Incidence and Risk Factors Associated with Respiratory Compromise in Planned PICU Admissions Following Tonsillectomy

Abstract

Objectives: Review the incidence and factors associated with respiratory compromise requiring intensive care unit level interventions in children with planned admission to the pediatric intensive care unit (PICU) following tonsillectomy or adenotonsillectomy (T/AT). Study design: Retrospective cohort study. Methods: Review of all patients with PICU admissions following T/AT from 2015 to 2020 at a tertiary care pediatric hospital. Patient demographics, underlying comorbidities, operative data, and respiratory complications during PICU admission were extracted. Results: Seven hundred and seventy-two patients were admitted to the PICU following T/AT, age 6.1 ± 4.6 years. All children were diagnosed with obstructive sleep apnea or sleep-disordered breathing (mean pre-operative apnea-hypopnea index 29 ± 26.5 and O2 nadir 77.1% ± 11.1). Neuromuscular disease, enteral feed dependence, and obesity were common findings (N = 240 (31%), N = 106 (14%), and N = 209 (27%) respectively). Overall, 29 patients (3.7%) developed respiratory compromise requiring PICU-level support, defined as new-onset continuous or bilevel positive airway pressure support (n = 25) or reintubation (n = 9). Three patients were diagnosed with pulmonary edema. Multivariable regression analysis demonstrated pre-operative oxygen nadir and enteral feed dependence were associated with respiratory compromise (OR = 0.97, 95% CI 0.94-0.99, P = .04; OR = 6.3, 95% CI 2.36-52.6, P = .001 respectively). Conclusions: Our study found respiratory compromise in 3.7% of patients with planned PICU admissions following T/AT. Oxygen nadir and enteral feeds were associated with higher respiratory compromise rates. Attention should be given to these factors in planning for post-operative disposition.

Review of the Utility of Extended Recovery Room Observation after Adenotonsillectomy

“…Some of the most cited risk factors include age younger than 2-3 years old, severe OSA, craniofacial abnormalities, extremes of weight, black race, and cardiac, pulmonary, or neuromuscular diseases. [1][2][3][4][6][7][8]16,17 However, similar to our findings, respiratory compromise is unlikely even among these high-risk patients. [2][3][4][5][6][7][8][9][10] Previous studies suggested that most postoperative respiratory complications occur within a few hours of surgery.…”

“…[1][2][3][4][6][7][8]16,17 However, similar to our findings, respiratory compromise is unlikely even among these high-risk patients. [2][3][4][5][6][7][8][9][10] Previous studies suggested that most postoperative respiratory complications occur within a few hours of surgery. 3,8,13 Friedman et al conducted a prospective study aimed at identifying high-risk patients who require overnight admission after T/AT, and proposed that a child with no known preexisting oxygen requirements who is off oxygen 3 h after surgery can be safely discharged home regardless of baseline comorbidities and severity of AHI.…”

“…T/AT is a common and safe procedure, however, with a small risk of life-threatening respiratory complications. 2,7,8,10,14,15 Numerous studies investigated the preoperative risk factors that are associated with postoperative respiratory distress to accurately identify patients at risk. Some of the most cited risk factors include age younger than 2-3 years old, severe OSA, craniofacial abnormalities, extremes of weight, black race, and cardiac, pulmonary, or neuromuscular diseases.…”

“…1 Even among high-risk patients, however, respiratory compromise is rare and difficult to predict. [2][3][4][5][6][7][8][9][10] Patients with Obstructive Sleep Apnea (OSA) and other comorbidities are prone to respiratory complications postoperatively and may require intensive care unit (ICU)-level of care. 1,3,[6][7][8][9] To date, controversy exists regarding indications for post-T/AT pediatric ICU admission, 2,10 and the postoperative disposition is at the discretion of the surgeon.…”

“…[2][3][4][5][6][7][8][9][10] Patients with Obstructive Sleep Apnea (OSA) and other comorbidities are prone to respiratory complications postoperatively and may require intensive care unit (ICU)-level of care. 1,3,[6][7][8][9] To date, controversy exists regarding indications for post-T/AT pediatric ICU admission, 2,10 and the postoperative disposition is at the discretion of the surgeon. While the incidence of post-T/AT respiratory compromise is very low, urgent escalation of care is associated with a worse prognosis, potentially driving providers to overutilize ICU-level resources to avoid adverse events.…”