Paper 40 Anaesthesia in Children with Respiratory Tract Infections Johan van der Walt MB, ChB, FFARCSI, FANZCA.

Women's and Children's Hospital, Adelaide, South Australia. Dr John van der Walt is the Director of Paediatric Anaesthesia at the Women's & Children's Hospital, North Adelaide. His research interests are centred around perioperative factors in improving pre and postoperative conditions in children. He has been the Guest Speaker at various national and international conferences. From AUSTRALASIAN ANAESTHESIA 1994 with the permission of the Australian & New Zealand College of Anaesthetists and the editor Dr John Keneally. Introduction In 1985 some interesting figures were published to the effect that respiratory infections were the most common infection worldwide, with individuals experiencing three to nine episodes each year. In the USA, this translated to 500 million episodes a year, 2 million admissions to hospital, 8 million hospital days and 2 billion dollars spent on specific medication! It is thus a major health problem and one that effects paediatric anaesthetists most days. The problem demands considerable judgement, as the social and economic implications to the patients and the hospital of deferring a procedure versus the risks of anaesthetising a child with a cold have to be carefully considered. The problem of respiratory tract infections (RTIs) have concerned anaesthetists for a long time. McGill published a series of 11 children in 1979, with intraoperative airway problems and postoperative radiologically proven 1 atelectasis . Ten of these children had a history of upper respiratory tract infections in the preceeding 4 weeks. That report set the scene for a closer look at this problem in the subsequent years and the factors are still being elucidated. The crucial questions that need to be answered are listed below: 1. 2. 3. 4. 5. 6. What are the effects of RTIs ? How can this affect anaesthesia ? Which patients should be deferred ? What is the length of deferment ? What is the optimal anaesthetic technique ? What are the likely future developments ? degree with decreased FEV1, FVC, VC, sevenfold increased bronchial reactivity and sensitised airway receptors. These effects last for up to six weeks. It is important to differentiate the common cold from other conditions such as vasomotor rhinitis, asthma, bronchiolitis, prodromal stages of viral infections and bacterial infections. Asthma is very common, with 25% of children having some element and 5% having frequent episodes. A history of asthma should therefore be actively sought, because asthma may complicate anaesthesia to a considerable degree. The common cold is a viral infection with a variety of viruses being implicated eg rhinovirus, paraiinfluenza virus, respiratory syncitial virus, enterovirus, herpesvirus and influenza virus (in epidemics). Some of the effects of viral infections on the respiratory tract are now being clarified, although there is still much that is not understood. We know the effects of increased inflammation, secretions and oedema of the nasal mucosa throat and larynx causing nasal obstruction and an irritable airway. We also know about the systemic effects of pyrexia, myalgia, malaise and toxaemia. Something we do not consider enough is the possibility of a viral toxaemia causing a pancarditis, which probably can be implicated in the unexpected deaths of people being stressed from exercising or having an anaesthetic while suffering from a viral cold. There is some fascinating research being done on what viral infections do to the respiratory tract. Answers are slowly emerging about the relevance of: various viruses; the stage of the infection; the clinical signs and symptoms; the volume and consistency of secretions; the mechanisms of airway reactivity; oedema and debris in small airways and alveoli; and, the effects on the lung parenchyma. Airway hyperresponsiveness in response to physical stimuli such as touch or chemical irritation causes the dreaded

1. What are the Effectd of RTIs ? Although most clinicians and the literature refer to upper respiratory tract infections or URTI, I am deliberately referring to respiratory tract infections or RTIs because the WHOLE respiratory tract is involved. Bates, in the major textbook 2 "Respiratory Function in Disease" , cites a collection of studies showing that so-called upper respiratory tract infections affect the lower respiratory tract to a significant

