2024-03-20 08 Keynote Mike Rutter Pre- and Post-operative Airway Management in a Team Setting

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Plenary Lecture 1: Mike Rutter: Pre- and Post-operative Airway Management in a Team Setting

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>> . . a . Cotton in Cincinnati in 1999. And this was designed to meet the needs of increasingly complex children. And it’s now expanded to include children with quite a variety of different problems, not just strictly airway stenosis, which is how it started. And so we are interested in children with sleep problems, aspiration problems, tracheomalacia, esophageal disease. And there are a lot of aero-digestive centers in America and around the world, and each is its own individual with its particular different specialties and different areas of interest. So there are some aero teams that are really concentrating on neuromuscular problems in children. There are some aero teams that are concentrating on sleep problems. And again, you work to the best abilities of your own team and your own environment. There’s not one size that fits all. So this is pre-pandemic. Back when we actually met in person, we now do a blend where half of it’s online and half of it is in person. This is a really peculiar microphone. Anyway, let’s ignore that. And so let’s talk about evaluation. And so this is the pre-op bit. And if you’re planning any sort of significant airway surgery, whether it’s for stenosis or for aspiration that’s anatomical, like a cleft or a fistula, or for functional, such as a drool procedure or a laryngotracheal separation, you basically want your patient optimized. And over the years, the things that we’ve learned that predict poor outcomes, uncontrolled reflux, eosinophilic esophagitis, infection, inflammation. And so this really is the pre-operative evaluation, collaboration, optimization. Get the patient as good as you can get them before you operate on them. And this is really the birth of the triple scope or extended beyond that, depending on the team players you actually need to involve. And team is a wide-ranging concept. So this can include anesthesia, pediatric surgery, cardiothoracic surgery, intensive care, radiology. Again, it’s a broad term, although most aero teams are driven by a core of ENT pulmonary and GI. And so what do we do? I mean, ENT, we have a bit of a look around. Pulmonology is interested in dynamics. They’re interested in whether a broncoalveolar lavage will show any suspicion of either infection or aspiration. And EGD, we’re looking at biopsies and risks of reflux or eosinophilic esophagitis. Pediatric surgery, optimizing reflux management, for an example. And so we look around. I’m gonna go through this fast because I know this bit is boring you and other people have spoken on all of this. We size an airway. There’s a lot of different grading scales and they all have pros and cons. This is the Meyer Cotton Grading Scale, which is relatively unsophisticated but actually still useful partly because of that. Flexible bronchoscopy is wonderful looking at dynamics. It can go places that rigid scopes cannot go and it’s useful for getting samples from the alveoli and bronchial tree. Esophagoscopy, this is a picture of eosinophilic esophagitis. This is a child with bad reflux and this is the child refluxing with what their trachea looked like because of microaspiration, presumably at night. Eosinophilic esophagitis, white dots, furrows, trachealization. Again, this is being covered by others and I’m not going to dwell on this. But this is a very old photo and this is the same child on the left with eosinophilic esophagitis, on the right after it was medically managed. You can see that operating on the child after management surely is going to give you a better outcome. The active larynx is sort of the new kid on the block. So you can have an active larynx from reflux. You can have an active larynx from eosinophilic esophagitis. You can have an active larynx that’s idiopathic and this is becoming the more common thing we’re now seeing. Half of these children respond as azithromycin, which means we’ve got at least two different causes. We just don’t know what they are. MRSA, we pre-screen and over 50% of children with a trait that we’re operating on are MRSA positive if you check and if it gets into your graft or it gets into your anastomosis, the risk that things go wrong is significant. That’s why it’s worth checking. Aspiration assessment, if they’re aspirating ahead of time, they’re gonna aspirate worse afterwards and that’s why it’s worth evaluating. And again, what we’ve learned, we check for MRSA, we check for pseudomonas, we treat it if they have it before we operate. We look at