Anesthesia for the child with a recent upper respiratory infection

INTRODUCTION — 

Upper respiratory infection (URI) is the most frequent human illness and the most common infection in childhood; infants and preschoolers have six to eight URIs per year [1]. Thus, children commonly present for surgery and anesthesia with a current or recent URI, with a potential for increased risk for perioperative respiratory adverse events.

This topic will discuss the preoperative assessment of children with a current or recent URI, as well as intraoperative anesthesia management. Diagnosis, treatment, prevention, and complications of URIs in children are discussed separately. (See "The common cold in children: Clinical features and diagnosis" and "The common cold in children: Management and prevention".)

TERMINOLOGY — 

The term "upper respiratory infection" (URI) may be used to describe a variety of infections. For the purposes of this topic, URI is meant to refer to a constellation of signs and symptoms otherwise called "the common cold," an acute viral infection of the upper respiratory tract involving, to variable degrees, sneezing, nasal congestion and discharge (rhinorrhea), sore throat, cough, low-grade fever, headache, and malaise.

RISKS OF ANESTHESIA FOR THE CHILD WITH AN UPPER RESPIRATORY INFECTION — 

Multiple studies have shown that children who undergo general anesthesia with a current or recent URI are at increased risk of perioperative respiratory adverse events (PRAEs), primarily related to airway hyperreactivity. PRAEs include laryngospasm, bronchospasm, atelectasis, coughing, airway obstruction, hypoxia, stridor, and breathholding. Most of these events are mild and easily managed [2-8], and long-term consequences of brief oxygen desaturations are rare [9]. However, more significant events can occur. According to data from the Pediatric Perioperative Cardiac Arrest Registry, after cardiovascular causes, respiratory events were the second-most common cause of perioperative cardiac arrests in children, with laryngospasm being the most likely cause for respiratory-induced cardiac arrests [10,11].

PRAEs increase admission rates and costs and prolong hospitalizations [12].

Time course of PRAE risk — Airway hyperreactivity, which increases the risk of laryngospasm and bronchospasm, decreases over time with a URI, though the literature on the time course of resolution (as evidenced by reduced risk of PRAEs) is inconsistent. While some studies have shown increased airway reactivity for up to four weeks after the URI [2-4,6,8], one study found no increase in PRAEs in children with rhinorrhea two to four weeks prior to anesthesia [13]. In one large study, there was an increase in PRAEs in children with a URI within two weeks of a procedure, and a decrease in PRAEs in patients who had a URI two to four weeks prior to a procedure, compared with children without infection in the prior four weeks [2].

Evidence for increased risk of PRAEs in children with URIs comes from prospective and retrospective observational studies. Most studies of the effect of a recent URI on PRAEs have excluded patients who were obviously ill with purulent rhinitis, productive cough, fever, and malaise. Studies that have included patients with intercurrent URI have consistently found an increase in PRAEs in such children [7,14].

Recent or current URI may increase the risk of PRAEs during procedural sedation as well as general anesthesia. In a prospective multicenter database study including approximately 83,500 children who underwent procedural sedation reported increases in the incidence of airway-related adverse events and airway interventions in children with recent URIs, and further increases in children with current URIs [14]. An airway adverse event (eg, cough, laryngospasm, desaturation, apnea >15 seconds) occurred in approximately 6 percent of children without a URI, 9 percent of children with a recent URI, 15 percent of children with a current URI with clear secretions, and 22 percent of children with a current URI with thick secretions.

Other risk factors for PRAEs — A number of patient, surgical, and anesthetic factors have been shown to increase the risk for PRAEs in patients with and without a URI (table 1). The following risk factors increase the risk for PRAEs in patients with and without URI and should be considered in assessing the risk of anesthesia for a specific child:

●Ear, nose, and throat (ENT) procedures [2,13]

●Airway anomalies such as subglottic stenosis, cleft palate, Pierre-Robin sequence, and laryngomalacia [7]

●Absence of a pediatric anesthesiologist [2,15]

●Passive exposure to smoke [16,17]

●Patient or family history of asthma or atopy [18]

●Young age, with premature infants at highest risk [3,13,15,19,20]

●Use of an endotracheal tube rather than a supraglottic airway. (See 'Airway management' below.)

