Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty

STUDY OBJECTIVES

Postoperative respiratory complications (PORCs) can occur following supraglottoplasty (SGP) for obstructive sleep apnea. However, there are very limited data on risk factors associated with these complications. This study aims to evaluate the occurrence of PORC in children undergoing SGP and to assess clinical factors and polysomnographic parameters predicting these complications.

METHODS

A retrospective study was performed in children with laryngomalacia who underwent SGP with preoperative polysomnography.

RESULTS

400 children who underwent SGP met the criteria for entry into the analysis with a total of 416 surgeries with corresponding preoperative polysomnography. The median age (interquartile range) at the time of polysomnography was 0.4 (0.2, 1.5) years. A total of 96 (23.1%) PORCs were noted. Compared with those without complications, children with PORCs had a higher proportion of congenital heart disease (P < .05), higher median obstructive apnea-hypopnea index (obstructive AHI; median 16.0 vs 11.4 events/h; P < .01), and lower median oxygen saturation (SpO2) (P < .001). The unadjusted odd ratio indicated an increased risk of PORCs in children with congenital heart disease (odds ratio 1.66; P < .05) and those with an obstructive AHI > 10 events/h (odds ratio 2.06; P < .01). Multiple regression analysis demonstrated that an obstructive AHI > 10 events/h was the only independent risk factor for PORCs (P < .05).

CONCLUSIONS

In our cohort of children with laryngomalacia undergoing SGP, those with underlying congenital heart disease, higher obstructive AHI, and lower SpO2 were more likely to develop PORCs. Only children with an obstructive AHI > 10 events/h were at significantly increased risk for PORCs following SGP. Preoperative polysomnography is useful in preoperative planning in children undergoing SGP.

CITATION

Kanavitoon S, Ngamprasertwong P, Gurbani N, et al. Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty. J Clin Sleep Med. 2024;20(1):9-16.

Perioperative management of children with neuromuscular disorders based on a common protocol: A prospective, national study in Italy

BACKGROUND

Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared perioperative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped).

METHOD

We conducted a multicentre, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals.

RESULTS

We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs, and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 (2-14) days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher intensive care unit (ICU) admission rate and longer hospital LOS.

CONCLUSION

Disease severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs.

A comparison of postoperative respiratory complications associated with the use of desflurane and sevoflurane: a single-centre cohort study

Sevoflurane and desflurane are the most commonly used volatile anaesthetics for maintenance of anaesthesia. In this study, we aimed to evaluate the relationship between choice of volatile anaesthetic and early postoperative respiratory complications, and to address a critical knowledge gap in safety outcomes between these two commonly used agents. We performed a retrospective analysis of adult (non-cardiac surgery) patients who received sevoflurane or desflurane for the maintenance of general anaesthesia at our institution between 2005 and 2018. We evaluated the association between desflurane exposure (when compared with sevoflurane) and the primary outcome of postoperative respiratory complications, defined by early post-extubation desaturation (S_p O₂  < 90%) or re-intubation within 7 days postoperatively. Multivariable regression analyses were performed and adjusted for confounding factors, including patient, anaesthetic and surgical factors. Propensity matched, interaction and sub-group analyses were performed to assess outcomes in high-risk groups: morbidly obese (BMI > 35 kg.m^-2 ); elderly (age > 65 years); and high risk of respiratory complications as well as the primary outcome at 24 h. Desflurane was used for 23,830 patients and sevoflurane for 84,608 patients. Patients exposed to desflurane did not demonstrate a reduced risk of postoperative respiratory complications when compared with sevoflurane (adjusted odds ratio 0.99, 95%CI 0.94-1.04, p = 0.598). These findings were consistent across all sub-groups of high-risk patients and in the propensity score matched cohort. In summary, desflurane use was not associated with reduced postoperative respiratory complications when compared with sevoflurane. In the context of environmental and cost concerns with volatile anaesthetic agents, our study provides important data to support organisational decisions regarding the use of desflurane.

Ventilatory frequency during intraoperative mechanical ventilation and postoperative pulmonary complications: a hospital registry study

BACKGROUND

High ventilatory frequencies increase static lung strain and possibly lung stress by shortening expiratory time, increasing intrathoracic pressure, and causing dynamic hyperinflation. We hypothesised that high intraoperative ventilatory frequencies were associated with postoperative respiratory complications.

METHODS

In this retrospective hospital registry study, we analysed data from adult non-cardiothoracic surgical cases performed under general anaesthesia with mechanical ventilation at a single centre between 2005 and 2017. We assessed the association between intraoperative ventilatory frequency (categorised into four groups) and postoperative respiratory complications, defined as composite of invasive mechanical ventilation within 7 days after surgery or peripheral oxygen desaturation after extubation, using multivariable logistic regression. In a subgroup, we adjusted analyses for arterial blood gas parameters.

RESULTS

A total of 102 632 cases were analysed. Intraoperative ventilatory frequencies ranged from a median (inter-quartile range [IQR]) of 8 (8-9) breaths min^-1 (Group 1) to 15 (14-18) breaths min^-1 (Group 4). High ventilatory frequencies were associated with higher odds of postoperative respiratory complications (adjusted odds ratio=1.26; 95% confidence interval, 1.14-1.38; P<0.001), which was confirmed in a subgroup after adjusting for arterial partial pressure of carbon dioxide and the ratio of arterial oxygen partial pressure to fractional inspired oxygen. We identified considerable variability in the use of high ventilatory frequencies attributable to individual provider preference (ranging from 22% to 88%) and temporal change; however, the association with postoperative respiratory complications remained unaffected.

CONCLUSIONS

High intraoperative ventilatory frequency was associated with increased risk of postoperative respiratory complications, and increased postoperative healthcare utilisation.

Admission Criteria for Children With Obstructive Sleep Apnea After Adenotonsillectomy: Considerations for Cost

STUDY OBJECTIVES

Postoperative respiratory complications (PRCs) are common among children with obstructive sleep apnea (OSA) after adenotonsillectomy. We analyzed postoperative admission guidelines to determine which optimally balanced patient safety and cost.

METHODS

Retrospective study of children aged 12 years or younger undergoing adenotonsillectomy for OSA after polysomnography at a tertiary academic care center over 2 years. Demographics, medical History, and hospital course were collected. Advanced Excel modeling was used to assess the number of children with PRCs identified with guideline admission criteria and to validate the significance of these findings in our patient population with logistic regression.

RESULTS

Six hundred thirty children were included; 116 had documented PRCs. Children with PRCs were younger (P = .024) and more frequently male (P = .012). There were no significant differences in race (P = .411) or obesity (P = .265). More children with PRCs had an apnea-hypopnea index (AHI) > 24 events/h (P < .001). Following guidelines from the American Academy of Pediatrics, American Academy of Otolaryngology - Head and Neck Surgery, and Nationwide Children's Hospital, 82%, 87%, and 99% of children with PRCs would be identified, costing $535,962, $647,165, and $1,053,694 for admission, respectively. Using a non-validated, forced model to refine predictors described in published guidelines, our model would have identified 95% of children with one or more PRCs, with a moderate cost.

CONCLUSIONS

Current admission guidelines attempt to identify children with OSA at high risk for PRCs after adenotonsillectomy; however, none consider the economic cost to the health care system. We present a comparison of the number of patients identified with PRCs after adenotonsillectomy and the cost of expected admissions using currently published guidelines.

COMMENTARY

A commentary on this article appears in this issue on page 1371.