Test GPT4o

Moderator: Emily DeBoerSpeakers: Aparna Rao, Matt Abts, Sarah Hofman-DeYoung
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Yes. We’re going to move right into the next session. If anyone wants to stand up and come down closer so you have a better view, you are welcome to move around. Let me just put this on. So I think I have been waiting for this session for how many years is this conference? 11 years. This is one of the reasons we’re in the meetings and we’re seeing the patients because everyone wants to know, do I need to fix that cleft? Do I need to get the swallow study? Do I need to do this? Do I need to do that to prevent bronchiectasis? And I say, I don’t know yet. And I think this morning in the best of poem, it highlighted, are we doing the right studies? Are we doing too much? Are we doing enough? And those questions that we have ongoing. So I’m very pleased to moderate this session on preventing and treating bronchiectasis here in the aerodigestive setting. And I’m joined by Dr. Aparna Rao, who’s Associate Clinical Professor of Pediatrics at UC San Diego School of Medicine, pulmonologist and medical director at the Center for Pediatric Aerodigestive Disorders and Airway Surgery at Rady Children’s Hospital, who’s going to tell us hopefully how to prevent it. And then if it’s happened, Dr. Matt Apps is Clinical Associate Professor of Pediatrics at University of Washington, pulmonologist, medical director of bronchoscopy services, and the co-director of the aerodigestive program at Seattle Children’s. Okay. Thank you. And he’s going to talk about treatment once it’s happened. Aparna, why don’t you come on up? Yes. The screen is shared. Should be good. And we’ll do this. And then that should take care. That way the thing left is… We’re a very well qualified IT person. Well, I don’t know whether I’ll have the answer, but I have some hypothesis which can be applied. So I think this is a great conference. I’m really enjoying myself. One thing we all share is a common vision that we get all children all over the world feeding, growing, and having the least amount of respiratory infection with the least amount of medication. That is a shared vision between all of us. So the question… We are already doing a lot for the lungs, but how do we prevent development of bronchiectasis? What do we… Let’s see. That’s this one, right? Yeah. You can use this thing too. So just click on it. So this is how we prevent it. The pediatric aero digestive team all across the world globe can protect the lungs and prevent bronchiectasis. This is our team and thanks to every individual expertise, we are getting better at it. What is… It’s not… Is this the… Okay. So before… Let’s talk about bronchiectasis first. It is a chronic lung condition which is characterized by productive cough and repeated lung infection and progressive loss of lung function. It is shocking that there are 3 million children all over the world with bronchiectasis compared to the cystic fibrosis population, which is 70,000. Research is increasing in non-CF bronchiectasis, but we have to do more. And as we all know, gold standard for diagnosing bronchiectasis is a high resolution CT scan. So before we talk about development of bronchiectasis, we need to talk about cough. Cough is the most common presenting symptom in a pediatric office. And we think of cough after acute respiratory infection, which is expected cough, and there’s a non-specific cough and a specific cough. This is all a big overlap. body way earlier and not later in life. So we prevented bronchiectasis. So this is one patient that we all work together. The next child is a teenager who’s a 13 year old presented with a wet cough since this is her first clinic visit and eight years of age. Typical history of getting the theme middle ear infections, sinus infections, treatment for asthma not improved. We saw bilateral ear infusion. We could elicit crackles on a clinical exam. The chest X-ray is right there that shows that the one side is probably down on the left and now retrospectively, I can even see bronchiectasis there, but I knew I was not dealing with asthma. So this child had bronchiectasis and we treated her, managed her, which Matt’s going to talk about very effectively. We could not prevent bronchiectasis, but we did not allow her to have a progression and her diagnosis was primary celery dyskinesia. So this is how we as a team work together. So now we talk about aero digestive hemostasis. This is a very collaborative system, just like our teams. We collaborate very well and we need every system well aligned for successful feeding, breathing, and growth. If anything is compromised, the lungs seize it, but lung is a fantastic organ. It compensates very well with minimal symptoms and everybody knows those symptoms. Although our teams are doing a lot, we are all working towards improving the lung health. So it’s a multidisciplinary thought process that is extremely important when we offer surgical intervention, medical intervention, feeding therapies, all of it is done to prevent the, to protect the lung. So when I was digging into literature on bronchiectasis and aero digestive population, this is just a few of it. Every diagnosis that comes to our clinic has potential to develop bronchiectasis. What we don’t know is the exact timeline. What we don’t know is when do we do the imaging? When do we do the same questions? A lot of unanswered