Children who undergo surgery for congenital heart disease with an active URI may be at increased risk for postoperative complications, compared with such children without a URI. (See 'Postoperative concerns' below.)

The COLDS score — A decision-making tool, "COLDS" ("Current signs/symptoms, Onset, Lung disease, airway Device, Surgery"), incorporates most risk factors for the child with a URI, with the notable exception of age (table 2) [21,22]. The COLDS score does not designate a cutoff that would indicate a safe anesthetic; it can serve as a reminder of all factors one should consider. It helps in identifying where on the spectrum of perioperative risk a particular patient lies. If this risk is acceptable, the decision to proceed or postpone still needs to be made based on local resources and individual experience.

PREOPERATIVE EVALUATION

History — Most decisions regarding the anesthetic plan for children with a URI can be made based on history and physical examination, if not by history alone. Signs and symptoms that should be elicited include fever, clear or green nasal secretions, wet or dry cough, wheezing, changes in respiratory pattern, shortness of breath, anorexia, malaise, and/or changes in playfulness and physical activity. The disease course of sick contacts in the patient's family can help predict the course of the illness.

Simply asking the parents or caregivers whether a child is sick is an important part of preoperative evaluation. A case-control study of 123 children who developed perioperative laryngospasm found that laryngospasm was twice as likely in patients with an active URI, as defined by the parents, compared with those without an active URI [23].

Most often, a patient with a significant URI who is scheduled for an elective procedure can be advised to postpone the procedure during a preoperative screening phone call the day before the anesthetic. Postponement before the patient even reaches the health care facility avoids unnecessary fasting, interruption of the operating room schedule, economic hardship, and inconvenience for the patient and family. At our institution, the nurses who make the preoperative phone calls are authorized to cancel elective cases at the time of the phone call if symptoms of URI are present.

Physical examination — Patients should be examined for obvious signs of a URI such as nasal discharge, repeated coughing, appearing sick, and/or fever. The chest should be auscultated, looking for wheezing, crackles, or rhonchi as signs of lower respiratory infection. Inspection of the throat can help in making a more specific diagnosis (eg, patients with coxsackie infections who present with herpangina). (See "The common cold in children: Clinical features and diagnosis".)

Laboratory and radiologic examination — Preoperative laboratory and radiologic evaluation are rarely necessary or helpful for otherwise healthy children with a URI. The need for testing should be individualized based on patient comorbidities and the surgical procedure.

Laboratory testing can identify the pathogen if it is necessary to do so (eg, if SARS-CoV-2 or respiratory syncytial virus [RSV] is a consideration). Patients with RSV may be at increased risk of postoperative complications. (See 'Postoperative concerns' below.)

It is likely that children who have had mild coronavirus disease 2019 (COVID-19) should be managed similarly to children with other viral URIs. Management of children with more severe COVID-19 should be individualized. (See "COVID-19: Perioperative risk assessment, preoperative screening and testing, and timing of surgery after infection", section on 'Risk related to timing of surgery after infection'.)

Blood tests for immunologic markers of allergic sensitization and systemic inflammation are not useful predictors of perioperative respiratory adverse events (PRAEs) [18].

Timing of elective procedures — Timing of elective surgery for a child with current or recent URI symptoms remains controversial. The goal for delaying elective surgery is to minimize the risk of PRAEs. While each situation must be individualized, taking into account both medical and practical concerns, our approach is generally as follows:

●URI found on preoperative screening – For children who are found during preoperative screening prior to an elective procedure to have or have had a URI, we postpone the procedure until two to four weeks after symptoms subside. (See 'Time course of PRAE risk' above.)

●Patients who present with an ACTIVE URI the day of an elective procedure – When patients present the day of surgery with symptoms of a URI, we decide whether to postpone the procedure on an individual basis, taking into account the severity of URI symptoms, the patient's risk factors, the planned procedure, and the medical and practical disadvantages of postponement.

