Point - Counterpoint
Counterpoint: Some Patients With Upper Respiratory Infection Will Require Endotracheal Intubation For Surgery
Jennifer Krupp, MD, FAAP
The Children's Hospital
University of Colorado School of Medicine
Denver, CO
Predictable, yet still accurately labeled "infrequent", complications accompanying endotracheal intubation in the pediatric population with upper respiratory infections are best managed by pediatric anesthesiologists. We cultivate this expertise both in training as fellows and as practitioners, in large part because we repeatedly encounter pediatric-specific surgical situations for which the choice to postpone either is not an option or would not serve the best interest of the child. In many of these situations use of a mask airway or an LMA is not an option.
Perhaps the clearest example of this is found when we encounter a pediatric patient presenting for emergency surgery who coincidentally also has an upper respiratory infection. This excludes neonatal surgical emergencies, as these patients likely have had insufficient time to contract an upper respiratory infection. Additionally, in the serious trauma patient who may come to us already intubated, the presence of an upper respiratory infection may be extremely low on the list of immediate anesthetic concerns, particularly when the patient is to remain intubated. These specific exceptions aside, the patient needing emergency surgery who also has an upper respiratory infection could call upon and develop our upper respiratory complication management acumen.
There is next a seemingly ever-growing list of "justifiably urgent" procedures for which we may find ourselves intubating children with upper respiratory infections. For example, infants presenting for fundoplication may also have compromised pulmonary function due either to repeated aspiration, to upper respiratory infection, or to some indistinguish-able combination of both. In an attempt to prevent development of further pulmonary compromise, our best plan for this type of patient is to proceed with surgery. A patient with a cleft lip may also fall into this category of having consequent pulmonary compromise which may only worsen if surgical repair is delayed. Another example is the infant with a history of prematurity, prior ventilation, and retinopathy of prematurity who presents for laser therapy for which there is apparently a defined window of optimal treatment timing. These infants potentially test our skills as "many have some degree of bronchopulmonary dysplasia and thus long-term pulmonary dysfunction and a tendency to airway reactivity"(1). Further, newly diagnosed oncology patients may urgently need central access for chemotherapy and/or transfusion therapy, or they may need additional diagnostic or chemotherapeutic procedures such as bone marrow sampling or lumbar puncture. Next, a child with an upper respiratory infection who presents with a dental abscess and/or extensive painful dental decay that prevents intake of adequate nutrition for growth and normal immune function needs urgent repair. An impaired immune system could prolong or may even prevent recovery from an upper respiratory infection. Also, not infrequently, we may find ourselves urgently providing anesthesia for children presenting with increased intracranial pressure for ventricular shunt revision. Finally, a specific example of needing to intubate a pediatric patient who may also have an upper respiratory infection is the child with Osler-Weber-Rendu (hereditary hemorrhagic telangiectasias) who needs general anesthesia for urgent coil embolization to slow escalating compromise from worsening pulmonary (or other) arteriovenous malformations. Again, in all of these representative situations just described, we would rarely be able to justify postponing anesthesia or using an alternate airway management technique!
We demonstrate/gain expertise when we find ourselves managing the elective surgical patient whose upper respiratory infection remained preoperatively undiscovered. This could occur for several of reasons. First, children older than toddler age may not reveal their congested cough which on occasion may be their only current sign of an upper respiratory infection. Second, a parent's denial of the presence of upper respiratory symptoms in their child may be the result of a language barrier, of parental acclamation to their child's longstanding symptoms, or of the desire to achieve secondary gain by avoiding the inconveniences that accompany cancellation.
There are other arenas in which we tend to provide anesthesia in a pediatric patient even though they have an upper respiratory infection. For instance, absence of consensus support among anesthesiology colleagues may in reality powerfully direct the decision to proceed. Also, it seems that the greater the number of surgical specialties involved in a case, the less popular the decision becomes to postpone due to upper respiratory infection or for any other reason!
Further, in the setting of surgical missions which provide corrective or palliative procedures during a small window of time opportunity to the greatest number of patients as safely as possible, we are much less inclined to cancel an anesthetic.
These are but some of the examples which illustrate the point that we probably on a daily basis are in fact justifiably subjecting pediatric patients with upper respiratory infections to general endotracheal anesthesia. And at least in some part because of this high frequency, we are experts in managing potential complications of upper respiratory infection during endotracheal anesthesia. As Tait et al. conclude, "children with active and recent upper respiratory infections are at increased risk for adverse respiratory events", but "with careful management, most of these children can undergo elective procedures safely". Pediatric anesthesiologists provide this careful management.
References:
1. Cote, C. J. "The Upper Respiratory Tract Infection (URI) Dilemma". Anesthesiology 2001; 283-5.
2. Tait, A. R., et al. "Risk Factors for Perioperative Adverse Respiratory Events in Children with Upper Respiratory Tract Infections". Anesthesiology 2001; 299-306.
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