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Postoperative bilevel positive airway pressure ventilation after tonsillectomy and adenoidectomy in children — a preliminary report
International Journal of Pediatric Otorhinolaryngology 51 (1999) 177 – 180 www.elsevier.com/locate/ijporl
Postoperative bilevel positive airway pressure ventilation after tonsillectomy and adenoidectomy in children — a preliminary report Oren Friedman a, Aaron Chidekel b, Stephen T. Lawless c, Steven P. Cook d,* a Thomas Jefferson Uni6ersity, Philadelphia, PA, USA Di6ision of Pulmonology, Alfred I. duPont Hospital for Children, Wilmington, DE, USA c Di6ision of Critical Care Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE, USA d Di6ision of Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, DE, USA b
Received 21 May 1999; received in revised form 31 August 1999; accepted 1 September 1999
Abstract Obstructive sleep apnea (OSA) in children, characterized by hypoventilation secondary to upper airway obstruction, often results from tonsil and adenoid hypertrophy. Adenotonsillectomy is the standard therapy in this patient population. The immediate postoperative period is complicated occasionally by respiratory difficulties that may require intubation and mechanical ventilation. Recently, physicians have provided temporary airway support using continuous and bilevel positive airway pressure (BiPAP) devices. Reported complications of positive airway pressure devices include local abrasions to the nose and mouth; dryness of the nose, eyes, and mouth; sneezing; nasal drip, bleeds, and congestion; sinusitis; increased intraoccular pressure; non-compliance; and pneumocephalus. Subcutaneous emphysema following facial trauma, dental extractions, adenotonsillectomy, and sinus surgery has been reported. There is also a hypothetically increased risk of subcutaneous emphysema following the use of positive airway pressure ventilation in the tonsillectomy patient. Between January 1997 and July 1998, 1321 patients underwent tonsillectomy and/or adenoidectomy at our institution. In reviewing the records of all pediatric intensive care unit admissions during that time period, we identified nine patients, of the 1321, who required BiPAP postoperatively. Of these, four children were obese, four had preexisting neurological disorders, and one underwent endoscopic sinus surgery and adenoidectomy. Three children were asthmatic, and three were less than 3 years of age. Two obese children were discharged with home BiPAP, one of whom had been on BiPAP prior to surgery. All patients tolerated BiPAP without complications. This preliminary report suggests that BiPAP is a safe and effective method of respiratory assistance in the adenotonsillectomy patient with preexisting conditions who is predisposed to postoperative airway obstruction. Furthermore, with BiPAP, the risks of intubation and ventilator dependence are avoided. © 1999 Elsevier Science Ireland Ltd. All rights reserved.
This study completed at the Alfred I. duPont Hospital for Children, Wilmington, DE, USA. * Corresponding author. Tel.: + 1-302-6515895; fax: + 1-302-6515328. E-mail address: [email protected] (S.P. Cook)
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 2 6 0 - 8
178
O. Friedman et al. / Int. J. Pediatr. Otorhinolaryngol. 51 (1999) 177–180
Keywords: Bilevel positive airway pressure (BiPAP); Adenotonsillectomy; Airway obstruction
1. Introduction Tonsillectomy and adenoidectomy (T&A) are among the most commonly performed surgical procedures. During the past 20 years, the number of T&As performed for obstructive sleep apnea (OSA) and upper airway obstruction has increased markedly [1]. It is estimated that 5% of children snore habitually, and 50% of habitual snorers have OSA. Up to 63% of children undergoing adenotonsillectomy have a history of snoring, and 59–75% of these children have OSA [2]. The standard therapy for OSA in children is adenotonsillectomy. The current use of strict indications for T&A has resulted in a sicker cross section of the population undergoing this procedure [3,4]. While improved anesthetic and surgical techniques have made T&A safer procedures, the possibility of serious complications, including respiratory failure, hemorrhage, and anesthetic sequelae, persists. Children with OSA have a significantly greater risk of developing severe respiratory compromise requiring medical intervention following adenotonsillectomy than children who undergo T&A for other indications [2,5,6]. There have been reports of subcutaneous emphysema following adenotonsillectomy that resulted in pneumomediastinum and pneumothorax [7,8]. The potential cardiorespiratory collapse which may result from such complications can be lifethreatening. Preoperatively, OSA is commonly treated in both children and adults with non-invasive positive pressure ventilation with good success and minimal complications. Recently, acute perioperative respiratory stabilization in cases of post-T&A respiratory compromise has been achieved with noninvasive positive pressure ventilation [2,6,9]. Continuous positive airway pressure devices (CPAP) and BiPAP are generally thought to be safe alternatives to intubation and mechanical ventilation. Complications of CPAP and BiPAP, including nasal drying and congestion, eye irritation, ulcerations on the nasal bridge, and non-
compliance have been well recognized as limiting factors in the use of these devices [10–13]. Unusual complications of subcutaneous emphysema and pneumocephalus following the use of CPAP have been reported in adults. These complications are most likely the result of air dissecting through a defective mucosal and soft-tissue barrier and facilitated by the positive pressure from CPAP [11–13]. We performed a preliminary review of the use of BiPAP in T&A patients at our institution to determine its safety and efficacy. This was undertaken because of concerns regarding the potential risk of subcutaneous emphysema, pneumomediastinum, and pneumothorax, and the increasing use of noninvasive positive pressure ventilation to support acute respiratory compromise immediately following surgery.
2. Methods A total of 1321 children underwent tonsillectomy and/or adenoidectomy at our institution between 1 January 1997 and 31 July, 1998. Pediatric intensive care unit (PICU) admissions during this time period were examined, and all patients admitted with a diagnosis of respiratory compromise were identified. Those patients who had undergone tonsillectomy and/or adenoidectomy and were admitted to the PICU for respiratory compromise were selected for review for this study. Nine of the 1321 patients were found to have respiratory compromise following surgery, and required ventilatory support with BiPAP. The indication for surgery in all of these patients was OSA. The charts of these nine patients were reviewed in detail. Patient age, weight, sex, craniofacial abnormalities and comorbid disease were noted. The surgical technique in all cases was Bovie cautery for tonsillectomy. Operative time did not vary significantly in the nine patients, and there were no intraoperative complications. There were no anesthesia complications. Polysomnogram studies are not routinely obtained prior to T&A at our insti-
O. Friedman et al. / Int. J. Pediatr. Otorhinolaryngol. 51 (1999) 177–180
179
tution, and, therefore, were not included. Respiratory compromise was diagnosed by the otolaryngologist or the anesthesiologist. The need for respiratory support with BiPAP was identified by the intensivist.
postoperative respiratory compromise in OSA patients were consistent with our patient population. These features included obesity, young age, craniofacial abnormalities, and comorbid disease [2,3,5,6].
3. Results
4. Discussion
Of the nine patients identified for the study, eight underwent T&A, and one underwent functional sinus surgery with adenoidectomy. Four of the patients were obese. One child had Prader – Willi syndrome, mental retardation, asthma, and mitral valve insufficiency, and required home BiPAP upon discharge from the hospital. Four of the nine children had underlying neurologic disorders, including mental retardation/cerebral palsy (MRCP) (two children), seizures, and encephalopathy. Reactive airway disease prior to surgery was present in four children. Three children were less than three years of age. One child required BiPAP for OSA for one month prior to surgery. This child continued to require BiPAP subsequent to discharge from the hospital. Only one child had no known comorbid disease; her only risk factor for the development of postoperative respiratory compromise was her young age of 2 years. All children tolerated BiPAP without significant complications. One child refused to wear the BiPAP mask after the first 4 h, by which time he was able to be managed with oxygen support via nasal cannula. Bilevel positive airway pressure requirements ranged from 4 to 6 h for one child to long-term home BiPAP in another. The patients were monitored in the PICU. In six of the nine cases, the children were discharged home with no further need for respiratory support. Two children required home BiPAP postoperatively. One of these patients had Prader – Willi syndrome; the other had severe sleep apnea requiring home BiPAP prior to surgery. One child required long-term home oxygen therapy but did not need positive pressure ventilatory assistance. There was no evidence of subcutaneous emphysema in any of the patients, despite treatment with BiPAP immediately following surgery. Clinical features identified previously as increasing the risk of
