Airway Disorders and Reconstruction in Children Video

Transcript: What to Expect: Steps Before Surgery

Transcripts in This Video Series
Introduction to Airway Disorders and Our Pediatric Airway Center What to Expect: Steps Before Surgery Reconstruction: Airway Surgeries A New Voice: After The Surgery Team for the Future: Research and Hope

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Joanne Stow, MSN: When a family is first referred to the Center for Pediatric Airway Disorders, it's frequently a very traumatic event for them. They've learned that their child has an issue that's life threatening, life changing, and sometimes very devastating.

Ian N. Jacobs, MD: And many times they become immediately relieved that there are people, there are specialists, that have an interest and a special expertise in the disorder that their child has.

Joanne Stow, MSN: Their first contact with some of us is either with the Airway Program Coordinator when they call to make an appointment, or with one of the nurse practitioners to find out how we're going to help care for their child.

Ian N. Jacobs, MD: Our airway nurse practitioners play a vital role in the management and the care of the children with airway disorders.

Karen B. Zur, MD: She's there to, pretty much, be their hand holder along this process. They know her by name. They have her telephone number.

Ian N. Jacobs, MD: They'll do the intake process, and they'll gather all the information and start the relationship that we have with families that will go on for years and years.

Mary Kelly, Mother: If I had questions from home, I would call them, and they were so great at getting back to me.

Jed Kelly, Father: There's no such thing as a dumb question. They made you feel comfortable and explained every step of the way.

Karen B. Zur, MD: The management of patients with pediatric airway disorders is obviously very complex, and we have a large team of clinicians who are involved with their care.

Joanne Stow, MSN: That we have such a variety of specialties that are all a part of caring for that child in that family.

Asim Maqbool, MD: You have physicians. Certainly, you have surgeons. You have occupational therapists. You have speech and language pathologists. You have social workers. You have Child Life.

Ralph F. Wetmore, MD: And, from the time the patient comes into our program, that team is geared up to care for them and to give them the best care that we can.

Joanne Stow, MSN: When a child's airway needs to be evaluated, many different things need to happen all at once. It requires a lot of coordination and communication between all the team members.

Ian N. Jacobs, MD: We want to make it a one-stop shop. So we want to find out exactly what tests have been done in the past, and what operative procedures have been performed. And then we want to determine what tests need to be performed when they get here.

Karen B. Zur, MD: So, depending on the type of airway problem that the child presents with, we may order a variety of studies.

Ian N. Jacobs, MD: We'll work closely in the Airway Center with speech and swallowing therapists who evaluate every child. We'll evaluate their voice. We will want to evaluate their aerodigestive tract, which means their swallowing passage, prior to going to the operating room. So, many times, they'll have an upper GI series or barium swallow to look at the swallowing passage. Then we'll often get a chest x-ray, various labs, and then they'll see our Anesthesia Resource Center, which does the preoperative evaluation for children undergoing anesthesia at our hospital.

John E. Fiadjoe, MD: We get involved very early in the process during the diagnosis and evaluation phase, and we interact very closely with the subspecialist to craft an optimal plan for these patients around the time of surgery.

Karen B. Zur, MD: So the plan of what type of anesthetic to give, is the child going to be fully sedated, meaning paralyzed? Or are they going to be spontaneously breathing on their own for the procedure?

John E. Fiadjoe, MD: Because the surgery is happening on the airway, we often will not use the gas to maintain anesthesia and keep the patient anesthetized. Often what we will do is use an intravenous drug to maintain our anesthetic.

Ian N. Jacobs, MD: After we evaluate them in the office, the patients will be scheduled for an operative procedure which includes a full diagnostic airway and GI evaluation in the operating room.

Karen B. Zur, MD: And the bronchoscopy is our gold standard diagnostic tool for evaluating the airway.

Ralph F. Wetmore, MD: We examine the airway with a telescope. We look down. We look at all the problems that start from the area above the voice box, down through the voice box all the way down the trachea, or windpipe, to where the trachea spreads off into the right and left mainstem bronchus.

Ian N. Jacobs, MD: So we perform a microlaryngoscopy, bronchoscopy, and our gastroenterology service will perform an upper GI endoscopy.

Asim Maqbool, MD: Looking at the esophagus, stomach, and the small intestine with a video camera through which we're able to get biopsies and specimens as well. The other test that we do commonly is either a PH probe or an impedance probe, which is a long thin spaghetti-like tube that goes in through the nose and sits typically where the esophagus and the stomach meet, and it sits there for about 24 hours, and it gives us information about reflux. Reflux is the effortless spit up of previously ingested food. So, for example, when you see a baby who's just had a bottle feed and you put them over your shoulder or you pick them up you see some milk dribble out onto your clothes, that's reflux.

Karen B. Zur, MD: So the reason we're concerned about reflux, both acid and nonacid reflux, is it can cause irritation. And, if we're planning a large surgical intervention to reconstruct the child's airway and you make an incision into their airway, the healing process can be affected by reflux.

Asim Maqbool, MD: And for that reason one of the things that our otolaryngology colleagues like us to do is to say, "Does the child have reflux?" And if reflux is there, "How well can we control it?" to give the repair every chance of success. We try to combine these procedures with any other procedures that our airway colleagues may be performing in the operating room, such as bronchoscopies or laryngoscopies so that within a 24-hour period of time we do gather a lot of information.

John E. Fiadjoe, MD: This avoids multiple anesthetics, multiple procedures, and the interaction between the different teams works very well at CHOP.

Ian N. Jacobs, MD: After we perform the microlaryngoscopy, bronchoscopy, and the GI endoscopy, we will meet as a team with the family in the postoperative parent waiting area.

Karen B. Zur, MD: We review what the images of the airway look like and come up with a plan.

Ian N. Jacobs, MD: Now, that plan might include immediate airway surgery, or it might not. If there are still issues to deal with, we'll discuss those. We'll make a plan for dealing with those issues. If the child is ready for surgery or requires a number of tests to be checked, we'll make a plan to contact the family as soon as those tests are completed.

Jed Kelly, Father: We got Addison home, she'd been home for some time, and we started to sprint her. So we would take her off the machine for short periods of time, and the goal with that was to see if she could handle breathing on her own.

Mary Kelly, Mother: We got to the point where we were talking about decannulation and one of the steps that had to happen before decannulation was a bronchoscopy.

Jed Kelly, Father: We did not expect there to be anything that would happen, and we expected him to just say "Yep, great, let's go forward," when she was off the ventilator just breathing fine.

Mary Kelly, Mother: But sure enough, she actually developed a narrowing in her airway that we were told was just a result of having a tracheostomy long term.

Jed Kelly, Father: And that meant that she would need to have another procedure to fix that. It was disappointing. Because you work and strive for a goal and you think you can reach a goal, and all of a sudden you have to have more conditions put on that goal, and it was a challenge to prepare ourselves for what we had go through for the surgery.

Mary Kelly, Mother: But we also were still hopeful, like, you know, getting the trach out. We did not anticipate that Addison would be a candidate to get her trach out this soon. So we were just thrilled. We knew this was just one more hurdle. One more piece of the process to get there. You know, even though it was a little frustrating we felt like we were just getting so close, and it was almost there.