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Paediatric Respiratory and OSA

Paediatric Respiratory and OSA. Objectives. Recent RTi: Proceed vs Postpone Management of ‘ Irritable Airways ’ Asthma: Management of Acute Severe Episodes OSA: Definitions and Risk Factors Perioperative Anaesthetic Management RHSC Guidelines for Postop Monitoring and Analgesia.

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Paediatric Respiratory and OSA

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  1. Paediatric Respiratory and OSA

  2. Objectives • Recent RTi: Proceed vs Postpone • Management of ‘Irritable Airways’ • Asthma:Management of Acute Severe Episodes • OSA: Definitions and Risk Factors • Perioperative Anaesthetic Management • RHSC Guidelines for Postop Monitoring and Analgesia

  3. RTi and Anaesthesia

  4. URTi increases perioperative adverse events: • Coughing • Breath holding • Laryngospasm/bronchospasm • SaO2 <90% for >10 secs • Unanticipated intubation/reintubation • Atelectasis/pneumonia • Risk is greatest in presence of active infection but remains increased for 2-6 weeks post RTi. Airway reactivity remains increased for 6-8 weeks post RTi

  5. Mild URTi Clear runny nose, apyrexial, normal activity/appetite Minimal concern and usually proceed as planned

  6. Symptomatic RTiIdeally Postpone Clingy/irritable, lethargic, pyrexial, reduced activity and appetite Purulent Nasal Discharge, productive cough

  7. Have to take into account: Procedure (complexity, priority) • Ease of rearranging (staff, family) • What’s normal for individual child • Discuss with surgeon • Discuss with family: Risk vs Benefit of Proceed vs Postpone • Low threshold to postpone if: • Age < 1 year • Major op/airway op • Asthma/atopy/other respiratory disease • ETT required 11x increased risk complication Cohen et al Anesthesia &Analgesia 1991 • 2.5 increased risk esp. < 5year olds Tait et al Anesthesiology 2001

  8. Anaesthesia for the Irritable Airway

  9. Preop: Consider β2 agonist + Steroid inhalers • Combination 10-30 mins preop reduced bronchoconstriction and • perioperative respiratory events more than salbutamol alone • Silvanus et al Anesthesiolody 2004 • Induction: IV induction (propofol) less irritating than gas induction (sevo) • Limit airway stimulation/irritation (Facemask /LMA rather than ETT) • Consider lubricating LMA with lignocaine gel • Schebesta et al Can J Anesthesia 2010 • Anticholinergics theoretically should reduce bronchoconstriction • but studies showed glycopyrrolate to be no better than placebo • Tait et al Anesthesia & Analgesia 2007

  10. Maintenance: TCI (propofol) = Volatile (sevo) so long as maintain adequate depth • Fentanyl / Remifentanil reduce airway irritability • Airway humidification • IV hydration • Removal of LMA/ETT: Awake vs Deep no difference in complications • Tait et al Anesthesia & Analgesia 2005

  11. Asthma Acute Severe Exacerbations

  12. Airway inflammation • Excessive mucous production/plugging • Bronchospasm •  • Increased work of breathing Increased intrathoracic pressure • Reduced airflow Preload Afterload • Air trapping Catecholamine depletion • Respiratory insufficiency/failure  insensible losses dehydration

  13. Recognised Risk Factors • Previous sudden/rapid respiratory deterioration • Previous admission to PICU • Previous Ventilation • Syncope/seizures with asthma exacerbations • Poor adherence to recommended treatment • Poor control despite treatment/ oral steroids • Denial of severity/late presentation • Up to a third of children who die due to asthma were not previously identified as at risk of fatal asthma!

  14. Management • Pharmacotherapy: To ease work of breathing • To achieve adequate oxygenation and ventilation • Monitoring: HR, RR, SaO2, conscious level/agitation, PEFR • accessory muscle use, wheeze • In HDU/PICU setting as prone to rapid deterioration • Clinical signs correlate poorly with severity of airway • obstruction • If possible endeavor to avoid intubation and ventilation

  15. Scottish Paediatric Retrieval Guidelines • Step 1 (no more than 30 minutes) (Grade 1A) • Salbutamol:MDI Salbutamol 100microgram x 10 puffs via spacer • or • Salbutamol via PaediatricNebuliser • < 4 years of age 2.5mg > 4 years of age 5mg • (should be diluted to 4mls with normal saline) • Oral Prednisolone: < 1 year 2mg/kg 1-2 years 20mg 3-4 years 30mg 5+ years 40mg • High flow oxygen+SaO2 monitoring • If child requires nebulisers more frequently than half hourly then move to Step 2.

