Introduction

1. Passive Smoke Exposure (PSE) is Correlated with Perioperative Adverse Effects in Children that Undergo General Anesthesia: A Prospective, Double-blind, Clinical Study. Tulay Hosten Seyidov1, Levent Elemen2, Mine Solak1, Melih Tugay2, Kamil Toker1Kocaeli University Medical School 1-Anesthesiology and Reanimation Department 2-Pediatric Surgery Department

2. Introduction Passive smoke exposure relates to smoke of lit tobacco in locations where tobacco is smoked as well as the inhaling of air contaminated with mixture of exhaled tobacco smoke.

3. Introduction Tobacco smoke seriously damages human health due to its high contents of ammonium, benzene, nicotine, CO and various carcinogens.

4. Introduction In children exposed to tobacco smoke, asthma and airway reactivity are more frequently encountered and lower airway infections increase in infants. Middle ear infections are also known to increase due to deterioration of cellular and mucociliary functions in upper airways. Chilmonczyk B, N Engl J Med, 1993. Wrihgt AL, J Pediatr, 1991. Etzel RA, Pediatrics, 1992.

5. Introduction It is also reported that in case children exposed to tobacco smoke undergo general anesthesia, airway complications increase. Skolnick ET, Anesthesiology, 1998.

6. Objective The objective of our study is to investigate Passive Smoke Exposure (PSE) prevelance and its relation with Perioperative Respiratory Adverse Events (PRAE) in children operated under general anesthesia.

7. Materials and Methods Patients between the ages of 3 months to 12 years operated in Kocaeli University Medical School operating theaters under general anesthesia between 01 June and 30 September 2008 were included in this prospective, double-blind study after the approval of the local ethics committee was obtained.

8. Materials and Methods PRAE was defined as: • Coughing (3 or more episodes wit each episode lasting at least 5 seconds) • Laryngospasm (requiring active glottic widening) • Increase in airway secretions • Breath holding (lasting for more than 15 seconds) • Bradycardia (Drop of HR by 50% from its basal value) • Desaturation (SpO2 < 95%) .

9. Materials and Methods • In all the patients, anesthesia induction was performed by at least one specialist and two anesthesia assistants with at least two years of experience. • PRAE was evaluated during anesthesia (induction-emergence) and following anesthesia (recovery) by anesthesia specialist who performed the anesthesia induction of the child and who was unaware of PSI.

10. Materials and Methods • PSEwas defined as smoking a minimum of 10 cigarettes at home in the presence of the child or in another room. • It was questioned by anamneses taken from the parents and/or attendants of the child by the recovery nurse who was unaware of PRAE following anesthesia, in the recovery phase.

11. Statistical Analysis • NCSS 2007 & PASS 2008 software was used. • In addition to definitive statistical methods (Mean, Standard Deviation), Student’s t test and Mann Whitney U test was used in the evaluation quantitative data and Chi-square test and Fisher’s Exact Chi-square test were used in the comparison of qualitative data. • The results were considered to be in the 95% confidence interval and significance as p<0.05.

12. Results • 239 patients were evaluated throughout the study. • 17 patients with acute or chronic airway or lung diseases, asthma and who received medical treatment due to coughing in the last six weeks were excluded from the study.

13. 222 PSE 121 54.5% CONTROL 101 45.5% FATHER 70 57.8% MOTHER 12 9.9% MOTHER+FATHER 39 32.2%

15. PRAE 23 ( % 10.4 ) PSE 17 ( % 14.1 ) CONTROL 6 ( % 6 )

17. Results The recovery times PSE: 5.89±7.37 min Control: 4.86±4.49 min P=0.22

18. Discussion A study shows that PSE and airway complications are very strongly correlated in children who undergo general anesthesia. Another study asserts that in the absence of upper airway tract infection, PSE does not affect airway complications. Skolnick ET, Anesthesiology, 1998. Mamie C, Pediatric Anesthesia, 2004

19. Discussion PSE increases postextubation laryngospasm, oxygen desaturation, coughing and breatholding incidence in the recovery room. Chilmonczyk B, N Engl J Med, 1993. Wrihgt AL, J Pediatr, 1991. Etzel RA, Pediatrics, 1992.

20. Discussion Although we did not find significant differences in the distribution of complications, the high number upper airway secretions, particularly in the recovery phase, is remarkable. For the distribution of complications become statistically significant, 160 more patients are still required and therefore, our study is continuing.

21. Discussion Smoke exposure causes goblet cell metaplasia and excess mucus production in the small airways and proximal trachea. In animals smoke inhalation studies demonstrated increases in the number of goblet cells in the proximal trachea. Churg A, Am J Physiol Lung Cell Mol Physiol, 2008 Jones R, Br.Med j, 1972

22. Discussion Increased upper airway secretions in the recovery phase may be attributed to the increase in the number of goblet cells and excess mucus production.

23. Discussion Despite this, the similarity of recovery times in both groups can be attributed to the fact that our nurses have vast experience and to the exclusion from the study of those patients that have risk factors that would lead to an increase in respiratory complications along with PSE.

24. Discussion • Defining PSE by anamnesis taken from the family rather that via cotinin levels might be considered a weak aspect of our study. • While there are studies asserting that family anamnesis is unrealistic in PSE, there are other studies showing that urine cotinin levels are in accordance with family anamnesis as well. • A study suggests that questioning PSE with family anamnesis would be a practical but valuable method. Boyacı H, Pediatr Int, 2006. Skolnick ET, Anesthesiology, 1998. Jones DT, Otolaryngol Head Neck Surg, 2006.

25. Discussion Considering that collecting blood and urine samples in the preoperative period would be costly and tiresome, we preferred questioning PSE via family anamnesis in our study.

26. Conclusion PSE has increased PRAE's of children that received general anesthesia. When that PSE prevelance was 54.5% is considered, it can be argued that questioning PSE in the preoperative period is important in the prevention of respiratory complications due to general anesthesia.