# Aspiration — GCMD Library living collection

Everything in the library about aspiration — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 66 cited statements

## Episodes
### Evidence & Research
- [Best of the Best APSA Winner](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349) — video · 9:46 · [machine version](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349.md)

### In-Depth Reviews
- [Aerodigestive Management of Pediatric Aspiration - FULL SHOW](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796) — video · 2:37:09 · [machine version](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796.md)

### Patient & Family Education
- [Care and Nutrition in Esophageal Atresia: An ERNICA animation for parents and families](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604) — video · 2:48 · [machine version](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604.md)

## Chapters
- [0:04](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4) Defining Pediatric Aspiration and At-Risk Populations (Ep 1)
- [4:55](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=295) Pulmonary Perspective on Chronic Aspiration (Ep 1)
- [11:11](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=671) Swallowing Physiology and Dysphagia Causes (Ep 1)
- [20:30](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1230) Diagnostic Approach: What Is Being Aspirated (Ep 1)
- [26:51](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1611) Instrumental Evaluation: VFSS and FEES (Ep 1)
- [37:22](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2242) Differential Diagnosis of Aspiration (Ep 1)
- [52:29](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3149) Tracheostomy and Aspiration Management (Ep 1)
- [57:37](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3457) Medical Management of Functional Aspiration (Ep 1)
- [67:39](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4059) Surgical Management: Drool Procedures and Laryngotracheal Separation (Ep 1)
- [80:08](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4808) Unilateral Vocal Fold Paralysis Management (Ep 1)
- [87:21](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5241) Tracheoesophageal Fistula: Diagnosis and Endoscopic Repair (Ep 1)
- [100:00](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6000) Open TEF Repair Techniques (Ep 1)
- [109:29](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6569) Slide Tracheoplasty for Complex TEFs (Ep 1)
- [125:00](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7500) Laryngeal Cleft Classification and Endoscopic Repair (Ep 1)
- [141:14](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=8474) Open Cleft Repair and Type 4 Clefts (Ep 1)
- [152:34](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=9154) Esophageal Pathology and Pharyngeal Stenosis (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=0) Introduction to Best of the Best Event and APSA Presentation (Ep 2)
- [1:33](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=93) Study Presentation: Safety of Contrast Challenges in Pediatric Adhesive Small Bowel Obstruction (Ep 2)
- [5:59](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=359) Discussion: Protocol Variation and Clinical Adoption (Ep 2)
- [8:50](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=530) Closing Remarks on Clinical Impact (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=0) Introduction to Esophageal Atresia and Aspiration Risk (Ep 3)
- [1:00](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=60) Replogle Tube Management and Oral Stimulation Techniques (Ep 3)
- [2:00](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=120) Multidisciplinary Team and Long-term Follow-up Protocol (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Chronic pulmonary aspiration is defined as repeated aspiration into the lower airways causing pulmonary injury or chronic respiratory disease, with consequences determined by frequency, magnitude, nature of material, and effectiveness of host defenses. — Katherine Hart (clinical) [Ep 1 · 3:31](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=211)
- Four major groups aspirate: premature babies, those with neurologic disabilities, those with airway disease (anatomic, dynamic, or functional), and those with gastrointestinal disorders. — Katherine Hart (clinical) [Ep 1 · 4:34](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=274)
- Children with associated obstructive airway symptoms (snoring, retractions, stridor, desaturation) should undergo airway endoscopy to look for anatomic causes of dysphagia. — Claudia Schweiger (clinical) [Ep 1 · 10:17](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=617)
- Video swallow study (VFSS) and functional endoscopic evaluation of swallowing (FEES) are complementary tests that show different things and evaluate different parts of the swallow—it is important to explain to families they are not the same test. — Sandra Stinnett (clinical) [Ep 1 · 16:33](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=993)
- Impedance probe is the best test for gastroesophageal reflux but is not necessarily widely available. — Michael Rutter (clinical) [Ep 1 · 18:05](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1085)
- CT scanning is excellent for evaluating long-term consequences of aspiration but shows damage already done (tells about the past, not the present) and requires anesthesia, radiation, and radiologic expertise. — Michael Rutter (clinical) [Ep 1 · 19:23](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1163)