the causes of an active larynx, we talked about that. And then we get the team together to operate. So I’m gonna take you through five quick cases. So here’s a four-year-old girl. She’s referred with a recurrent tracheoasophageal fistula. She’s had several endoscopic repairs and an open repair. She gets reconstructed as a revision open repair. The comment was, despite a latissimus dorsi flap, the esophagus was impossible to mobilize and she’s sent to us with a an out-pouching from a esophagus, leaking into a mediastinum, aspirating with a chest tube that’s actively draining and needing high-flow oxygen. So she’s not all that stable. Our initial scopes, again, it’s a triple scope. So the flex bronc shows the TEF. You go down with an EGD and you just hit a wall of suture material. You can’t work out where the lumen is. You can get into the chest cavity. That’s not helpful. So going from below up through the G-tube, you can actually work out where the connection is and actually get up to the pharynx. We placed a temporary esophageal stent. So again, this is Phil Putnam. This is a part of a team approach. She gets healthy. Her out-pouching of her esophagus, this chest strain stops draining. We take it out. She no longer has a mediastinal collection. We replace the stent every few weeks. The TEF doesn’t go away. We take out the stent and she gets COVID. Thank you. And so we have to wait a month. She comes back. Severe stenosis. The bigger hole at the top doesn’t go anywhere. The little hole at the bottom goes to her esophagus. And what are we gonna do? She’s still got a TEF. She’s got a severe esophageal structure. She’s two thoracotomies in. The last comment was, “Esophagus impossible to mobilize.” And so this is where a team builds value. And so we decided that ENT, pediatric surgery, pulmonology, GI would combine to do something non-routine. So we did a trans-ternal, trans-tracheal approach to the esophagus. So you get fantastic exposure of the esophagus and we can repair the TEF at the same time, resect that bit of esophagus and really mobilize it through a virgin road. We took a tibial periosteal graft as an interposition graft. We’ve got ECMO on standby, but didn’t need it. And so what you’re seeing here is you’ve got, how does this thing, I’m not gonna do the pointer. On the left, you’ve got one loop around the innominate artery, one loop around the innominate vein. At the bottom, you can see we’ve entered the trachea. How do you know where to enter the trachea? You stick a needle in it while pulmonary shows you where you are. We’re right beside the TEF, so we know where to transect. And as you can see on the left, we’ve got one endotracheal tubular trachea and the other endotracheal tubular esophagus because I can inflate the cuff and move it up and down and I know exactly where I am. And so we’ve transected the trachea on the left, intubated that one and a half centimeter distal trachea, and now we’re starting to mobilize the esophagus ’cause we’ve got fantastic access to the esophagus through this approach. And this is me cleaning up the esophagus and then I hand over to our pediatric surgeon, Aaron Garrison, and say, Aaron, could you just sew that together for me? And so Aaron then goes, and you can see we can really mobilize that. So we’re sewing together the esophagus. We’re gonna put in the interposition graft. There’s the interposition graft. The trachea looks like it’s miles apart. But you just keep pulling and it sorta comes together. And we’re doing a slight tracheoplasty over a very short segment of trachea because it gives you a more oblique, less tension suture line. And then we intubate from above. I’m just gonna move on in the interest of time. So extubated the next day. This is an esophogram a week later followed by a bronc the day after. Trachea looks a little funky but it’s fine. And you can see how short a bit of trachea she was intubated into. And that’s her 10 days later. So that’s what you want. And she’s actually done very well. Her esophagus will never be perfect. She’s an EA kid. But it’s pretty good. So let’s take you on to case two. Here’s a little girl, EA, TEF, repaired at birth, unrepaired type 3 cleft. Went home, no G-tube, no trachea, unrepaired type 3 cleft, very motivated mother. And around nine months she’s running into trouble. She’s having apnea spells, choking spells, stridor, apnea, cyanosis, something’s gotta be done. They try and repair her cleft. Doesn’t work. They try again. Doesn’t work. Sent to us, intubated for two weeks. This is her on transfer. And when you look left is flexible, right is rigid. She’s got a TEF pouch that’s really high. She’s got a tracheal bronchus. She’s got distal malacia going down her left main. And a cleft. So she’s got