Incidence and Factors Associated with Perioperative Respiratory Adverse Events in Pediatric Patients with Upper Respiratory Tract Infection Undergoing Surgery Under General Anesthesia: A Retrospective Cohort Study

Sutida Boonkamjad, R.N.1, Darunee Sripadungkul, M.D.2,*, Cattleya Kasemsiri, M.D.2, Prathana Wittayapairoch, M.D.2, Panaratana Ratanasuwan, M.D.2

1Nurse Anesthetist Division, Department of Nursing, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand,

2Department of Anesthesiology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand.

*Corresponding author: Darunee Sripadungkul E-mail: daruneeta@kku.ac.th

Received 29 September 2025 Revised 15 November 2025 Accepted 19 November 2025 ORCID ID:http://orcid.org/0000-0003-2228-2224 https://doi.org/10.33192/smj.v78i1.277950

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

Previous presentation in conferences

Part of this study was previously presented as a poster presentation at the SANCON-ASPA 2025 Conference: Scaling New Heights in Pediatric Anesthesia and Beyond (24th Annual Conference of the Society of Anesthesiologists of Nepal and 21st Meeting of the Asian Society of Paediatric Anesthesiologists), held in Kathmandu, Nepal, on April 5, 2025. The abstract was presented under the title “Incidence of perioperative respiratory events in children with upper respiratory tract infections.”

INTRODUCTION

Upper respiratory tract infections (URIs) are the most common medical issue in pediatric surgical patients and the leading cause for postponing surgery.1,2 Postponing surgery can cause stress for the child, parents, surgeon, and hospital.1,2 URIs are typically caused by viral infections.1-4 Children under four years old may experience an average of eight episodes of URIs per year, each lasting up to two weeks.1 The incidence of URIs decreases as children age, with older children and adults averaging about two to four URIs per year.1,2,4 However, airway hypersensitivity can persist for approximately two to six weeks.2,5 To diagnose an active URI, a child must exhibit at least two of the following symptoms: rhinorrhea, nasal congestion, sneezing, cough, sore or scratchy throat, malaise, or fever exceeding 38°C.1,6 These symptoms should have manifested within two weeks of the perioperative period and must be confirmed by a parent.6,7 The severity of pediatric URI is commonly categorized as mild, moderate, or severe according to clinical presentation, though criteria vary by reference.1,2 For severe URIs, studies recommend

postponing surgery until the child has been symptom-free for two weeks, followed by a re-evaluation.1-3 Identifying high-risk children preoperatively is challenging.7,8 Due to their anatomical and physiological characteristics and frequent URIs, children are vulnerable to perioperative respiratory adverse events (PRAEs).7 The incidence of PRAEs is between 24% and 30% in children with a current and/or recent URI, compared to 8% to 17% in children without a URI.5 Common PRAEs under general anesthesia (GA) include desaturation, breath holding, laryngospasm, bronchospasm, and coughing. Laryngospasm, bronchospasm, and persistent hypoxemia can lead to severe complications and death.7,9 Factors associated with PRAEs in children with URIs include age, respiratory comorbidities, URI severity, passive smoking, COLDS score, type of surgery, anesthetic technique, and anesthesiologist experience, though criteria may vary by clinical setting.3,7,10,11

We hypothesized that the incidence of PRAEs in our pediatric patients would be low due to the hospital policy of postponing elective surgery for severe URIs

until patients are symptom-free for at least two weeks and have been re-evaluated. Our hospital has no prior information about the incidence of PRAEs or the factors associated with PRAEs in children with URI. Therefore, the primary objective of this study is to determine the incidence of PRAEs among pediatric patients with URI undergoing surgery under GA. The secondary objective is to identify the factors associated with PRAEs in these pediatric patients. The findings will provide guidelines for anesthetic services and improve the efficacy of anesthesiology practices for children with URIs undergoing surgery under GA.

MATERIALS AND METHODS

This retrospective cohort study involves pediatric patients aged 0-18 years with URIs who were scheduled for surgery under GA at the Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. Ethical approval was obtained from Khon Kaen University's Ethics Committee (HE671456), and the requirement for written informed consent was waived by the Institutional Ethics Committee. Before commencement, the study was also registered in the Thai Clinical Trial Registry (TCTR20250109001). The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines in order to ensure comprehensive and transparent reporting of the observational data.

