UPPER RESPIRATORY INFECTIONS
Viral upper respiratory infections (URIs) can increase complications in many children in the perioperative period of anesthesia. Some complications include bronchospasm, hypoxemia, strider caused by subglottic edema, atelectasis, laryngospasm, coughing, and breath holding. It is important to obtain a thorough history because events such as history of prematurity, reactive airways disease, parental smoking, and the symptoms of URI are considered perioperative risks as well. However, there are some studies that do not find a correlation with URIs and postoperative complications, and thus it is important to weigh the potential risk with the need for surgery. A chest radiograph may also be indicated as well. Elective procedure can be delayed 1–2 weeks for a recent uncomplicated URI. If there is lower airway involvement, delay is 4–6 weeks as a conservative approach.
When managing patients with URIs in elective surgery, it is best to avoid intubation if possible, lowering the incidence of bronchospasm in children with URI. If intubation is required, then it is appropriate to use an endotracheal tube at least one size smaller than typically appropriate while under deep anesthesia. Heated humidification is recommended. Intravenous lidocaine or opioids are useful to decrease airway reflexes.
Epiglottitis, also known as acute supraglottitis, is a life threatening disease of children involving an acute bacterial infection that causes inflammation in the supraglottic structures, such as the epiglottis, the aryepiglottic folds, and the arytenoids. Before the vaccine became available, Haemophilus influenzae type B was the main culprit. Other organisms now include Group A B-hemolytic streptococci, Staphylococcus, and Candida with a high decline in the incidence of the disease since the vaccination. Symptoms include a rapid onset of dysphagia, dysphonia, dyspnea, and drooling. The patient will likely have a high fever with tachycardia. Differential diagnosis includes laryngotracheobronchitis and tracheitis. The classic position of the child is sitting up with the mouth open and drooling and the chin thrust forward. Due to the upper airway obstruction, inspiratory phase is slow. If the patient’s symptoms are not too severe a lateral neck radiograph can be obtained, which will show a shadow in the supraglottic area indicating swelling of the supraglottic structures as well as loss of the normal curvature of the cervical spine.
If the patient is in severe distress, it is important to transfer the patient to the operating room for emergency intubation without examining the airway. Intravenous access should be obtained and atropine given to block vagal-stimulated bradycardia. Muscle relaxants are contraindicated. Intubation should be performed with a tube that is one or two sizes smaller than appropriate. The epiglottis may have the classic cherry-red epiglottis, an omega shape, or be partially inflamed. If there is severe obstruction, and the identification of structures is difficult, forcible manual chest compression can open the expiratory passages and produce bubbles of air allowing the advancement of the tube toward that region. Once the tube ...