OBJECTIVE: To compare the indications for and the postoperative course of children who are electively left intubated postoperatively vs. those who are not after urgent adenotonsillectomy (T&A) for severe Obstructive Sleep Apnea (OSA). METHODS: A retrospective study of children with severe OSA diagnosed by polysomnogram (PSG) who were admitted to the Pediatric Intensive Care Unit (PICU) after urgent adenotonsellectomy between January 2002 and June 2006. Those who were electively left intubated after surgery were compared to those who were extubated. RESULTS: n=70. Fifty-three were extubated postoperatively. Seventeen remained intubated. All were admitted to the PICU postoperatively. Method of tonsillectomy and PSG indices were not significantly different between the two groups. Children who remained intubated had a higher complication rate (47%) than those who did not (2%). Children who remained intubated were younger and had a higher ASA (American Society of Anesthesiologist) physician status classification and had a longer PICU and hospital stay. Children under three who were extubated did not require reintubation. CONCLUSIONS: Children who electively remain intubated after urgent adenotonsellectomy for severe OSA have a higher complication rate and require a longer hospital stay than those who are extubated. None of the extubated children required reintubation. We recommend a trial of extubation in these patients.