•For patients with only mild rhinorrhea and mild symptoms at the time of a minor procedure, we do not postpone anesthesia.

•For patients who present with fever ≥38°C or a wet cough, we postpone elective procedures until two to four weeks after symptoms subside.

•For patients with moderate symptoms, we make an individualized decision.

●Patients who present with a RECENT URI the day of an elective procedure – For patients who are currently asymptomatic but are found to have had a recent URI, we use the following approach:

•URI within two weeks – When patients present on the day of surgery with a history of URI in the preceding two weeks, we decide whether to postpone the procedure on an individual basis, taking into account the patient's risk factors, the planned procedure, and the medical and practical disadvantages of postponement. In general, we proceed with elective procedures for older children who have been asymptomatic for more than one week. We often postpone the procedure for two to four weeks for younger, higher-risk patients who are to undergo higher-risk procedures. (See 'Other risk factors for PRAEs' above.)

•URI two to four weeks ago – We do not usually postpone a procedure when a patient has been asymptomatic for two to four weeks after a URI, recognizing that airway hyperreactivity may persist longer in some patients.

●Urgent procedures – For patients who present with a URI for urgent or semiurgent procedures, the risks and benefits of postponement should be weighed in a discussion between the anesthesiologist, the surgeon, and the other care providers. When we proceed, we medically optimize as time allows. For urgent procedures, we administer inhaled beta₂ agonists and a nasal decongestant, as needed. Truly emergent procedures that cannot wait until an inhaled beta₂ agonist or a nasal decongestant is administered are rare. (See 'Preoperative optimization' below.)

PREOPERATIVE OPTIMIZATION

Inhaled short-acting beta-2 agonist — Patients with asthma or recurrent wheezing who present with a URI are treated preoperatively with an inhaled short-acting beta₂ agonist (SABA) such as albuterol. We routinely administer a SABA 20 to 30 minutes prior to induction of anesthesia (albuterol via nebulizer 2.5 mg if <20 kg, 5 mg if >20 kg, or via metered dose inhaler [MDI] with spacer, two to eight puffs). (See "Anesthesia for the child with asthma or recurrent wheezing", section on 'Premedication'.)

In most cases, there is little disadvantage to premedication with an inhaled beta₂ agonist for children without asthma who present with current or recent URI symptoms, though literature on the benefits is conflicting. A prospective observational study of 400 children with a recent URI reported a 35 percent decrease in perioperative respiratory events in children who were premedicated with an inhaled beta₂ agonist compared with those who were not treated [24]. In contrast, in a randomized trial of school age children with risk factors for perioperative respiratory adverse events (PRAEs) who underwent general anesthesia with a laryngeal mask airway (LMA), 24 percent of whom had a URI ≤2 weeks prior to surgery, the rates of perioperative PRAEs were similar in children who were premedicated with salbutamol and those who received placebo [25].

Antisialagogue — Once intravenous (IV) access is established, we usually administer an antisialagogue (eg, glycopyrrolate 4 mcg/kg IV) to minimize secretions and to decrease the chance of laryngospasm. Repeated use of glycopyrrolate leads to thickened secretions, which can lead to mucus plugs, particularly in neonates. (See 'Laryngospasm' below.)

Nasal decongestant — For patients ≥6 years of age with significant rhinorrhea who require urgent procedures, we administer topical nasal decongestant spray (eg, oxymetazoline nasal spray 0.05%, not more than two to three sprays per nostril) before induction of anesthesia to decrease laryngeal and tracheal irritation from secretions. We also suction the nose prior to induction. For toddlers and children up to six years of age, we use extreme caution when administering topical nasal decongestant, limiting the dose to one gentle half-spray per nostril, with the child and the bottle held upright during administration and while monitoring vital signs [26]. We do not administer nasal decongestant spray to infants.

Chest physical therapy — Whenever significant bronchial secretions are present, we clap the chest with a cupped hand or a facemask to loosen secretions, and we encourage the patient to cough them up. Use of incentive spirometry is encouraged postoperatively in all patients with a URI who are hospitalized and old enough to use it.