questions, which as a team, we could probably get into and improve, but this is, there are a lot of them. So then I was lookingduced us. Butwell. It’s a profound economic cost. So there was a study a couple of years ago from Australia again that showed each hospitalization cost upwards of about $30,000 Australian dollars. I’m not sure what that means. I’m sure it’s way higher here in the US. I don’t even want to know. But really the one big point I want people to take away from this is that we now know that bronchiectasis is very preventable and that’s incredibly important, but it’s also reversible. And there was plenty of evidence out there in the literature as well as in case reports. There was one study that looked at 22 kids with non-CF bronchiectasis and there was 64% of them had some improvement after appropriate management. And there was a 27% of that population improved. This is a patient of ours from Seattle who had, I think this is a patient with congenital heart disease who had some aspiration issues, developed bronchiectasis. We treated the things that needed to be treated. And three years later there’s significant improvements in the degree of bronchiectasis. This is a patient who got hit hard with H flu and adenovirus, was treated accordingly. And you can see just three months later there’s improvement in that bronchiectasis as well. These are before and after pictures. This is a case report in the literature of a patient with a foreign body. So you see some pretty gnarly bronchiectasis on the left there. And then just six months later after foreign body removal, almost complete resolution of that bronchiectasis. So this is a very treatable and reversible disease. So the guidelines talk about the importance of early treatment in children and their recommendation is very straightforward that whenever it’s possible interventions to prevent or reverse bronchiectasis should be undertaken. The goals are to optimize lung growth, to preserve lung function, to optimize quality of life, minimize exacerbations, prevent complications, and if possible reverse that structural lung injury. And that’s kind of based on like a couple important concepts. One is that adults with bronchiectasis have worse disease and poor prognosis, and that up to 80% of adults with bronchiectasis are symptomatic from childhood. So hitting this hard and hitting this early is incredibly important. And within our aerodigestion community, it’s also really important to mention that we want to treat the disease, not the symptom. I know this is very intuitive and everybody knows this, but of course, if bronchiectasis can be treated, right? But if you take care of the things that are causing that bronchiectasis in the first place, whether it be aspiration or whatever, that’s of utmost importance. And that’s what we do a lot of in aerodigestive. So onto the guidelines. I’m going to kind of rapid fire through all of these and then hopefully again, it’ll be a framework for discussion afterwards. But the ERS process was basically to put together a panel of multidisciplinary experts and families to ask clinically relevant questions, to stratify those questions based on importance and to arrange them into like a PICO versus a narrative format. They did a systematic review for each of those questions and then did an assessment of the confidence and quality and strength of each recommendation. So pretty straightforward approach. And I’ll first talk about acute management. The first question is a pretty, I think controversial one within pulmonary is how do you even define an exacerbation? I think that’s like step one. And it turns out it’s really hard to do. And based on these recommendations, really, they mentioned that all you need is cough, respiratory symptoms for three days or more with or without increased speed and production. This is a conditional recommendation, of course, a low quality of evidence, of course. But what the authors do point out is that we shouldn’t really be relying on changes in chest oscultation or X-ray. Obviously, if there’s positive findings, that’s very helpful, but in many cases, oscultation, chest X-rays are negative. We also can’t really rely on systemic symptoms and blood markers. They’re not very specific. And it’s important to mention that there are certain patient populations that we need to pay a little bit of extra attention to. So those who have severe symptoms like dyspnea or hypoxemia are automatically characterized as having a severe exacerbation should be managed accordingly. Those with a high risk primary disease like an immunodeficiency, we should really have a lower threshold for treating a suspicion of a bronchiectatic exacerbation. For those who have developmental delays who really can’t express themselves or can’t articulate their symptoms, we should probably have a low threshold for treating. So if we do diagnose an exacerbation, how do we treat it in regards to antibiotic choices? And the recommendations are very straightforward. So we recommend a systemic course of appropriate antibiotic for 14 days. This is a very strong recommendation, is really the standard of care at this point. In patients with non-CF bronchiectasis who do not have a history of speed and cultures or BAL cultures, we treat empirically and the antibiotic of choice should be Augmentin or Amox clavulanic. And there’s data behind that, which I’ll show you in a second. However, if the patient has had