sequence, familiar to anaesthetists, of coughing, laryngeal spasm, bronchoconstriction and desaturation. Although this is in part due to direct irritation of the inflamed mucosa, it is now realised that a more significant part is played by a vagally mediated reflex bronchoconstriction, which can be blocked by atropine. There are two mechanisms that have been postulated, and proven to a certain extent, that support this. The first is that some viruses (parainfluenza and influenza viruses in particular) produce a viral neuraminidase which decreases the function of M2 muscarinic receptors, increasing release of acetylcholine in virus infected airways. The second is that viral infections also decrease airway neutral endopeptidase activity, thereby potentiating tachykinins. These tachykinins are a family of sensory neuropeptides found in vagal afferent fibres. They cause contraction in airway smooth muscle in response to direct stimulation and they facilitate cholinergic transmission. Viral infections also increase the volume and consistency of airway secretions, promoting the risk of atelectasis. There are now a number of reports attesting to this fact. The clinical scenario seen quite often is of a child with a virally affected airway reacting to an anaesthetic by coughing or laryngospasm resulting in significant desaturation, that does not improve with the cessation of the episode. In my experience, saturation is only restored by manual expansion of the lung with a controlled, prolonged compression of the ventilation bag to re-expand atelectatic portions of lung. 2. How Can This Affect Anaesthesia? or "what are we afraid of?" The fears associated with RTIs can be summarised under the following headings: Laryngeal spasm; Stridor; Bronchospasm; Breathholding; Coughing; Parenchymal lung effects; and, Systemic effects. In 1987, Tait and Knight published a retrospective survey of 3585 children. They compared children with symptoms of RTI, asymptomatic children and those with a history of RTI in the 3 previous 2 weeks . They concluded that it was only those patients with a recent history of RTI who were more at risk of intraoperative complications which included laryngospasm, bronchospasm, stridor and breathholding. The group then published a prospective study, comparing perioperative complications in 246 children not having anaesthesia with 4 243 having a mask anaesthetic for myringotomy . They found no difference and concluded that there was no reason for postponing anaesthesia in children with RTI having minor surgery. These results have been critisized, both for the patient sampling criteria and for the statistics used.

Nevertheless, this work has acted as a catalyst for further studies. In 1984, Olsson surveyed 24,540 anaethetised children and found an incidence of 1.7% laryngospasm. This increased five 5 fold if they were suffering from a RTI at the time . Then Cohen and Cameron produced a prospective study of 20,000 children, showing anaesthesia in presence of RTI had a two to sevem times greater incidence of respiratory complications, 6 which rose 11 times if the trachea had been intubated . These results serve to underline the fact that manipulation of the airway in the presence of RTI can aggravate existing airway oedema, with resulting stridor. A review of some mathematics explains the propensity for stridor in children. The adult trachea has a 20mm diameter and 1mm oedema causes a 19% reduction in cross sectional area. The infant trachea has a 4mm diameter, with a 75% reduction in area for the same amount of oedema. This explains why infants and toddlers with RTIs get into difficulty more readily with croup. Similarly, intubating the trachea is more to produce problems in the young, because the endotracheal tube may excacerbate any inflammatory oedema. The age of a child as a factor was emphasised by Liu et al, who showed that anaesthetised infants had a greater risk of critical incidents compared with anaesthetised children. In the presence of RTI this increased from 26% to 71% in infants 7 and from 12% to 26% in children . These findings have been corroborated by Kinouchi et al, who showed that young children desaturated more rapidly than older ones and that 8 RT1 exacerbated the problem . Levy et al have shown that children with a recent or currently symptomatic RT1 demonstrated a greater tendency to arterial desaturation in 9 the recovery phase of anaesthesia . Williams et al produced a case report demonstrating the tendency of children with symptomatic RTI's to desaturate during anaesthesia, with radiological evidence of lung collapse associated with 10 tracheal secretions . The problem only resolved with suctioning, physiotherapy and "bagging". During the viraemic phase of an acute viral infection, the patient exhibits signs and symptoms of systemic toxicity. I regard this situation with great significance, because of the potential for a viral pancarditis which may complicate an anaesthetic with sudden arrhythmias and cardiac arrest. There is little evidence to support this opinion, but it is a logical assumption and I am sure that it will be clarified in the future. In summary, the answers to the first two questions are that RTI cause an inflammation of the mucosa of the respiratory tract with effects from the nose to the alveoli. The secretions and mucosal swelling cause obstructive symptoms to breathing. The larynx and trachea are more irritable with a vagally mediated reflex bronchoconstriction Lung function is adversely affected with increased incidence of intra - and

postoperative complications, especially in children with a recent history or a current RTI. The effects are aggravated if the airway is manipulated, for example, by intubating the trachea, Younger children are more at risk of complications. The effects of RTIs can last up to 6 weeks. 3. Management of a Child with RTI Presenting for Anaesthesia or - What is the Optimal Anaesthetic Technique? I believe in a pragmatic approach and in assessing each patient's case on its merits. There are likely to be many modifying factors to consider. A) Elective cases This is where judgement is required. If the RTI is mild in nature, causing a runny nose and moderate cough, and surgery is minor, then it is reasonable to proceed. However, there should be no systemic symptoms like fever, irritable behaviour or the cold causing the child problems with eating or sleeping. All children with moderate to severe RTIs should be postponed. Indications for postponing patients with a mild RTI are: if they are younger than one year of age; if they have signs of asthma (wheezing); and, if the procedure requires tracheal intubation.

