2024-03-20 13 Panel 9 Aerodigestive Clinical Case Presentations and Closing

>> So this is the panel. Andres, please, can you come up? We don’t have — okay. This is the panel. We’re going to go very fast because we only have 27 minutes left. So maybe we’ll leave one case behind. So we’re going to present some cases and we want you to participate. So we usually tell everybody to put your phones down, but this time we want you to take out your phones and scan that QR code so you can participate in the panel with us. We’re done? Okay. We’ll move on. So we are going to leave this first case behind because we won’t be able to do that. We’ll go for the next one. And this next one will be presented by Kimberly. You want to present from there? Okay. You’re going to come here? Okay. Come here. No, we won’t be able to make both. >> We’ll just do this one. Sounds good. >> I’ll stay here because I have to do the whole thing. >> Of course. Okay. There we go. Perfect. Okay. So we’re going to go briefly over this patient. This is a patient who was born in Saipan and was a preemie, 31 weeks, Noonan syndrome, had an ASD and severe laryngomalasia. Ended up needing intubation for a while and then eventually a tracheostomy when we could not decannulate, eventually needing a G tube as well. And then was discharged at six months of age on a ventilator and needed to go to a pediatric nursing facility. We saw that patient in our aerodigestive outpatient clinic at six and a half months of age. Okay. So before we get into management of this patient, what else would you like to know about this case? >> It’s a free word. You can type in whatever you would like to know. What else would you like to know about the case? >> Okay. Are we good? Okay. Yes. >> So we have a question that — something that repeats. And that’s probably a question by pulmonologists. They want to know about the vent settings. Why would this be important, Dr. Peixoto? Why would the ventilation settings the patient is in would be important in this case? >> The most important in this case is investigating symptoms about wheezing, cough, chronic wet. How can I say this in English? Sorry. We need to do exam. So such as CT, scan. >> So in regards to how the patient was feeding, we were not doing any oral feeding at the time. We were not able to do any use of a speaking valve, swallowing valve, one-way valve, all the things that we’ve described over this conference because of secretion management and because of upper airway access. Remember that’s why he ended up needing a trach was because of his severe laryngomal aesia. We were doing just some conservative tastes but mostly secretion management. As far as his vent settings, he was on pretty — I don’t remember the exact specifics of that, but pretty conservative vent settings and not a lot of lung disease. It was mostly from being premature but improving over time. There was no failure to thrive. He was growing okay and we were able to have him on bolus feeds as well. So if you want to go ahead and answer, what would the goals of the aerodigestive team and children with tracheostomies be? When you approach these patients, where do you start? If you have a patient on a vent and feeding and I’ll let you go ahead and ask. Decannulation, yep. People are shy. Good. Looks like informing the family, making sure we get what their family goals are, figuring out what a safe airway would be. So we’re looking at airway management, weaning the vent and the question is what do you start with? Does anyone from the panel have any input? Where would you start with this patient? I think that it is important to analyze the safe of the airway mainly for the good attention of the whole team, yes, and in the future in the family. And maybe to analyze the possibility in, I don’t know this is a conflict question, but I think that the speaking is possible in includes in a very low children. Speaking about? Yes, speaking about. Sure. Yes, go ahead. Two words, burden of care. Burden of care. We can do so many things and all that words there that I think an AD team with checkers to me everything involves in burden of care. And in that realm, I’d like to know what is the family’s wish? What is their goal of care right now? And that honestly is one of the biggest things, right, as we talk of burdens of care and being partners in care with the family. And so for this family who is from Saipan, they want to take their kid home. They can’t even have their kid living with them right now. They’re visiting every day. And so trying to figure out what are the first steps that we’re going to do to get the patient thriving. And he was beginning to, but then quality of life and quality of life for the family to go back to their home. And so as an air digestive team, we looked, oh, we’re getting more. Yeah, we’re getting more answers. Perfect. So it’s not only decannulation, which is the most frequent answer, but also feeding. That’s what we do at the air digestive team, right? Safe feeding, decannulation, and to lower the burden of care for the family and for the patient. So, yeah, it wasn’t letting me go before. You have to get there. To here? Oh, actually. Yeah. Okay. That’s fine. Perfect. Okay. So as a TRAC/AS arrow team, we were looking at, we want to make sure that we ensure all potential candidates that are going to be able to ensure all potential candidates that are being identified for a speaking valve or swelling valve, one-way valve. This patient was not a candidate. Couldn’t, even in line with the event, his upper airway access was not able to be able to exhale through his upper airway. So we tried that, but we then targeted vent weaning. We tried to make