QUAD #16 - Flexible Bronchoscopy in Management of Slide Tracheoplasty Patients - Sara Zak

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi, everyone. I'm M Gody from Cincinnati Children's Hospital Medical Center. In October 2022, Cincinnati Children's hosted the Quad conference, which was a combination of four conferences: The International Organization for Esophageal Atresia, the Aero Digestive Society conference, the Cincinnati Children's Airway course, and the Cincinnati Children's Pediatric Dysphasia series. And in this video, we're going to hear from Dr. Sarah Zack, a pulmonologist at Cincinnati Children's, on utilization of flexible bronchoscopy in management of slide tracheoplasty patients. At our institution, we do the majority of the flexible bronchoscopy by far, and I recognize that this is not necessarily true in other places. Dr. Zack mentions that there is really no standard practice for how to incorporate flexible bronchoscopy into these big airway procedures. And so, I think as a pulmonologist that a flexible bronchoscopy is indicated at every point in the patient care and for slide tracheoplasty. And so, we'll try to go through indications both preoperatively, intraoperatively, and postoperatively based on how we practice here in Cincinnati. Preoperative evaluation is about the airway anatomy and dynamics, understanding what needs to happen to plan for repair, and making sure that everything is aligning clinically for the best results of the repair. We know that infection can increase your risk for dehiscence complications postoperatively, and so we always obtain a BAL preoperatively. We can treat an active infection if you have time to delay the procedure slightly. And this also can help providers select their perioperative antibiotic therapy as we're opening the chest and taking care of this patient in the ICU. We can also make sure that there's no other lesions present that need to be addressed. And the video here that I'm going to show is a little 11-month-old with Trisomy 21 and complete tracheal rings who got transferred to us for consideration of repair. He had a history of multiple failed extubations in the setting of respiratory illnesses, primarily due to the stridor and increased work of breathing, which progressed to hypoxemic respiratory failure. When he arrived to us, he had a 3.5 mm endotracheal tube in place. We took him to the OR, and this is us going through the nose. You can see he's got very large tonsils here. He's got a lot of pharyngomalacia. And as you get closer to his larynx, his epiglottis curls in on itself with inspiration. As you slide underneath there, his arytenoids are big, they're bulky, they're obstructive. And what's not included in this video is the strider that you hear during the exam. He still did have complete tracheal rings. So we made the decision to proceed with supraglottoplasty and adeno-tonsillectomy in this patient before a slide tracheoplasty. He had a fair amount of improvement, but his stenosis had worsened, and ultimately did undergo a slide tracheoplasty. Intraoperatively, I think there's several indications for bronchoscopy as well. First, we can help intubate and sure the tube is in the correct position. Some of these kids have complex congenital issues that may make exposure difficult, that may make getting a tube through the mouth a little bit more challenging. We can also make sure that tube is in the right position with relation to any airway lesions. You can help remove any secretions that have built up or at the beginning of the procedure prior to their most recent evaluation. And that can really help visualize the airway from the inside with relation to the outside. We can also help to remove any secretions, blood clots, mucus plugging that's built up throughout the case, especially as we're preparing to to have the patient come off of cardiopulmonary bypass and be transported to the ICU. According to Dr. Zack, they can assess the anastomotic site without putting any tension on the trachea at the end of the procedure, either with the chest still open or with the chest closed. We can look for figure eight deformities that may have occurred as a result of this surgery. We can look for any leaks. We can make sure that tube is in the right position as they're getting ready to go to the ICU with relationship to the repair. ENT surgeons at Cincinnati Children's have a pulmonology team join in pretty much every postop evaluation down in the operating room. There can certainly be some life-threatening complications from these procedures, and if you're certainly concerned about anything, we can quickly get a cart up to the ICU without having to move the patient, so can get a good look at that repair site. Let's ask the pulmonologist that are part of the team, what patients are they doing bronchoscopies on postoperatively? It's the little kids, the kids with heart disease, the kids that have been on bypass, the kids that have had prior airway surgeries, but nothing's really published about this. Dr. Zack tells us that she has been working on trying to see if there are risk factors that can predict who's going to need an urgent bronchoscopy postoperatively. So, I have done a retrospective chart review of patients under 20 years of age that underwent slide tracheoplasty between January of 2010 and the end of September of 2021 here in Cincinnati, to see if there are any common themes. There were 135 thoracic slide tracheoplasties done in Cincinnati in this time period. Several patients had cervical slides or bronchial slides at the time of their thoracic slide. The most common indication for slide tracheoplasty was complete tracheal rings, followed by acquired or congenital tracheal stenosis and tracheoesophageal fistula. They found that about 60% of these patients were male. The mean age at the time of their slide was just about two and a half years of age. And the majority of them were done on cardiopulmonary bypass. Most commonly seen associated conditions were congenital heart disease, including things like ASD, VSD, PA slings, and other congenital lesions. 21% of these patients had a preoperative tracheostomy, and 28% had a prior airway surgery that did not include cricotracheal. Just over a third of them had another underlying genetic condition, like Trisomy 21, Charge Syndrome, or Vectral or Vader. And just about a third of them were premature. At the time of the slide tracheoplasty, half of them did not need any respiratory support, and then ranged all the way from just some low flow nasal cannula all the way to the ECMO support. 38 of our 135 patients required at least one urgent postop flex bronk. The mean postop day was day three, most commonly on day one. The children that required a bronchoscopy was just under a year of age, ranging anywhere from two days of age all the way to eight years old. And the bronchoscopy group was about two and a half years of age, ranging from two weeks to 20 years of age. And when you compare those two groups in those variables, both of them were statistically significant. And in this data set, no patient older than eight required an urgent postop flex bronk. Looking at other associated conditions for these patients with relation to the group that required a bronchoscopy and the group that didn't, the ones that stand out are the presence of congenital heart disease, respiratory support at the time of their procedure, specifically the need for positive pressure ventilation, whether that's invasive or non-invasive, and then a history of prior airway surgery. I don't think that's a surprise. The kids that are smaller, that are sicker and that have already had something done to them are more likely to have complications postoperatively. But why does this matter? It can help understand the risks and the complications prior to surgery, so you can make sure that you have the right team in place to be able to take care of these kids. You can counsel families on what to expect postoperatively, but also, if we understand who's at higher risk, can we do things about that in the future? Can we change our preoperative management? Can we change what we do intraoperatively? And so, I hope that I've convinced you that flexible bronchoscopy is indicated at all stages of patient care during a slide. I think really the most important thing is having somebody that knows what they're doing with the scope, knows what they're looking at, and knows how to handle any complications that may come up. The big key is really having the right team in place to be able to take care of these kids. In summary, flexible bronchoscopy helps understand airway anatomy, plan repairs, identify and treat infections, and ensure that no other lesions need attention. It also aids in proper tube placement, visualizes the airway, removes secretions, and assesses the anastomotic site for deformities or leaks. Regular bronchoscopy checks for complications in high-risk patients, ensures timely intervention. Patients with congenital heart disease requiring respiratory support or with prior airway surgeries are more likely to need urgent post-operative bronchoscopy. Dr. Zack's retrospective study showed younger, sicker patients and those with prior interventions have higher complication rates, highlighting the need for specialized care teams. Thank you for watching this video. Don't forget to subscribe to the State Current MD YouTube channel. Follow our social media channels and download the State Current MD app for tons of content in pediatric surgery. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.