  16. Step 2 (1 hour) (Grade 1A) • Combined Salbutamol +Ipratropium nebulisers: x 3 over 1 hour • < 4 years of age: Salbutamol 2.5mg + Ipratropium 250microgram • > 4 years of age: Salbutamol 5mg + Ipratropium 500microgram • (diluted to 4mls with normal saline) • Apply Emla/Ametop cream in preparation for venous access.

  17. Step 3 (1hour) • Continuous Salbutamol nebulisersfor 1 hour • Obtain IV access • Capillary blood gas, U+E, FBC, Blood glucose • Constant observation required with senior medical (consultant) input. • Move patient to High Dependency care.

  18. Step 4 IV Medication • IV Hydrocortisone: 4mg/kg (max 100mg) 6hrly • IV Magnesium50mg/kg MgSO4 (max 2g) over 20 mins(Grade 2A) • Cheuk et al Arch Dis Child (Metanalysis) • Should be used in severe asthma, or moderate asthma deteriorating despite β2 agonist/ipratropium/IV steroid • IV SalbutamolLoading dose 15mcg/kg over 15 mins (Grade 2B) • Maintenance 2-5mcg/kg/min • Nebulised Salbutamol continued half hourly • ECG monitoring and monitor serum potassium regularly • Contact PICU for advice / retrieval unless senior (consultant) medical staff are happy that adequate control is being gained.

  19. Step 5 • Intravenous Salbutamol: Max 10 mcg/kg/min in consultation with PICU • Repeat capillary blood gas, blood potassium and blood glucose . • (continue to monitor potassium regularly) • Apply Emla/Ametop cream should a second cannula be required • Contact PICU for advice / retrieval

  20. Step 6 • Ondansetron: 0.1mg/kg (max 4mg) • IV Aminophyline: Loading dose 5mg/kg over 20 mins • Maintenance 1mg/kg/hr • Do not mix with intravenous Salbutamol • Repeat capillary blood gas, blood potassium and blood glucose • Contact an Anaesthetistto review patient. • Ongoing discussion with PICU

  21. Indications for Intubation in Severe Asthma • Decision made on case by case basis • Reserved for cases who continue to deteriorate despite maximal medical treatment. • Estimated 2-3% mortality in children ventilated for acute severe asthma • Securing the airway does not cure the problem: • Instrumenting reactive airway • CV instability • Difficulties with ventilation remain

  22. No guideline or consensus to predict precisely when ETT may be required • Fatigue/somnolence/reduced conscious level • O2 despite FiO2 • Progressive CO2 despite maximal treatment • Unable to speak/exhausted from work of breathing • Respiratory/cardiorespiratory arrest

  23. RSI: Preoxygenation • Ketamine + Fentanyl + Suxamethonium (likely BP) • Microcuff ETT • Maintenance: Sedation/ NMB (avoid histamine releasing drugs) • A-line • IV fluids • Regular IV Hydrocortisone • MgSO4 to keep levels upper end normal • Physio and saline nebs • PRVC: Copes with changes in resistance/compliance and limits barotrauma • Cautious PEEP/ low tidal volume/ increased expiratory time • Permissive hypercapnoea/ accept pH ≥ 7.2 • Vigilance for breath stacking/pneumothorax

  24. OSA in Children

  25. Definition: • Episodic partial or complete airway obstruction during sleep, resulting in disrupted sleep and abnormal gas exchange. • Incidence: • Affects 1-5% of children at any age, most common between 2-6 years • M:F 1:1 (changes post puberty 2M:1F by adulthood) • Risk factors: • Adenotonsillar Hypertrophy • BMI (Hannon et al Jpaediatrics 2012Adolescents with BMI >97th centile, 45% OSA on PSG)

  26. Other Risk Factors • Craniofacial abnormalities (micrognathia, retrognathia, midface hypoplasia) • Neuromuscular disorders/CP (altered tone) • Macroglossia(mucopolysaccharidosis, Beckwith Wiedemann, hypothyroidism) • Downs (midface hypoplasia, macroglossia, reduced tone) • HbS

  27. What’s the Problem? • Sleep fragmentation • Intermittent hypoxia/elevated CO2 • Increased work of breathing •  • Neuroapoptosis in developing brain • Reduced memory • Reduced learning performance • PAP (>35% with mod/severe OSA)

  28. Snoring  Obstructive OSA • Hypoventilation • 3-12% of children snore at night. • Presence of snoring not diagnostic of OSA • Absence of snoring can’t exclude OSA • (peak obstruction during REM sleep, when muscle tone is lowest. REM usually during final third of sleep when least likely to be observed by parent).