cultures, obviously we want to treat based on those cultures and sensitivities. And again, this is considered the standard of care. The choice of empiric antibiotic is based on really one single high quality randomized control trial that compared Augmentin to Azithromycin to placebo. And the Augmentin was superior to placebo. The Azithromycin did show some improvement, but it did not meet statistical significance for superiority over the placebo. So if you are treating bronchiectasis and exacerbation empirically, please use Augmentin. And then a quick note on eradication. I think this is a little bit controversial as well. And a lot of this comes from the CF literature. Fortunately, in the pediatric world, Pseudomonas aeruginosa is not very common in non-CF bronchiectasis. We see it sometimes. If we do see it, there is a role for eradication. So if you have a patient with non-CF bronchiectasis who grows Pseudomonas on a BAL culture or speed and culture, we should probably try to eradicate. This is again, a conditional recommendation, pretty low quality of evidence, and there’s no pediatric studies to support it. Adult studies do suggest that eradication can improve quality of life, decrease antibiotic use and decrease exacerbation frequency, and has a pretty lasting effect up to about two years. The guidelines themselves have a really nice algorithm for how to do this. So I don’t have the time to go into the details, but every time I have a patient with non-CF bronchiectasis who grows Pseudomonas, I can refer to these guidelines and they give a pretty well-described way of treating both with systemic and inhaled antibiotics. On to chronic management, should we be using airway clearance therapies in non-CF bronchiectasis? The answer is a resounding yes. This is a strong recommendation, again, low quality of evidence, but it’s important that when we do airway clearance that it’s age and developmentally appropriate and that it should be taught by an experienced chest physiotherapist. So in Seattle, we just got some additional FTE and we now have respiratory therapists at our hip for every clinic and every OR day, which has been fantastic. So it’s improved my workflow. Our patients are happier. They’re getting the things they need in a timely fashion. Our therapists can schedule zoom visits. They can see patients in person for vest fittings and coffices trials and things like that. So it’s really important that we target airway clearance therapy to the patient’s needs, to the family’s needs. And I think that’s probably the most important part of this recommendation. I think we all agree that airway clearance can be really helpful. The limited evidence out there suggests that it can improve lung function, quality of life, as well as freedom volume. And the guidelines also have a nice graphic where they kind of talk about all the different types of airway clearance on the Y-axis. On the X-axis is sort of like patient age, so infant to adolescent, and which of those techniques or which of those modalities are best for what age group. So that’s really helpful. Should we use mucoactive agents? I’ve stratified this into two categories. One is sort of mucolytics like Dornase. And the answer to that is absolutely not. There’s no evidence that it helps in non CF bronchiectasis. This is a strong recommendation. And as other talks have noted, it can actually increase exacerbation rates and worsen lung function, and it can be associated with worse events. So please don’t use Dornase in your non CF bronchiectasis.urse, patients who have non-CF bronchiectasis can also have airway hyperactivity and asthma. So in those patients who have TH2 type inflammation, who have documented airway hyperreactivity that’s reversible, we should be using these medications. But if it’s a straightforward patient with non-CF bronchiectasis, we really shouldn’t be using inhaled steroids. There’s really no role for beta-2 agonists either. And there’s a lot of potential side effects. I think Dr. Besch gave a great talk yesterday about some of the potential consequences of inhaled corticosteroids. And I think we under appreciate that. And I think I probably use inhaled steroids more than I should as a clinician. And so this is something I need to kind of think about and probably change my practice on. And then the guidelines go on to talk about a lot of sort of just kind of basic recommendations. So of course, nutrition should be optimized. We should encourage exercise, which is in and of itself a form of airway clearance. Patients should be immunized. It’s important to have psychological and educational support. So when you think about your aero-digestive clinics, do you have social work available? Do you have psychological support available? I think probably most of us don’t. It’s hard to come by, but it’s really important when we think about holistic care for these patients. And then they also talk about surveillance practices, which is a little bit out of the scope of this talk. But they do make recommendations about how often we should be seeing these patients, how often we should be getting sample collections of sputum, doing lung function testing, and then repeating chest CTs and things like that. And that’s really it. So I’ll just leave you with one thought. I’ve taken care of two almost identical patients in the last month or so, one of which lives in Seattle and Laurelhurst.

Work to do. The daughter of Sanjiv is Anika