Should a Child with a Respiratory Tract Infection Undergo Elective Surgery?

Introduction

Acute respiratory infections are one of the leading medical causes of surgery cancellation in children. Anesthesiologists are often confronted with patients demonstrating symptoms of upper respiratory tract infections (URIs) (e.g., runny nose, congestion, and coughing) and lower respiratory tract infections (LRIs) (e.g., crackles, rales, wheezing, and sputum production) on the day of surgery. Additional pressures to proceed with anesthesia and surgery despite respiratory symptoms often involve nonmedical issues, which may be social, emotional, and even financial in nature, and these pressures can come from the patient’s family, the surgeon, and the hospital.

What is the evidence regarding the risk of proceeding with anesthesia and surgery in the face of acute URI or LRI symptoms? Many large retrospective studies have shown an increased risk of adverse intraoperative and perioperative events such as croup, laryngospasm, and bronchospasm. Physiologic experiments in animals and humans have shown increased small airway reactivity during and after viral respiratory tract infections. Although the exact mechanisms are unknown, it appears that the airways are affected for up to 6 weeks after a viral respiratory infection.

Another confounding issue in dealing with respiratory tract infections in children is the frequency with which they occur. The average child less than 5 years of age is reported to have from five to six URIs per year with a duration of 7 to 10 days of active symptoms and residual pulmonary effects of 2 to 6 weeks. This creates a practical problem of children becoming reinfected as often as every 2 weeks, especially during the winter months. Adverse respiratory events such as bronchospasm and laryngospasm have been shown to occur more frequently in all pediatric patients, even in the absence of respiratory infections, especially in children younger than 1 year of age. Pediatric patients have an incidence of laryngospasm of 17.4 per 1000 in the age group of 0 to 9 years, which increases in patients with reactive airways disease to 63.9 per 1000. The ratio rises to 95.8 per 1000 when children have a history of respiratory tract infections. Children with underlying chronic pulmonary diseases (e.g., reactive airways disease, asthma, cystic fibrosis, and lung disease of prematurity) have been shown to have an increased risk of perioperative events such as prolonged intubation, reintubation, hypoxemia, bronchospasm, and laryngospasm. There is some evidence that the risk of airway events is also increased in children who are exposed to secondhand smoke even in the absence of a history of reactive airways disease or infection.

Options

Although there is a great deal of anecdotal information in the literature concerning adverse events in children with respiratory infections, the clinical dilemma of managing those patients who are demonstrating symptoms of URI or LRI persists for many practitioners. Numerous studies have attempted to elucidate the risks of anesthesia in children with respiratory infections. The following studies and their results are reviewed to better understand the current state of anesthetic care for infants and children with respiratory tract infections.

Evidence for Perioperative Risk in Children with Respiratory Infections

No randomized prospective studies have evaluated the different management options and the relationship to perioperative respiratory complications in children who are currently symptomatic or in those who are recovering from a respiratory tract infection. Other than one study of the risks of URI in children undergoing cardiac surgery, no studies evaluating children with URI who undergo prolonged or invasive procedures have addressed the possibility of benefit from delaying versus proceeding with nonurgent surgery. Therefore one must rely on cohort studies for determining the clinical evidence that exists for management of children with symptomatic and resolving respiratory tract infections ( Table 69-1 ).

TABLE 69-1

Overview of Study Design and Findings of Major Studies Involving Risk of General Anesthesia in Children with Upper Respiratory Tract Infection