  29. History • Snoring (loud, ≥3 night/week suspicious of OSA) • Witnessed apnoeas • Restless sleep/night terrors/frequent waking/enuresis • Sweating • Sleep position (side, neck flexion, AO extension) • Daytime sleepiness (school, car journeys, reading, watching TV) • Morning headaches/difficulty waking • Inattention/poor concentration/behaviour problems/hyperactivity • Even well validated questionnaires are not reliable for diagnosis or exclusion of OSA (sensitivity & specificity 50-60%) • Audio/video recordings and overnight SaO2 all have low NPV (negative result insufficient to exclude OSA).

  30. PolysomnographyGold Standard for diagnosis/exclusion of OSA in infants/children/adults • Measure • Oral and nasal airflow • Abdominal/chest wall movement • ETCO2/transcutaneous CO2 • SaO2 • ECG • Snore microphone • EEG/EMG (face/leg movement) • Electrooculography (detect eyes open/shut) • Has to be in a sleep lab, overnight and interpreted by specialist in sleep medicine

  31. Polysomnography (PSG) Report • AHISeveritySaO2 Nadir • (no classification uniformly accepted) (92% lowest nadir in normal sleeping children) • AHI: Number of apnoeas+hypopnoeas/hour of sleep recorded • AHI ≥ 1 with relevant symptoms, diagnostic for OSA • Apnoea: >90% reduction in airflow lasting ≥90% duration of 2 breaths • Obstructive: inspiratory effort during reduced airflow • Central: no inspiratory effort during reduced airflow • Hypopnoea: ≥30% reduction in airflow lasting ≥90% duration of 2 breaths • Assoc. with arousal or transient SaO2 ≥3% • Obstructive/ central/ mixed

  32. First Line TreatmentAdenotonsillectomy +/- Weight Optimisation • Tonsillectomy alone less effective • Adenoidectomy alone not recommended for OSA management • Size of tonsils and adenoids does not correlate with presence/severity of OSA or response to resection • Obese/craniofacial abnormality/abnormal tone/severe OSA: less likely to normalise PSG, but AHI should decrease • FTT and PAP should resolve • Conflicting results as to whether school performance improves • Friedmann et al Otolarygology, Head and Neck surgery 2009 • (>1000 children 58.9% completely PSG after adenotonsillectomy) • Marcus et al NEJM 2013 • (464 children 5-9 years, normal PSG 7 months later in 79% after adenotonsillectomyvs 46% without surgery)

  33. Anaesthetic Management • Preop Assessment: • History (sleep, current/recent RTi, comorbidity) • Examination (BMI, FTT, facial appearance, mouth/nasal breather, pectus excavatum) • Investigations (PSG) • ? Ward or HDU postop • Recognised Risk Factors of Respiratory Compromise Post Adenotonsillectomy • (Grade 1B) • Age <3 years • Severe OSA on PSG (AHI ≥ 24/hr, SaO2 nadir ≤ 80%) • Abnormal airway tone/structure (NM disease/craniofacial/BMI) • FTT • Recent RTi • Cardiac Complications of OSA (PHT, RVH)

  34. PreopAnalgesia: Paracetamol (15mg/kg)/Ibuprofen (10mg/kg) • Induction: Propofol 1%+Remifentanil (5mcg/ml) TCI • or • Propofol bolus + Remi bolus (2mcg/kg) • Maintenance:Propofol+Remi TCI • or • O2+N2O+Des • IV Hartmanns 10ml/kg bolus maintenance • Ondansatron (0.1mg/kg) + Dexamethasone (0.15mg/kg) • Morphine (25-100mcg/kg)