sure, we really want to make sure that we’re optimizing the pulmonary health. So we targeted secretion management and then making sure that we can progress feeding and swallowing skills. For this patient, it really was targeting vent weaning because from a burden of care standpoint, that’s the biggest thing. So what are the steps that are needed to get that patient home? Do we know why he was in ventilation? From just being premature, bronchopulmonary dysplasia. But again, it was on really low vent settings and we were able to wean the vent pretty quickly and that’s what we targeted first. I mean, this kid is a Noonan and generally I don’t trust Noonans and a lot of them are pulmonary hypertension, a lot of them have underlying cardiovascular disease and sometimes it’s better to just have a trach. And that was the question. Are we going to, we knew that there was, as the patient grows, are we going to have to do any airway surgery? But to start, it was just stabilizing the patient and he became stable off of the ventilator. But then it became, what do we do? How are we going to get that patient home as they’re getting older? So we did wait, just like you said, we wanted to make sure we trusted the stability of the patient. And then when he was 14 months old, he ended up going under a staged cervical tracheoplasty for the stomal collapse. He was still having really difficult airway exposure. We had been progressing from a feeding standpoint and he was able to start doing some tastes, he started drinking, but we still needed to get this patient home. The mom kept saying, what are we going to do? So she couldn’t go home, he couldn’t go home to Saipan with a tracheostomy. This is an image of what would happen just at rest with his breathing. And most of his obstruction was because of his epiglottis. So would you do an epiglottis pexi based off of everything that we have been saying so far? >> I don’t necessarily do, but recommend. >> Oh, recommend, of course, not personally, nor am I. Looking at the whole profile of the patient, do you think that that would be helpful in advancing care and what else would you think about? >> Okay, so most people say yes. Any input from the panel? >> My experience with Noonan’s is that when you operate on their larynx, it never, ever goes quite as well as you thought it should go. But I would definitely try, but a lot of this is about counseling the family. And so I would tend to try and under-promise and hope I could over-deliver. >> Are there any other barriers to vent weaning in this patient that we should consider before this? >> No, so at this stage, he is off of the ventilator and we just can’t get him decannulated because of his upper airway. We tried valves, he’s waited time, and it’s really his upper airway access and just that prolapse with his epiglottis. So we needed to figure out what we were going to do. But the question is, in the meantime, he’s progressing feeding-wise and the family was really starting to be able to interact with him more. He was more a part of meal times. He was getting a portion of his nutrition by mouth now and starting to progress. But we still need to be able to get the kid home and that is mom’s still biggest goal. So if you — most of you answered yes. And if you did, would you do a swallow study before you actually do the epiglottic PEXI or recommend it, not do personally? Okay, interesting. Going down. One question. Does it matter which study? I was going to say that, yeah. And so I — that’s another question. Which would you do? Because you get different information from both. In this case — I’ll speak to this. In this case, we ended up deciding to do a video fluoroscopic swallow study. We chose that for the purpose of understanding where his true physiology of his swallow was. If you think about what you’re going to do with an epiglottic PEXI, you need to understand a few key things and that’s what we looked for. Was one, timing of a swallow. So was he initiating at the molecular space or at the puroform sinuses? And if you’re initiating at the molecular space, you’re going to be way less at risk for aspiration when you’re tacking up that epiglottis. If he persistently had a delayed swallow, then he would be more at risk and we would need to determine what strategies could help him initiate a little bit higher up. The biggest thing that we wanted to look at for predicting how his swallow would change or not change was his laryngeal elevation. So that approximation of your arytenoids to the epiglottic pedial, that is your core of airway protection. Whether or not a bolus is going that way or not. Whether you aspirate or you don’t. If you have a column of air that’s in that space and you go to swallow, then now you have an extra risk factor with your epiglottis that’s tacked up. And so those were the two main things that we were looking at. Not to necessarily say that we could or couldn’t do it, but to let family understand what we would predict, how his swallow may change. And if we were going to do surgery, what we could do ahead of time to say, oh, this is what we would expect when we do this surgery. So post-op, this is how I might treat you and continue to be on an oral diet safer. Can you comment on the percentage of energy that this child is receiving by G2 prior to this procedure? Yeah, so he, we were not, it was about 30% by mouth and the rest through the tube. Yeah. And a lot of that was not all pharyngeal. It was oral efficiency. He was aversive for a long time, but that’s where we really wanted to understand the swallow function. So what we could anticipate. What if we would have done a very bad swallow study? And no epiglottal plexi? I