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Aerodigestive Management of Pediatric Aspiration - FULL SHOW
With Dr. Katherine Hart & Dr. Claudia Schweiger & Dr. Sandra Stinnett & Dr. Hugo Rodríguez · hosted by Dr. Michael Rutter
Chapter 1 of 16 · Fundamentals
Aspiration definition
Defining Pediatric Aspiration and At-Risk Populations
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Chronic pulmonary aspiration is defined as repeated aspiration into the lower airways causing pulmonary injury or chronic respiratory disease, with consequences determined by frequency, magnitude, nature of material, and effectiveness of host defenses.
Four major groups aspirate: premature babies, those with neurologic disabilities, those with airway disease (anatomic, dynamic, or functional), and those with gastrointestinal disorders.
Children with associated obstructive airway symptoms (snoring, retractions, stridor, desaturation) should undergo airway endoscopy to look for anatomic causes of dysphagia.
Video swallow study (VFSS) and functional endoscopic evaluation of swallowing (FEES) are complementary tests that show different things and evaluate different parts of the swallow—it is important to explain to families they are not the same test.
Impedance probe is the best test for gastroesophageal reflux but is not necessarily widely available.
CT scanning is excellent for evaluating long-term consequences of aspiration but shows damage already done (tells about the past, not the present) and requires anesthesia, radiation, and radiologic expertise.
Elevated lipid-laden macrophages are not pathognomonic of aspiration—they can result from natural airway debris (dead neutrophils, macrophages from inflammation) or circulation after bleeding or airway surgery.
Lipid-laden macrophages are a limited tool because aspirated material has variable lipid content (saliva has no lipid), there is variable time between aspiration and BAL sampling affecting lipid metabolism, and individuals have variable rates of lipid catabolism.
Decanulation should not proceed until the child has proven capacity to clear their airway through a prolonged capping trial that includes going through illnesses without needing the tracheostomy for clearance.
Speaking valves help with airway clearance by allowing glottic closure for better cough and creating positive end-expiratory pressure that distends airways, even if they do not decrease aspiration coming in.
CHARGE patients frequently need tracheostomy or interventions for salivary aspiration at young age but often develop compensatory strategies over time and can be decannulated as they mature.
The pulmonologist's role in the aerodigestive team is to protect children from developing irreversible long-term pulmonary sequelae while managing anatomic abnormalities or waiting for maturity.
Medical management of functional aspiration should target five aspects: decrease aspiration events, improve airway clearance, address quality of aspirated material, control inflammation, and treat or prevent infections.
Chronic inflammation from aspiration is managed with inhaled steroids and systemic anti-inflammatory medication (azithromycin, not systemic steroids as first-line), with systemic steroids reserved for acute aspiration events to prevent pneumonitis.
Patients with bronchiectasis from chronic aspiration should receive longer antibiotic courses (10-14 days instead of 7-10 days) because bronchiectatic cavities have more difficult clearance.
Prophylactic inhaled antibiotics (tobramycin or colistimethate, either every other month or 14 days per month) are reserved for patients with severe bronchiectasis and pulmonary injury or significant frequency of infections.
Cuff tubes cannot stop aspiration because inflating the cuff enough to decrease leak causes unacceptable tracheal injury or dilation.
Positive pressure ventilation (CPAP or BiPAP) can decrease aspiration events, especially during sleep in patients with reflux aspiration, even in patients who do not need it for gas exchange or ventilation.
Passy-Muir valves should never be used during sleep because they allow inhalation through the tracheostomy but not exhalation, risking obstruction from mucus accumulation, and they cause over-drying of secretions leading to mucus plugging.
For injection materials, radiance gels dissipate within weeks in animal models and do not work well; Restylane is used as a bridge and fat for longer-term injection.
Reinnervation advantages include single general anesthetic (no awake thyroplasty needed for children), one-and-done if successful, low risk, allows other procedures later, and uses patient's own tissue; disadvantages include lack of long-term pediatric data, 6-9 months to final results, and neck incision.
Reinnervation is a misnomer—it does not restore movement but provides tone and better closure, with outcomes measured by voice and swallowing improvement.
Sensory reinnervation (great auricular nerve to superior laryngeal nerve) can restore sensation and is valuable when the sensory component is the primary deficit, allowing recognition of secretions and swallowing.
Botox for sialorrhea has 90% success rate in the speaker's experience and is first-line treatment.
Laryngotracheal separation guarantees no aspiration but eliminates voice, and attempts to restore voice with speaking valves (Blom-Singer) are not effective in children because the larynx remains in the way—complete laryngectomy with cricopharyngeal myotomy is required for voice restoration.
The Cincinnati laryngotracheal separation technique involves peeling mucosa up subperichondrially within the cricoid, purse-string closure, splitting cricoid laterally at 3 and 9 o'clock, quilting sutures to sandwich cricoid, tisseal in subglottis, and crisscrossing medial heads of SCM over the laryngeal stump—this has eliminated fistula formation and stomal stenosis.
In children, laryngotracheal separation stomas will stenose without a tube until growth stops, so a relatively big, wide, short tube must remain in the tracheal stoma.
Tracheoesophageal fistulas can be surprisingly challenging to find and require high index of suspicion, angled telescopes, probing, and positive pressure breath with endotracheal tube in esophagus to visualize bubbling.
