time after 4 months of age. It affects about 1.5-3% of children.
Symptoms are generally snoring, noisy breathing, observed apnoeas, restless sleep and/or
frequent awakenings. In severe cases it may cause cor pulmonale and result in hypoxic
respiratory drive. Obesity is uncommon in children - poor weight gain and small stature are
the norm. Also differentiating the syndrome from that in adults, hyperactivity is more usual
than daytime somnolence and poor concentration.
Although very frequently adenotonsillectomy is the treatment of choice the severity of the
disease is not necessarily proportional to the size of the tonsils/adenoids. All have a decreased
pharyngeal air space and this can be added to by other factors such as maxillary/mandibular
hypoplasia, macroglossia or hypotonia, which causes reduced upper airway dilatory muscle
activity during inspiration. Sedatives including opiates will cause a decrease in this tone as
well as a reduced response to hypoxia, hypercarbia and airway obstruction. Postoperative
analgesia therefore presents a problem.
2. Who is at risk postoperatively?
Polysomnography (ref. 2)(sleep studies) are used to assess severity of the disease. An
Obstructive Sleep Apnoea (OSA) is defined as a SpO2 drop of >2% associated with an
apnoea of >10 seconds and a decrease in airflow of at least 50%. A Breathing Related
Arousal (BRA) is defined as a drop in airflow of >30% with a change in breathing pattern
and an arousal and at least a 1% drop in SpO2. Respiratory Disturbance Index (RDI) is the
sum of these two (OSA & BRA) per hour. A RDI greater than 10 is a risk factor for
postoperative complications.
Polysmonography is not available in Nottingham at present. The best we can do at present is
to offer overnight monitoring of pulse oximetry – this is an interest of Dr David Thomas at
the QMC (ext 42320) and Dr Alan Smyth at the City Hospital (ext 46475) and can be
organised by either of them.
Other risk factors are (ref. 3):
young age (<3 years)
oxygen saturation nadir c 70%
failure to thrive
cor pulmonale
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Paediatric Clinical Guideline
Surgical/Procedures 7.8
February 2002
neuromotor disease (hypotonia, cerebral palsy, seizures)
craniofacial abnormalities (Down’s syndrome, achondroplasia)
chromosomal abnormalities
history of prematurity
recent respiratory infection
obesity
(All the above at risk children should be admitted to PICU postoperatively for observation.)
3. Investigations
3.1 All children:
FBC (? polycythaemia)
ECG (?RVH/cor pulmonale (rare))
SpO2 at rest.
It is good practice to carry out oximetry studies in all children. (see note earlier re Drs David
Thomas (QMC) and Alan Smyth (City) who are willing to carry out these studies)
NB no need for arterial gases!
If RAH or RVH on ECG then a CXR (? Heart size; ?pul. oedema)
If RVH then Echo (?RV function)
Refer to cardiologist if ?pul HT.
3.2 Children with disturbed sleep:
Polysomnography to:
Assess number of episodes per hour
Clarify diagnosis
4. Anaesthetic Management
4.1 Assessment:
Sleeping habit and snoring history
Hct; ECG; SpO2
If RVH or chronic low SpO2 then further investigations as above.
4.2 Premedication
No sedation
?? antisialogues
4.3 Induction
Anticipate difficult intubation if craniofacial abnormalities
Anticipate cardiac decompensation if RVH
Standard monitoring
Preoxygenate if possible
Inhalational induction with Sevoflurane (esp. if difficult airway)
Tracheal intubation under deep Sevoflurane (or relaxant if no difficulty with ventilation)
IPPV (deep volatile/SV causes respiratory and myocardial depression and potentially failure)
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Paediatric Clinical Guideline
Surgical/Procedures 7.8
February 2002
4.4 Analgesia (NB this section is to be used in theatre - anaesthetic management - not
paediatric management):
Paracetamol 30-45mg/kg pr to a maximum of 90mg/kg/day
NSAIDS if platelet count normal (Brufen/Voltarol)
Avoid opiates if possible but:
codeine 1mg/kg im/pr is next stage
?morphine (up to 0.1mg/kg iv) in theatre, recovery or on PICU with close monitoring
?? laryngeal airway to pharynx (but loss of sensation can risk airway obstruction)
4.5 Extubation:
Extubate light, fully reversed, on side, slightly head down in case of bleeding.
If not in at risk group (see above) then no need for intensive postoperative monitoring.
Normal postoperative TPR hourly decreasing to 4 hourly when stable.
5.0 Intensive postoperative monitoring if in at risk group:
1:2 nurse: patient ratio preferably on PICU.
NB It is our policy for a medical escort to return with the patient to PICU
5.1 Monitor:
respiratory rate
respiratory effort (?obstruction)
End tidal PCO2 (?obstruction)
SpO2
Inspired oxygen concentration
ECG
NB Most improve over several days. Need to be kept on PICU for 12 hours at least –
preferably 24 hours
A J Matthews
Monday, 25 June 2001
Revised Monday, 19 November 2001
References
1. Obstructive sleep apnoea syndrome in children. Warwick JP and Mason DG.
Anaesthesia 1998, 53, 571-579.
2. Postoperative respiratory compromise in children with obstructive sleep apnea
syndrome: can it be anticipated? Rosen MD et al. Pediatrics 1994, 93, 784-788.
3. Cardio respiratory sleep studies in children. Establishment of normative data
4and polysomnographic predictors of morbidity. American Thoracic Society. Am
J Resp Crit Care Med 1999, 160, 1381-1387.
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Paediatric Clinical Guideline
Surgical/Procedures 7.8
February 2002
PAEDIATRIC CLINICAL GUIDELINES
ISSUE:
VERSION: FINAL
Title: Sleep Apnoea guideline
Author:
Job Title:
Dr Andy Matthews
Consultant Paediatric Anaesthetist
First Issued:
Date Revised: February 2002
Review Date: February 2005
Document Derivation:
i.e. References:
Consultation Process:
Included in document
Ratified By:
Paediatric Clinical Guidelines Committee
Chaired By:
Consultant with Responsibility: Dr Stephanie Smith
Distribution:
Training issues:
All wards QMC and CHN
Included in Induction Programme
Audit:
This guideline has been registered with Nottingham City Hospital NHS Trust and
QMC Clinical Guidelines Committee. However, clinical guidelines are ’guidelines’
only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or
expert. Caution is advised when using guidelines after the review date.
MANUAL AMENDMENTS RECORD
(please complete when making any hand-written changes/ amendments to guideline and not processed
through guideline committee)
Date
Page 4 of 4
Author
Description