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Obstructive sleep apnoea syndrome
Paed
Sleep-disordered breathing & OSA
Sleep-disordered breathing (SDB) describes a spectrum of disorders that range in severity from primary snoring through to obstructive sleep apnoea (OSA)
OSA is characterized by recurrent partial or complete obstruction to airflow during sleep causing fragmented sleep and gas exchange abnormalities.
It affects 3–5% of children and most commonly occurs between 2 years and 8 years of age.
Symptoms include
- snoring,
- apnoea,
- restless sleep
- neuro-cognitive disruption
- e.g. attention deficits and hyperactivity
OSA can lead to cardiorespiratory, neurocognitive and behavioural consequences
The most common predisposing factors in children are
- adenotonsillar hypertrophy,
- neuromuscular disorders
- craniofacial abnormalities
OSA ↑ risk of PRAE e.g.
- airway obstruction,
- laryngospasm,
- bronchospasm,
- apnoeas
- desaturation.
PRAE after tonsillectomy/adenoidectomy are 20% in the presence of OSA
(cf 1% w/o OSA)
Chronic obstruction with oxygen desaturation → disrupted central respiratory reflexes
→ ↑ sensitive to opioids
Diagnostic criteria differ in children and adults. OSA is diagnosed if PSG shows:
- Apnoea–Hypopnoea Index (AHI) >1 (number of apnoeas or hypopnoeas averaged over hours of sleep);
- mild: 2–5 AHI,
- mod: 5–10 AHI,
- severe: >10 AHI
- SpO2 nadir <90%
- ETCO2 >50 mmHg for >10% total sleep time + paradoxical respiration or snoring in children without lung disease.
Risk factors for postoperative respiratory complications in children with SDB include:
- age <3 years
- SpO2 nadir <80%
- severe OSA on PSG
- history of prematurity
- failure to thrive
- medically complex patients (chronic lung disease, cardiac disease, craniofacial abnormalities, neuromuscular disease, sickle cell disease, trisomy 21, obesity).
Anaesthetic Mx
-
Preoperative risk assessment:
- high-risk children require postoperative admission for monitoring and respiratory support
- escalation to intensive care in the most complex or severe disease.
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Avoid sedative premedication where possible.
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Employ multimodal analgesia and minimize opioids (NSAIDs, regional/local techniques).
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Avoid codeine due to risk of respiratory depression in CYP2D6 fast metabolizers.
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Dexamethasone (0.25 mg/kg) for airway oedema.
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Extubation should take place in a controlled environment with the patient awake.