The Laryngoscope

V
C 2012 The American Laryngological,
Rhinological and Otological Society, Inc.

Incidence of Laryngospasm and Bronchospasm in Pediatric

Adenotonsillectomy

Michael I. Orestes, MD; Lina Lander, ScD; Susan Verghese, MD; Rahul K. Shah, MD

Objectives/Hypothesis: To evaluate and describe airway complications in pediatric adenotonsillectomy.

Study Design: Retrospective case-control study.
Methods: A chart review of patients that underwent adenotonsillectomy between 2006 and 2010 was performed. Peri-
operative complications, patient characteristics, and surgeon and anesthesia technique were recorded.
Results: A total of 682 charts were reviewed. Eleven cases (1.6%) of laryngospasm were identified: one was preopera-
tive, seven occurred in the operating room postextubation, and three occurred in the recovery area. Four patients were given
succinylcholine, one was reintubated, and the other cases were managed conservatively. Mean age of patients with laryngo-
spasm was 5.87 years (standard deviation [SD], 4.01; 1.9–15.8 years). There were 12 cases (1.8%) of bronchospasm; all were
treated with nebulized albuterol. Mean age of patients with bronchospasm was 5.81 years (SD, 4.17; 1.8–14.1 years). Overall,
22 patients required antiemetics (3.3%), 19 required albuterol (2.9%), and five required racemic epinephrine (0.8%). Com-
pared to the children without airway complications, there was no difference in age, weight, American Society of Anesthesiolo-
gists status, length of surgery, need for admission, and anesthesia technique in those that had laryngospasm. Patients with
bronchospasm, compared to the patients without complications, had faster surgeries (P < .05), were more likely to have
underlying asthma (P < .05), and were more likely to be admitted (P < .05). There were no unexpected admissions or other
morbidities.
Conclusions: The rates of laryngospasm (1.6%) and bronchospasm (1.8%) are significantly lower than reported in the
literature, reflecting refinements in modern anesthesia/surgical technique. Knowledge of at-risk patients can facilitate plan-
ning to potentially reduce the incidence of perioperative airway complications during adenotonsillectomy.
Key Words: Tonsillectomy, adenoidectomy, outcomes, laryngospasm, bronchospasm.
Level of Evidence: 2b.
Laryngoscope, 122:425–428, 2012

INTRODUCTION prolonged hospitalization for the patient.5,6 Such compli-

Pediatric adenotonsillectomy remains one of the cations require intense, rapid response from the
most common surgical procedures in the United States.1 anesthesia and surgical team as well as comprehensive
In the past few decades, there have been significant postoperative monitoring around the time of the event.
advances in the surgical technique, anesthetic As outcomes have improved for pediatric adenoton-
approaches, and recovery and postoperative manage- sillectomy, the surgery is now performed more
ment of these patients. As a result, the outcomes and frequently in higher-risk populations such as younger
resultant morbidity have significantly improved.2 One of children and children with syndromes and craniofacial
the most feared complications of pediatric adenotonsil- abnormalities.4,7
lectomy is airway complications.3,4 These complications Despite the frequency of this surgery, the incidence
can occur during adenotonsillectomy or in the periopera- and significance of perioperative airway complications in
tive period and may include laryngospasm and this cohort of patients has not recently been studied.
bronchospasm and result in significant morbidity and Indeed, the historic citations of the rates of laryngo-
spasm and bronchospasm for adenotonsillectomy have
From the National Capitol Consortium Otolaryngology Residency not been recently updated.8,9 With advanced surgical
Training Program (M.I.O.), Walter Reed Army Medical Center, Washington,
DC; Department of Epidemiology, University of Nebraska Medical Center
techniques and refined anesthetic approaches with
(L.L.), Omaha, Nebraska, Division of Anesthesiology (S.V.), Division of faster-acting anesthetic agents resulting in faster recov-
Otolaryngology (R.K.S.), Children’s National Medical Center, Washington, ery times, the role that airway complications play in the
DC, U.S.A.
overall outcomes of these patients is significant.
Editor’s Note: This Manuscript was accepted for publication July
21, 2011. The objective of this study is to evaluate a single
Delivered in part as an oral presentation at the Annual Meeting of surgeon’s experience at a tertiary care academic medical
the Triological Society, Chicago, Illinois, U.S.A., April 28, 2011. center to obtain a current rate of airway complications
The authors have no funding, financial relationships, or conflicts
of interest to disclose. during the perioperative period for adenotonsillectomy
Send correspondence to Rahul K. Shah, MD, Division of Otolaryn- as well as determine the outcomes and management of
gology, Children’s National Medical Center, 111 Michigan Avenue NW, these patients with the anticipation that identification of
Washington, DC 20010. E-mail: rshah@childrensnational.org
high-risk patients for such complications will allow sur-
DOI: 10.1002/lary.22423 gery in these patients to be tailored as needed.

