R. Paul Boesch

Foreign body aspiration: An important etiology of respiratory symptoms in children

Allergists and pulmonologists are commonly confronted with patients who have symptoms of chronic cough, wheeze, and dyspnea. Most of these children are diagnosed with asthma and successfully treated with asthma medications. A subset of these patients, however, does not respond as expected to standard asthma therapy and presents a diagnostic challenge. The possibility of foreign body aspiration should be considered in any child who presents with these symptoms.

Slide tracheoplasty for the treatment of tracheoesophogeal fistulas

PURPOSE The purpose of this study is to determine the surgical outcome of slide tracheoplasty for the treatment of tracheoesophageal (TE) fistula in pediatric patients. METHODS After internal review board approval, the charts of pediatric patients (0-18years old) who had undergone slide tracheoplasty for tracheoesophageal fistula were retrospectively reviewed. Patient information and surgical outcomes were reviewed. RESULTS Nine patients underwent slide tracheoplasty for correction of TE fistula. In five patients the original TE fistula was congenital. Other causes included battery ingestion, tracheostomy tube complications, foreign body erosion, and an iatrogenic injury. The average age at repair was 48±64 months (range: 1-190). Seven patients had undergone previous TEF repair either open or endoscopically. There were no recurrences after repair. Two patients had sternal periosteum interposed between the esophagus and trachea. There were no TEF recurrences. A single patient had dehiscence of the tracheal anastomosis and underwent a second procedure. CONCLUSION Slide tracheoplasty is an effective method to treat complex TE fistulas. The procedure was not associated with any recurrences. This is the first description of a novel, effective, and safe method to treat TE fistulas.

Structure and functions of pediatric aerodigestive programs: A consensus statement

We present a multi-disciplinary consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients.

The Multidisciplinary Approach to Pediatric Aerodigestive Disorders

Multidisciplinary programs for the care of children with upper and lower respiratory and gastrointestinal tract disorders have emerged across the United States and become known as aerodigestive centers. This model is designed to improve clinical outcomes and healthcare value through a coordinated approach by a team that appreciates the inter-relatedness of these disorders. The primary elements include: (1) Interdisciplinary medical and surgical team, (2) Care coordination, (3) Team meeting, and (4) Combined endoscopic procedures. This article will describe the origin and current trends in the multidisciplinary approach to pediatric aerodigestive disorders.

Management of traumatic tracheobronchial separation in a teenager using a fabricated extra-long endotracheal tube

Tracheobronchial separation (TBS) due to blunt chest trauma in children is extremely rare. We report the case of a 14-year-old boy who fell 20 feet and developed respiratory distress, bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema. Computed tomography imaging at the initial institution failed to detect tracheobronchial disruption, and the patient was managed conservatively. The patients worsening condition prompted bronchoscopic examination which revealed complete separation of the right main bronchus from the trachea. Single-lung ventilation was instituted using a fabricated extra-long nasotracheal tube due to the patients large size and mandibular fracture, and the airway was primarily anastamosed with an open thoracotomy approach. The clinical features of tracheobronchial separation as well as anesthetic, clinical and surgical management of this rare but life-threatening injury are described.

Three-dimensional printed models in multidisciplinary planning of complex tracheal reconstruction

Three‐dimensional printed models are increasingly used in medicine and surgery, but applications of these models in the planning of operative procedures is not well described. In particular, their benefits have not been documented in complex, multiservice, high‐risk operations. We describe five cases of complex pediatric tracheal reconstruction for which three‐dimensional models had specific benefits in planning as well as in education of trainees, operating room staff, and patient families. We also describe our method for producing models so that others can adopt the technology if desired. Laryngoscope, 127:967–970, 2017

Respiratory Complications of Maxillofacial and Otolaryngologic Disorders

Congenital and acquired disorders affecting the upper airways are common in children. Their effect on breathing varies, but in general it consists of inspiratory or expiratory airflow limitation or impairment in lung protection from inhaled or aspirated material. The limitation to airflow can be anatomic (e.g., choanal atresia) or functional (e.g., vocal cord dysfunction). Obstruction above the thoracic inlet may be congenital or acquired in etiology. Airway obstruction below the thoracic inlet may cause expiratory obstruction only (dynamic lesions) or biphasic obstruction and stridor (fixed lesions). The following chapter reviews the pathophysiology of the upper airway obstruction as well as specific anatomic and functional disorders affecting the upper airways.

Outcome measures for pediatric laryngotracheal reconstruction: International consensus statement: Pediatric Airway Outcomes Consensus

Develop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies.

Indirect management of full-thickness tracheal erosion in a complex pediatric patient

Prolonged tracheostomy dependence in pediatric patients can be associated with significant complications, including damage to the tracheal wall requiring reconstruction. We present a case of an 8 year-old female with full-thickness tracheal erosion secondary to the presence of a tracheostomy tube combined with a narrow thoracic inlet. A direct tracheal reconstruction was considered but eliminated due to the poor tissue quality of the trachea. Instead, a multi-disciplinary surgical team conceived of a novel indirect approach to manage the patients tracheal defect. To our knowledge the use of indirect repair of a full-thickness tracheal defect has not been reported in the literature.

Interdisciplinary aerodigestive care model improves risk, cost, and efficiency

OBJECTIVE This study sought to evaluate the impact of an interdisciplinary care model for pediatric aerodigestive patients in terms of efficiency, risk exposure, and cost. METHODS Patients meeting a standard clinical inclusion definition were studied before and after implementation of the aerodigestive program. RESULTS Aerodigestive patients seen in the interdisciplinary clinic structure achieved a reduction in time to diagnosis (6 vs 150 days) with fewer required specialist consultations (5 vs 11) as compared to those seen in the same institution prior. Post-implementation patients also experienced a significant reduction in risk, with fewer radiation exposures (2 vs 4) and fewer anesthetic episodes (1 vs 2). Total cost associated with the diagnostic evaluation was significantly reduced from a median of