Patient population

We included all pediatric patients aged 0-18 years with URIs undergoing surgery under GA at Srinagarind Hospital between January 1, 2018, and December 31, 2022. Both elective and emergency surgeries were included. Patients whose records did not contain sufficient documentation were excluded.

Data collection

The database consisted of anesthesia records and medical records. The anesthesia records provided data on pre-anesthesia evaluation, intraoperative care, post-anesthesia care, and post-anesthesia visits. These records contained preoperative, intraoperative, and postoperative data. The medical records contained patient characteristics, operative notes, and events after anesthesia. We compared the groups with PRAEs and No-PRAEs group.

The first section assessed patient characteristic data consisting of gender, age, body weight, height, the American Society of Anesthesiologists (ASA) physical status, comorbidities including cardiovascular disease, respiratory disease, central nervous system disease, hematologic disease, kidney disease, coagulopathy, and

obesity (body mass index (BMI) ≥ 95th percentile for children of the same age and weight).7 We also recorded underlying respiratory diseases, including asthma, allergic rhinitis, bronchopulmonary dysplasia, tracheal stenosis, presence of a tracheostomy tube pneumonia, and scoliosis. Additionally, we noted parental concern, history of wheezing, and abnormal preoperative chest X-ray (CXR). In the second section assessed data of preoperative diagnosis of URI including symptoms of URI (runny nose, dry cough, productive cough, mucopurulent secretion, nasal congestion, sore throat, wheezing, rhonchi, fever

> 38°C, and lethargy). We recorded duration of URI and symptom-free period before surgery. The severity of URI was classified as mild, moderate, or severe.2 Mild URI was defined as a recent history of URI without current signs or symptoms within the past 2-4 weeks. Moderate URI was defined as the presence of any URI symptoms, such as a runny nose or dry cough, without wheezing and no systemic symptoms for one or two days before surgery. Severe URI was defined as the presence of any URI symptoms with systemic manifestations, including fever above 38°C, productive cough, mucopurulent secretion, nasal congestion, sore throat, wheezing, pulmonary involvement, and lethargy.2 We also documented of COLDS score.3,11 The COLDS score is a heuristic preanesthetic risk assessment tool commonly used to predict the incidence of PRAEs in children with URI. It is based on five categories: the severity of current symptoms (none, mild, moderate/ severe), the onset of signs (> 4 weeks, 2-4 weeks, < 2 weeks), lung disease (none, mild, moderate/ severe), the airway management device (facemask, supraglottic airway (SGA), endotracheal tube (ETT)), and the type of surgery (other, minor airway, major airway). Each category of the COLDS score is assigned 1, 2, or 5 points, resulting in a total score that can range from 5 to 25 points.3,11

The third section assessed operative details, including type of surgical urgency (elective or emergency), and type of surgery detailed.11 Major airway surgery, such as cleft palate repair, rigid bronchoscopy, and maxillofacial surgery. Minor airway surgery, such as tonsillectomy, adenoidectomy, and nasolacrimal duct surgery. Other surgery, such as ear tube insertion.11 We also recorded operative time, and intraoperative blood loss.

The fourth section assessed anesthesia detailed including anesthetic techniques included balanced GA, inhalational GA, total intravenous anesthesia (TIVA) for GA, and sedation, anesthetic agents for induction (sevoflurane, propofol), anesthetic time, and anesthesiologist experience.

The fifth section assessed PRAEs, including incidence and detailed of PRAEs including abnormal breath sounds after anesthesia, breath holding (defined as apnea lasting more than 15 seconds, irregular breathing, or apnea associated with bradycardia or cyanosis),7 hypoxemia (defined as oxygen saturation (SpO2) < 95% lasting more than 30 seconds),7 laryngospasm (defined as airway obstruction with abdominal and chest muscle rigidity requiring positive pressure ventilation or administration of succinylcholine),7 bronchospasm (defined as increased work of breathing, especially during expiration and wheezing, or requiring bronchodilators),7 excessive respiratory secretions requiring ETT suctioning during anesthesia, chest retraction, postoperative diagnosis of pneumonia or bronchitis, abnormal postoperative CXR (atelectasis, pneumonia, bronchiolitis), and need for prolonged oxygen support (> 1 hour postoperative) to maintain SpO2 > 95%.3 Additionally, we summarized of when PRAEs occurred (during induction, intraoperatively, after extubation, in the PACU, or postoperatively in the ward or intensive care unit (ICU)). Additionally, we noted anesthetic management (suction, steroid, salbutamol inhaler, antibiotic treatment, retained ETT and on ventilator support). We also assessed ICU stay, postoperative hospital stay, and postoperative outcomes (uneventful, on oxygen support, retained ETT, transferred to ICU).