Glucocorticoids — Perioperative systemic glucocorticoids should be reserved for patients with poorly controlled asthma (see "Anesthesia for the child with asthma or recurrent wheezing" and "Anesthesia for the child with asthma or recurrent wheezing", section on 'Supplemental glucocorticoids'). Limited data suggest that inhaled glucocorticoids may reduce the incidence of perioperative oxygen desaturation in children with URI [27]. Further study is required before recommending routine use of inhaled glucocorticoids in this setting.

ANESTHESIA MANAGEMENT

Premedication — We prefer to use distraction techniques (eg, toys, video games, stickers) or parental presence prior to anesthesia for patients with a URI, rather than administration of sedatives. Multiple studies have shown that premedication of a patient with a URI with benzodiazepines increases the risk for respiratory complications [2,6,7,13]. Premedication with midazolam may invite respiratory complications by delaying awakening and prolonging the excitatory phase of emergence from anesthesia, and can also lead to decreased functional residual capacity (FRC) and an alteration in respiratory mechanics [28]. In a small observational study including 164 children who were premedicated with midazolam for strabismus surgery, antagonism of midazolam with flumazenil during emergence from anesthesia was associated with a decrease in respiratory complications in the post-anesthesia care unit [29].

Airway management — When possible, we minimize airway instrumentation for patients with current or recent URI to decrease the risk of laryngospasm and bronchospasm. When appropriate, we prefer the use of a face mask over the use of a supraglottic airway (SGA), and the use of an SGA over endotracheal intubation.

A number of observational studies have compared the risks associated with various anesthesia airway management devices for children with URIs. Studies that have compared endotracheal intubation with either the use of an SGA or mask ventilation for airway management in children with a URI have consistently found that endotracheal intubation was associated with increased risk of perioperative respiratory adverse events (PRAEs) [3,8,30,31].

As an example, a prospective observational study that included approximately 750 children who presented for anesthesia with a recent or current URI found that use of an endotracheal tube (ETT) increased the incidence of breath-holding, severe cough, oxygen desaturation, and overall PRAEs compared with the use of a facemask or laryngeal mask airway (LMA) [3]. The majority of adverse events associated with an ETT occurred during removal of the ETT or in the recovery room.

However, avoiding endotracheal intubation may reduce but does not eliminate the risk of PRAEs in children with a URI. A prospective observational study of 831 children (223 of whom had a URI ≤2 weeks prior to surgery) who underwent anesthesia with a LMA found an approximately two fold increase in the incidence of laryngospasm, cough, and oxygen desaturation in children with a URI compared with healthy children [13].

Induction and maintenance of anesthesia — Management of induction and maintenance of anesthesia for the child with a URI are similar to such management for children with asthma, which are discussed separately. (See "Anesthesia for the child with asthma or recurrent wheezing", section on 'Induction of anesthesia' and "Anesthesia for the child with asthma or recurrent wheezing", section on 'Maintenance of anesthesia'.)

Ventilation during anesthesia — Ventilatory strategy for children with URIs during anesthesia should be designed to avoid atelectasis. Ciliary clearance of bronchial and tracheal secretions is impaired under general anesthesia (more so with sevoflurane compared with propofol) [32], which can lead to a decrement of pulmonary function and increased risk of atelectasis in patients with URIs.

As for most patients who have general anesthesia, we use lung-protective mechanical ventilation principles (ie, low tidal volumes; positive end-expiratory pressure [PEEP]; if necessary, prolonged inspiratory to expiratory ratio) for children with URIs.

If bronchospasm develops during anesthesia, the ventilatory strategy should be designed to reduce air trapping via reduction in minute ventilation and inspiratory to expiratory ratio. (See "Anesthesia for the child with asthma or recurrent wheezing", section on 'Ventilation during anesthesia'.)

Intraoperative airway events — Laryngospasm, bronchospasm, coughing, and breath-holding are more likely to occur in patients with a current or recent URI. Management can include deepening the level of anesthesia, as well other specific maneuvers.