Endoscopic TEF repair is ideal for long skinny tracts (usually recurrent TEFs after congenital repair); the concept is to demucosalize the tract with Bugby cautery to get raw-against-raw, inject filler beside the tract to compress it, and place fibrin glue.
Endoscopic TEF repair has a recognized failure rate and surgeons must be prepared to repeat the procedure multiple times.
Congenital H-type tracheoesophageal fistulas, with very few exceptions, do not do well with endoscopic repairs and typically require open repair.
For H-type TEFs, the upper 2/3 of trachea is accessible through the neck, the lower third is easier through the chest, and the middle third is no-man's land where whoever has better expertise (pediatric surgery or ENT) should do it.
Slide tracheoplasty technique for large or multiply-failed TEFs involves transecting trachea above and below the hole, peeling trachea off esophagus, using the tracheal segment attached to the hole to repair the esophagus, and reconnecting the trachea over the top with a slide technique that oversizes the airway and reduces tension.
For the case of isolated esophagus with multiple TEFs connecting to trachea, leaving the esophagus isolated at both ends prevents aspiration through the holes while the holes prevent mucocele formation by allowing drainage.
Flexible bronchoscopy is not a good tool for evaluating posterior laryngeal clefts—rigid bronchoscopy is required for diagnosis.
The Cincinnati endoscopic cleft repair technique uses laser (KTP or CO2) to remove a wide swath of mucosa on both sides of the cleft, creating raw-against-raw surfaces, then places 2-3 sutures (60 PDS on bent BV1 for babies, 40 PDS on P2 for older children) and releases aryepiglottic folds.
Endoscopic cleft repair has become a fellow-level case in Cincinnati due to the volume performed (at least 20, likely way more).
For long type 4 clefts, the Cincinnati technique involves transecting trachea at cricoid, peeling trachea off esophagus to beyond the cleft, repairing esophagus, placing sternal periosteum interposition graft, reconnecting trachea, and placing tracheostomy 2-3 weeks later after healing.
Almost all children under 4 kg who had type 4 cleft repairs died; waiting until the child is over 5 kg improves outcomes.
The greatest risk with laryngotracheoesophageal clefts is that the distal end of the repair may form a tracheoesophageal fistula.
For severe pharyngeal stenosis, management is a step ladder approach: voice, breathing without trach, no aspiration, swallowing without G-tube—typically cannot achieve all four, usually one or two steps up the ladder, rarely three.
Composite stents (suprastomal stent with silastic sheet wrapped around it supraglottically) are effective for severe pharyngeal stenosis—the stent goes through vocal cords and locks in trachea while the silastic holds open the supraglottic raw areas during re-mucosalization.
Aspiration is defined as any solid or liquid matter passing below the vocal cords, though some define it as requiring pulmonary compromise in addition to passage below the cords.
Aspiration can be silent with no clinical indication, or obvious with coughing, choking, and sputtering.
Children with CHARGE syndrome have 80 to 90% prevalence of aspiration at some point in their lifetime and should be assumed to aspirate until proven otherwise.
Children with severe neurologic compromise regardless of etiology should be assumed to aspirate until demonstrated otherwise.
The clinical significance of aspiration depends on the quantity—small isolated events are usually cleared by host defenses (cough, mucociliary transport), while large or repeated events overcome host defenses.
A single aspiration event of caustic substance can have lifelong consequences.
Syndromes with significant swallowing dysfunction include CHARGE, Cri-du-chat, Möbius syndrome (cranial nerve abnormalities), and craniofacial defects like Pfeiffer, Crouzon, and Treacher Collins.
Dysphagia can occur in any of the four swallowing phases (oral preparatory, oral transit, pharyngeal, esophageal) and can result in aspiration or retrograde flow into the nasal cavity.
Children who aspirate may present with breathing difficulties during feeding (increased respiratory rate, bradycardia, tachycardia, cyanosis, apnea, desaturation), coughing/choking during or after swallowing, frequent congestion after meals, noisy or wet vocal quality, prolonged meal times, food refusal, or vomiting.
A radionucleotide spit scan (placing radioactive tracer on tongue) can test for saliva aspiration but involves radiation and is a one-off window in time.
Medication for reflux generally stops acid but does not stop reflux events.
Lipid-laden macrophages are the most commonly used aspiration biomarker, with a lipid-laden macrophage index >90 or >20% of macrophages containing lipid suggesting aspiration.
Having a tracheostomy tube changes the dynamics of laryngeal elevation but most studies show it does not create aspiration.
For airway clearance, comorbidities that compromise clearance include tracheobronchomalacia, airway compression/stenosis/hypoplasia, restrictive lung disease (neuromuscular, chest wall deformities, scoliosis), and vocal cord or diaphragmatic dysfunction/paralysis from esophageal or cardiac surgery.
Temporary laryngeal injection is a useful test-drive procedure before permanent medialization, can be repeated, and serves as a bridge between more permanent operations.
Early injection (1-3 months after recurrent nerve injury) may lead to less need for permanent procedures based on adult literature, though pediatric data is limited.
Reinnervation (ansa-to-recurrent laryngeal nerve) is not a new concept but has gained popularity in the last few years; ideal candidates are <40 years old, within 1-2 years of injury, with known injury location.
Bilateral submandibular gland excision and bilateral parotid duct ligation (drool procedure) has 60-100% success rate in the literature.