repaired EA. She’s got a cleft. She’s got a pouch. She’s got a pig. She’s got tracheal malacia, left bronchial compression, and a nominant artery compression. So where do you start? This is her sagittal CT scan, and that’s showing that her nominate is pretty much in her neck. So we did a thoroscopic posterior trachea paxi. And that worked really well for the lower trachea, but they couldn’t get high enough to do an aorta paxi or to do sutures up in the neck of the posterior trachea. So she’s extubated. She gets reincubated. And she looks pretty malasic up in her neck, right where her nominate artery is. So what next? If her nominate artery is in her neck, why not fix it through her neck? So we did a thymectomy through her neck, and the whole key to any sort of vascular paxi is giving it room to move. So if you’ve got a kid with DeGeorge, this never works well ’cause they don’t have a thymus. So this is take, you know, back of her sternum, some stitches through the wall of her artery. You’re trying not to go through the artery, by the way. And then you just sort of pax it up. And in the interest of time, I’m gonna blow through this. We marsupialized her pouch and passing as well. That also tightens up the back wall a bit. And we extubate her, and she ends up reincubated because her type III cleft one side overgrew. And on the right, you know, we’ve done well with her compression but she’s failing at laryngeal level because when she breathes hard, her flat flips in. So we had to do a type III cleft repair on her endoscopically. Then we could send her home. And this is her two years later, no airway symptoms, never had a trach, never had a G-tube. And she’s cute, she’s a really cute kid. And this is her 10 days ago in my clinic ’cause she needs her tonsils out. So we’ll go on to case III, a long cleft. I’m not gonna go into the details of this, but you need a team to look after a long cleft. So this is a cleft. As clefts go, it’s quite a bad cleft. Right bronchus. Esophagus. Left upper lobe bronchus. If that’s the left upper lobe, this is a cleft at the end of the left bronchus. Somewhere there’s gotta be a left lower lobe bronchus. And that’s her left lower lobe bronchus. So, you know, as clefts go, that’s a bad one. And this is where, you know, without Dan Benschguler, Sarah Zach, Catherine Hart, Phil Putnam, this is the team you’ve gotta keep these kids alive with. And we grew her for three months. We found that if you repair these kids small, they die. All the type IVs we’ve repaired under four kilos, 100% mortality rate. If we can get them over four and a half to five kilos, we’re about a 60% survival rate. It’s not fabulous, but it beats what we used to do. And so this is her after repair, very high trach. It’s not a perfect outcome, but it’s not bad. She went home not ventilated with an intact trachea. And again, I’m mainly putting up these cases ’cause these are cute kids. I mean, you gotta have cute kid photos in these talks. So, TEF, another cleft, 14 year old girl. She’s had lots of things done. Did I show you all of those? Five TEF repairs, a type III cleft repair times two. Lots of ways it was done. Has a T tube. Anesthetically, you need your anesthetist involved. This girl’s chronically aspirated long enough. She goes into ST depression within five minutes of an anesthetic if you’re not very, very careful. She’s got cyclic vomiting. You don’t want that to happen when you’re about to repair her trach here. So we had Phil Putnam, our GI, give her a mipramine and get that into a window. We timed our surgery to give us the maximal window so she wouldn’t go through a cyclic vomiting run. This is when we initially evaluated her. She’s got a T tube and gotta take it out. Now, as you know, many TEFs are really quite hard to find. So you’ve gotta look very carefully and see if you can locate where it is. And you sort of think, did I really see what I just saw? And you come back in and you think, you know, I think I’m gonna be able to find this. That’s a five centimeter TEF. And so I won’t go into the details of the repair in terms of time, but basically this is using trachea to repair esophagus. You can see the bougie. And because the trachea’s now a little way apart, you sort of think, how the hell is that ever gonna get back together? And the answer is, if you just pull very, very hard, good things happen. So esophogoscopy at one month. I’m just putting this in here ’cause it’s sort of cool ’cause you can see trachea is involved in the wall of her esophagus repairing it. That’s trachea on the right we just passed. And this is her back home in Sweden four months later. And she’s got a bit of a short trachea, but who cares? So this is the final case. We’ve only just got enough time to go through