Conference Lectures

The Child with a Runny Nose
Prof Elsa Varghese
Bangalore
Upper Respiratory Tract Infection is defined as a minimum of two of the following symptoms: sore or scratchy throat, sneezing rhinorrhoea, nasal congestion, malaise, cough fever, or laryngitis, together with confirmation by a parent. Respiratory complications are more likely in a child with a URI who is administered anesthesia however, the morbidity is low. (1, 2, 3)
URI - related adverse events. These include:

  • Rehospitalization:  for stridor, pneumonia, atelectasis
  • Anesthesia related deaths in children with URI have been reported: < 2 weeks prior to surgery in a 3-yr-old, where the postmortem report was of  viral myocarditis. (4) And in a 15-month-old child who developed, laryngospasm after tracheal extubation possibly due to  early extubation and inadequate monitoring.(5)
  • Reactive Airway & URI: Increased incidence of laryngospasm in the presence / recovery from active upper respiratory tract infection.(6)
  • Morbidity Related to Severe Laryngospasm:

Oxygen desaturation 61%, bradycardia 6%, negative pressure pulmonary oedema 4%, pulmonary aspiration 3%, cardiac arrest 0.5% (7, 8)
Associated respiratory events & anesthesia
 Breath holding, desaturation (SpO2 < 90%) and severe coughing
Independent risk factors for URI and Anesthesia related complications include; prematurity, airway surgery and copious secretions.
Clinical predictors of anesthetic complications in child with URI include: (2)

  1. Parent informs  that child has a ‘cold’
  2. Productive cough, nasal congestion, snoring
  3. Passive smoking
  4. Induction agent used: thiopentone > halothane > sevoflurane > propofol
  5. Airway management used: (ETT > LMA > face mask)
  6. Anticholenergic drugs

Airway hyperreactivity & URI (9): these include abnormal airway conductance persist for 6 weeks, sloughing of the respiratory epithelium, reduced ciliary activity. The Ideal time for optimization and delay of surgery is 4 weeks(10) In addition reported reduction in FVC, FEV1, FRC , PEFR , diffusion capacity have been noted. Along with chemical mediators released from inflamed areas which contribute to the development of bronchoconstriction. In addition there is increased reactivity to secretions and irritant anesthetic gases. (11)
Preoperative Assessment
If URI is present, make an anesthetic plan to minimize complications
Ask if surgery urgent?   If the answer is yes – proceed, if not, then take a detailed history to determine if it is an Infectious etiology with severe symptoms which include: Fever >38°C, asthma, purulent, secretions, crepitations, rhonchi, dull, lethargic, loss of appetite

Patient Related Factors for intraoperative laryngospasm (12, 13)

  • Age :< 6 months > 6 months – 2 yr > 2 – 5 yr
  • Presence of active URI: 2-7 times the increased risk compared to asymptomatic child, active URI & URI < 2 wks >2-4wks > 4-6 wks
  • Surgery Related Factors
  • Adenotonsillectomy (25%)
  • Head & neck and oropharyngeal surgery
  • Tracheal and oesophageal procedures
  • Appendicectomy
  • Anesthetic Factors (14,15)
  • Induction agents / anaesthetic technique
  • Propofol & Sevoflurane / Halothane
  • ETT vs. LMA

