Postoperative respiratory complications (PORC) in children with obstructive sleep apnea syndrome (OSAS) undergoing tonsillectomy: a narrative review

Abstract

Background: Obstructive sleep apnea syndrome (OSAS) in children often necessitates adenotonsillectomy as a primary intervention. However, postoperative respiratory complications (PORC) pose significant concerns in this population, warranting careful management and monitoring.

Objective: This narrative review aims to explore the prevalence, types, and risk factors associated with PORC in children undergoing adenotonsillectomy for OSAS. Additionally, current practices and guidelines for postoperative monitoring and management in this vulnerable population were investigated.

Methods: A comprehensive search of PubMed and the Cochrane Library was conducted from January till March 2024 to identify relevant studies. In addition, most recent guidelines of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS), the American Academy of Pediatrics (AAP), the European Respiratory Society (ERS), French Oto-Rhino-Laryngology – Head and Neck Surgery Society (SFORL) and the German guidelines regarding pediatric adenotonsillectomy were included.

Results: Twenty-nine studies addressing risk factors for PORC and 12 studies focusing on postoperative monitoring were included. PORC prevalence ranged from 1.4% to 30%, with desaturation being the most common. Identified risk factors included young age, presence and severity of OSAS, polysomnographic parameters, comorbidities, race, timing of surgery, and red cell width distribution. Guidelines varied in recommendations for inpatient admission and monitoring post-adenotonsillectomy. Notably, recent evidence suggests potential for monitoring in high-care wards or post-anesthesia care units, with selective use of pediatric intensive care units.

Conclusion: Various risk factors have been identified in predicting PORC following (adeno)tonsillectomy in children with OSAS such as age < 3 years, the presence of OSAS, presence of associated comorbidities, and PSG parameters. Recent guidelines suggest inpatient admission in the presence of specific risk factors. High-care wards or Post Anesthetic Care Units (PACUs) may suffice, avoiding unnecessary pediatric intensive care (PICU) admissions. A “grey zone” approach before deciding on further care is promising, but its optimal duration needs more research. Prospective studies are needed to refine and validate current guidelines, focusing on safely increasing the number of ambulatory (adeno)tonsillectomies.