To delay or not to delay: upper respiratory tract infections in children: a focused narrative review
Myron Yaster MD, Lynne G. Maxwell MD, Melissa Brooks Peterson MD, and Francis Veyckemans MD
We’ve all been there: a youngster arrives to Preop for PE tubes and/or adenoid/tonsil surgery and has an acute upper respiratory infection (URI). You know these children have an increased risk of perioperative respiratory adverse events such as laryngospasm, bronchospasm, and desaturation. Further, you discover the child is in day care and realize that the entire reason she presents for surgery is because she gets a URI about every 4-6 weeks. Should you proceed or delay (cancel) surgery? And if you delay surgery, how long should you wait to reschedule? Today’s PAAD by Stepanovic et al.1 provides some evidence-based guidance. The senior author Britta von Ungern-Sternberg is well known to the PAAD readership as one of the premier thought leaders in our specialty. Finally, for those of you who lecture or teach, this is a terrific review article to use or add to your teaching files/portfolio…particularly useful are the tables and figures in the article, some of which we will include in today’s PAAD. Myron Yaster MD
Original article
Stepanovic B, Regli A, Becke-Jakob K, von Ungern-Sternberg BS. Preoperative preparation of children with upper respiratory tract infection: a focused narrative review. Br J Anaesth. 2024 Dec;133(6):1212-1221. doi: 10.1016/j.bja.2024.07.035. Epub 2024 Oct 2. PMID: 39358184.
Upper airway infections (URIs) are: “Self-limited viral or bacterial infection of the upper airways with irritation and oedema of the mucosa. Incidence: Seasonal variability, on average eight URTIs per year in children <4 yr. Symptoms: Rhinitis, sneezing, nasal congestion, sore throat, cough, muscular pain, headache, fever, malaise, and lethargy. Children with URIs confer a significant social and economic burden in terms of increased healthcare resource use, child absences from school, and parental absences from work.”1 Delaying surgery places a significant burden on the health care system and on parents who must take time off from work and in many cases travel long distances to get the surgery done.
Why do we care? “Children with URTI are at an ~30% risk of perioperative respiratory adverse events,2 equating to a two-to three-fold increased risk compared with healthy children.”1,3 What are these perioperative respiratory adverse events? “Laryngospasm, bronchospasm, hypopnoea or apnoea, breath holding and hypoxaemia (saturation <95%), and severe persistent coughing, and can lead to serious consequences such as premature surgical termination, prolonged need for oxygen therapy, aspiration, airway obstruction, reintubation, prolonged hospital length of stay, and unintended ICU admission.”1 In addition, we tend to overlook atelectasis which is often asymptomatic unless accompanied with hypoxemia, and postoperative lung infection, which is often unrecognized because it occurs after child’s return home.
“URIs are defined as two of the following symptoms: rhinorrhoea, sore or scratchy throat, sneezing, nasal congestion, malaise, cough, or fever over 38C. In addition to these most commonly reported symptoms, muscular pain, headache, and lethargy can also occur.4 Children with more severe symptoms of fever, a green runny nose, or moist cough are at a three-fold increased risk of perioperative bronchospasm and laryngospasm.3,5 Children undergoing surgery within the first 2 weeks after symptom resolution are at similar risk; after 2 weeks airway inflammation tends to decrease.6 Children generally return to a baseline risk within 4 weeks of URTI.”7 1
Risk factors associated with increased risk of perioperative respiratory adverse events are listed in Table 1 from the article.1
A decision making tool that I (MY) had never heard of is the COLDs score8 which the authors felt that despite its limitations is quite useful. It is easy to use and has been validated9 in 536 children < 6 years-old. The rate of complications increases with the score: 5% if < 7, 20% if 8-11, 55% if 16-18. Moreover, the 13 children in this series who were postponed had all a score >19. I (FV) think it has the advantages of combining objectively patient, surgery and airway interface data, and could be used at a departmental level to determine a threshold score for cancelling a procedure.9
Regarding anesthetic management, I (FV) think every anesthesiologist should use the induction technique he/she masters the best. Inhalation induction is probably better (for the child’s psychological well-being) and safer than many attempts to insert an IV line with a resulting screaming child with more secretions than at baseline. Concerning muscle relaxation, rocuronium 0.3 mg/kg after inhalation induction with sevoflurane provides as good intubation conditions as 0.6 mg/kg if you wait 2 minutes before laryngoscopy 10 but with a shorter duration of action.10
Do you use the COLDs score in your practice? Does your anesthetic management differ from the one in the presented algorithm and if so how? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Stepanovic B, Regli A, Becke-Jakob K, von Ungern-Sternberg BS. Preoperative preparation of children with upper respiratory tract infection: a focussed narrative review. British journal of anaesthesia 2024;133(6):1212-1221. (In eng). DOI: 10.1016/j.bja.2024.07.035.
2. Michel F, Vacher T, Julien-Marsollier F, et al. Peri-operative respiratory adverse events in children with upper respiratory tract infections allowed to proceed with anaesthesia: A French national cohort study. European Journal of Anaesthesiology | EJA 2018;35(12):919-928. DOI: 10.1097/eja.0000000000000875.
3. Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med 2017;5(5):412-425. (In eng). DOI: 10.1016/s2213-2600(17)30116-9.
4. Regli A, Becke K, von Ungern-Sternberg BS. An update on the perioperative management of children with upper respiratory tract infections. Current opinion in anaesthesiology 2017;30(3):362-367. (In eng). DOI: 10.1097/aco.0000000000000460.
5. von Ungern-Sternberg Britta S, Boda K, Schwab C, Sims C, Johnson C, Habre W. Laryngeal Mask Airway Is Associated with an Increased Incidence of Adverse Respiratory Events in Children with Recent Upper Respiratory Tract Infections. Anesthesiology 2007;107(5):714-719. DOI: 10.1097/01.anes.0000286925.25272.b5.
6. VON UNGERN-STERNBERG BS, HABRE W. Pediatric anesthesia – potential risks and their assessment: part I. Pediatric Anesthesia 2007;17(3):206-215. DOI: https://doi.org/10.1111/j.1460-9592.2006.02097.x.
7. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet (London, England) 2010;376(9743):773-83. (In eng). DOI: 10.1016/s0140-6736(10)61193-2.
8. Lee BJ, August DA. COLDS: A heuristic preanesthetic risk score for children with upper respiratory tract infection. Pediatric Anesthesia 2014;24(3):349-350. DOI: https://doi.org/10.1111/pan.12337.
9. Lee LK, Bernardo MKL, Grogan TR, Elashoff DA, Ren WHP. Perioperative respiratory adverse event risk assessment in children with upper respiratory tract infection: Validation of the COLDS score. Paediatric anaesthesia 2018;28(11):1007-1014. (In eng). DOI: 10.1111/pan.13491.
10. Eikermann M, Hunkemöller I, Peine L, et al. Optimal rocuronium dose for intubation during inhalation induction with sevoflurane in children. British journal of anaesthesia 2002;89(2):277-81. (In eng). DOI: 10.1093/bja/aef177.