Is day stay adenotonsillectomy safe in children with mild to moderate obstructive sleep apnoea? A retrospective review of 100 patients

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Abstract

Objective

This study explored the perioperative course of 100 children with polysomnogram (PSG) proven mild to moderate OSA to evaluate if day stay adenotonsillectomy is safe.

Methods

A retrospective chart review of patients who had undergone tonsillectomy with or without adenoidectomy following an overnight PSG at The Children's Hospital at Westmead Sleep Laboratory. 263 records were reviewed. Patients with apnoea hypopnea index (AHI) ≥1 and <15/h and/or a final sleep study report of mild to moderate OSA were included. Exclusion criteria were age <3 years, weight <10 kg, or any significant co-morbidities or other surgery that would preclude day stay surgery. Demographic, PSG and post-operative data was analyzed.

Results

No major respiratory complications occurred. No patient required an unplanned medical review for respiratory concerns, or admission to a high care facility. Eleven children left recovery with oxygen prescribed. One child had a desaturation to 88% in recovery, and one child had laryngospasm. The nine other children required oxygen to maintain saturation >90%.

Supplemental oxygen was prescribed to 7 patients on the ward. Of these, three patients received supplemental oxygen beyond 6 h. The other 97 patients had an uncomplicated post-operative course and would have been suitable for day-stay surgery. Increasing severity of OSA grade on pre-operative PSG was significantly associated with post-operative supplemental oxygen use (p = 0.003; Cochrane-Armitage test for trend).

Conclusions

Children who are otherwise well with mild to moderate OSA have a sufficiently low risk of respiratory complications following adenotonsillectomy to permit day-stay surgery in the setting of appropriate facilities with careful post-operative monitoring for the first 6 h to identify a small sub-group who require overnight observations.

Introduction

Obstructive sleep apnoea (OSA) is now the leading indication for adenotonsillectomy in children [1], [2]. The potential cardiorespiratory and neurocognitive complications of untreated OSA are well recognized, and surgery with adenotonsillectomy remains the first line treatment of this condition. Studies suggest the incidence of OSA to be 2–3% of the paediatric population under 10 years of age, with primary snoring estimated to affect 8–12% [3]. In many countries the current rates of adenotonsillectomy performed suggest that the groups of children affected by OSA are being significantly undertreated [4].

The serious potential perioperative complications of severe OSA patients are well documented, and these patients need to be managed postoperatively in a monitored or intensive care setting. The risks associated with the perioperative course of mild to moderate OSA patients however is less well known, and many of these patients are routinely admitted for overnight monitoring based on concerns raised from the literature regarding severe OSA patients. There are few studies that have evaluated the perioperative course of mild to moderate paediatric OSA patients.

We undertook a retrospective review of patients who had polysomnogram (PSG) proven mild to moderate OSA prior to adenotonsillectomy. The aim was to explore the perioperative course of these paediatric patients to evaluate the safety of performing adenotonsillectomy as a day-stay procedure in those with mild to moderate OSA.

Section snippets

Methods

Retrospective chart review of patients who had undergone tonsillectomy with or without adenoidectomy following an overnight PSG was performed. 263 charts from the period March 2007 to March 2012 were assessed in order to find 100 patients suitable for inclusion.

All children had undergone overnight PSG to determine if they had OSA, in the David Read Paediatric Sleep Unit at the Children's Hospital at Westmead. Studies were performed in accordance with the American Thoracic Society guidelines and

Patient demographics and PSG data (Table 1)

Of 100 patients meeting inclusion criteria 62 were male. The median age was 5 years. Length of stay is shown in Table 1, with no child staying longer than one day for any airway complication.

Five patients had an AHI ≥15. Obstructive AHI results were available for 65 patients with mean, SD and range shown. There were 68 patients with mild OSA, 9 with mild to moderate OSA, 17 with moderate OSA and 6 with moderate to severe OSA (Fig. 1). 17 patients showed carbon dioxide retention on their PSGs,

Discussion

Adenotonsillectomy is one of the commonest paediatric surgeries performed, and will continue to be so if we aim to surgically treat the predicted population of children with OSA. Day-stay tonsillectomy is widely utilized especially in the USA, and with appropriate facilities and selection parameters, it is an effective way of reducing inpatient admissions without compromising patient safety or morbidity [8].

Traditionally, patients undergoing adenotonsillectomy for OSA have been excluded from

Conclusion

Based on the results of this study, we propose that children who are otherwise well with mild to moderate OSA, have a low risk of respiratory complications following adenotonsillectomy. In the appropriate facility with careful post-operative monitoring and if no concerns arise in a 6-h post-operative period, day-stay surgery is a safe option for these children.

Acknowledgement

The authors are grateful for the assistance of Elizabeth Barnes, Statistician, The Children's Hospital at Westmead.

References (13)

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