Study	Design	No. of Patients Studied	No. of Children with URI	No. of Children with Recent URI	Intubation	LMA	Facemask	Adverse Events	Conclusions
Tait (1987)	Retrospective	3585	122	133	Yes	Yes		L, B, S, A	No increased risk if URI; no difference between ETT versus facemask; if recent URI, had a three times higher rate of bronchospasm
Tait (1987)	Prospective	489	78	84	No	Yes		L, Dy, A	No increased rate of complications in groups with acute or recent URI
DeSoto (1988)	Prospective	50	25	—	Yes	Yes		D	If URI present, increased risk of desaturation
Cohen (1991)	Prospective	22,159	1283	—	Yes	Yes	Yes	L, B, S, A	If URI, then two to three times more likely to have event; 11 times more likely if URI and ETT
Rolf (1992)	Prospective	402	30	—	Yes	Yes	Yes	L, B, D	If URI, then increase in minor desaturation; if URI and ETT, then higher frequency of bronchospasm
Kinouchi (1992)	Prospective	61	20	—	No	Yes		D, A	Desaturation occurs more frequently in young children and is of longer duration
Levy (1992)	Prospective	130	22	28	No	Yes		D	If acute or recent URI, then an increased risk of desaturation
Schreiner (1996)	Case control	15,183	30	17	Yes	Yes	Yes	L	Laryngospasm was more likely to occur in patients with URI, younger children; no correlation between mask versus ETT versus LMA
Skolnick (1998)	Prospective	602	?	?	Yes	Yes		L, B, S, A	Increased risk of adverse events if URI; smoking exposure increase airway complications
Tait (1998)	Prospective	82	82	?	Yes	Yes	Yes	C, A, L, B, D	LMA suitable alternative to ETT
Homer (2007)	Prospective	335	?	?	Yes	Yes	Yes	D, C	Specific preoperative symptoms were not predictive of specific adverse respiratory events
Tait (2001)	Prospective	1078	407	335	Yes	Yes	Yes	B, L, A, C, D	Child with active or recent URI at increased risk of adverse events, but most can be safely anesthetized
von Ungern-Sternberg (2007)	Prospective	831	223	223	No	Yes	No	B, C, D, L	LMA use in child with recent URI associated with higher rate of complications compared with healthy children

A, apnea/breath holding; B, bronchospasm; C, coughing; D, desaturation; Dy, dysrhythmia; ETT, endotracheal tube; L, laryngospasm; LMA, laryngeal mask airway; S, stridor; URI, upper respiratory tract infection.

Appropriately Identifying Children with Respiratory Tract Infections

The diagnosis of a respiratory tract infection is made based on symptoms. There are no laboratory tests or radiographic findings that make the diagnosis more or less accurate. As mentioned earlier, symptoms can involve the upper respiratory tract, the lower respiratory tract, or both ( Table 69-2 ). Unfortunately, other chronic conditions such as a nasal foreign body or allergic rhinitis can occur with symptoms similar to a respiratory tract infection. There are no published guidelines on diagnosing a child with a respiratory tract infection. Studies have used varying definitions ranging from rigid criteria to simply asking parents, “Does your child have an upper respiratory tract infection?” An early study by Tait and Knight used two symptoms of the following list for the diagnosis of URI. These were sore or scratchy throat, sneezing, rhinorrhea, congestion, malaise, cough, fever (higher than 38.3° C), or laryngitis. The most prevalent and statistically significant symptoms for URI were sneezing (24.4%, n = 78), congestion (53.8%, n = 78), and a nonproductive cough (76.9%, n = 78) that were more common when compared with asymptomatic control subjects. In a later study, Tait and colleagues surveyed 212 pediatric anesthesiologists and found the following symptoms being used by anesthesiologists in diagnosing respiratory tract infections. The single symptoms used as contraindications to surgery were fever (64%, n = 125), productive cough (62.4%, n = 121), wheezing (80.3%, n = 163), and rales and/or rhonchi (78.2%, n = 151). Further, the most frequently cited combination of symptoms resulting in cancellation of the case were fever and a productive cough (45.4%) or fever and yellow/green rhinorrhea (40.5%). Of note, the average temperature cutoff for cancellation of surgery was 100.8° F (38.3° C). After deciding if a patient is currently symptomatic, one must also consider how to manage a “recently” symptomatic child. The following studies often use a 1- to 2-week period after resolution of acute symptoms as having a “recent” or “resolving” URI. This is one of the confounding elements in dealing with these studies.

TABLE 69-2

Signs and Symptoms of Respiratory Tract Infections in Children with Upper or Lower Respiratory Tract Infection

	Mild URI	Severe URI	LRI	Allergic Rhinitis
History	No fever Minimal cough Clear runny nose Sneezing	Malaise Fever Purulent coryza Sneezing Cough	Severe cough Sputum production Wheezing ± fever	Atopy Seasonal history Sneezing
General examination	Nontoxic appearance Clear runny nose	Toxic appearance Malaise Fever	± Toxic appearance Tachypnea ± irritability	No fever Allergic shiners
Pulmonary examination	Clear lungs ± upper airway congestion	Maybe clear lungs Upper airway congestion	Rales Rhonchi