QUAD #27 - Multidisciplinary - How Do Teams Enhance Outcomes by the CCHMC ADEC Team

Global Cast MD along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Lizzie Lee from Cincinnati Children's Hospital Medical Center. In October 2022, Cincinnati Children's hosted the Quad Conference, which is a combination of four conferences. The International Organization for Esophageal Atresia, the Aerodigestive Society Conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia Series. Today, we will highlight the multi-disciplinary team approach in caring for esophageal atresia and tracheoesophageal fistula patients at the aerodigestive and esophageal center at Cincinnati Children's. These are complex patients that really benefit from a multi-disciplinary approach, and Cincinnati Children's has one of the largest aerodigestive centers in the world. The expert multidisciplinary team includes speech pathology, otolaryngology, gastroenterology, pulmonology, and pediatric general surgery. Each of these five specialties is integral in the care of these complex patients, but in this video, we will highlight speech pathology, GI, and pulmonology, and how this integrated approach achieves the best patient outcomes. First, we have Claire Miller, a speech language pathologist who is the aerodigestive team's program director to talk about her role and the multidisciplinary team structure. The vision of the aerodigestive and esophageal center was to improve efficiency, communication between the team members and family. They provide coordinated multidisciplinary care to children with congenital or acquired complex digestive and airway disorders. We have medical directors, interdisciplinary feeding team, underneath this umbrella of what we call the aerodigestive and esophageal center. Underneath all of that is the administrative infrastructure, from the initial referral and speaking to the family, to gathering data and getting the patients back in for follow-up. The underlying operations are complex, everything from helping the patient get coverage, making sure that we've got our weekly meeting. They also have an executive team of physicians from each of the disciplines. This is where the strategic planning, goals, and objectives for the team are created. We have bi-monthly process meetings with all of the nurse practitioners and the nurses that manage the care of the patients. What is the role of speech pathologists in the team? The role of the speech pathologist is to evaluate dysphagia, voice, communication issues. The speech pathologist begins with a clinical assessment to look at how patients are functioning and eating and to identify signs and symptoms of possible swallowing dysfunction. The clinical assessment is a poor predictor when there are airway protection issues, so we are involved in the instrumental studies. Speech pathologists work with radiologists to do a videofluoroscopic swallowing study to analyze different phases of swallowing. They also work with the ENT to do fees, or fiberoptic endoscopic evaluation of swallowing study, which allows us to see pharyngeal and laryngeal structures and assess the function, aspiration and residual after each swallow. And high resolution pharyngeal manometry allowing us to look objectively at the pressures of the swallow to understand what is underlying a swallowing dysfunction. Future opportunities for the speech pathologist include using manometry, EMG, and ultrasound during dysphagia treatments as biofeedback, as well as implementing clinical protocols to ensure that best practices are utilized. To give us an ENT perspective, we had Dr. Alexander de Alarcon, an otolaryngologist, explain ENT's role on the aerodigestive team. ENT looks at the swallowing study results and helps stratify the risk of proceeding with airway reconstruction and decannulation. In aerodigestive patients, ENT performs esophageal and airway reconstruction, cleft repair, drool procedures, and manages vocal fold and mobility. Next, we have Dr. Scott Pentic here to talk about the GI perspective and his role on the aerodigestive team. My job is to find things that affect the airway. Common things that we run into that as part of the aerodigestive team. Gerd, or gastroesophageal reflux disease is a very common issue that a GI specialist treats in aerodigestive patients and the pathophysiology includes an incompetent lower esophageal sphincter. As a GI person, now I realize that these patients with the TF have a lot of other things other than incompetent lower esophageal sphincters. We see a lot of kids with motility problems, hernias, delayed emptying. Here are general signs and symptoms of Gerd including regurgitation, vomiting and heartburn. When I think of reflux, I think of how do we measure it. One of the tools that we often talk about during our weekly meetings is does this child actually need an impedance to help measure reflux. This is an impedance tracing that measures a swallow versus an actual reflux impedance. Swallow on the left versus the difference that we see when a patient is refluxing on the right. So if you see this really