- Elevated lipid-laden macrophages are not pathognomonic of aspiration—they can result from natural airway debris (dead neutrophils, macrophages from inflammation) or circulation after bleeding or airway surgery. — Katherine Hart (clinical) [Ep 1 · 45:56](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2756)
- Lipid-laden macrophages are a limited tool because aspirated material has variable lipid content (saliva has no lipid), there is variable time between aspiration and BAL sampling affecting lipid metabolism, and individuals have variable rates of lipid catabolism. — Katherine Hart (clinical) [Ep 1 · 46:38](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2798)
- Decanulation should not proceed until the child has proven capacity to clear their airway through a prolonged capping trial that includes going through illnesses without needing the tracheostomy for clearance. — Katherine Hart (clinical) [Ep 1 · 49:10](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2950)
- Speaking valves help with airway clearance by allowing glottic closure for better cough and creating positive end-expiratory pressure that distends airways, even if they do not decrease aspiration coming in. — Katherine Hart (clinical) [Ep 1 · 49:56](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2996)
- CHARGE patients frequently need tracheostomy or interventions for salivary aspiration at young age but often develop compensatory strategies over time and can be decannulated as they mature. — Sandra Stinnett (clinical) [Ep 1 · 50:54](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3054)
- The pulmonologist's role in the aerodigestive team is to protect children from developing irreversible long-term pulmonary sequelae while managing anatomic abnormalities or waiting for maturity. — Katherine Hart (opinion) [Ep 1 · 51:44](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3104)
- Medical management of functional aspiration should target five aspects: decrease aspiration events, improve airway clearance, address quality of aspirated material, control inflammation, and treat or prevent infections. — Katherine Hart (clinical) [Ep 1 · 58:16](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3496)
- Positive pressure ventilation (CPAP or BiPAP) can decrease aspiration events, especially during sleep in patients with reflux aspiration, even in patients who do not need it for gas exchange or ventilation. — Katherine Hart (clinical) [Ep 1 · 65:45](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3945)
- Cuff tubes cannot stop aspiration because inflating the cuff enough to decrease leak causes unacceptable tracheal injury or dilation. — Katherine Hart (clinical) [Ep 1 · 64:56](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3896)
- Passy-Muir valves should never be used during sleep because they allow inhalation through the tracheostomy but not exhalation, risking obstruction from mucus accumulation, and they cause over-drying of secretions leading to mucus plugging. — Katherine Hart (clinical) [Ep 1 · 66:39](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3999)
- Chronic inflammation from aspiration is managed with inhaled steroids and systemic anti-inflammatory medication (azithromycin, not systemic steroids as first-line), with systemic steroids reserved for acute aspiration events to prevent pneumonitis. — Katherine Hart (clinical) [Ep 1 · 62:17](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3737)
- Patients with bronchiectasis from chronic aspiration should receive longer antibiotic courses (10-14 days instead of 7-10 days) because bronchiectatic cavities have more difficult clearance. — Katherine Hart (clinical) [Ep 1 · 63:30](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3810)
- Prophylactic inhaled antibiotics (tobramycin or colistimethate, either every other month or 14 days per month) are reserved for patients with severe bronchiectasis and pulmonary injury or significant frequency of infections. — Katherine Hart (clinical) [Ep 1 · 63:42](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3822)
- Botox for sialorrhea has 90% success rate in the speaker's experience and is first-line treatment. — Hugo Rodríguez (clinical) [Ep 1 · 78:03](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4683)
- Laryngotracheal separation guarantees no aspiration but eliminates voice, and attempts to restore voice with speaking valves (Blom-Singer) are not effective in children because the larynx remains in the way—complete laryngectomy with cricopharyngeal myotomy is required for voice restoration. — Michael Rutter (clinical) [Ep 1 · 81:41](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4901)
- The Cincinnati laryngotracheal separation technique involves peeling mucosa up subperichondrially within the cricoid, purse-string closure, splitting cricoid laterally at 3 and 9 o'clock, quilting sutures to sandwich cricoid, tisseal in subglottis, and crisscrossing medial heads of SCM over the laryngeal stump—this has eliminated fistula formation and stomal stenosis. — Michael Rutter (clinical) [Ep 1 · 83:52](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5032)
- In children, laryngotracheal separation stomas will stenose without a tube until growth stops, so a relatively big, wide, short tube must remain in the tracheal stoma. — Michael Rutter (clinical) [Ep 1 · 85:19](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5119)
- For injection materials, radiance gels dissipate within weeks in animal models and do not work well; Restylane is used as a bridge and fat for longer-term injection. — Sandra Stinnett (clinical) [Ep 1 · 71:40](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4300)
