Adverse respiratory events are a major cause of morbidity and mortality from general anesthesia in children. Established risk factors include upper respiratory tract infection (URTI) in the previous 2 weeks, wheezing more than three times during the previous year, a history of asthma, cystic fibrosis, bronchopulmonary dysplasia or other lung disease, eczema, family history of atopy, and exposure to passive smoking. Many of these are markers of underlying airway inflammation, which can lead to airway irritability and bronchial hyper-reactivity. Age is another factor, and infants have double the risk compared to older children. Airway, cardiac or upper abdominal surgeries also increase risk. Premedication with midazolam is associated with increased risk (OR 3.5), while alpha-2 adrenergic agonists are theoretically better. Salbutamol premedication reduces respiratory events in young children with URTI, children undergoing tonsillectomy and in those with multiple risk factors. Intravenous induction, and possibly maintenance with propofol, reduces risk compared to a volatile anesthetic technique. The least invasive suitable airway is preferred for the child with an irritable airway. For example in infants, the laryngeal mask is associated with a lower risk of perioperative respiratory events compared with endotracheal intubation (RR 2·94). Children with multiple risk factors or active symptoms may benefit from deep removal of their endotracheal tube or supraglottic airway. Finally, care by a specialist pediatric anesthetist has been shown to decrease the risk for respiratory events.
Asthma and anesthesia Bronchospasm during anesthesia children Upper respiratory tract infection and anesthesia children Anesthesia for cystic fibrosis Airway irritability during anesthesia
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