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MATERIALS AND METHODS laryngospasm showed no difference in age, weight, ASA
Institutional review board approval from Children’s status, length of surgery, need for admission, and anes-
National Medical Center was obtained. Patients that underwent thesia technique. Patients with bronchospasm, compared
adenotonsillectomy by the senior author (R.K.S.) were enrolled in to the patients without complications, had faster sur-
the study. In an attempt to control for as many variables as pos- geries (P < .05), were more likely to have asthma (P <
sible, it was deemed appropriate to use data from only one
.05), and were more likely to be admitted (P < .05).
surgeon, as it enabled comparison of myriad variables without
the confounding variable of different surgeons. We included
There were no other morbidities and no mortalities in
patients who underwent an adenotonsillectomy between August the patients reviewed.
2006 and December 2010 at either the main campus operating
room or the ambulatory surgery center at Children’s National
Medical Center. DISCUSSION
Each patient’s chart was reviewed in totality to extract Pediatric adenotonsillectomy is one of the most com-
pertinent information such as patient characteristics (demo- mon surgeries performed in the United States.1 There
graphics and complications) including the American Society of have been significant advances in the surgical technique,
Anesthesiologists (ASA) Physical Status classification, perioper- anesthesia technique, and characteristics of patients
ative data (length of surgery, time of recovery, disposition
undergoing surgery in the past decades. This is juxta-
status), intraoperative data (medications administered, oxygen
saturation characteristics), and postoperative outcomes and
posed by external forces to shorten the length of stay of
complications. For all cases with airway complications, the sen- patients and perhaps to minimize the need for patients to
ior authors (S.V., R.K.S.) reviewed each chart in detail. remain in a monitored setting.4 A recent, robust,
For bronchospasm, the authors erred on the side of cau- prospective study outlined risk factors for a child under-
tion in classifying a case as such—for example, if the patient going pediatric anesthesia.10 Some of these included a
received albuterol, the patient was considered to have increased positive respiratory history, upper respiratory tract infec-
airway reactivity and hence we classified this patient as having tion when symptoms were present 2 weeks before the
bronchospasm. Because this was a retrospective review, it was procedure, and a history of at least two family members
nearly impossible to know for sure whether intraoperative bron- having asthma, atopy, or smoking.10 In our recent anec-
chospasm actually occurred. Hence, administration of albuterol
dotal experience, we have noted a significant decrease in
was used as a surrogate marker for such. Comorbid conditions
for the patients were recorded and included asthma, gastro-
the rate of perioperative airway complications in
esophageal reflux disease, sickle cell, trisomy 21, and failure to pediatric adenotonsillectomy. However, a literature review
thrive. demonstrates that there have not been recent studies
Statistical analysis was performed to calculate significance supporting this sentiment. As such, the present study
for these variables for the respective airway complications. was conducted to examine this hypothesis.
In our study population, an inner city, tertiary-care,
free-standing, academic medical center with fellowship
RESULTS trained pediatric otolaryngologists and fellowship-trained
A total of 682 charts were reviewed (54% male); pediatric anesthesiologists, the rate of laryngospasm and
patient ages ranged from 0.7 to 19.3 years, and patients bronchospasm in pediatric adenotonsillectomy was 1.6%
underwent adenotonsillectomy with a mean duration of and 1.8%. Historically, and in other institutions, the rate
surgery of 19.6 minutes in those patients without airway of laryngospasm and bronchospasm has been noted to be
complications (Table I). The average weight of the significantly higher. A recent study comparing laryngeal
patients in the noncomplication group was 34.4 kg. mask airway to endotracheal tube intubation for manag-
Patients were classified as follows: 34% were ASA 1, ing the airway in pediatric adenotonsillectomy identified
61% were ASA 2, and 5% were ASA 3. rates of laryngospasm of 12.5% in the laryngeal mask air-
Eleven cases (1.6%) of laryngospasm were identi- way cohort and 9.6% in the intubated patients; this is
fied: one was following anesthetic induction before higher than our rate by almost an order of magnitude.11
surgery, seven occurred in the operating room postextu- Their findings are supported by other studies with a rate
bation, and three occurred in the recovery area. Four of about 8% in a large study conducted over 4 years with
were given succinylcholine, one was reintubated, and more than 1,000 patients.6 A study from 2 decades prior
the other cases were managed conservatively. Mean age noted that the use of topical lidocaine reduced the rate of
of patients with laryngospasm was 5.87 years (standard laryngospasm from 12% to 3%.8 Similarly, a comparison of
deviation [SD], 4.01; 1.9–15.8 years). There were 12 anesthesia techniques found that using propofol reduced
cases (1.8%) of bronchospasm or increased airway resist- the rate of laryngospasm from 20% to 6.6%; however, the
ance; all were treated with nebulized albuterol using a sample size in that study was quite small.5 Patient char-
metered-dose inhaler. Mean age of patients with bron- acteristics can, of course, affect the rate of airway
chospasm was 5.81 years (SD, 4.17; 1.8–14.1 years). complications as noted in the study by Mitchell and Kelly,
Overall, 22 patients required additional antiemetics as almost one-quarter of the young children in the group
(3.3%), 19 needed albuterol (2.9%), and five required undergoing surgery had postoperative complications
racemic epinephrine (0.8%). including laryngospasm and marked desaturations.12
Table I lists each variable studied and the incidence Interestingly, in the general pediatric population
and significance with regard to those patients at risk for that undergoes surgery, the risk of laryngospasm has
laryngospasm and bronchospasm. Compared to the been shown to be increased in children with upper respi-
children without airway complications, those that had ratory tract infection, a preexisting airway anomaly, or

