Risk factors for postoperative pulmonary complications in children with severely compromised pulmonary function secondary to severe scoliosis

Abstract

Objectives After corrective surgery for scoliosis, postoperative pulmonary complications lead to increases in morbidity, length of hospital stay (LOS) and mortality. This study aimed to identify associations with such respiratory complications, and to assess the utility of noninvasive ventilation (NIV) in children with severe scoliosis Methods This retrospective cohort study included all children aged ≤17 years who underwent spinal surgery for scoliosis between January 2009 and January 2012 at a quaternary pediatric hospital. Data were collated regarding polysomnography (PSG) and NIV use, before and after corrective surgery. Factors associated with severely compromised pulmonary function (SCPF) were established and correlations with the occurrence of postoperative pulmonary complications and LOS were identified. Results Altogether, 133 children had corrective surgery for scoliosis, aged 12.7 (range: 2‐17) years at operation. Scoliosis causes were identified as: idiopathic (39.8%), neuromuscular disease (32.2%), syndrome (15.7%), and congenital (12%). Correlates with SCPF (forced vital capacity [FVC] <40% predicted, n = 10) included markers of sleep hypoventilation, including serum bicarbonate ≥29 mmol/L, morning pCO2 > 50mm Hg (P = .003), and overnight, episodic CO2 retention of >7 mm Hg. Using these parameters an additional eight children with SCPF were identified making a total of 18 out of 133 (13.5%) of the patients. Postoperative pulmonary complications were seen in 24 children (18%) and their occurrence correlated with higher Cobb angle (>90°), lower pulmonary function (FVC), higher serum bicarbonate and underlying neuromuscular disease. Amongst the 18 children with SCPF, regular use of NIV preoperatively was associated with reduced rate of postoperative pulmonary complications (P = .02) and reduced LOS by 6.4 days (P = .01). Conclusion Nocturnal hypoventilation on PSG identifies children with SCPF. Use of NIV in children with SCPF was linked to fewer postoperative pulmonary complications and reduced duration of hospital stay.

Respiratory failure after scoliosis correction surgery in patients with Prader-Willi syndrome: Two case reports

“…Although a previous study reported that preoperative PSG did not predict prolonged postoperative ventilator use after scoliosis surgery[ 20 ], a recent study revealed that before severe scoliosis repair surgery, severely compromised respiratory function could be confirmed in advance through PSG and overnight TcCO 2 monitoring, both of which measure hypoventilation. According to the PSG and TcCO 2 results, there was an advantage of the timely use of a non-invasive ventilator that could avoid tracheostomy[ 6 ].…”

“…Sleep disordered breathing (SDB) is known to be a common cardiopulmonary complication in PSW[ 3 ]. The most two representative causative factors are obstructive sleep apnea (OSA) due to airway narrowing caused by obesity and hypotonia[ 3 , 4 ], and hypoventilation due to progressive deterioration of the restrictive pattern of the lungs caused by scoliosis[ 3 , 5 , 6 ]. Respiratory symptoms appear from infancy, and OSA is known to be a major contributing factor after 2 years of age[ 7 ].…”

“…Therefore, in order to establish criteria for prophylactic scoliosis surgery and to properly monitor respiratory function in PWS patients, reliable respiratory function tests are needed. To date, one of the methods of respiratory function evaluation for pediatric scoliosis, including children with PWS, is known as the patient effort-based test such as forced expiratory volume in the first second (FEV 1 )[ 4 , 9 ], total lung capacity (TLC)[ 5 ] and forced vital capacity (FVC)[ 6 ] in several studies. Even if reproducibility and reliability are improved through multiple test trials[ 10 ], results of patient effort-based tests such as FEV1, FVC, and TLC have a fundamental limitation that results might vary depending on patient participation[ 6 ].…”

“…To date, one of the methods of respiratory function evaluation for pediatric scoliosis, including children with PWS, is known as the patient effort-based test such as forced expiratory volume in the first second (FEV 1 )[ 4 , 9 ], total lung capacity (TLC)[ 5 ] and forced vital capacity (FVC)[ 6 ] in several studies. Even if reproducibility and reliability are improved through multiple test trials[ 10 ], results of patient effort-based tests such as FEV1, FVC, and TLC have a fundamental limitation that results might vary depending on patient participation[ 6 ]. In particular, multiple trials of tests will be clinically difficult due to poor cooperation for children who have neurologic deficits accompanied by mental retardation, such as PWS, and the efforts to participate are likely to be inconsistent by circumstance (parental attendance, evaluation room environment, psychological state, etc.…”

“…On the other hand, as a patient non-effort-based respiratory tests, end-tidal CO 2 monitoring, transcutaneous CO 2 monitoring[ 6 , 11 ] or polysomnography (PSG)[ 6 ] can be tried, but it is not easy when compared to the patient effort-based pulmonary function test because monitoring is required for several hours during sleep and hospitalization is required. In the case of neuromuscular disease in which respiratory muscle weakness is common, these tests are conventionally performed according to established guidelines[ 12 , 13 ].…”