Preoperative identification of children at high risk of obstructive sleep apnea

Abstract

Obstructive sleep apnea is a common childhood disorder which can lead to serious health problems if left untreated. Enlarged adenoid and tonsils are the commonest causes, and adenotonsillectomy is the recommended first line of treatment. Obstructive sleep apnea poses as an anesthetic challenge, and it is a well‐known risk factor for perioperative adverse events. The presence and severity of an obstructive sleep apnea diagnosis will influence anesthesia, pain management, and level of monitoring in recovery period. Preoperative obstructive sleep apnea assessment is necessary, and anesthetists are ideally placed to do so. Currently, there is no standardized approach to the best method of preoperative screening for obstructive sleep apnea. Focused history, clinical assessments, and knowledge regarding the strengths and limitations of available obstructive sleep apnea assessment tools will help recognize a child with obstructive sleep apnea in the preoperative setting.

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia—Part 1 patient and surgical factors

“…Most commonly used in the perioperative setting include The Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire and the pediatric sleep questionnaire (PSQ). 13,14 The STBUR is a five-question screening tool to assess for pediatric sleep-disordered breathing and correlates with subsequent perioperative respiratory adverse events risk (snoring, loud snoring, trouble breathing, stopping breathing, unrefreshed in the morning). Although not diagnostic, a score greater than 3 has been shown to have a threefold increase in the likelihood of perioperative respiratory adverse events.…”

“…27 Classification scoring varies, however, an apnea hypopnea index of 10 or more per hour and/or oxygen saturation nadir of <80% typically represent severe OSA. 14 It is generally believed that those with greater abnormalities on polysomnography are at increased risk of perioperative respiratory complications. 32 Polysomnography is particularly useful in determining the postoperative disposition plan, particularly for those with comorbidities.…”

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia—Part 2: Anesthesia‐related risk and treatment options

“…Opioid administration can also impair the pharyngeal dilator muscles placing these patients at further risk of upper airway obstruction through airway hypotonia especially in REM sleep. 87,88 Opioid limiting techniques (typically 50% of usual) with a preference of short over long-acting agents have been suggested, in combination with opioid-sparing strategies such as local anesthetic, ketamine, and dexmedetomidine. 23,86 Interestingly, controlled studies demonstrating increased sensitivity to opioid-induced ventilatory depression in children with OSA are limited.…”

Respiratory prehabilitation in pediatric anesthesia in children with muscular and neurologic disease

“…There is no standard recognized scoring system that can be universally used across all pediatric age ranges, and a full review can be found elsewhere. 37,38 Briefly, in adolescents with obesity, a 3% oxygen desaturation index <6/h makes important obstructive sleep apnea unlikely. 39 We would suggest use of an index >10/h as a reasonable cutoff for important obstructive or central sleep apnea in this group.…”