Laryngospasm — Laryngospasm is the sustained closure of the vocal cords by constriction of the intrinsic muscles of the larynx. It can make ventilation difficult or impossible and can quickly lead to hypoxemia and bradycardia, as well as significant morbidity or mortality. The risk of laryngospasm increases with airway instrumentation and/or unnecessary stimulation during a light level of anesthesia, as well as with copious airway secretions. Prevention and management of laryngospasm are discussed in detail separately. Management of laryngospasm is shown in an algorithm (algorithm 1). (See "Complications of pediatric airway management for anesthesia", section on 'Laryngospasm'.)

Bronchospasm — Intraoperative bronchospasm may be suspected in the patient with wheezing on chest auscultation, slow or incomplete expiration on inspection, change in the end-tidal carbon dioxide waveform, decreased tidal volume, high inspiratory pressure, or decreasing oxygen saturation. The evaluation and management of intraoperative bronchospasm in the child with a recent URI is similar to that in the child with asthma. This is discussed in more detail separately. (See "Anesthesia for the child with asthma or recurrent wheezing", section on 'Intraoperative bronchospasm'.)

EMERGENCE — 

Laryngospasm and other perioperative respiratory adverse events (PRAEs) can occur during emergence from anesthesia and at extubation. In many cases, the airway device can be removed either "deep," while the patient is still deeply anesthetized, or awake. Deep extubation can result in smoother emergence without the irritation of the airway device in place. We usually extubate patients with URIs deep unless there is a contraindication, such as blood or secretions in the airway (eg, during ear, nose, and throat procedures) or previous difficulty with mask ventilation or intubation.

Literature on the risk of PRAEs related to the timing of extubation is inconsistent. One prospective study of approximately 1100 anesthetized children with and without current or recent URIs found that the depth of anesthesia at the time of removal of either an endotracheal tube (ETT) or a laryngeal mask airway (LMA) had no effect on the incidence of PRAEs [3]. Another prospective study of approximately 9300 children with and without URIs reported a lower incidence of PRAEs when an LMA was removed deep, but a lower incidence of PRAEs if an ETT was removed awake [2].

POSTOPERATIVE CONCERNS — 

Adverse respiratory events can occur intraoperatively or during the postoperative period. Laryngospasm is almost exclusively an intraoperative event and rarely occurs once the patient completely regains consciousness. However, oxygen desaturation, bronchospasm, and cough can occur in the recovery room and later in the postoperative course. (See "Postoperative airway and pulmonary complications in adults: Etiologies and initial assessment and stabilization".)

Most otherwise healthy children with URIs have an uncomplicated postoperative course and rarely require unplanned admission to the hospital [3]. If the intraoperative course is uneventful and pain and nausea are well controlled, postoperative management may be similar to that of children without URIs [3].

Children with asthma or recurrent wheezing are at increased risk for postoperative respiratory complications. Other groups of patients with URIs at higher risk of significant postoperative respiratory complications include those with documented influenza or respiratory syncytial virus (RSV) infection and those with congenital heart disease.

●A retrospective case-control study of 24 children with documented influenza and RSV infection who underwent anesthesia prior to the viral diagnosis reported an increase in unplanned intensive care unit (ICU) admission and hospital length of stay compared with controls [33]. Half of the infected patients had no preoperative URI symptoms, and there was no increase in overall perioperative complications, need for positive pressure ventilation, or mortality in the patients with RSV or influenza.

●Children with congenital heart disease who undergo cardiac surgery with a URI may be at increased risk for perioperative respiratory adverse events (PRAEs) and other postoperative complications, compared with those without a URI. A prospective study of 713 children who presented for open heart surgery, 96 of whom had an active URI, reported that those with a URI were at increased risk of respiratory complications, postoperative infections, multiple complications, and increased length of ICU stay [34]. However, there was no increase in major morbidity or mortality or hospital length of stay in patients with a URI.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric anesthesia".)