  35. Postop • SaO2 monitoring for any child with OSA • Avoid supplementary O2 • Analgesia * AVOIDING CODEINE* • IV fluid at maintenance rate till drinking well

  36. Post op Analgesia in Hospital • Children having tonsillectomy will receive multimodal analgesia from their anaesthetist in theatre. Unless there are contraindications specific to an individual patient, for inpatient analgesia postoperatively the anaesthetist will prescribe: • Paracetamol 15mg/kg 4 hourly PRN • Ibuprofen 10mg/kg 6 hourly PRN • Morphine solution 100-300 micrograms/kg 2 hourly PRN (maximum 6 doses in 24 hours) • (maximum per dose 10mg) • In line with recentrecommendations from the MHRA and the APA (Association of PaediatricAnaesthetists) nochildrenhavingtonsillectomyshouldreceive Codeine postoperatively, either in hospital or at home.

  37. For discharge home these children should be prescribed: • Paracetamol as per discharge analgesia guidelines • Ibuprofen as per discharge analgesia guidelines • Morphine Solution 200micrograms/kg (maximum per dose 10mg) • 3 postoperative doses to be given on the mornings of day 3, day 4 and day 5 (day of surgery being day 0). For children below 2 years please seek Pain Team advice. • On discharge home please ensure parents receive a copy of the Parent Information Leaflet ‘Pain Relief after Tonsillectomy’. This provides guidance on giving children regular pain relief post tonsillectomy, the signs to look out for in children receiving opioid medications and when to seek medical attention.

  38. Analgesia Post Adenoidectomy • Children having adenoidectomy alone will receive multimodal analgesia from their anaesthetist in theatre. • In line with recent recommendations from the MHRA and the APA (Association of PaediatricAnaesthetists) no children having adenoidectomy should receive Codeine postoperatively, either in hospital or at home. • For these children paracetamol and ibuprofen postoperatively on the ward and for discharge home should be sufficient.

  39. Guideline for Postop Monitoring of Patients with OSA • This includes a spectrum of patients, ranging from mild through moderate to severe OSA. Excluding those with severe OSA, or those with significant co-morbidity (listed below), the majority of patients should be able to return to ward 3 postoperatively. • Mild, Mild/Moderate, Moderate or Moderate/Severe OSA with • SaO2 ≥ 60% on Sleep Study • Return to a monitored bed on ward 3 opposite the nurse’s station, to facilitate close observation. • SaO2 should be monitored during all periods of sleep until achieve restful sleep with SaO2 ≥ 90% overnight. • If SaO2 < 90% on air, over a 5 minute period despite repositioning, the anaesthetist and surgeon involved in the case should be contacted. If this occurs out of hours the PICU fellow and PICU Band 7 should be contacted. • If PET criteria are met a PET call should be activated. • In this patient group the most likely cause of desaturation is airway obstruction, therefore managing desaturations with supplementary O2 alone is not appropriate. • Noisy breathing or restlessness during sleep are also signs of airway obstruction and warrant review. • Patient transfer from ward 3 to HDU requires Consultant to Consultant referral, therefore both the on call PICU consultant and ENT consultant should be informed.

  40. Severe OSA with SaO2 < 60% on sleep study, or any grade of OSA plus significant comorbidity including: Downs, craniofacial anomalies, age ≤ 2years, neuromuscular disorders, obesity • Should consider postop admission to HDU under PICU care, for at least the first postop night. This patient group usually come from, and therefore return to, the care of the respiratory team on ward 1 following discharge from HDU. • Postop management may vary from this guideline at the discretion of the anaesthetist or surgeon if there are airway concerns during induction, emergence or in recovery.

  41. HDU admission under PICU care is mandatory for patients: • With adenoidal packs in situ • Requiring an NPA • Following removal of an NPA patients must remain on HDU under PICU care until they maintain SaO2 ≥ 90% during sleep. They can then return to a monitored bed on ward 3, where SaO2 should be monitored during sleep for a further 24 hours at least. • Referral to the Respiratory team is appropriate for patients who > 2 days postop: • Have noisy breathing awake • Have signs of increased respiratory effort • Are restlessness with noisy breathing during sleep • Have SaO2 < 90% on air with witnessed obstructive episodes  

  42. We’ve Discussed • Management of Children with RTi • Management of Children with Acute Severe Asthma • Management of Children with OSA

  43. Questions ????????

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