Medical Student Loma Linda University School of Medicine Calimesa, California
Introduction: Inpatient monitoring is indicated for select children following tonsillectomy and adenoidectomy for obstructive sleep apnea depending on the risk for postoperative respiratory complications. AAO-HNS guidelines recommend monitoring for children less than 3 years old or having severe OSA; however, the guidelines recognize the lack of consensus regarding the definition of severe OSA in children. Based on a number of observational studies, an apnea-hypopnea index (AHI) greater than 10 events per hour is widely considered the cutoff for severe OSA, but opinions vary widely.
Methods: Retrospective review of all patients aged 3-18 years having tonsillectomy and adenoidectomy between October 2017 and July 2021 with pre-operative polysomnogram. Practice patterns at our institution vary, between use of the standard AHI greater than 10 and oxygen nadir less than 80% and a modified criterion of AHI greater than 30 and oxygen nadir less than 70 to define severe OSA requiring admission.
Results: Mid-study analysis of cohorts with complete data showed no significant difference in pre-operative apnea-hypopnea index (14.4±27.5 versus 15.4±22.4; p=0.75) between the patients discharged based on revised and standard criteria, respectively. The rate of admission in the revised criteria cohort was 21% compared to 64% in the standard criteria group (p < 0.001). There was no significant difference in the rates of readmission (3.6% versus 6.2%; p=0.5) or return to the ED (2.1% versus 6.5%; p=0.9) between the revised and standard criteria cohorts. On study conclusion, multi-level modelling will be used to further assess differences in study outcomes between groups.
Conclusion: Post-operative monitoring in select children is essential for safe tonsillectomy and adenoidectomy in the treatment of pediatric OSA. However, given the debate regarding accurate classification of OSA severity in children there remains room for optimization of admission criteria. In our experience, expanded criteria for discharge result in lower admission rates without increase in post-operative respiratory complications. In the era of increased medical demand, expansion of outpatient surgical indications optimizes resource utilization and workflow while potentially improving the subjective experience of patient recovery.