SUMMARY AND RECOMMENDATIONS

●Risks of anesthesia – Upper respiratory infection (URI) is a common illness, and children often present for anesthesia with a current or recent URI. Children with current or recent URIs are at increased risk for perioperative respiratory adverse events (PRAEs) including laryngospasm, bronchospasm, oxygen desaturation, cough, and breath-holding, though most of these events are mild and easily treated. (See 'Risks of anesthesia for the child with an upper respiratory infection' above.)

●Timing of anesthesia – For patients with an active or recent URI, our decision to postpone surgery is individualized, taking into account the severity of URI symptoms, the patient's risk factors, the planned procedure, and the medical and practical disadvantages of postponement (see 'Timing of elective procedures' above):

•URI found on preoperative screening – For children who are found during preoperative screening to have a current or recent URI, we postpone elective procedures until two to four weeks after symptoms subside.

•ACTIVE URI day of surgery – For patients found to have an active URI on the day of surgery:

-For patients with only mild rhinorrhea and mild symptoms at the time of a minor procedure, we do not postpone anesthesia.

-For patients who present with fever ≥38°C or a wet cough, or who are obviously ill, we postpone elective procedures until two to four weeks after symptoms subside.

-For patients with moderate symptoms, we make an individualized decision.

•RECENT URI discovered the day of an elective procedure – For patients who are currently asymptomatic but are found to have had a recent URI, we use the following approach:

-URI within two weeks – In general, we proceed with elective procedures for older children who have been asymptomatic for more than one week. We often postpone the procedure for two to four weeks for younger, higher-risk patients who are to undergo higher-risk procedures.

-URI two to four weeks ago – We do not usually postpone a procedure when a patient has been asymptomatic for two to four weeks after a URI, recognizing that airway hyperreactivity may persist for up to six weeks.

•Urgent procedures – For patients who present with a current or recent URI for urgent or semiurgent procedures, the risks and benefits of postponement should be weighed in a discussion between the anesthesiologist, the surgeon, and the other care providers.

●Premedication – For children with symptoms of a URI, we usually premedicate as follows:

•We administer a short-acting beta₂ agonist (eg, albuterol via nebulizer 2.5 mg if <20 kg, 5 mg if >20 kg, or via metered dose inhaler [MDI] with spacer, two to eight puffs).

•For children ≥6 years of age with rhinorrhea, we administer topical nasal decongestant spray (eg, oxymetazoline nasal spray 0.05%, not more than two to three sprays per nostril) before induction. For toddlers and children up to six years of age, we use extreme caution when administering topical nasal decongestant, limiting the dose to one gentle half-spray per nostril, with the child and the bottle held upright during administration and while monitoring vital signs.

•Once intravenous (IV) access is established, we administer an antisialagogue (eg, glycopyrrolate 4 mcg/kg IV). (See 'Preoperative optimization' above.)

●Induction and airway management

•Principles for induction and maintenance of anesthesia for the child with a URI are similar to those for the child with asthma or recurrent wheezing. (See 'Induction and maintenance of anesthesia' above.)

•When possible, we minimize airway instrumentation for patients with a current or recent URI. We prefer facemask ventilation to the use of a supraglottic airway (SGA) and SGA placement to endotracheal intubation. (See 'Airway management' above.)

●Intraoperative airway events

•Intraoperative laryngospasm can quickly lead to hypoxia and bradycardia and can result in morbidity and mortality. The risk of laryngospasm increases with airway instrumentation, especially under light levels of anesthesia, and with the presence of airway secretions. Treatment of laryngospasm includes continuous positive airway pressure with 100 percent oxygen and, if necessary, administration of a neuromuscular blocking agent (NMBA) (algorithm 1). (See 'Laryngospasm' above and "Complications of pediatric airway management for anesthesia", section on 'Laryngospasm'.)

•Laryngospasm, bronchospasm, and other PRAEs can occur at the time of emergence from anesthesia and extubation. We prefer to remove airway devices under deep levels of anesthesia to minimize airway stimulation under light anesthesia. (See 'Emergence' above.)