Pediatric Examination and Board Review (27 page)

12.
Appropriate anesthetic care of a child with OSA for tonsillectomy should omit

(A) muscle relaxants

(B) volatile agents

(C) nitrous oxide

(D) nonsteroidal anti-inflammatory agents

(E) acetaminophen

13.
Appropriate immediate postoperative care from tonsillectomy for the child younger than 2 years of age with significant OSA is

(A) short stay unit observation for 6 hours after surgery

(B) discharge to home from the recovery room after the child demonstrates the ability to drink

(C) admission to the hospital for 24 hours of cardiorespiratory monitoring

(D) A or B

(E) none of the above

14.
The risk of postoperative bleeding is highest

(A) on postoperative day 1 or 2

(B) at the end of the first postoperative week

(C) on postoperative day 2 or 3

(D) for the entire first postoperative week

(E) for the first postoperative month

ANSWERS

1.
(B)
Symptoms of OSA in a child are different than those in an adult. When one compares the child with OSA with the adult, the child frequently also has failure to thrive. In children there are often other concomitant symptoms such as enuresis, behavior abnormalities, and attention deficit disorder.

2.
(C)
During sleep, functional residual capacity falls, ventilatory drive is decreased from the awake state, and resistance in the upper airway is significantly increased.

3.
(C)
When compared with adults, children are less likely to have sleep arousal triggered by hypoxia, hypercapnia, or airway resistance. Hypercapnia and airway resistance are more potent stimuli for sleep arousals in children than is hypoxemia. Because sleep arousal is uncommon in children, daytime sleepiness is unusual in children with sleepdisordered breathing.

4.
(C)
Central apnea is considered significant when it exceeds 20 seconds or is accompanied by bradycardia. Of note, central and obstructive apnea may occur in the same patient.

5.
(A)
Central apnea is more common than obstructive apnea in children.

6.
(C)
The child with OSA is rarely an obese patient in contrast to the typical adult OSA patient. A child with OSA frequently also has failure to thrive. In children, REM sleep is the most erratic phase of sleep, and most sleep disorders occur during this phase. This is different from the adult in whom OSA occurs during non-REM sleep. Untreated OSA is a severe health problem and can result in the development of heart failure unresponsive to surgical or medical treatment and ultimately can result in death.

7.
(E)
Should the symptoms of OSA in children be overlooked, complications will occur. These include neurocognitive difficulties in school, systemic hypertension, and congestive heart failure, including cor pulmonale. The systemic and pulmonary hypertension that accompanies OSA is secondary to the chronic exposure of the pulmonary arterial circulation to hypercarbia and hypoxemia.

8.
(B)
Children with a significant history of snoring and periods of apnea during sleep should be fully evaluated for OSA with polysomnography. The polysomnogram will evaluate not only central apnea but obstructive apnea as well.

Sleep disorders are very common during childhood, occurring in 20-30% of children. They are generally a source of stress and sleeplessness for parents, and behavioral issues as well as learning difficulties for the child. These difficulties are not necessarily accompanied by OSA. A careful history of breathing disorders with sleep is indicated under these circumstances. Questions about the child’s sleep should be asked, including how long it takes him to fall asleep, the child’s routine bedtime every night, the child’s sleep location, and how much time there is between feeding and bedtime. Should the sleep abnormality be accompanied by significant airway symptoms, polysomnography should be performed to delineate the contribution of airway obstruction to the disorder of sleep. More commonly, disorders of sleep are related to emotional issues and disruption of either home or school and not to OSA.

9.
(C)
In a child, should the findings on polysomnography be significant, the first treatment option in a child almost without exception is a tonsillectomy and adenoidectomy.

The lymphoid tissue of the upper airway increases in mass until approximately age 12. Simultaneously there is a growth in the size of the upper airway. Between 2 and 8 years of age, the tonsils and adenoids are the largest in relation to the underlying airway, resulting in a relatively narrow upper airway. The prominence of the lymphoid tissue in the upper airway makes a significant contribution to airway obstruction during sleep in children. The prominence of the lymphoid tissue in children may often be responsible for the symptoms of OSA. Most children significantly improve with respect to sleep pathology following tonsillectomy and adenoidectomy.