The sixth section assessed factors associated with PRAEs, including patient factors, anesthesia factors, and surgical factors. Patient factors included gender (male, female), age (< 1 year, ≥ 1 year), ASA classification (I, II, III), obesity, severity of URI (mild, moderate, severe), onset of URI before surgery (< 2 weeks, 2-4 weeks, > 4 weeks), and underlying respiratory disease. Anesthesia factors included anesthetic technique (balanced GA, inhalational GA, TIVA for GA, and sedation), anesthetic agents for induction (sevoflurane, propofol), airway device (facemask, SGA, ETT), anesthesiologists’ experience, and COLDS score > 10. Surgical factors included type of surgical urgency (elective, emergency), type of surgery (major airway, minor airway, other), and surgical time.

Statistical analysis

Data analysis was performed using STATA for Windows, version 18 (StataCorp, College Station, TX). Descriptive statistics were used to summarize the participants’ characteristics. Categorical variables were reported as numbers and percentages, based on the number of participants with non-missing data. Continuous variables were presented as the median and

interquartile range (IQR) for non-normally distributed data, or as the means and standard deviations (SDs) for normally distributed data. The primary analysis focused on the incidence of PRAEs among children with URIs undergoing surgery under GA. Statistical significance was defined as p < 0.05. For the secondary analysis, we evaluated the factors associated with PRAEs using univariable and multivariable logistic regression models. Univariable analyses were conducted using chi-square tests or Fisher's exact tests, as applicable, to examine associations between categorical variables. To control for potential confounders, baseline variables that were statistically significant in the univariable analysis (p < 0.2) were included in the multivariable model. The final multivariable logistic regression model was constructed using the enter method and refined through sequential backward elimination based on the likelihood ratio test. Variables were retained in the model if they remained significant during the elimination process. The strength of association was expressed as adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

The estimated required sample size for the study was determined using the formula for estimating an infinite population proportion. This calculation was based on a previous study that reported the incidence of PRAEs as 21.50%.12 Using 25% as the proportion (p), a type I error of 0.05, and a power of 80%, we determined that a sample size of 225 participants was required for this study. This is a retrospective data collection study. Therefore, we aimed to include all patients over a 5-year period. The total population consisted of 229 patients.

RESULTS

A total of 17,183 pediatric patients aged 0–18 years underwent surgery (both elective and emergency cases) under GA. Of these, data were collected from 229 patients with URIs (Fig 1). We analyzed 229 pediatric patients scheduled for surgery under GA.

Patient characteristics

There were 144 males (62.9%). Median age was

4.1 (2.1, 6.4) years, weight was 14.7 (10.9, 22) kg, and

height was 100 (85, 116) cm. Most patients (97.4%) were ASA physical status classification II. The most common comorbidities were respiratory disease (100%), central nervous system disease (7.9%), age < 1 year (7.9%), hematologic disease (6.6%), and cardiovascular disease (3.9%). The most common respiratory conditions were asthma (4.8%), allergic rhinitis (3.9%), and presence of a tracheostomy tube (1.3%) (Table 1).

Fig 1. Study flow diagram

Preoperative diagnoses of URI and COLDS score

As shown in Table 2, the most common URI symptoms were runny nose (76.4%), dry cough (32.8%), and mucopurulent secretions (15.7%). The median duration of URI was 3 (2, 3) days. Most patients (50.7%) remained symptomatic before surgery, while 41.9% had 1–6 symptom-free days. Most patients (83.4%) had moderate URI severity.

Based on the COLDS score, most patients (83.4%) had mild URI symptoms, with 96.1% of cases occurring less than two weeks before surgery. Lung disease was absent in 90.0% of patients. Airway devices used included SGA (50.7%), ETT (38.9%), and facemasks (10.5%). Most surgeries were other types (87.3%), with minor and major airway surgeries comprising 7.9% and 4.8%, respectively. The median COLDS score was 12 (11, 14), ranging from 5 to 25. In the PRAEs group, the median score was 15 (15, 17), compared to 11.5 (11, 14) in the No-PRAEs group. A COLDS score above 10 was observed in 90% of patients, including all patients in the PRAEs group. Additionally, 96.1% had parental concern about URI, 1.3% had a history of wheezing, and 3.1% had abnormal preoperative CXR.

