Tonsillectomy and Adenoidectomy for OSA Anesthetic Considerations by Denise Chan MD
Tonsillectomy and Adenoidectomy for ObstructiveSleep Apnea: Anesthetic Considerations, by Denise Chan. Hello, my name is Denise Chan, and I'm a pediatricanesthesiologist at Boston Children's . Today, I'll be discussing important aspectsof taking care of children with obstructive sleep apnea syndrome in the perioperativesetting. Introduction. Now, first let's define what is obstructivesleep apnea syndrome. Well, it's a disorder of breathing during sleep, and it's characterizedby a few different things, according to the
American Thoracic Society. First of all, these patients have either prolongedupper airway obstruction, which is known as obstructive hypopnea, or intermittent completeobstruction, known as obstructive sleep apnea. And this occurs with or without snoring. Second, the patient exhibits moderate to severeoxygen desaturation. Third, normal ventilation is disrupted. And fourth, normal sleep patternsare disrupted. So these are the components of obstructive sleep apnea syndrome. Now, in children, obstructive sleep apneasyndrome is oftentimes caused by enlarged
adenoid or tonsillar tissue. And you can seein this illustration that the hypertrophied tonsils really do get in the way of normalairflow. So what do you expect to see in a patientwith this syndromeé First of all, you'll probably see snoring. They'll have difficulty breathingduring sleep, restless sleep, or even nightmares or night terrors. You may see excessive sweating.They may have nocturnal enuresis, or bedwetting, mouth breathing, pauses in breathing, or chronicrhinorrhea. More importantly, though, what is the significanceof having obstructive sleep apnea, and what are the consequences for the patienté Well,there are a number of problems that can occur.
Daytime somnolence patients have fallenasleep while driving older patients, of course and this can lead to motor vehicleaccidents; cognitive dysfunction, which leads to behavioral problems or problems with workor school performance; metabolic effects, such as insulin resistance, type 2 diabetesmellitus, or metabolic syndrome; or other metabolic effects, such as failure to thriveor stunted growth. Or if obstructive sleep apnea is more severeor left untreated, this could lead to cardiovascular morbidity, such as pulmonary or systemic hypertension,cor pulmonale, or stroke. Obstructive sleep apnea syndrome can even lead to death. Andit's been hypothesized to be a factor contributing
to SIDS, or Sudden Infant Death Syndrome.Diagnosis and al Features. In order to diagnose whether or not someonehas obstructive sleep apnea, you must first and foremost perform a thorough history andphysical exam. A sleep history screening for snoring should be a part of every child'sroutine health care visits. It's really unlikely that someone's goingto have obstructive sleep apnea if they don't snore. So if a child does snore, ask the parentsmore details about the sleep history. Does your child have difficulty breathing or stopbreathing during sleepé Or are you worried about their breathing at nighté Does yourchild sweat during sleepé Does your child
have restless sleepé Does he or she breathethrough his mouth while awakeé Has anyone in the family had obstructive sleep apneaor sudden infant death syndromeé Or does your child have behavioral problemsé When you examine the patient, you may noticecertain features that are suggestive of obstructive sleep apnea, such as a small, triangular chin,retrognathia, a high arched palate or a long soft palate, a long oval face, or, of course,large tonsils. There are also certain patients who are athigh risk for having obstructive sleep apnea. And these are patients with obesity; Downsyndrome; PraderWilli syndrome; certain neuromuscular