Day-case adenotonsillectomy for sleep apnoea in children?

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Abstract

Objectives

Many clinicians are concerned about possible airway or respiratory complications following adenotonsillectomy for sleep related breathing disorder (SRBD), and routinely admit such patients for overnight monitoring. However, published guidelines suggest this is unnecessary in some cases. This study firstly aimed to establish current UK practice, and secondly to investigate whether children with mild/moderate SRBD experience respiratory problems during the first post-operative night.

Methods

To establish current UK practice, we carried out a telephone survey asking if the procedure was carried out as a day-case, and admission criteria. For the second aim, a prospective study of children admitted following adenotonsillectomy for mild/moderate SRBD was carried out to investigate occurrence of respiratory complications on first post-operative night.

Results

Forty-two UK ENT doctors responded to the telephone survey, 50% routinely admitted patients having adenotonsillectomy for SRBD. Discharge criteria included stable observations and eating and drinking (14 hospitals), no bleeding (1), stable oxygen saturations (1) and age above 5 years (1); four had no specific criteria. Of 51 children admitted following adenotonsillectomy for mild/moderate SRBD, 11 (21.6%) experienced oxygen desaturations overnight. Of these, nine were under 4 years old, and two older children had asthma. Irrespective of comorbidities, 9/27 (33.2%) children under 4 years old experienced desaturations. The only children aged more than 4 years that had desaturations were ones that had additional comorbidities.

Conclusion

Half of surveyed doctors admit all children following surgery for SRBD. The number of admissions could be reduced, because same-day discharge for otherwise-healthy children over 4 years old having adenotonsillectomy for mild/moderate SRBD appears to be safe.

Introduction

Sleep related breathing disorders (SRBD) are common in childhood. The condition may be caused by multiple factors but is typically a result of adenotonsillar hypertrophy. It affects between 2% and 4% of children and mainly occurs in children aged 1–8 years [1]. In a minority it can adversely affect neural sites in regions of the brain controlling important functions such as memory and cognition, and may be associated with several cardiovascular complications including cor pulmonale, cardiac failure and hypertension [1], [2].

The main treatment is adenotonsillectomy. Due to concerns about possible post-operative airway problems or negative pressure pulmonary oedema, overnight inpatient care for all children having adenotonsillectomy for SRBD may be considered [3], [4]. However, whether overnight admission is required or not is unclear, and there is a variation among institutions on admission or day-case criteria [5], [6]. Recent French and USA guidelines indicate that admission is only required in select children, and a 2009 UK consensus document deemed day-case surgery acceptable [7]. Selective admission of only those patients deemed at increased risk of complications would avoid unnecessary admission for many children, resulting in significant cost benefits, and increased capacity for other admissions.

Our study had two aims. Firstly, to establish whether hospitals in UK are performing day-case adenotonsillectomy for SRBD. Secondly, to examine (in a hospital that admits all children for observation) whether children with mild to moderate SRBD experience respiratory problems on the first night post adenotonsillectomy. From the results, we aim to establish if same-day discharge is safe and UK practice should change.

Section snippets

Establishing current UK practice on admission post adenotonsillectomy for children with SRBD

A telephone survey was carried out, calling 65 out of approximately 125 hospitals providing an ENT service across the UK; the hospitals were chosen through convenience sampling. The ENT on call junior doctor or registrar were contacted, and asked if their institution carried out the procedure as a day-case, and if so what the criteria for same-day discharge was. The authors recognize that responses may be influenced by the familiarity of the on-call doctor with their hospital guidelines.

Complications on first post-operative night

Our

Current UK practice

The telephone survey included responses from 42 out of 65 hospitals contacted. The other hospitals were excluded because the doctor was not available for a telephone conversation (22 hospitals) or not willing to participate (1 hospital). Overall, 50% (21/42) of hospitals routinely admitted patients having adenotonsillectomy for SRBD. In those that performed day-case surgery, the main criterion for discharge cited was that the patient had stable observations and was eating and drinking (14

Discussion

Our study shows that half of UK hospitals surveyed may be performing day-case adenotonsillectomy for SRBD. In a hospital that currently admits all, the children experiencing desaturations following adenotonsillectomy for mild/moderate SRBD were those children that were either aged under 4 years old or had additional comorbidities. This suggests that it is possible to identify children at increased risk of airway complications, and that discharging some children on the day of surgery would be

Conclusion

Same-day discharge for otherwise-healthy children over 4 years old having adenotonsillectomy for mild/moderate SRBD appears to be safe. In our study, respiratory complications occurred in children under 4 years old or with comorbidities. Identification of children suitable for day-case surgery appears to be possible, in keeping with published USA and French guidelines. Our survey of UK ENT doctors suggests that many institutions currently admit all children following surgery for SRBD (like our

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