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426
 TABLE I.
Pertinent Variables and Characteristics of Patients Who Had a Perioperative Airway Complication During an Adenotonsillectomy (N 5 682).
Patients Without Patients With Patients With
Variable Complications Laryngospasm P Value Bronchospasm P Value

No. of patients 659 11 12

Sex, female, no. (%) 306 (46) 6 (55) .5927 4 (33) .4002
Age, mean (SD) 7.28 (4.04) 5.87 (4.01) .2504 5.81 (4.17) .2105
Weight, kg, mean (SD) 34.43 (25.02) 27.52 (16.89) .3618 26.09 (19.16) .2513
Length of surgery, min, mean (SD) 19.64 (11.50) 24.27 (15.89) .1891 15.17 (5.57) .0192
Preoperative oxygenation level, 98.98 (4.53) 99.0 (1.55) .9723 98.36 (3.59) .6531
oxygen saturation (SD)
Postoperative oxygenation level, 98.43 (4.15) 98.82 (1.54) .4419 98.83 (1.47) .3863
oxygen saturation (SD)
ASA status, no. 657 11 .2796 .3092
1 227 2 2
2 397 8 9
3 33 1 1
Comorbidity, no.
Asthma 177 3 .9999 10 <.0001
GERD 20 1 .2974 2 .0555
Down syndrome 12 0 .9999 1 .2108
Sickle-cell disease 6 0 .9999 0 .9999
Failure to thrive 21 0 .9999 0 .9999
Intraoperative medications, no.
Propofol 533 10 .6995 10 .9999
Dexmedetomidine 17 1 .2609 0 .9999
Sevoflurane 641 11 .9999 12 .9999
Desflurane 445 6 .3514 5 .0687
Nitrous oxide 635 11 .9999 11 .3684
Decadron 641 10 .2370 11 .2936
Antiemetic 626 10 .4386 11 .4670
Postoperative complications and management, no.
Emesis 46 1 .5541 1 .5853
Immediate bleed 3 0 .9999 0 .9999
Reintubation 3 1 .0642 0 .9999
Succinylcholine 0 3 <.0001 0 .9999
Albuterol 19 1 .2853 10 <.0001
Racemic epinephrine 5 0 .9999 1 .1031
CXR 6 0 .9999 2 .0077
Antiemetics 22 0 .9999 1 .3443
Admitted 23 0 .9999 5 <.0001
SD ¼ standard deviation; ASA ¼ American Society of Anesthesiologists; GERD ¼ gastroesophageal reflux disease; CXR ¼ chest radiograph.