Operative details

Almost all cases were elective, with 227 patients (99.1%), while only 2 patients (0.9%) underwent emergency procedures. Major airway surgery was performed in 11 patients (4.8%) including rigid bronchoscopy (3.1%), cleft palate repair (0.9%), and maxillofacial surgery (0.9%). Minor airway surgery was performed in 18 patients (7.9%), consisting of nasolacrimal duct probing (2.6%), cleft lip repair (2.2%), tonsillectomy (1.3%), flexible bronchoscopy (0.9%), and tongue-tie release (0.9%). Other types of surgery were performed in 200 patients (87.3%), including ophthalmologic surgery (24.0%), magnetic resonance imaging (20.1%), general surgery (14.8%), orthopedic surgery (14.0%), urologic surgery

(7.4%), ear reconstruction (3.5%), computed tomography

(1.3%), radiation therapy (0.9%), neurological surgery (0.9%), and cardiovascular and thoracic surgery (0.4%). The median operative time was 60 (40, 90) minutes, and estimated blood loss 0 (0, 3) ml.

Anesthesia details

The anesthetic techniques used included inhalational GA in 139 patients (60.7%), balanced GA in 77 patients

Abbreviations: PRAEs group, Perioperative respiratory adverse events group; No-PRAEs group, No perioperative respiratory adverse events group; IQR, interquartile range; ASA, the American Society of Anesthesiologists

TABLE 2. Data of preoperative diagnosis of upper respiratory tract infection and COLDS score.

Abbreviations: PRAEs group, Perioperative respiratory adverse events group; No-PRAEs group, No perioperative respiratory adverse events group; URI, upper respiratory tract infection; IQR, interquartile range; SGA, supraglottic airway; ETT, endotracheal tube

(33.6%), TIVA for GA in 10 patients (4.4%), and sedation in 3 patients (1.3%). The agents used for induction were sevoflurane in 153 patients (66.8%) and propofol in 76 patients (33.2%). The median (IQR) anesthetic time was 90 (60, 120) minutes. Anesthetics were administered by anesthesiologists with less than 5 years of experience in 44 patients (19.2%), and by those with 5 or more years of experience in 185 patients (80.8%).

The perioperative respiratory adverse events

The incidence of PRAEs in pediatric patients with URIs undergoing GA was 9 out of 229 (3.9%). The most common PRAEs were abnormal breath sounds after anesthesia, prolonged oxygen requirement, chest retraction, bronchospasm, breath-holding, and hypoxemia. Most events occurred intraoperatively, and during induction, as shown in Table 3. Anesthetic management for PRAEs included: two patients received succinylcholine, salbutamol inhaler, and oxygen support; two received suction, salbutamol inhaler, and oxygen support; two received succinylcholine, suction, and salbutamol inhaler, requiring a retained ETT with ventilator and oxygen support; one received only oxygen support; one received succinylcholine and oxygen support; and one received suction, salbutamol

inhaler, and required a retained ETT with ventilator and oxygen support. In the PRAEs group, the median ICU stay was 1 (0, 1) day.

For all patients, the median postoperative hospital stay was 3 (1, 4) days. For postoperative outcomes, all 220 patients in the No-PRAEs group had uneventful recoveries. Among the nine patients in the PRAEs group, one had an uneventful recovery, two required oxygen support, three needed retained ETT, oxygen support, and ICU admission, and three required both oxygen support and ICU admission. No severe adverse events or fatalities occurred.

The factors associated with perioperative respiratory adverse events

As shown in Table 4, univariable logistic regression analyses were performed to identify factors associated with PRAEs. Patient factors (ASA classification III, severe URI, and underlying respiratory disease), anesthesia factors (use of an ETT compared with an SGA), and surgical factors (emergency surgery and minor airway surgery compared with other surgery types) were all statistically significantly associated with PRAEs (p < 0.05), based on ORs with 95% CIs. In the multivariable

TABLE 3. Perioperative respiratory adverse events (N = 9).

Abbreviations: CXR, chest X-ray; ETT, endotracheal tube; PRAEs, perioperative respiratory adverse events; ICU, intensive care unit

TABLE 4. The factors associated with perioperative respiratory adverse events.