Subcutaneous emphysema, pneumomediastinum, and pneumothorax may complicate T&A. Subcutaneous air resulting from tonsillectomy is postulated to infiltrate through a disruption of the epithelial mucosal layer in the oropharynx. Alternatively, it may result from endotracheal tube trauma to the laryngotracheal tree. Once air is trapped in the soft-tissue spaces, it may dissect along the fascial planes of the neck, mediastinum, and abdominal wall [14]. While the clinical course of subcutaneous emphysema and pneumomediastinum is generally self-limited and benign, there is the potential for life-threatening cardiorespiratory consequences. Pneumothorax has been reported in 50% of patients with pneumomediastinum [13]. Tension pneumomediastinum resulting in compression of the heart by accumulated mediastinal air may cause massive decreases in cardiac output and circulatory arrest. Impedance of pulmonary vascular flow by air within the vascular sheaths may lead to additional cardiorespiratory complications [14]. The possibility of acute airway obstruction due to massive amounts of retropharyngeal subcutaneous emphysema must be recognized. Lastly, some important, although not life-threatening, complications of subcutaneous cervical air are eustachian tube dysfunction, serous otitis media, and hearing loss. When air dissects along the peritubular fascial planes and movement of palatal muscles is limited, aeration of the middle ear may be compromised [12]. Once a stabilized airway is assured, management of this complication involves conservative therapy including time, reassurance of the patient and family, and avoidance of actions that may exacerbate or potentiate subcutaneous air. Avoiding Valsalva’s maneuvers, which may increase alveolar pressures and cause alveolar rupture, may be achieved with cough suppressants, stool
180
O. Friedman et al. / Int. J. Pediatr. Otorhinolaryngol. 51 (1999) 177–180
softeners, analgesics, and bed rest. Increased positive pressure in the oropharynx, as occurs with CPAP and BiPAP, may need to be limited to prevent exacerbation of the subcutaneous air. The increasing number of T&As performed for OSA also increases the risks of postoperative respiratory compromise. Preoperative identification of high-risk patients with obesity, age less than 2 years, craniofacial abnormalities, neuromuscular disorders such as MRCP, and preoperative BiPAP support is essential in the preparation for management of postoperative complications. While there are many options for the management of respiratory compromise, we have found BiPAP to be a safe alternative to intubation. The BiPAP system provides a noninvasive means of delivering ventilatory assistance to a spontaneously breathing patient. It has been proven useful in improving ventilation and oxygen saturation in both chronic and acute respiratory failure [9,15,16]. This device may obviate the need for and prevent the associated physical and psychological trauma and complications of translaryngeal intubation. Patients may communicate verbally, cough, and swallow independently while on BiPAP. All nine postoperative patients treated by this method and reviewed in this study had positive responses with no complicating events. These patients were all monitored in the PICU during the immediate postoperative period while on BiPAP. This pilot study suggests that BiPAP is a safe and effective means of managing perioperative respiratory compromise in the T&A patient. Close monitoring of these patients for evidence of subcutaneous emphysema and its associated morbidities is necessary. A heightened awareness in physicians managing the post-T&A patient on BiPAP is essential, as the increased risk of subcutaneous emphysema due to both the surgical procedure and the use of positive pressure ventilation may result in severe, life-threatening complications.
.