that the trachea will not be interfered with, although there is still the potential to stimulate the epiglottis. The usual care in administering an anaesthetic to someone with an irritable airway is still required. (ii) Maximal Support Technique If the surgery requires tracheal intubation, then a maximal support technique must be used, with due consideration for postoperative care. The maximal support technique is outlined for consideration to use all or only some of the principles depending on individual circumstances. I recommend giving atropine and employed a rapid sequence induction, in view of the irritable airway and the potential for vagal reflex bronchoconstriction. It may be advisable to administer a bronchodilator, such as nebulised salbutamol before induction, especially if there is a history of asthma. Once the airway has been secured then IPPV with some constant distending pressure is advised. Should desaturation occur, manual expansion of the lungs with X-ray image intensification, if necessary, may remedy significant atelectasis. In this setting, I have seen a whiteout of a lung that could not be cleared despite bronchoscopy and angle tip suction to the relevant lung, which cleared very dramatically after extubation, with a bout of coughing. Maintenance of anaesthesia is dictated by clinical needs, with due consideration for minimising postoperative respiratory depression. The patient should be extubated awake and postoperative oxygen administration is important. Postoperative analgesia and respiratory function should be carefully monitored. Same day anaesthesia is contraindicated in these circumstances. 4. Future Developments Some of the effects of RTI and the incidence of complications in anaesthetised children have been outlined. However, there are still many facets that need clarification. The true nature and incidence of the risks have yet to be ascertained and put into perspective. Anaesthetic techniques will also need improvement as our understanding improves. Dramatic changes in pharmacological developments are expected to be implemented in a number of areas. A greater understanding of the vagal reflex bronchoconstriction will allow more selective blocking of M3 receptors, without blocking inhibitory M2 receptors. Some studies already are being undertaken in experimental animals. Recombinant human neutral endopeptidase has also been developed to replace the loss due to viral RTI. Substances may also become available that will favourably alter the volume and consistency of airway secretions.

Patients should have the anaesthetic postponed for 4 to 6 weeks, for the effects of the RT1 to have truly abated. This is not always practical, but if there is no urgency and if it is a question of choosing a date, then this dealy is optimal. Frequently, the child picks up another infection in that period and sometimes frequent and recurring RTI may force a decision to proceed, according to the principles stated below. B) Emergency or Urgent Procedures and RTI Urgent or emergency cases will always be accepted on the basis that the risks are increased, but that with insight into the potential problems, the anaesthetic management can minimise the possible complications. (i ) Minimal Interference Technique If possible a minimal interference technique should be used. This implies the administration of a volatile agent with a mask and avoidance of tracheal intubation. The role of the laryngeal mask in RTIs has not been determined. In principle, the idea is attractive as it implies

Antiviral medications may change the nature, duration or airway irritability associated with infection. Conclusion An attempt has been made to answer all the questions which were posed with some insight to enable a rational approach to anaesthetic assessment and management of a child with RT1. Despite the current state of knowledge and developments in the last 15 years, McGill's statement in 1979 1 is still relevant : "Common sense dictates that a patient with an active but self limited disease not be subject to elective anaesthesia and surgery until resolution of the illness". References 1. McGill WA, Coveler LA, Epstein BS. Subacute upper respiratory infection in small children. Anesth Analg 1979;58:331-333. 2. Bates DV. in: Respiratory Function in Disease, WB Saunders Company Philadelphia, Third Edition. 1989;Chapter 18:344. 3. Tait AR, Knight PR. Intraoperative respiratory complications in patients with upper respiratory tract infections. Can J Anaesth 1987;34:300-303. 4. Tait AR, Knight PR. The effects of general anesthesia on upper respiratory tract infections in children. Anesthesiology 1987;67:930-935. 5. Olsson GL. Laryngospasm during anaesthesia. A computer incidence study in 136929 patients. Anesthesiol Scand 1984;28:567-675. 6. Cohen MM, Cameron CB. Should you cancel the operation when a child has an upper respiratory tract infection. Anesth Analg 1991;72:282-288. 7. Liu LMP, Ryan JF, Cote CJ, Goudsouzian NG. Influence of upper respiratory infections on critical incidents in children during anaesthesia. 9th World Congress of Anaesthesiology Abstract 1988;2:AO786. 8. Kinouchi K, Tanigami H, Tashiro C, et al. Duration of apnea in anaesthetized infants and children required for desaturation of hemoglobin to 95%. Anesthesiology 1992;77:1105-1107. 9. Levy L, Pandit UA, Randel GI, Lewis IH, Tait AR. Upper respiratory tract infections and general anaesthesia in children: Peri-operative complications and oxygen saturation. Anaesthesia 1992;47:678-682. 10. Williams OA, Hills R, Goddard JM. Pulmonary collapse during anaesthesia in children with respiratory tract symptoms. Anaesthesia 1992;47:411-413.