Abbreviations: CI, confidence interval; ASA, the American Society of Anesthesiologists; URI, upper respiratory tract infection; CXR, chest x-ray; GA, general anesthesia; TIVA, total intravenous anesthesia; SGA, supraglottic airway; ETT, endotracheal tube; NA, not applicable.

*Statistically significant (p < 0.05).

logistic regression analyses, only ASA classification III compared with ASA classification II (adjusted OR, 83.33; 95% CI, 7.10 to 1,363.56; p < 0.001) and minor airway surgery compared with other surgery types (adjusted OR, 18.54; 95% CI, 1.97 to 237.98; p = 0.009) remained

statistically significantly associated with PRAEs.

DISCUSSION

This study found that the incidence of PRAEs among pediatric patients with URIs undergoing surgery under GA was 3.9%. In multivariable logistic regression analysis, factors associated with PRAEs were ASA classification III and minor airway surgery.

A retrospective study involving 267 pediatric patients (ages 0–13) with recent URIs undergoing GA reported a PRAE incidence of 8.6% (23 cases).13 A prospective observational study of 270 children under 2 years old with oropharyngeal cleft deformity found a PRAE incidence of 1.85% (5 cases).14 Similarly, our study observed a low PRAE incidence. In contrast, a prospective observational study of 216 children (ages 1–5) with mild to moderate URIs undergoing ambulatory ilioinguinal surgery found a PRAE incidence of 21.3%.3 Another retrospective study of pediatric patients (ages 0–18) with recent URIs undergoing GA reported a PRAE incidence of 21.5%.12 Our study observed a low incidence of PRAEs, likely because most patients (83.4%) had only moderate URIs, and our hospital policy requires postponing elective surgery for severe URI cases until at least two weeks after full symptom resolution and re-evaluation. Additionally, differences in PRAE incidence across studies may reflect variation in PRAE definitions, URI severity, study design, inclusion criteria, surgery type, and pediatric age range.

For the occurrence of PRAEs, a previous study of ambulatory ilioinguinal surgery found that 78.3% occurred during anesthesia and 21.7% in the PACU.3 Similarly, in our study, 77.8% of PRAEs occurred during anesthesia, with 11.1% occurring after extubation and 11.1% in the ICU. In contrast, a study of airway surgery in children under two years of age with oropharyngeal cleft deformity reported that all cases of PRAEs occurred after extubation.14 PRAEs occurred most often immediately after tracheal extubation and were much less common during the induction and maintenance phases.7 The timing of PRAEs varies depending on patient characteristics (e.g., very young age), the type of surgery (especially airway procedures), the severity of URIs, and the adequacy of perioperative management—from preoperative preparation to intraoperative and postoperative care.7,14

From univariable logistic regression, factors associated with PRAEs included ASA classification III, severe URI,

underlying respiratory disease, use of an ETT (compared with an SGA), emergency surgery, and minor airway surgery (compared with other surgery types), consistent with previous systematic reviews.1,2

In multivariable analysis, the prior study identified respiratory comorbidities, postponement of surgery for less than 15 days, passive smoking, and a COLDS score greater than 10 as predictors of PRAEs.3 Additionally, abnormal findings on preoperative chest imaging and a symptom-free period of 7–13 days were independently associated with PRAEs.13 In contrast, our study found that only ASA classification III and minor airway surgery (compared with other surgery types) were significantly associated with PRAEs. This may be attributable to the low incidence of PRAEs in our cohort. Major airway surgery (compared with other types of surgery) was not an independent factor associated with PRAEs, possibly because of the small sample size—only eleven cases of major airway surgery (one in the PRAEs group and ten in the No-PRAEs group)—which may have limited the statistical power to detect a significant association.