References [1] R.M. Rosenfeld, R.P. Green, Tonsillectomy and adenoidectomy: changing trends, Ann. Otolaryngol. Rhinol. Laryngol. 99 (1990) 187 – 191. [2] G.M. Rosen, R.P. Muckle, M.W. Mahowaid, G.S. Goding, C. Ullevig, Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated?, Pediatrics 93 (1994) 784 – 788. [3] D.A. Randall, M.E. Hoffer, Complications of tonsillectomy and adenoidectomy, Otolaryngol. Head Neck Surg. 118 (1998) 61 – 68. [4] E.S. Deutsch, Tonsillectomy and adenoidectomy changing trends, Pediatr. Clin. N. Am. 436 (1996) 1319 – 1338. [5] S.A. McColley, M.M. April, I.L. Carroll, R.M. Nacleiro, G.M. Loughlin, Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea, Arch. Otolaryngol. Head Neck Surg. 118 (1992) 940 – 943. [6] K.A. Waters, F. Everett, J. Bruderer, F. MacNamara, C.E. Sullivan, The use of nasal CPAP in children, Pediatr. Pulmonol. 11 (1995) 91 – 93. [7] H.M. Prupas, S.D. Fordham, Emphysema secondary to tonsillectomy, Laryngoscope 87 (1977) 1134 – 1136. [8] L. Podoshin, M. Persico, M. Fradis, Posttonsillectomy emphysema, Ear Nose Throat J. 58 (1979) 73 – 82. [9] W.G. Teague, J.D. Fortenberry, Noninvasive ventilatory support in pediatric respiratoy failure, Respir. Care 40 (1995) 86 – 96. [10] J.L. Pepin, P. Leger, D. Veale, B. Langevin, D. Robert, P. Levy, Side effects of nasal CPAP in sleep apnea syndrome, Chest 107 (1995) 375 – 381. [11] N.R. Kramer, M.D. Fine, R.G. McRae, R.P. Millman, Unusual complication of nasal CPAP: subcutaneousemphysema following facial trauma, Sleep 20 (1997) 895 – 897. [12] D.A. Breznick, I.L. Saporito, Iatrogenic retropharyngeal emphysema with impending airway obstruction, Arch. Otolaryngol. Head Neck Surg. 115 (1989) 1367 – 1372. [13] J.L. Rossiter, R.A. Hendrix, Iatrogenic subcutaneous cervicofacial and mediastinal emphysema, J. Otolaryngol. 20 (1991) 315 – 319. [14] R.J. Maunder, D.I. Pierson, L.D. Hudson, Subcutaneous and mediastinal emphysema, Arch. Int. Med. 144 (1984) 1447 – 1453. [15] R.J. Padman, S.T. Lawless, R.G. Kettrick, Noninvasive ventilation via BiPAP support in pediatric practice, Crit. Care Med. 26 (1998) 169 – 173. [16] R.J. Padman, S.T. Lawless, S. Von Nessen, Use of BiPAP by nasal mask in the treatment of respiratory insufficiency in pediatric patients, Pediatr. Pulmonol. 17 (1994) 119 – 123.
Postoperative bilevel positive airway pressure ventilation after tonsillectomy and adenoidectomy in children — a preliminary report Oren Friedman a, Aaron Chidekel b, Stephen T. Lawless c, Steven P. Cook d,* a Thomas Jefferson Uni6ersity, Philadelphia, PA, USA Di6ision of Pulmonology, Alfred I. duPont Hospital for Children, Wilmington, DE, USA c Di6ision of Critical Care Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE, USA d Di6ision of Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, DE, USA b
Received 21 May 1999; received in revised form 31 August 1999; accepted 1 September 1999
Abstract Obstructive sleep apnea (OSA) in children, characterized by hypoventilation secondary to upper airway obstruction, often results from tonsil and adenoid hypertrophy. Adenotonsillectomy is the standard therapy in this patient population. The immediate postoperative period is complicated occasionally by respiratory difficulties that may require intubation and mechanical ventilation. Recently, physicians have provided temporary airway support using continuous and bilevel positive airway pressure (BiPAP) devices. Reported complications of positive airway pressure devices include local abrasions to the nose and mouth; dryness of the nose, eyes, and mouth; sneezing; nasal drip, bleeds, and congestion; sinusitis; increased intraoccular pressure; non-compliance; and pneumocephalus. Subcutaneous emphysema following facial trauma, dental extractions, adenotonsillectomy, and sinus surgery has been reported. There is also a hypothetically increased risk of subcutaneous emphysema following the use of positive airway pressure ventilation in the tonsillectomy patient. Between January 1997 and July 1998, 1321 patients underwent tonsillectomy and/or adenoidectomy at our institution. In reviewing the records of all pediatric intensive care unit admissions during that time period, we identified nine patients, of the 1321, who required BiPAP postoperatively. Of these, four children were obese, four had preexisting neurological disorders, and one underwent endoscopic sinus surgery and adenoidectomy. Three children were asthmatic, and three were less than 3 years of age. Two obese children were discharged with home BiPAP, one of whom had been on BiPAP prior to surgery. All patients tolerated BiPAP without complications. This preliminary report suggests that BiPAP is a safe and effective method of respiratory assistance in the adenotonsillectomy patient with preexisting conditions who is predisposed to postoperative airway obstruction. Furthermore, with BiPAP, the risks of intubation and ventilator dependence are avoided. © 1999 Elsevier Science Ireland Ltd. All rights reserved.
This study completed at the Alfred I. duPont Hospital for Children, Wilmington, DE, USA. * Corresponding author. Tel.: + 1-302-6515895; fax: + 1-302-6515328. E-mail address: [email protected] (S.P. Cook)
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 2 6 0 - 8
178
O. Friedman et al. / Int. J. Pediatr. Otorhinolaryngol. 51 (1999) 177–180
Keywords: Bilevel positive airway pressure (BiPAP); Adenotonsillectomy; Airway obstruction
1. Introduction Tonsillectomy and adenoidectomy (T&A) are among the most commonly performed surgical procedures. During the past 20 years, the number of T&As performed for obstructive sleep apnea (OSA) and upper airway obstruction has increased markedly [1]. It is estimated that 5% of children snore habitually, and 50% of habitual snorers have OSA. Up to 63% of children undergoing adenotonsillectomy have a history of snoring, and 59–75% of these children have OSA [2]. The standard therapy for OSA in children is adenotonsillectomy. The current use of strict indications for T&A has resulted in a sicker cross section of the population undergoing this procedure [3,4]. While improved anesthetic and surgical techniques have made T&A safer procedures, the possibility of serious complications, including respiratory failure, hemorrhage, and anesthetic sequelae, persists. Children with OSA have a significantly greater risk of developing severe respiratory compromise requiring medical intervention following adenotonsillectomy than children who undergo T&A for other indications [2,5,6]. There have been reports of subcutaneous emphysema following adenotonsillectomy that resulted in pneumomediastinum and pneumothorax [7,8]. The potential cardiorespiratory collapse which may result from such complications can be lifethreatening. Preoperatively, OSA is commonly treated in both children and adults with non-invasive positive pressure ventilation with good success and minimal complications. Recently, acute perioperative respiratory stabilization in cases of post-T&A respiratory compromise has been achieved with noninvasive positive pressure ventilation [2,6,9]. Continuous positive airway pressure devices (CPAP) and BiPAP are generally thought to be safe alternatives to intubation and mechanical ventilation. Complications of CPAP and BiPAP, including nasal drying and congestion, eye irritation, ulcerations on the nasal bridge, and non-
compliance have been well recognized as limiting factors in the use of these devices [10–13]. Unusual complications of subcutaneous emphysema and pneumocephalus following the use of CPAP have been reported in adults. These complications are most likely the result of air dissecting through a defective mucosal and soft-tissue barrier and facilitated by the positive pressure from CPAP [11–13]. We performed a preliminary review of the use of BiPAP in T&A patients at our institution to determine its safety and efficacy. This was undertaken because of concerns regarding the potential risk of subcutaneous emphysema, pneumomediastinum, and pneumothorax, and the increasing use of noninvasive positive pressure ventilation to support acute respiratory compromise immediately following surgery.
2. Methods A total of 1321 children underwent tonsillectomy and/or adenoidectomy at our institution between 1 January 1997 and 31 July, 1998. Pediatric intensive care unit (PICU) admissions during this time period were examined, and all patients admitted with a diagnosis of respiratory compromise were identified. Those patients who had undergone tonsillectomy and/or adenoidectomy and were admitted to the PICU for respiratory compromise were selected for review for this study. Nine of the 1321 patients were found to have respiratory compromise following surgery, and required ventilatory support with BiPAP. The indication for surgery in all of these patients was OSA. The charts of these nine patients were reviewed in detail. Patient age, weight, sex, craniofacial abnormalities and comorbid disease were noted. The surgical technique in all cases was Bovie cautery for tonsillectomy. Operative time did not vary significantly in the nine patients, and there were no intraoperative complications. There were no anesthesia complications. Polysomnogram studies are not routinely obtained prior to T&A at our insti-
O. Friedman et al. / Int. J. Pediatr. Otorhinolaryngol. 51 (1999) 177–180
179
tution, and, therefore, were not included. Respiratory compromise was diagnosed by the otolaryngologist or the anesthesiologist. The need for respiratory support with BiPAP was identified by the intensivist.
postoperative respiratory compromise in OSA patients were consistent with our patient population. These features included obesity, young age, craniofacial abnormalities, and comorbid disease [2,3,5,6].