when a laryngeal mask airway was utilized.13 A rate of these respiratory complications. Early effective commu-
bronchospasm of 1.5% in healthy children was reported nication between the pediatrician, pulmonologist (as
in a study comparing healthy children with those with needed), otolaryngologist, preoperative screening nurse,
respiratory tract infections. Children with such infec- parents, anesthesiologist, and the postanesthesia care
tions were able to have the rate of bronchospasm and unit nurse is critical in assessing the risks and maximiz-
coughing reduced by use of a b-2 agonist.14 These ing therapy in the perioperative period.
authors showed that children at high risk for The low incidence of bronchospasm in our review
perioperative adverse events could be assessed preopera- may be the result of our institutional policies regarding
tively by using highly specific and selective questions at preoperative assessment and preparation of asthmatic
the telephone screening.14 This early screening can help patients. When the otolaryngologist encounters a brittle
triage specific perioperative prophylactic therapy as well asthmatic patient who requires surgery, he or she usu-
as tailor the specific anesthetic to potentially decrease ally sends that patient for pulmonary and anesthesia

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427
consults to alert them about the impending surgery and into answering such question. In an effort to reduce
the need for maximizing antiasthmatic therapy. In laryngospasm, attention should be focused on the intra-
addition, parents are instructed to give the patient a operative period, particularly the periextubation period,
nebulizer treatment on the night before surgery and the with the knowledge that these patients may need to be
morning of surgery as well as to be highly aware of the reintubated; however, this will usually not result in an
need to contact the preoperative team should the patient admission. For bronchospasm, significant effort, includ-
develop upper respiratory infection just before the ing perhaps formal pulmonary evaluation of severe
planned surgery. Furthermore, additional nebulized asthmatics before surgery, should be focused on clarify-
albuterol is frequently given during surgery especially ing and optimizing the patient’s history of asthma as
just before extubation. well as including a preoperative asthma plan. One may
Our study does not resolve the controversy regard- consider that this be done on a national level to stand-
ing the incidence of perioperative airway complications; ardize preoperative preparation of children for adenoton-
however, with our large sample size and detailed review sillectomy in the setting of asthma. Not only will such
of the anesthesia record, we believe that our conclusions interventions be of benefit to the patient, but also
regarding the refinement in anesthesia and surgical the health-care system will avoid a costly, potentially
techniques resulting in this marked decrease in peri- preventable admission.
operative airway complications will be corroborated by
similar studies in the coming years.
CONCLUSION
As the rate of perioperative airway complications
The rates of laryngospasm (1.6%) and broncho-
has been reduced significantly, there is an onus to better
spasm (1.8%) reported here are lower than those
define those patients that are at risk for such. Compared
reported in the literature, reflecting modern refinements
to the children without airway complications, those that
in anesthesia and surgical technique. Knowledge of
had laryngospasm showed no difference in age, weight,
patients vulnerable to these complications allows for
ASA status, length of surgery, need for admission, and
optimal anesthesia technique in high-risk patients and
anesthesia technique. As expected, the majority of
may potentially further reduce the incidence of perioper-
patients with laryngospasm (63%) were in the postopera-
ative airway complications during adenotonsillectomy.
tive period in the periextubation period. Interestingly,
there exists the belief and the studies to indicate that
patients with laryngospasm are younger.12 Our data BIBLIOGRAPHY
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