ASA classification III is an independent risk factor for PRAEs in children with URIs undergoing GA. These patients have more than a fivefold increased risk of PRAEs compared to those with lower ASA status, likely due to more severe underlying disease and reduced physiological reserve.7 Undergoing airway-related procedures further increases the risk of PRAEs by about sixfold compared to non-airway surgeries, mainly because airway manipulation stimulates airway reflexes and increases reactivity, particularly in children with URIs.7,13

The COLDS score is a preanesthetic risk assessment tool commonly used to predict the likelihood of PRAEs in pediatric patients with URIs.11 Previous research identified a COLDS score > 10 as a risk factor for PRAEs in pediatric URI patients.3 However, in our study, the median COLDS score was 12; 90% of patients scored above 10, and all patients with PRAEs exceeded this threshold. Univariable logistic regression showed that a COLDS score > 10 was not significantly associated with PRAEs (p = 0.604), possibly due to the low incidence of PRAEs in our cohort. Notably, prior studies have reported a higher cutoff value of 12.5 for the COLDS score when predicting PRAEs.12 The COLDS score helps assess PRAE risk, but no specific cancellation threshold is established.3 It should guide risk assessment and interventions, with surgery cancellation considered when the COLDS score is high (especially ≥ 10) alongside other clinical factors.3 Perioperative management to prevent PRAEs in pediatric patients can be structured into three parts.1,2 Preoperative care focuses on risk assessment, joint decision-

making about surgery timing, experienced teams for high-risk cases, and individualized premedication—favoring alpha-2 agonists, beta-2 agonists for recent URI or bronchospasm risk, and corticosteroids when urgent surgery is needed in severe bronchial hyperreactivity.1 In the intraoperative phase, propofol is preferred for induction and maintenance; lidocaine or dexmedetomidine may be used adjunctively. Minimize and monitor neuromuscular blockers. Prefer facemask or SGA over ETT. Use sevoflurane or propofol, not desflurane, for maintenance. Apply lung-protective ventilation, opioid-sparing strategies, remove airway devices under deep anesthesia if safe, and consider lateral positioning.1 In the postoperative phase, continuous respiratory monitoring, staff training, and standardized handover to ensure early detection and response to complications.1

In our pediatric URI cases, elective surgery for severe URIs is postponed until at least two weeks after symptoms resolve and re-evaluation, per hospital policy.1-3 However, surgery for children with mild to moderate URIs may proceed provided that the procedure’s nature and duration are appropriate for the patient’s condition, suitable airway equipment is used, and it is performed by an experienced anesthesiologist in a proper institutional setting with full parental cooperation.1,2 High-risk patients with recent URI receive nebulized beta-2 agonists preoperatively and are managed in consultation with an expert anesthesiologist. Intraoperatively, propofol is preferred for induction when IV access is available, and sevoflurane is favored over desflurane for maintenance. SGA devices or facemasks are used instead of ETTs whenever possible to reduce airway complications. Deep extubation with an SGA is performed when it is safe. Lung-protective strategies and multimodal analgesia, including regional techniques, are employed for optimal perioperative care. In the postoperative phase, we closely monitor pediatric patients and reserve a bed in the pediatric intensive care unit (PICU) for high-risk cases to ensure early detection and management of complications.

Although this study was carefully designed and evaluated the COLDS score as a preanesthetic risk assessment tool for PRAEs, several limitations should be acknowledged. Ethical requirements necessitated a retrospective cohort design, which may have introduced confounding factors and reliance on potentially incomplete medical records. The single-center setting limits generalizability. The low incidence of PRAEs reduced statistical power, increasing the risk of type II error in both univariable and multivariable analyses. Larger studies are needed to clarify these findings.

Future research should employ a prospective,

multicenter design to more accurately assess the incidence and risk factors for PRAEs in pediatric patients with URIs and minimize bias. Establishing a standardized definition of PRAEs and URI severity is recommended to improve consistency across studies.

CONCLUSIONS

The incidence of PRAEs among pediatric patients with URIs undergoing surgery under GA was 3.9%. ASA classification III and minor airway surgery were factors associated with PRAEs. Preoperative management should carefully assess pediatric patients with URIs and implement strategies to prevent PRAEs.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

ACKNOWLEDGMENT

We appreciate the support of Kaewjai Thepsuthammarat from the Clinical Epidemiology Unit for biostatistical assistance.

DECLARATIONS

Grants and Funding Information

None.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Registration Number of Clinical Trial

This study was registered with the Thai Clinical Trials Registry (TCTR20250109001) on January 9, 2025.

Author Contributions

Conceptualization and methodology, S.B., D.S., C.K., P.W. and P.R.; Investigation, S.B., D.S. and C.K.; Formal analysis: S.B., D.S. and C.K.; Data Curation, S.B., D.S., P.W. and P.R.; Visualization and writing - original draft, S.B., D.S. and C.K.; Writing - review & editing, S.B., D.S. and C.K.; Supervision, D.S. and C.K. All authors have read and agreed to the final version of the manuscript.