Should tonsillectomy and adenoidectomy not result in significant improvement in sleepdisordered breathing, further surgical intervention may be necessary. Uvulopalatoplasty is an uncommon surgical intervention in the child with OSA, particularly when compared with the adult patient. In OSA refractory to other interventions, tracheostomy may be required. Nonsurgical treatment for OSA is also a viable therapeutic alternative. However, the use of nighttime constant positive airway pressure (CPAP), common for adults with OSA, is not approved for children (although it is used with some frequency). Further studies in children with OSA for interventions other than tonsillectomy and adenoidectomy are needed.

Most children with OSA are not obese in contrast to most adults. Therefore, a reduced-calorie diet is not indicated.

10.
(B)
Snoring is a relatively common complaint offered to the pediatrician. Only on rare occasions is snoring a clue to the diagnosis of OSA. In the case presented, the mother describes not only snoring, but also the irregularity of her child’s breathing with sleep, and even occasional periods of apnea. Should sleep abnormality be accompanied by significant airway symptoms as described in this child, polysomnography can determine the contribution of airway obstruction.

11.
(A)
In general, marked improvement does not occur immediately after the procedure, although there is some resolution in symptoms the first night after surgery. More improvement is seen as the residual anesthetic agent is eliminated and procedure-related edema in the immediate perioperative period resolves.

Children with significant sleep apnea in the perioperative period may well have more apnea during the first 24 hours following tonsillectomy and adenoidectomy.

12.
(D)
NSAIDs enhance bleeding risk. Thus these medications should not be administered in the perioperative period.

13.
(C)
Children should be monitored in a setting where respiratory expertise is immediately available. Perioperative desaturation is common in the child with concomitant craniofacial abnormality and in the child younger than 3 years.

14.
(B)
Bleeding following a tonsillectomy and adenoidectomy occurs commonly at the end of the first postoperative week if not in the first 6 hours after surgery.

S
UGGESTED
R
EADING

Helfaer MA, McColley SA, Puzik PL, et al. Polysomnography after adenotonsillectomy in mild pediatric obstructive sleep apnea.
Crit Care Med.
1996;24(8):1323-1327.

Marcus CL. Sleep-disordered breathing in children.
Am J Res Crit Care Med.
2001;164:16-30.

Munford RS, Pugin J. Normal responses to injury prevent systemic inflammation and can be immunosuppressive.
Am J Respir Crit Care Med.
2001;163:316-321.

Strollo PJ, Rogers RM. Obstructive sleep apnea.
Curr Concepts.
1996;334(2):99-104.

CASE 14: A 16-MONTH-OLD BOY WITH FEVER AND COUGH

A 16-month-old African American boy presents to the emergency department with a 3-day history of fever and cough. He was well until 3 days ago when his mother reports that he began to cough and felt warm to touch. His temperature was 38.5°C. She gave him acetaminophen and put him to bed early. For the last 2 days he has not been hungry but continues to drink well. His fever has persisted despite antipyretics and is now 39°C. There have been no other symptoms, no sick contacts, and no travel history.

On physical examination, the child appears toxic but is well-hydrated. The heart rate is 140, the respiratory rate is 52, and the oxygen saturation is 82% on room air. The only significant finding on examination is markedly decreased breath sounds over the right hemithorax. There is no adenopathy or hepatosplenomegaly.

A chest radiograph reveals an opacified right hemithorax with slight mediastinal shift to the left. The CBC shows a white count of 28,000/mm
³
with many bands.

SELECT THE ONE BEST ANSWER

1.
What is the next diagnostic procedure indicated?

(A) a throat culture

(B) a review of the blood smear

(C) an ultrasound of the right hemithorax

(D) a nasopharyngeal aspirate for viral DFA testing

(E) a repeat leukocyte count

2.
Of the following, the most urgently indicated step is

(A) administration of supplemental oxygen

(B) measurement of a blood gas

(C) placement of a thoracostomy tube

(D) bronchoscopy

(E) reviewing the peripheral blood smear