Point - Counterpoint
Alan R. Tait, PhD
Associate Professor
Director of Clinical Research
Department of Anesthesiology
University of Michigan Health System
Ann Arbor, MI
Few issues in pediatric anesthesia have been as contentious as those regarding anesthesia for the child with an upper respiratory tract infection (URI). Much of the controversy has revolved around the relative merits of cancelling or proceeding with elective surgery for these children. While some studies suggest that the risks of perioperative complications in children with URIs warrant cancellation of surgery, others suggest that the risks are minimal and that most complications can be easily managed.
The majority of complications in children with URIs are related to the presence of secretions and heightened airway reactivity. Specific complications that have been identified include: breath holding, airway obstruction, laryngospasm, bronchospasm and arterial oxygen desaturation. Although the reported incidence of these complications varies from study to study, the use of an endotracheal tube (ETT) has been consistently associated with an increased risk of perioperative adverse events. In one large-scale study by Cohen et al. (1) involving over 20,000 subjects, children with URIs were shown to have an eleven-fold increase in respiratory complications if their tracheas were intubated. Furthermore, two large-scale prospective studies identified the ETT as an independent risk factor for adverse outcomes in children with URIs (2, 3). In one of these studies, the interaction between use of an ETT and young age (<5 yrs of age) was found to be strongly predictive of perioperative adverse events (2).
Several studies have described heightened airway
reactivity in patients with URIs that may persist for up to 6 weeks following
the infection. Viral infections are known to cause morphological and physiological
pulmonary changes including, sloughing of the respiratory epithelium, altered
ciliary beat frequency, and decreased airway conductance, forced vital capacity,
functional residual capacity, and diffusion rates. Given that these viral-induced
changes can occur, it would seem prudent to prevent their exacerbation by minimizing
manipulation of a potentially irritable airway. Indeed, in a survey of members
of The Society for Pediatric Anesthesia, 52% (mode) stated that they
frequently avoided tracheal intubation in children with URIs (4). Traditionally,
anesthesia administered via facemask has been the technique of choice for children
with URIs, however, this may be impractical for long surgical procedures. In
a study by Tait et al. children with a URI receiving an ETT were 2.5 times more
likely to experience an adverse respiratory event compared to those in whom
a facemask was used (2). Recently, two randomized studies found that the LMA
was a suitable alternative to the ETT for use in children with URIs (5, 6).
In one of these studies, Tartari et al. showed that children with URIs whose
tracheas were intubated had a significantly increased incidence of minor post-surgical
events compared to those who received an LMA (74% vs 32% respectively)
(5). In the other study, use of an ETT was associated with a significantly increased
risk of minor bronchospasm, major (<90%) arterial oxygen desaturation, and
overall respiratory adverse events compared to an LMA (6). One could argue that
once in place, the ETT provides a more secure airway than an LMA or facemask,
however, placement and removal of an ETT are, in and of themselves, associated
with an increased incidence of complications. In one study, the incidence of
adverse respiratory events was as high as 14.1% and 24.3% during ETT placement
and removal respectively (2).
Other potential complications associated with the use of an ETT in children with URIs include a higher incidence of sore throat and the potential for mucoid plugging of the ETT, particularly in small children. The incidence of sore throat among intubated children without URIs has been reported to be as high as 49%, whereas in one study of children with URIs, there was a twofold increase in sore throat among intubated children compared with those managed by LMA (6). Mucoid plugging of the ETT or bronchi due to inspissation of secretions leading to hypoxemia may also occur in children with URIs.
Despite compelling evidence that children with URIs who are intubated are at increased risk of perioperative complications, the data also suggest that these complications can be anticipated, recognized and treated without any long-term adverse sequelae (7). Serious adverse events, including death, have been associated with the presence of a URI, however, these were likely related to other factors independent of the URI. In any case, despite the apparent manageability of adverse events in this population of children, the primary goal is to avoid their appearance altogether. Based on the current evidence, we have information identifying specific risk factors for complications in children with URIs. As such, anesthesiologists are in a position to tailor their management of children with URIs to minimize the negative impact of these risk factors and to optimize care. Given that the use of an ETT has been identified as an independent predictor of perioperative adverse events, it would appear prudent to avoid its use whenever possible.
References:
1. Cohen MM, Cameron CB. Should you cancel the operation when a child has an upper respiratory tract infection? Anesth Analg 1991;72(3):282-8.
2. Tait AR, Malviya S, Voepel-Lewis T, Munro H, Siewert M, Pandit U. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology 2001;95:299-306.
3. Parnis SJ, Barker DS, Van Der Walt JH. Clinical predictors of anaesthetic complications in children with respiratory tract infections. Paediatr Anaesth 2001;11(1):29-40.
4. Tait AR, Reynolds PI, Gutstein HB. Factors that influence an anesthesiologist's decision to cancel elective surgery for the child with an upper respiratory tract infection. J Clin Anesth 1995;7(6):491-9.
5. Tartari S, Fratantonio R, Bomben R, Paolazzi M, Gritti G, Alvisi R. Laryngeal mask vs tracheal tube in pediatric anesthesia in the presence of upper respiratory tract infection (English abstract). Minerva Anestesiologica 2000;66(6):439-43.
6. Tait AR, Pandit UA, Voepel-Lewis T, Munro HM, Malviya S. Use of the laryngeal mask airway in children with upper respiratory tract infections: a comparison with endotracheal intubation. Anesth Analg 1998;86(4):706-11.
7. Coté CJ. The upper respiratory tract infection (URI) dilemma: Fear of complication or litigation? Anesthesiology 2001;95:283-5. #include ./footer_include.iphtml