3. Results
4. Discussion
Of the nine patients identified for the study, eight underwent T&A, and one underwent functional sinus surgery with adenoidectomy. Four of the patients were obese. One child had Prader – Willi syndrome, mental retardation, asthma, and mitral valve insufficiency, and required home BiPAP upon discharge from the hospital. Four of the nine children had underlying neurologic disorders, including mental retardation/cerebral palsy (MRCP) (two children), seizures, and encephalopathy. Reactive airway disease prior to surgery was present in four children. Three children were less than three years of age. One child required BiPAP for OSA for one month prior to surgery. This child continued to require BiPAP subsequent to discharge from the hospital. Only one child had no known comorbid disease; her only risk factor for the development of postoperative respiratory compromise was her young age of 2 years. All children tolerated BiPAP without significant complications. One child refused to wear the BiPAP mask after the first 4 h, by which time he was able to be managed with oxygen support via nasal cannula. Bilevel positive airway pressure requirements ranged from 4 to 6 h for one child to long-term home BiPAP in another. The patients were monitored in the PICU. In six of the nine cases, the children were discharged home with no further need for respiratory support. Two children required home BiPAP postoperatively. One of these patients had Prader – Willi syndrome; the other had severe sleep apnea requiring home BiPAP prior to surgery. One child required long-term home oxygen therapy but did not need positive pressure ventilatory assistance. There was no evidence of subcutaneous emphysema in any of the patients, despite treatment with BiPAP immediately following surgery. Clinical features identified previously as increasing the risk of
Subcutaneous emphysema, pneumomediastinum, and pneumothorax may complicate T&A. Subcutaneous air resulting from tonsillectomy is postulated to infiltrate through a disruption of the epithelial mucosal layer in the oropharynx. Alternatively, it may result from endotracheal tube trauma to the laryngotracheal tree. Once air is trapped in the soft-tissue spaces, it may dissect along the fascial planes of the neck, mediastinum, and abdominal wall [14]. While the clinical course of subcutaneous emphysema and pneumomediastinum is generally self-limited and benign, there is the potential for life-threatening cardiorespiratory consequences. Pneumothorax has been reported in 50% of patients with pneumomediastinum [13]. Tension pneumomediastinum resulting in compression of the heart by accumulated mediastinal air may cause massive decreases in cardiac output and circulatory arrest. Impedance of pulmonary vascular flow by air within the vascular sheaths may lead to additional cardiorespiratory complications [14]. The possibility of acute airway obstruction due to massive amounts of retropharyngeal subcutaneous emphysema must be recognized. Lastly, some important, although not life-threatening, complications of subcutaneous cervical air are eustachian tube dysfunction, serous otitis media, and hearing loss. When air dissects along the peritubular fascial planes and movement of palatal muscles is limited, aeration of the middle ear may be compromised [12]. Once a stabilized airway is assured, management of this complication involves conservative therapy including time, reassurance of the patient and family, and avoidance of actions that may exacerbate or potentiate subcutaneous air. Avoiding Valsalva’s maneuvers, which may increase alveolar pressures and cause alveolar rupture, may be achieved with cough suppressants, stool
180
O. Friedman et al. / Int. J. Pediatr. Otorhinolaryngol. 51 (1999) 177–180
softeners, analgesics, and bed rest. Increased positive pressure in the oropharynx, as occurs with CPAP and BiPAP, may need to be limited to prevent exacerbation of the subcutaneous air. The increasing number of T&As performed for OSA also increases the risks of postoperative respiratory compromise. Preoperative identification of high-risk patients with obesity, age less than 2 years, craniofacial abnormalities, neuromuscular disorders such as MRCP, and preoperative BiPAP support is essential in the preparation for management of postoperative complications. While there are many options for the management of respiratory compromise, we have found BiPAP to be a safe alternative to intubation. The BiPAP system provides a noninvasive means of delivering ventilatory assistance to a spontaneously breathing patient. It has been proven useful in improving ventilation and oxygen saturation in both chronic and acute respiratory failure [9,15,16]. This device may obviate the need for and prevent the associated physical and psychological trauma and complications of translaryngeal intubation. Patients may communicate verbally, cough, and swallow independently while on BiPAP. All nine postoperative patients treated by this method and reviewed in this study had positive responses with no complicating events. These patients were all monitored in the PICU during the immediate postoperative period while on BiPAP. This pilot study suggests that BiPAP is a safe and effective means of managing perioperative respiratory compromise in the T&A patient. Close monitoring of these patients for evidence of subcutaneous emphysema and its associated morbidities is necessary. A heightened awareness in physicians managing the post-T&A patient on BiPAP is essential, as the increased risk of subcutaneous emphysema due to both the surgical procedure and the use of positive pressure ventilation may result in severe, life-threatening complications.
