Secondhand Smoke Exposure as a Risk Factor for Perioperative Airway Complications in Pediatric Outpatient Procedures

Abstract: The purpose of this study is to assess the risk of perioperative airway complications, analyze extubation times, and PACU Length Of Stay (LOS), and their association with secondhand smoke exposure in pediatric populations receiving outpatient procedures that require general anesthesia. Introduction: Tobacco Smoke Exposure (TSE), is well documented to cause physiologic changes in lung tissue that are associated with decreased lung function, increased risk of lower and upper respiratory tract illness, exacerbation of asthma or increased risk of asthma, increased prevalence of non-allergic bronchial hyperresponsiveness, sudden infant death syndrome, and a host of other respiratory complications in adult and pediatric patients. Perioperative airway complications are a major cause of morbidity during general anesthesia for the pediatric population and there are limited studies linking TSE and the frequency of adverse airway complications during general anesthesia in pediatric patients. Methodology: This research study used a retrospective, quantitative, randomized case control design at Charleston Area Medical Center in West Virginia. The chart review was conducted on pediatric patients who presented for outpatient procedures from January 1, 2005 through June 1, 2014. Two groups were developed, the control group which were pediatric patients documented as non-exposed to tobacco smoke on the preoperative screening form and the case group who were acknowledged as Tobacco Smoke Exposed (TSE) on the preoperative screening form. These two groups were used for comparison of demographics and clinical characteristics such as recorded perioperative adverse airway events, Post Anesthesia Care Unit (PACU) recorded adverse airway events, extubation times, and PACU Length Of Stay (LOS). Results: There was no statistical significance found between the two groups in association with airway complications; 7% in the smoke exposed group and 3% in the non-exposed group. The mean age of the study sample was 4.37 ±(2.4), mean BMI was 17.02 ± ( 3.2), the mean number of minutes from the end of surgery until successful removal of nasotracheal tube was 6.95 ±(4.8), and the mean minutes until discharge from the PACU was 48.27 ±(13.3),. Of the 200 patients, 109 (55%) were male, 91 (45%) were female. Statistical significance was found in the TSE group for length of time until extubation (approximately 2 min longer) and for discharge from PACU (approximately 4 minutes longer). Also, there was statistical significance between age in years and the length of time spent in the PACU whereas for every year older the patients in the TSE group were in the PACU approximately one minute longer. Discussion: In the TSE group the average time to successful extubation was 8 minutes (p=.032) compared to the non-exposed group where extubation occurred after 6 minutes. Furthermore, the LOS in the PACU was an average of 50 minutes (P= .041) in the TSE group, as compared to an average of 46 minutes in the non-exposed group. Literature has shown that TSE does increase risks of airway complications, extubation times, and PACU LOS. Several study limitations were identified and discussed. Conclusion: TSE does increase the time from surgery stop to successful extubation as well as post anesthesia unit length of stay until discharge. Implications/Recommendations: This study was able to demonstrate an association with an increase in the time to extubation, as well as the time spent in the post anesthesia recovery unit in the group exposed to secondhand smoke. A longer stay in the PACU means that these pediatric patients are requiring longer time to meet discharge criteria which can include prolonged oral airway use, oxygen use, respiratory therapies such as racemic epinephrine and albuterol nebulizers, more cost to the patient and the hospital, as well as delayed achievement of baseline neurological status. While not reaching statistical significance, there was a 7% complication rate in the TSE group and a 3% complication rate in the non-exposed group which can impact perioperative patient care