Should intubation be avoided in children with URI?
ETT consistently associated with increased risk of perioperative adverse events
In a study by Cohen et al, over 20,000 children with URIs – 11 x increased incidence of respiratory complications if intubated. ETT is an independent risk factor for adverse outcomes in children with URIs in children aged <5 yrs (16)
The advantage LMA In child with URI (17)
ETT increases the incidence of minor post-surgical events compared to LMA (74% vs. 32%). ETT is associated higher risk of minor bronchospasm, major (<90%) arterial oxygen desaturation, respiratory adverse events compared to LMA. Placement & removal of ETT is associated with increased complications. 14.1% and 24.3% during ETT placement and removal respectively. Other complications of intubation in child with URI include; sore throat (49% 2 X than with LMA), increased potential for mucoid plugging of ETT or bronchi in small children
When is Intubation Indicated in Child with URI?
Few events evoke more trepidation for the pediatric anesthesiologist than a failed airway. In planning the anesthetic for a child with an URI we are riding into battle against an airway likely to cause problems. Maintaining the airway with an ETT may be our best defense”
Advantages of Intubation in a Child with URI
ETT indicated in surgery for head, oropharynx, neck and major thoracic, abdominal & laparoscopic surgery; lateral or prone position, surgery > 2 hours and also to facilitate IPPV. Without an ETT there is risk of breath-holding, bronchospasm and laryngospasm
Disadvantages of LMA / Face Mask: include increased pooling of secretions in the upper respiratory tract, coughing, aspiration, laryngospasm. During spontaneous ventilation there are chances of the development of desaturation, hypoventilation, and distention of stomach during assisted ventilation or positive pressure via LMA. Abdominal distension further reduces the FRC, thereby worsening oxygenation & ventilation. ETT desirable in these setting
Extubation technique
To extubation when deeply anaesthetised or completely awake is the question (18)
Homer et al. evaluated 335 children and noted that the airway device used & timing of extubation contributed to respiratory events.  A higher incidence if peak URI symptoms occurred within preceding 4 weeks. Early recognition and gauging depth of anesthesia related to the procedure, prompt, professional management more likely with Anesthesiologist more experienced with anesthetizing children. (19)              
Cancellation of surgery should be considered if there is a poor risk / benefit. There is no clear consensus on optimal time for rescheduling of surgery (ideal 4 wks). One need to balance the need to proceed with the surgery and time required for symptoms to resolve. Most anesthesiologist reported waiting for 3-4 weeks proceeding for elective surgery if symptoms severe (20)
Proceed with surgery if the there is a good risk / benefit ratio but proceed with caution! Blanket cancellation of surgery is not practical with increasing case loads & production pressures as well as emotional and economic burdens on the parents. More experienced anesthesiologists are less likely to cancel cases compared with those less experienced. (21) Older children may not reveal congested cough which may be only sign of URI. Parent's denial of URI symptoms in child: language barrier, chronic symptoms, avoids inconvenience of cancellation. Absence of support from anesthesiology colleagues may result in decision to proceed. The more surgical specialties involved in the case, the less likely of postponement of the case. During surgical missions when surgery done during a small time frame in maximum number of patients - less likely to cancel
Precautions to Minimize Perioperative Complications in a Child with URI

  • Hydration ( secretions)
  • Humidification (minimize drying & formation of mucous plugs) 
  • Pediatric oxymetazoline nasal drops
  • Reduce anxiety (midazolam)
  • Routine IM atropine/glycopyrrolate not advocated, may give IV
  • Smooth inhalation induction
  • Continue with face mask / LMA avoid ETT
  • Bronchodilators
  • Smooth emergence
  • Postoperative O2 , close monitoring

References:

  • Cohen MM et al. Anesth Analg 1991;72:282-8
  • Parnis SJ et al.  Paediatr Anaesth 2001;11:29-40     
  • Tait AR et al.  Anesthesiology 2001;95:299-306
  • Konarzewski WH et al. Anaesthesia 1992;47:624.
  • Jones A. Anaesthesia 1993;48;642
  • Van der Walt J. Paediatr Anaesth 1995;   5:257
  • Roy WL et al. Can J Anaesth 1988; 35: 93–98
  • Visvanathan T et al. Qual Saf Health Care 2005; 14: e3
  • Empey DW et al. Am Rev Respir Dis 1976;113:131-9
  • Cate TR et al. Am Rev Respir Dis 1973;108:858-65
  • Collier AM et al. 1978; 117:47-53
  • Olsson GL et al Acta Anaesthesiologica   Scandinavica 1984; 28: 567–575
  • Van der Walt J. Paediatr Anaesth 1995;   5:257
  • Oberer C et al. Anesthesiology 2005; 103: 1142–1148.Miller’s Anesthesia, 6th edn. Philadelphia: Elsevier Churchill Livingstone, 2005: 2373
  • Flick RP et al. Paediatric Anaesth  2008; 18: 289-296
  • Cohen MM et al. Anesth Analg 1991;72(3):282-8.
  • Tartari S et al (English abstract) Minerva Anestesiologica 2000;66(6):439-43.
  • Homer RJ et al. Pediatr Anesth 2007;17:154-161
  • Larson PC. Anesthesiology 1998; 89: 1293–1294
  • Tait AR et al. J Clin Anesth 1995;7:491-9
  • Tait AR, Malviya S. anesthesia for the child with a upper respiratory tract infection: Still a dilemma? Anesth Analg 2005;100;59-65