Upper respiratory tract infection

Learning objectives

Recognize the signs and symptoms of an upper respiratory tract infection
Decide whether or not surgery should be postponed in children with an acute upper respiratory tract infection
Anesthetic management of pediatric patients with upper respiratory tract infections

An upper respiratory tract infection (URTI) is an illness caused by an acute infection, which involves the upper respiratory tract, including the nose, sinuses, pharynx, larynx, or trachea
URTIs are characterized by cough, nasal congestion and discharge, sore throat, and sneezing
URTIs include the common cold, epiglottitis, tonsillitis, rhinitis, pharyngitis, laryngitis, sinusitis, and otitis media
Children experience 6 to 8 URTIs per year
Risk of perioperative adverse respiratory complications (i.e., coughing, breath holding, laryngospasm, bronchospasm, airway obstruction, oxygen desaturation <90%, atelectasis, post-extubation stridor, pneumonia, and unanticipated tracheal intubation or reintubation) is greatest during acute infection but remains increased for 2-6 weeks after URTI
Independent risk factors for adverse respiratory events in children with active URTI include intubation, prematurity (<37 weeks), child <1 year, history of asthma or atopy, passive smoking, airway surgery, presence of copious secretions, nasal congestion, parental confirmation “my child has a cold”, snoring, and use of an endotracheal tube (ETT)
Airway hyperreactivity is present for up to 6-8 weeks following a URTI

95% of URTIs are secondary to viral causes, with rhinoviruses accounting for 30-40% of infections

Preoperative assessment

Parents statement
Check for the presence of respiratory and cardiovascular comorbidities
Monitor vital signs and baseline saturation
Anticipate perioperative adverse respiratory events
Chest X-ray if physical examination suggests signs of lower respiratory tract involvement
Categorize URTI based on medical history and physical examination
- Mild URTIs: Clear runny nose, dry cough, appear healthy otherwise, clear lungs to auscultation, no fever
- Moderate URTIs: Green runny nose, mild moist cough, no wheezing or involvement of lower respiratory tract, no fever or irritability for 1-2 days
- Severe URTIs: Green runny nose, productive cough, mucopurulent secretion, nasal congestion, fever >38°C, severe sore or scratchy throat, pulmonary involvement (lower respiratory tract), wheezing, and lethargy

Anesthetic management

Goal: Minimize secretions and avoid or limit stimulation of a potentially irritable airway
Experienced pediatric anesthesia team
Preoperative bronchodilators 10-30 min before surgery to reduce bronchoconstriction and perioperative respiratory events
Humidifiers may help to clear secretions and prevent bronchial mucus plugging
Combining β2-agonist (e.g., salbutamol) with inhaled corticosteroids is more effective in minimizing bronchoconstriction due to intubation compared to inhaled β2-agonist alone
Avoid tracheal intubation, particularly in children <5 years
A laryngeal mask airway or facemask is preferred
IV lidocaine may be helpful in reducing the laryngospasm reflex
Less adverse respiratory events with propofol than sevoflurane as induction agent
Maintenance of anesthesia: Intravenous or inhalation techniques, anesthesia should be deep enough
Suction airway only under deep anesthesia

Children with active and recent URTI are at increased risk of perioperative respiratory complications
Assessment of suitability of any child with URTI symptoms for surgery includes the child’s age and presenting symptoms, frequency of URTIs, urgency and type of procedure, and presence of comorbidities
The decision to postpone or proceed with surgery for children with URTI should be made on an individual basis by considering the presence of identified risk factors and the anesthesiologist’s experience