Avoiding airway obstruction after pediatric adenotonsillectomy

International Journal of Pediatric Otorhinolaryngology
Volume 73, Issue 6, June 2009, Pages 803-806
Glenn Isaacsona,  aDepartment of Otolaryngology – Head & Neck Surgery, Temple University School of Medicine, USA  bDepartment of Pediatrics, Temple University School of Medicine, USA

Abstract
Objective

To evaluate the efficacy of a protocol designed to prevent post-adenotonsillectomy airway obstruction in small children with obstructive sleep apnea.
Design

Computerized retrospective review of single surgeon case series.
Setting

Tertiary children's medical center.
Methods

Children with sleep study proven obstructive sleep apnea or children under the age of 3 years with clinically suspected obstructive sleep apnea were treated according to a protocol that included: (1) rapid bloodless tonsillectomy; (2) repeated release of the tonsillar retractor; (3) avoidance of uvular edema; (4) routine intra-operative intranasal oxymetazoline, and placement of nasal airway; (5) extended recovery room observation. Primary outcome measures were (1) avoidance of unexpected intensive care unit admission; (2) post-extubation pulmonary edema; (3) aspiration pneumonia.
Results

During the period March 2004–August 2007, 864 children underwent adenotonsillectomy by a single surgeon—604 for the indication of obstructive sleep apnea or adenotonsillar hypertrophy with obstruction. Two hundred and ten were under the age of 3 years or had sleep study proven obstructive sleep apnea. There were two unexpected admissions to the pediatric intensive care unit for persistent upper airway obstruction—none required intubation. No child developed post-obstructive pulmonary edema. Three children were treated for infiltrates consistent with aspiration pneumonitis.
Conclusion

Most cases of post-extubation pulmonary edema and pneumonia can be avoided in young children and those with mild-to-moderate obstructive sleep apnea following a protocol that anticipates and avoids precipitating causes of upper airway obstruction.