Report of two cases of endobronchial tumour mass resection in children.

PURPOSE: Anesthesia for endotracheal tumour mass resection in pediatric patients is a rare, complex, and high-risk procedure. The purpose of this case report is to emphasize the importance of multidisciplinary team collaboration and close communication during the perioperative management of shared airway surgery. CLINICAL FEATURES: A six-year-old boy with no previous history of comorbidity and a 13-yr-old boy with a six-month history of upper respiratory tract infection, refractory asthma, chronic wheeze, and exercise-related dyspnea presented for acute endobronchial tumour mass resection. Decreased pulmonary function, religious beliefs (Jehovah's Witness), risk of intraluminal bleeding, and imminent complete airway collapse constitute areas of specific interest. CONCLUSION: Anesthesia for endotracheal tumour mass resection in pediatric patients is a rare, complex, and high-risk procedure. Decreased pulmonary function and low respiratory reserves combined with the need for extensive surgical airway access warrants multidisciplinary team collaboration and close communication. Maintaining spontaneous respiration is paramount to reduce the risk of hypoxemia-induced adverse events and preoperative considerations should include the possible need for extracorporeal membrane oxygenation. Finally, the use of nasal high flow for shared airway surgery shows promising prospects warranting further investigation.

RéSUMé: OBJECTIF: L'anesthésie pour la résection de masse tumorale endotrachéale chez les patients pédiatriques est une intervention à la fois rare, complexe, et à haut risque. L'objectif de cette présentation de cas est de souligner l'importance de la collaboration multidisciplinaire et d'une bonne communication entre les équipes pendant la prise en charge périopératoire d'une chirurgie sur des voies aériennes partagées. ÉLéMENTS CLINIQUES: Un garçon de six ans sans antécédents et un garçon de 13 ans avec des antécédents de six mois d'infection des voies respiratoires supérieures, d'asthme réfractaire, de respiration sifflante (wheeze) chronique, et de dyspnée liée à l'exercice, se sont présentés pour une résection semi-urgente d'une masse tumorale endobronchique. Une réduction de la fonction pulmonaire, les croyances religieuses (témoins de Jéhovah), le risque de saignement intraluminal, et l'imminence d'un collapsus complet des voies aériennes étaient les domaines d'intérêt spécifique. CONCLUSION: L'anesthésie pour la résection de masse tumorale endotrachéale chez les patients pédiatriques est une intervention à la fois rare, complexe, et à haut risque. Une fonction pulmonaire réduite et des réserves respiratoires diminuées, combinées au besoin d'un accès chirurgical étendu aux voies aériennes, nécessitent une collaboration multidisciplinaire et une excellente communication entre les équipes. Il est essentiel de maintenir la respiration spontanée pour réduire le risque d'événements indésirables induits par l'hypoxémie, et les considérations préopératoires devraient inclure le besoin possible d'oxygénation extracorporelle (ECMO). En conclusion, l'utilisation d'une lunette à haut débit nasal pour la chirurgie sur des voies aériennes partagées est prometteuse, justifiant des études plus approfondies.

Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates.

BACKGROUND: Postsurgical administration of opiates in patients with obstructive sleep apnea (OSA) has recently been linked to an increased risk for respiratory complications. The authors have attributed this association to an effect of recurrent oxygen desaturation accompanying OSA on endogenous opioid mechanisms that, in turn, alter responsiveness to subsequent administration of exogenous opiates. In a retrospective study, the authors have shown that oxygen desaturation and young age in children with OSA are correlated with a reduced opiate requirement for postoperative analgesia. METHODS: The current study was designed to test that conclusion prospectively in 22 children with OSA scheduled to undergo adenotonsillectomy. The children were stratified to those having displayed < 85% or > or = 85% oxygen saturation nadir during sleep preoperatively. Using a blinded design, the children were given morphine postoperatively to achieve an identical behavioral pain score. RESULTS: As compared with children in the > or = 85% group, the < 85% oxygen saturation nadir group required one half the total analgesic morphine dose postoperatively, indicating heightened analgesic sensitivity to morphine after recurrent hypoxemia. CONCLUSIONS: Previous recurrent hypoxemia in OSA is associated with increased analgesic sensitivity to subsequent morphine administration. Therefore, opiate dosing in children with OSA must take into account a history of recurrent hypoxemia.

Can assessment for obstructive sleep apnea help predict postadenotonsillectomy respiratory complications?

BACKGROUND: The aim of this study was to determine the frequency and type of respiratory complications after adenotonsillectomy in children. A second aim was to assess the ability of preoperative sleep studies to identify children at risk for respiratory complications. METHODS: Children referred for sleep studies between 1992 and 1998, who underwent adenotonsillectomy within 6 months of the preoperative study, were reviewed. The study focused on two variables: the obstructive apnea and hypopnea index and the oxygen saturation nadir. Medical charts were reviewed for postoperative respiratory complications. RESULTS: Three hundred forty-nine children were referred for sleep studies, and 163 met the inclusion criteria. Thirty-four children (21%) had postoperative respiratory complications requiring a medical intervention. Children experiencing respiratory complications were younger (aged < 2 yr; adjusted odds ratio, 4.3; 95% confidence interval, 1.7-11) and had an associated medical condition (odds ratio, 3; 95% confidence interval, 1.4-6.5). A preoperative obstructive apnea and hypopnea index of 5 or more events per hour increased the chance of postoperative respiratory complications (odds ratio, 7.2; 95% confidence interval, 2.7-19.3), as did a preoperative oxygen saturation nadir of 80% or less (odds ratio, 6.4; 95% confidence interval, 2.8-14.5). A preoperative oxygen saturation nadir of 80% or less had a likelihood ratio of 3.1, increasing the probability of postoperative respiratory complications from 20 to 50%. CONCLUSIONS: The data suggest, but do not prove, that preoperative nocturnal oximetry could be a useful preoperative test to identify children who are at increased risk for postoperative respiratory complications.