- Reinnervation advantages include single general anesthetic (no awake thyroplasty needed for children), one-and-done if successful, low risk, allows other procedures later, and uses patient's own tissue; disadvantages include lack of long-term pediatric data, 6-9 months to final results, and neck incision. — Sandra Stinnett (clinical) [Ep 1 · 74:11](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4451)
- Reinnervation is a misnomer—it does not restore movement but provides tone and better closure, with outcomes measured by voice and swallowing improvement. — Sandra Stinnett (clinical) [Ep 1 · 75:46](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4546)
- Sensory reinnervation (great auricular nerve to superior laryngeal nerve) can restore sensation and is valuable when the sensory component is the primary deficit, allowing recognition of secretions and swallowing. — Sandra Stinnett (clinical) [Ep 1 · 77:07](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4627)
- Tracheoesophageal fistulas can be surprisingly challenging to find and require high index of suspicion, angled telescopes, probing, and positive pressure breath with endotracheal tube in esophagus to visualize bubbling. — Michael Rutter (clinical) [Ep 1 · 92:40](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5560)
- Endoscopic TEF repair is ideal for long skinny tracts (usually recurrent TEFs after congenital repair); the concept is to demucosalize the tract with Bugby cautery to get raw-against-raw, inject filler beside the tract to compress it, and place fibrin glue. — Michael Rutter (clinical) [Ep 1 · 98:43](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5923)
- Endoscopic TEF repair has a recognized failure rate and surgeons must be prepared to repeat the procedure multiple times. — Michael Rutter (clinical) [Ep 1 · 104:26](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6266)
- Congenital H-type tracheoesophageal fistulas, with very few exceptions, do not do well with endoscopic repairs and typically require open repair. — Michael Rutter (clinical) [Ep 1 · 106:03](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6363)
- For H-type TEFs, the upper 2/3 of trachea is accessible through the neck, the lower third is easier through the chest, and the middle third is no-man's land where whoever has better expertise (pediatric surgery or ENT) should do it. — Michael Rutter (clinical) [Ep 1 · 106:27](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6387)
- Slide tracheoplasty technique for large or multiply-failed TEFs involves transecting trachea above and below the hole, peeling trachea off esophagus, using the tracheal segment attached to the hole to repair the esophagus, and reconnecting the trachea over the top with a slide technique that oversizes the airway and reduces tension. — Michael Rutter (clinical) [Ep 1 · 109:45](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6585)
- For the case of isolated esophagus with multiple TEFs connecting to trachea, leaving the esophagus isolated at both ends prevents aspiration through the holes while the holes prevent mucocele formation by allowing drainage. — Michael Rutter (clinical) [Ep 1 · 120:59](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7259)
- Flexible bronchoscopy is not a good tool for evaluating posterior laryngeal clefts—rigid bronchoscopy is required for diagnosis. — Michael Rutter (clinical) [Ep 1 · 127:00](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7620)
- The Cincinnati endoscopic cleft repair technique uses laser (KTP or CO2) to remove a wide swath of mucosa on both sides of the cleft, creating raw-against-raw surfaces, then places 2-3 sutures (60 PDS on bent BV1 for babies, 40 PDS on P2 for older children) and releases aryepiglottic folds. — Sandra Stinnett (clinical) [Ep 1 · 128:10](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7690)
- Endoscopic cleft repair has become a fellow-level case in Cincinnati due to the volume performed (at least 20, likely way more). — Sandra Stinnett (clinical) [Ep 1 · 131:18](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7878)
- Almost all children under 4 kg who had type 4 cleft repairs died; waiting until the child is over 5 kg improves outcomes. — Michael Rutter (clinical) [Ep 1 · 137:44](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=8264)
- For long type 4 clefts, the Cincinnati technique involves transecting trachea at cricoid, peeling trachea off esophagus to beyond the cleft, repairing esophagus, placing sternal periosteum interposition graft, reconnecting trachea, and placing tracheostomy 2-3 weeks later after healing. — Michael Rutter (clinical) [Ep 1 · 135:26](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=8126)
- The greatest risk with laryngotracheoesophageal clefts is that the distal end of the repair may form a tracheoesophageal fistula. — Michael Rutter (clinical) [Ep 1 · 139:09](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=8349)
- For severe pharyngeal stenosis, management is a step ladder approach: voice, breathing without trach, no aspiration, swallowing without G-tube—typically cannot achieve all four, usually one or two steps up the ladder, rarely three. — Michael Rutter (clinical) [Ep 1 · 153:04](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=9184)
- Composite stents (suprastomal stent with silastic sheet wrapped around it supraglottically) are effective for severe pharyngeal stenosis—the stent goes through vocal cords and locks in trachea while the silastic holds open the supraglottic raw areas during re-mucosalization. — Michael Rutter (clinical) [Ep 1 · 154:27](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=9267)
- Adhesive small bowel obstructions are a well-known cause of morbidity in children following abdominal surgery. — Nate Rubocava (clinical) [Ep 2 · 1:33](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=93)