would still do it because it might actually improve. I mean, he’s actually aspirating his epiglottis most of the time. So. Yeah, and that’s one of the things us as surgeons think if we aren’t really going to change what we do after the test, then maybe doing the test is not going to drive us too much except for being able to tell the family what to expect. And also not just whether you do the surgery or not, but how can we maintain oral intake and engagement post-op? We’re not going to do a swallow study immediately post-op. It’s not fair to the patient. You’re going to get false results. And so does that mean you don’t feed the patient post-op? No, but if we can understand what their swallow was and say he had really poor laryngeal elevation and a really delayed swallow, we could then be looking at whether it’s thickened liquids, different bolus sizes, and maybe we start there clinically post-epiglottic plexi so we can keep them practicing before we can do a study. So this is the swallow study. Are we going to actually play or are we going to do a study? It was earlier. Uh-oh. There we go. Okay. So you can see he has pretty timely initiation, initiating at the molecular space. And on this one, we did larger boluses to test him. He would take small amounts, but I wanted to see truly what would happen if he got a larger bolus and he was able to handle that. And so we knew that we would probably have to control bolus size post-op, but that we could probably start with thin liquid. And we did tell the family potentially he might need to go on to thickened liquids, but we were confident that we would be able to keep progressing him orally. This is an image of what it looked like preoperatively. Pretty poor visi- pretty poor exposure. For all the non-surgeons, this is what they did. We’re not going to go into depth, and this is an example of the actual procedure to get better opening. It’s coming. There we go. And then this is the after image. And then we did a post-operative phase. We didn’t need to do another swallow study because we already knew pharyngeal function. We weren’t expecting pharyngeal function to change with just opening the airway up more. So we wanted to do a phase and understand. This is immediate- not immediately after, maybe a week or two after. That was the first step that we wanted. And this is the post-operative phase. You can see how the anatomy changed. Initiating at the molecular space, we would have to compensate a little bit with bolus size, but did pretty well. This is the swallow study because if we were going to advance and send this patient back to Saipan at some point, we wanted to make sure when he’s challenged, how’s he going to do and how can we guide the parent even in advancing his diet. And then larger amounts. Right before the swallow had some penetration because he had an initiative, but when he initiated, he got full laryngeal elevation and airway protection. You didn’t have the trach at the time, right? This is after, yeah, this is post, yeah, yeah. This is post epiglottopexy. Yep. And this is him in clinic as parents started progressing or the mom started progressing with some solid food and engagement and him happy and getting ready to have a plan for advancing PO and going home to Saipan. Okay. Any comments? No comments? You want chips? Why always chips in America? The first food you give the children. All right. So we made up for the time five minutes early. Thank you very much for this day. It was amazing. I’m going to leave you with our Supreme Leader, Dr. Brigger. He’s going to talk to you for a little while. [ Applause ] >> All this extra time. Wow. I should have known without borrow up. So can we switch to that last slide? All right. So this concludes the program, at least for the aerodigestive part. This has been really exciting today and I really just as I look out here and have seen over the course of the day, seen our discussions run a little bit long, run a little bit short, work our way through, but really it’s the interaction is what this is all really about. So I think from housekeeping standpoint, we’re headed to the 17th floor, I believe. Is that where the cocktail reception is? I think it’s the 17th floor. That’s going to start up here next. Tomorrow obviously impact kicks off. And I want to just take a couple moments here just to really thank the sort of the all the people that sort of made this come together. There’s a lot of people in the room who really put a lot of time to this. And so when it came to the program, this was something that really came down to certainly Alvaro was a big part of it about bringing this collaboration between these two programs. Kalyn Johnson, Jeremy Prager, Carl Larson, Christopher Wooten, you guys really, really appreciate all the work that went into putting such a great. And I also want to thank just the executive board overall of the and the aerodigestive board and just all the people involved who come here and have made a point, even the people from afar, the fact that we had 25 people just jumping in on zoom for everybody, there will be links mailed to you. This has all been recorded, you’ll be able to watch it at any point. And I really want to just sit back and thank the vision of impact. And so Alvaro and Patricia, is Pato here somewhere? I see somewhere we really appreciate coming together and having the vision to bring this and really allow us to bring the arrow word. And I’d love to invite everybody here who is not a member to please join, check out our website and we’ll go from there. I’m looking forward to the next couple of days because I think it’s going to be great. Thank you all. [APPLAUSE] (audience applauding)