this. Buccopharyngeal membranes are difficult. It’s basically your oral cavity’s not connected to your pharynx. It’s difficult to fix. (audience member speaking faintly) (audience member speaking faintly) I’m doing a feast. The bubbles at the bottom of the hole from the mouth through the buccopharyngeal membrane. He’s not trached. We decannulated him eight years ago and he probably got lost to follow up. He gets the occasional pneumonia. He’s not on oxygen. He drinks a lot of milk. He eats a bag of chips a day. He eats a lot of goldfish. He likes goldfish. This is with him swallowing. This is the longest video you will ever see me put up at a conference. This is like nearly five minutes long, but it’s just so frighteningly disgusting. I really wanna go through this. And so this does not fall within the category known as normal. On the sort of just to the top left of the larynx, you can see his esophagus just bubbles every now and again. He’s got a little residue for the speech pathologists out there. Not normal. I initially tried to give him some goldfish. Oh yeah, isn’t that glorious? Yeah, that’s just, that’s just, oh. For those who’ve just had lunch, you really need to look at this closely. I tried to give him goldfish at this point, but none would go through because the telescope blocked his buccopharyngeal membrane hole. So we backed it out and then we started to pour the goldfish in. And again, in the interest of time, I’m gonna move forward. You can see the goldfish coming through here, it’s cool. You can see them sort of swimming down. And needless to say, they don’t look any prettier at laryngeal level, but I’m gonna move forward. So this is time to get interactive. I wanna show her hands. Who thinks this is a safe swallow? Okay, not difficult to count. Who thinks he should not be eating or drinking? Remember, he’s drinking a can of soup a day, tomato soup. He’s drinking a lot of milk. He’s eating a bag of chips a day. He eats a lot of goldfish. He does have a G-tube. He’s got a tracheocutaneous fistula. So who thinks he should not be eating? You all think he should be eating. Oh, this is fabulous. Is there any way he could eat or drink? So this is deliberately provocative because there are times you’ve got to take a step back and think. So is there any more information you would like? The Flexsprunk actually doesn’t look much worse than the last time, eight years earlier. CT scan, doesn’t look a hell of a lot worse than it did eight years ago. Here’s the key. What does the patient want? He’s an opinionated dude. He does not want to strike back. He strongly wants to keep eating and drinking. So what are we gonna do? So this is very recent, this is like a week ago. And so we’re going to have a family conference with him, couldn’t do it post anesthetic. And my proposal is that when he’s eating and drinking, he slides a little trach tube into his trachea cutaneous fistula, ’cause it’s big enough, and he puts a Passy Muir valve on it for when he’s drinking. And this won’t be perfect, but it might be enough. And we’ll keep an eye on him rather more than waiting eight more years. And so let’s wind this up. Preoperative evaluation and optimization. Think first, operate second. This is something I tell our incoming fellows. The first year of your fellowship, you’re gonna learn to operate. The second year of your fellowship, you’re going to learn to think. This is all about risk, evaluation, and mitigation. You do need to have an arsenal of tools at your disposal. You need to choose the right operation. But having a team around you and appreciating that team care does not stop at the operation. And this is a team sport. Diagnosis and management. Collaboration built on mutual respect. Patient-focused problem solving. It’s not who should do what. It is who can do the best for this individual patient. And that’s where a team builds value. You know, I can repair a TEF. Our CT surgeons can. We sometimes work with cardiothoracic for that. It’s who’s gonna do the best job for the patient. And advice. If you’re building in a team, an effective aerodigestive team should be greater than the sum of its component parts. The keys to success are mutual respect, do not be possessive, be accommodating, and make your team members feel valued. And so here’s team building yesterday in Valparaiso. Now, this does not need to include alcohol, but it clearly helps. And yes, it does look like Catherine has a cactus growing out of her head. So again, interactive question to the audience. Who here doesn’t think that Catherine’s got a cactus growing out of her head? Well, you’re wrong. She’s got a cactus growing out of her head. So thank you very much. One second, perfect. Yes! (audience applauding) [APPLAUSE] (audience