- Traditional treatment of adhesive small bowel obstruction has been gastric decompression, bowel rest, fluid resuscitation, and electrolyte replacement. — Nate Rubocava (clinical) [Ep 2 · 1:50](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=110)
- Over the last two decades, the use of water-soluble contrast agents in the management of small bowel obstructions has become well established in the adult literature, given their ability to predict the success of non-operative management. — Nate Rubocava (clinical) [Ep 2 · 2:05](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=125)
- A contrast challenge is performed when a patient presents with a small bowel obstruction that qualifies for non-operative management. After a period of gastric decompression, the patient is given the contrast and will wait a period of 8 to 10 hours after which an abdominal X-ray is obtained. — Nate Rubocava (clinical) [Ep 2 · 2:25](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=145)
- Contrast in the colon is considered having passed their contrast challenge, and after the patient demonstrates clinical improvement with tolerance of a regular diet, they are discharged from the hospital. — Nate Rubocava (clinical) [Ep 2 · 2:50](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=170)
- For those who still don't have contrast in their colon after a repeat abdominal X-ray at 24 hours, they're considered to have failed their contrast challenge and will be taken to surgery for exploration. — Nate Rubocava (clinical) [Ep 2 · 3:05](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=185)
- Limited data exists with regards to safety and use of a contrast challenge in the pediatric population, yet multiple pediatric institutions have adopted contrast challenge algorithms. — Nate Rubocava (epidemiological) [Ep 2 · 3:20](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=200)
- The study performed a retrospective review of all children undergoing a contrast challenge across 5 children's hospitals over a period of 8 years. — Nate Rubocava (epidemiological) [Ep 2 · 3:40](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=220)
- By group consensus, a complication rate less than 5% would be considered safe to use a contrast challenge for clinical practice. — Nate Rubocava (guideline) [Ep 2 · 3:55](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=235)
- Major complications were defined as aspiration, pneumonia, anaphylaxis, cardiovascular complications, and renal failure. Minor complications included urticaria, dyspnea, and worsening abdominal pain. — Nate Rubocava (clinical) [Ep 2 · 4:10](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=250)
- Overall, 82 children underwent a contrast challenge. 57 initially passed their challenge, of which 53 had clinical improvement and were successfully discharged. There were 25 who failed and were taken to surgery. The 4 that failed to completely resolve were also taken to surgery. — Nate Rubocava (epidemiological) [Ep 2 · 4:30](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=270)
- There was a significant age difference between the two groups, with those passing the challenge between a median of 7 years older. — Nate Rubocava (epidemiological) [Ep 2 · 4:55](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=295)
- The cohort included patients affected with neurologic and pulmonary comorbidities which were present in over 30% of patients. — Nate Rubocava (epidemiological) [Ep 2 · 5:10](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=310)
- The contrast agents used were institution-specific, all had relatively similar osmodality, with dilute gastrographin being the most commonly utilized agent. — Nate Rubocava (clinical) [Ep 2 · 5:20](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=320)
- There were no major or minor complications in the study, and with a 0% complication rate and a confidence interval of 0 to 3.6%, this was significantly below the pre-set acceptable complication rate of 5%. — Nate Rubocava (epidemiological) [Ep 2 · 5:35](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=335)
- There were no mortalities in either group. — Nate Rubocava (epidemiological) [Ep 2 · 5:55](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=355)
- The group that failed their contrast challenge had a significantly longer hospital stay by 5 days. — Nate Rubocava (epidemiological) [Ep 2 · 4:30](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=270)
- A total of 6 patients were readmitted within 30 days for a recurrent small bowel obstruction. — Nate Rubocava (epidemiological) [Ep 2 · 4:45](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=285)
- The contrast challenge has a sensitivity of 100%, specificity of 86%, negative and positive predictive values of 100% and 93% respectively for predicting successful non-operative management. — Nate Rubocava (epidemiological) [Ep 2 · 5:10](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=310)
- This review of 82 patients is the largest to date in children demonstrating that a contrast challenge is safe, effective, and highly predictive in children. — Nate Rubocava (epidemiological) [Ep 2 · 5:30](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=330)
- Every institution had a similar protocol that had been mirrored to Doctor Grace Mack from University of Chicago's study from 2018. — Nate Rubocava (clinical) [Ep 2 · 7:20](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=440)
- The Midwest Pediatric Surgery Consortium is doing a prospective study looking at contrast challenges in pediatric adhesive small bowel obstruction. — Nate Rubocava (epidemiological) [Ep 2 · 8:00](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=480)