.
References [1] R.M. Rosenfeld, R.P. Green, Tonsillectomy and adenoidectomy: changing trends, Ann. Otolaryngol. Rhinol. Laryngol. 99 (1990) 187 – 191. [2] G.M. Rosen, R.P. Muckle, M.W. Mahowaid, G.S. Goding, C. Ullevig, Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated?, Pediatrics 93 (1994) 784 – 788. [3] D.A. Randall, M.E. Hoffer, Complications of tonsillectomy and adenoidectomy, Otolaryngol. Head Neck Surg. 118 (1998) 61 – 68. [4] E.S. Deutsch, Tonsillectomy and adenoidectomy changing trends, Pediatr. Clin. N. Am. 436 (1996) 1319 – 1338. [5] S.A. McColley, M.M. April, I.L. Carroll, R.M. Nacleiro, G.M. Loughlin, Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea, Arch. Otolaryngol. Head Neck Surg. 118 (1992) 940 – 943. [6] K.A. Waters, F. Everett, J. Bruderer, F. MacNamara, C.E. Sullivan, The use of nasal CPAP in children, Pediatr. Pulmonol. 11 (1995) 91 – 93. [7] H.M. Prupas, S.D. Fordham, Emphysema secondary to tonsillectomy, Laryngoscope 87 (1977) 1134 – 1136. [8] L. Podoshin, M. Persico, M. Fradis, Posttonsillectomy emphysema, Ear Nose Throat J. 58 (1979) 73 – 82. [9] W.G. Teague, J.D. Fortenberry, Noninvasive ventilatory support in pediatric respiratoy failure, Respir. Care 40 (1995) 86 – 96. [10] J.L. Pepin, P. Leger, D. Veale, B. Langevin, D. Robert, P. Levy, Side effects of nasal CPAP in sleep apnea syndrome, Chest 107 (1995) 375 – 381. [11] N.R. Kramer, M.D. Fine, R.G. McRae, R.P. Millman, Unusual complication of nasal CPAP: subcutaneousemphysema following facial trauma, Sleep 20 (1997) 895 – 897. [12] D.A. Breznick, I.L. Saporito, Iatrogenic retropharyngeal emphysema with impending airway obstruction, Arch. Otolaryngol. Head Neck Surg. 115 (1989) 1367 – 1372. [13] J.L. Rossiter, R.A. Hendrix, Iatrogenic subcutaneous cervicofacial and mediastinal emphysema, J. Otolaryngol. 20 (1991) 315 – 319. [14] R.J. Maunder, D.I. Pierson, L.D. Hudson, Subcutaneous and mediastinal emphysema, Arch. Int. Med. 144 (1984) 1447 – 1453. [15] R.J. Padman, S.T. Lawless, R.G. Kettrick, Noninvasive ventilation via BiPAP support in pediatric practice, Crit. Care Med. 26 (1998) 169 – 173. [16] R.J. Padman, S.T. Lawless, S. Von Nessen, Use of BiPAP by nasal mask in the treatment of respiratory insufficiency in pediatric patients, Pediatr. Pulmonol. 17 (1994) 119 – 123.