red, irritated esophagus, it's got to be refluxing. Let's look at some endoscopy pictures of eosionophilic esophagitis or EOE, including the one on the right, which is a piece of chicken stuck on the esophagus. This was another study that showed that patients with EOE often have procedures performed on them even before their diagnosis. This data shows an increase in airway surgery complications in patients who were later found to have EOE. So now we do endoscopy as part of our workup prior to even considering surgery. Anatomic issues that may arise in aerodigestive patients include strictures that need balloon dilations or stenting. This is another picture of a large hernia. Kids who have Nissans and then have hernias later. One of the questions we're always dealing with is we had a Nissen, I should not be refluxing, my child should be doing fine and we'll find reasons for that. And then there's motility issues after TF repairs including narrowing of the esophagus. The esophagus doesn't squeeze, leading to more reflux, more dysphagia and impactions. Dr. Pentique also works with the feeding team. When they assessed 25 patients in their aerodigestive program, they found that 76% of them had a feeding disorder. We all need to work together to help improve both their swallowing and their eating. Next, we have Dr. Sherry Torres Silva, a pulmonologist on the aerodigestive team. She will review the pulmonary point of view, common diagnostic studies they recommend, and her role in airway reconstruction. So what is my goal in the initial evaluation? Identify pulmonary pathology contributing to symptoms and then decide which one of these are relevant in terms of the reconstruction or the aerodigestive management we're looking for. Pulmonary insufficiency. And who is at risk for pulmonary insufficiency? Premies with chronic lung disease, patients with restrictive lung disease, congenital or acquired abnormalities, and heart disease like pulmonary hypertension. Who are at risk? Patients will typically present to you with chronic symptoms, tachypnea, shortness of breath, retractions. Some of them will have known apneic hypoxemia. Some of the older ones might come in with exercise intolerance. You should suspect underlying pulmonary insufficiency if they have had complicated respiratory infections, requiring positive pressure ventilation. Now, let's talk about chronic pulmonary aspiration. Who are at risk? Premy babies, those with swallowing dysfunction, GI dysmotility, cardiothoracic, esophageal, and airway history. Syndromes that you need to think, aspiration on to proven otherwise would be your charge syndrome, Mobius, Credoshat and the trisomes. Next, we will discuss upper airway obstruction. Risk factors include those with airway abnormalities like mid-face hypoplasia, skeletal dysplasia, decreased muscle tone, and the same syndromes that come with airway obstruction. Those with airway obstruction, especially your upper airway will have symptoms with sleep and significant exertion or agitation. Noisy breathing might be one of the most significant symptoms reported. Risk factors for lower airway obstruction include those with acquired or congenital thoracic deformities and those who had thoracotomies done in the past. Patients with history of esophageal fistula or atresia because tracheomalacia is a very common comorbidity and patients with vascular abnormalities, syndromes like neurofibromatosis, like in the pictures shown right here. What's the gold standard for diagnosis? High resolution CT because it's highly sensitive in detect early changes of the small airways. You can do 3D reconstructions like right here, a patient with a long segment of complete tracheal rings. Another study they often use is flexible bronchoscopy, starting in the nose and ending in the subsegmental bronchi. We obtain the bronchial lavage that will help with the identification of infections and identifying markers of aspiration. Pulmonologists do medical management of aspiration in terms of control of sialorrhea, optimize airway clearance, use of anti-inflammatory medications for chronic aspiration or inflammation. For patients with ventilatory insufficiency, the role of the pulmonologist is to determine if the child still needs ventilatory support and whether they're ready for decannulation. The pulmonologist also assesses how ready the patient is for weaning from the vent and whether they can start or advance feeding. Finally, pediatric general surgeon Dr. Aaron Garrison explained the role of general surgery with aerodigestive patients. In the NICU, general surgeons obtain feeding access, manage anorectal malformations, and perform surgical procedures such as tracheopexies and lung resections. In summary, the aerodigestive and esophageal center is a multidisciplinary team caring for children with complex digestive and airway diseases. Each team member, whether they are the speech pathologist, ENT, GI, pulmonologist or general surgeon, works in tandem to coordinate care and optimize patient outcomes. Global Cast MD along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe.