AAP News •
www.aapnews.org • September 2015 13
by Sarena N. Teng, M.D., FAAP,
and Rita Agarwal, M.D., FAAP
Anesthesiology is a field where much emphasis is
placed on patient safety through the prevention of
error. A different approach to prevent perioperative
complications in children undergoing anesthesia involves helping caregivers stop smoking.
The literature purports an alarming 10 times increase
in the incidence of both perioperative laryngospasm
and bronchospasm in pediatric patients whose parents
reported environmental tobacco smoke exposure. The
presence of a respiratory tract infection or need for
intubation increases these risks (von Ungern-Sternberg
BS, et al. Lancet. 2010;376:773-783).
Other studies show that the effects of secondhand
smoke exposure continue into the recovery period and
impact the patients’ response to certain medications
such as rocuronium (Reisli R, et al. Paediatr Anaesth.
2004;14:247-250). Furthermore, many children, especially those with pre-existing pulmonary disease, recent
upper respiratory infection or other significant co-mor-bidities, will have a decreased peak expiratory flow rate
that may contribute to perioperative morbidity.
There are no good screening tests to determine the
degree of exposure a child may have had to tobacco
smoke. Both carboxyhemoglobin levels and pulse carbon monoxide (CO)-oximetry have been investigated,
but neither has been helpful (Yee BE, et al. Paediatr
In addition, the optimal time to terminate secondhand
smoke exposure before surgery to prevent morbidity is
not well-defined. In active smokers, cessation of smoking
even 12 hours before general anesthesia can be associated
with a reduction in carbon monoxide levels. Ciliary activity recovers within four to six days, and stopping smoking
five to 10 days before anesthesia decreases laryngeal and
bronchial reactivity. Sputum overproduction decreases
within two to six weeks of being smoke-free.
Because it takes days to weeks for the effects of smoke
exposure to subside, educating parents on the benefits of
smoking cessation as soon as possible for their pre-sur-gical child may be an opportunity particularly relevant
to pediatricians during a pre-anesthesia clearance visit.
An intervention to decrease children’s secondhand
smoke exposure at home was encouraging. Nine-
ty-seven percent of caregivers found discussions of
secondhand smoke with providers in a pediatric clinic
acceptable. At six- and 12-month follow-ups, respec-
tively, 14% and 13% of smokers reported quitting, and
63% and 70% of current smokers reported reduced
secondhand smoke exposure (Bunik M, et al. Pediatrics.
A 2011 study showed that parents whose children
were scheduled for surgery were willing to make an
attempt to quit smoking but had difficulty maintaining abstinence (Shi Y, Warner DO. Anesthesiology.
2011;115: 12-17). Additional support may be required
to help a parent quit for good.
Offending or coming across as judgmental to the smoker is a concern for many physicians. Resources are available
for scripting these conversations (See resource box).
Many children’s hospitals and pediatric anesthesiologists have pre-operative clinics to help evaluate and
prepare children for surgery. Many anesthesiologists
are advocating for a “surgical home” to help prepare
patients better. These would be ideal opportunities to
address the issue of smoking cessation.
In the absence of these resources, pediatricians can
make an enormous impact on a child’s preoperative
course by educating and offering support to help parents quit smoking.
Dr. Teng is a member of
the AAP Section on Anesthesiology and Pain Medicine, and Dr. Agarwal is
chair-elect of the section
by Miles M. Weinberger, M.D., FAAP
Asthma exacerbations are the leading diagnosis
among hospitalized children in the U.S. More than
5% of all children admitted to hospitals are diagnosed
with asthma, and most of these admissions are associated with viral respiratory infections (Keren R, Shah
SS. JAMA Pediatr. 2013;167:485-487).
While 24 years of guidelines and clinical parameters
have not altered the statistics related to the frequency of asthma exacerbations, early research on a novel
approach to prevent asthma exacerbations caused by
common cold viruses has been reported recently.
Association between colds, asthma flares
The association of asthma exacerbations with the
common cold has been recognized for nearly a thou-
sand years. In his Treatise on Asthma, Moses Maimon-
ides (1135-1204) stated, “This disorder starts with a
common cold, and the patient is forced to gasp for
breath day and night, until the phlegm is expelled, the
flow completed and the lung well cleared.”
While pharmacologic measures now are available to
provide some relief for those symptoms, Maimonides’
description fits many children with asthma, including
preschoolers who have the highest frequency of com-
mon cold viruses. Many of these children are non-atop-
ic with no evidence for a chronic component. Atopic
children also experience exacerbations with apparent
synergism between cold viruses and inhalant allergen
sensitization and exposure.
Preschool-age children average about five to seven
Misdiagnosis of pneumonia
colds per year, resulting in a great deal of increased
morbidity for those predisposed to have asthmatic
symptoms when they get a cold. We readily recognize
the seasonal increases in patients with asthma seen in
emergency departments and hospitals when children
return to school in the fall. Furthermore, the increase
in the frequency of cold viruses and the lower airway
symptoms they create among susceptible children in
child care and preschool is all too apparent.
Why do children with asthma experience a profuse
increase in lower airway inflammation when they get a
cold when others have only upper airway symptoms? It
appears that asthma is associated with a defect in innate
immunity related to respiratory epithelia production
of anti-viral interferons.
The lower airway inflammation resulting from those
viral respiratory infections can cause auscultatory and
radiologic findings that may be misinterpreted as pneumonias. These “pneumonias,” however, are due to the
effects of common cold viruses on genetically susceptible children and do not represent true infection of the
pulmonary parenchyma. In many cases, the associated
diagnosis of asthma is not even appreciated when the
symptoms are misdiagnosed as “pneumonia.” Often,
the result is administration of antibiotics to children
unlikely to benefit from them.
Unfortunately, limited means are available to prevent
exacerbations that result from common cold viruses.
Although maintenance therapy with inhaled corticosteroids generally is highly effective for children with
persistent symptoms, evidence does not support those
medications to prevent exacerbations due to common
cold viruses. Efforts to demonstrate benefit from mon-telukast in modifying asthmatic symptoms due to cold
viruses also have been unconvincing.
Are there any other options?
While still far from the medical marketplace, an
interferon product delivered by nebulization at the
onset of cold symptoms recently has shown a “proof
of concept” (Djukanović R, et al. Am J Respir Crit
Care Med. 2014;190:145-154). The hope is that such
treatment someday may prevent exacerbations caused
by common cold viruses. Perhaps, the development of
oral drugs effective against the common cold viruses
eventually will offer other options.
Preventing exacerbations of asthma from a common
cold would have a major impact on the high prevalence
of asthma hospitalizations. However, time will tell if
any of these treatments reach clinical practice.
Meanwhile, patients would benefit from recognition
of the most common causes of asthma exacerbations.
Misdiagnosis as pneumonia provides no benefit and is
likely to raise more anxiety in parents than recognizing
that asthma symptoms are the result of a common cold.
Dr. Weinberger is a member of the AAP
Section on Pediatric Pulmonology and
Sleep Medicine and the Section on Allergy
Educate parents on benefits of smoking cessation before child’s surgery
Asthma attacks caused by common colds continue to vex medical community
• The AAP Julius B. Richmond Center for Excellence has
tools and resources to protect children from tobacco
and secondhand smoke. Visit http://www2.aap.org/
• For information on how to counsel parents to stop
smoking, visit http://www2.aap.org/richmondcenter/
CounselingAboutSmokingCessation.html. Dr. Teng Dr. Agarwal