Use of Artificial Intelligence

The generative AI tool Perplexity (version sonar-pro) was used solely for grammar and language editing. Professional language editors at the Language Institute of Khon Kaen University also reviewed the final manuscript.

No AI tools were used for data analysis, content generation, or interpretation. The authors remain fully responsible for the study’s accuracy and scientific content.

IRB number

This study was approved by the Human Research Ethics Committee of Khon Kaen University in Thailand (HE671456). During this research project, the authors followed the applicable EQUATOR Network (STROBE) guidelines.

REFERENCES

1. Stepanovic B, Regli A, Becke-Jakob K, von Ungern-Sternberg BS. Preoperative preparation of children with upper respiratory tract infection: a focussed narrative review. Br J Anaesth. 2024;133(6): 1212-21.

2. Lema GF, Berhe YW, Gebrezgi AH, Getu AA. Evidence-based perioperative management of a child with upper respiratory tract infections (URTIs) undergoing elective surgery; A systematic review. Int J Surg Open. 2018;12:17–24.

3. Jarraya A, Kammoun M, Ammar S, Feki W, Kolsi K. Predictors of perioperative respiratory adverse events among children with upper respiratory tract infection undergoing pediatric ambulatory ilioinguinal surgery: a prospective observational research. World J Pediatr Surg. 2023;6(2):e000524.

4. Pohplook J, Puwarawuttipanit W, Koositamongkol S, Rongrungruang Y. Factors Influencing Severity and Impact of Symptoms in Patients with Upper Respiratory Tract Infection at Community Hospitals and Health-Promoting Hospitals. Siriraj Med J. 2021;73(8):510-7.

5. Regli A, Becke K, von Ungern-Sternberg BS. An update on the perioperative management of children with upper respiratory tract infections. Curr Opin Anesthesiol. 2017;30(3):362.

6. Malviya S, Voepel-Lewis T, Siewert M, Pandit UA, Riegger LQ, Tait AR. Risk Factors for Adverse Postoperative Outcomes

   in Children Presenting for Cardiac Surgery with Upper Respiratory Tract Infections. Anesthesiology. 2003;98(3):628–32.

7. Wudineh DM, Berhe YW, Chekol WB, Adane H, Workie MM. Perioperative Respiratory Adverse Events Among Pediatric Surgical Patients in University Hospitals in Northwest Ethiopia; A Prospective Observational Study. Front Pediatr. 2022;10:827663.

8. Lee S, Reddington E, Koutsogiannaki S, Hernandez MR, Odegard KC, DiNardo JA, et al. Incidence and Risk Factors for Perioperative Cardiovascular and Respiratory Adverse Events in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Procedures. Anesth Analg. 2018;127(3):724.

9. Ramgolam A, Hall GL, Zhang G, Hegarty M, von Ungern-Sternberg BS. Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events: A Randomized Controlled Trial. Anesthesiology. 2018;128(6):1065–74.

10. von Ungern-Sternberg BS, Boda K, Chambers NA, Rebmann C, Johnson C, Sly PD, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet Lond Engl. 2010;376(9743):773–83.

11. Lee BJ, August DA. COLDS: A heuristic preanesthetic risk score for children with upper respiratory tract infection. Pediatr Anesth. 2014;24(3):349–50.

12. Kim HS, Kim YS, Lim BG, Lee JH, Song J, Kim H. Risk Assessment of Perioperative Respiratory Adverse Events and Validation of the COLDS Score in Children with Upper Respiratory Tract Infection. Med Kaunas Lith. 2022;58(10):1340.

13. Lee HJ, Woo JH, Cho S, Oh HW, Joo H, Baik HJ. Risk Factors for Perioperative Respiratory Adverse Events in Children with Recent Upper Respiratory Tract Infection: A Single-Center-Based Retrospective Study. Ther Clin Risk Manag. 2020;16: 1227-34.

14. Shenoy U, Chirayath B, Narayanan PV, Francis A, Thomas MK, Rajagopal R. Predictors of Perioperative Respiratory Adverse Events in Children Undergoing Surgery for Oropharyngeal Cleft Deformity: A Prospective Observational Study (PRAE-OPCD Study). Paediatr Anaesth. 2025;35(12):1024-8.