Observation After Adenotonsillectomy Recommended for Patients With Extreme Pediatric OSA

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Pediatric patients with extreme obstructive sleep apnea (OSA) may have a higher risk of needing respiratory support after undergoing corrective adenotonsillectomy, warranting the need for postoperative observation in these populations.

Postoperative observation following adenotonsillectomy (AT) may be warranted in patients with extreme pediatric obstructive sleep apnea (OSA) due to needing respiratory support after surgery, according to study findings published in Sleep Medicine.

With adenotonsillar hypertrophy being the most common cause of obstruction in children with OSA, AT serves as the first-line surgical treatment option for these populations. However, several concerns have been addressed in prior research regarding the impact of AT on children, particularly the risk of complications postoperative and potential long-term health effects.

“Both the American Academy of Pediatrics and Academy of Otolaryngology-Head and Neck Surgery recommend inpatient observation in this population postoperatively, but no specific level of care has been identified,” said the researchers.

Assessing children with extreme OSA (total apnea-hypopnea index [TAHI] > 100 events/h), a population with limited participation in studies, the researchers sought to classify post-AT respiratory support, identify post-AT respiratory support requirements, and evaluate the frequency of residual OSA after AT.


“We hypothesized that polysomnography (PSG) variables assessing gas exchange, age, and body mass index (BMI) z-score predict postoperative respiratory support requirements and postoperative OSA resolution,” they added.

They conducted a retrospective cohort study of patients aged 0 to 21 years who underwent PSG at Rady Children's Hospital San Diego between August 2015 and March 2020 and who met the extreme OSA criteria (N = 41; mean [SD] age, 11.4 [4.3] years; 80.5% male; 73.2% Hispanic; 92.7% obese). Patients with chronic diseases other than obesity were excluded.

The PSG interpretation software database was used to collect PSG specific variables of TAHI, obstructive AHI (OAHI), and central AHI, with several PSG variables assessing gas exchange also included:

  • Time spent with oxygen saturation below 90% (% SpO2 < 90%)
  • Oxygen saturation nadir (Nadir SpO2)
  • Time spent with end-tidal CO2 greater than 50 mmHg (%etCO2 > 50 mm Hg)
  • Peak etCO2

From the study cohort, 28 patients (68.3%) underwent AT, in which lower age (P < .001), lower BMI z-score (P < .01), higher OAHI (P < .05), and larger tonsil size (P < .05) were associated with having surgery.

Moreover, 11 of these 28 (39.3%) surgical patients were reported to require respiratory support (oxygen or positive airway pressure [PAP]) postoperatively—although adherence to PAP therapy was found to be greater in nonsurgical than surgical patients (57.1% vs 40%).

In assessing characteristics of those who required airway support, longer time with SpO2 below 90% during PSG (P < .05) and lower Nadir SpO2 (P < .05) were cited. Of the 19 patients who had a postoperative PSG, 11 had residual OSA (AHI > 5 events/h), but significant improvement in TAHI was observed (P < .01).

There were no reported incidences of mortality, reintubation, or hospital readmission following AT, with a majority (71.4%) discharged 1 day postoperatively. A hospital stay of more than 1 day was associated with a higher BMI z-score (P < .05), longer time with SpO2 below 90% during PSG (P < .01), and requirement of respiratory support, whether minor or major.

As the cohort was primarily older, male, and Hispanic, the researchers said findings should be evaluated with caution.

“In patients who underwent AT, we found surgery to be a reasonably safe treatment option in this population when postoperative care occurs in the intensive care unit setting. However, families should be counseled that while PSG parameters will likely improve, PAP therapy will often be recommended postoperatively,” concluded the study authors.


Mills TG, Bhattacharjee R, Nation J, Ewing E, Lesser DJ. Management and outcome of extreme pediatric obstructive sleep apnea. Sleep Med. Published online September 20, 2021. doi:10.1016/j.sleep.2021.09.006