- More pediatric surgeons are now saying the study showed it was safe and effective in being able to predict which child will successfully be managed with non-operative management. — Nate Rubocava (opinion) [Ep 2 · 8:20](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=500)
- This contrast challenge will positively impact management in the hospital for every single child that undergoes abdominal surgery because for the rest of their life, they're at risk of adhesive small bowel obstruction. (opinion) [Ep 2 · 9:20](https://qa.library.globalcastmd.com/watch/best-of-the-best-apsa-winner-5349?t=560)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Aspiration is defined as any solid or liquid matter passing below the vocal cords, though some define it as requiring pulmonary compromise in addition to passage below the cords. — Katherine Hart summarizing the discussion [Ep 1 · 0:16](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=16)
- Aspiration can be silent with no clinical indication, or obvious with coughing, choking, and sputtering. — Katherine Hart summarizing the discussion [Ep 1 · 0:39](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=39)
- Children with CHARGE syndrome have 80 to 90% prevalence of aspiration at some point in their lifetime and should be assumed to aspirate until proven otherwise. — Katherine Hart summarizing the discussion [Ep 1 · 1:51](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=111)
- Children with severe neurologic compromise regardless of etiology should be assumed to aspirate until demonstrated otherwise. — Katherine Hart summarizing the discussion [Ep 1 · 2:01](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=121)
- The clinical significance of aspiration depends on the quantity—small isolated events are usually cleared by host defenses (cough, mucociliary transport), while large or repeated events overcome host defenses. — Katherine Hart summarizing the discussion [Ep 1 · 2:32](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=152)
- A single aspiration event of caustic substance can have lifelong consequences. — Katherine Hart summarizing the discussion [Ep 1 · 3:06](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=186)
- Syndromes with significant swallowing dysfunction include CHARGE, Cri-du-chat, Möbius syndrome (cranial nerve abnormalities), and craniofacial defects like Pfeiffer, Crouzon, and Treacher Collins. — Katherine Hart summarizing the discussion [Ep 1 · 5:02](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=302)
- Dysphagia can occur in any of the four swallowing phases (oral preparatory, oral transit, pharyngeal, esophageal) and can result in aspiration or retrograde flow into the nasal cavity. — Claudia Schweiger summarizing the discussion [Ep 1 · 6:09](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=369)
- Children who aspirate may present with breathing difficulties during feeding (increased respiratory rate, bradycardia, tachycardia, cyanosis, apnea, desaturation), coughing/choking during or after swallowing, frequent congestion after meals, noisy or wet vocal quality, prolonged meal times, food refusal, or vomiting. — Claudia Schweiger summarizing the discussion [Ep 1 · 6:48](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=408)
- A radionucleotide spit scan (placing radioactive tracer on tongue) can test for saliva aspiration but involves radiation and is a one-off window in time. — Michael Rutter summarizing the discussion [Ep 1 · 17:21](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1041)
- Medication for reflux generally stops acid but does not stop reflux events. — Michael Rutter summarizing the discussion [Ep 1 · 18:31](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1111)
- Lipid-laden macrophages are the most commonly used aspiration biomarker, with a lipid-laden macrophage index >90 or >20% of macrophages containing lipid suggesting aspiration. — Katherine Hart summarizing the discussion [Ep 1 · 44:25](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2665)
- Having a tracheostomy tube changes the dynamics of laryngeal elevation but most studies show it does not create aspiration. — Katherine Hart summarizing the discussion [Ep 1 · 48:08](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2888)
- For airway clearance, comorbidities that compromise clearance include tracheobronchomalacia, airway compression/stenosis/hypoplasia, restrictive lung disease (neuromuscular, chest wall deformities, scoliosis), and vocal cord or diaphragmatic dysfunction/paralysis from esophageal or cardiac surgery. — Katherine Hart summarizing the discussion [Ep 1 · 60:11](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3611)
- Bilateral submandibular gland excision and bilateral parotid duct ligation (drool procedure) has 60-100% success rate in the literature. — Hugo Rodríguez summarizing the discussion [Ep 1 · 78:38](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4718)
- Temporary laryngeal injection is a useful test-drive procedure before permanent medialization, can be repeated, and serves as a bridge between more permanent operations. — Sandra Stinnett summarizing the discussion [Ep 1 · 70:04](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4204)
- Early injection (1-3 months after recurrent nerve injury) may lead to less need for permanent procedures based on adult literature, though pediatric data is limited. — Sandra Stinnett summarizing the discussion [Ep 1 · 70:28](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4228)
- Reinnervation (ansa-to-recurrent laryngeal nerve) is not a new concept but has gained popularity in the last few years; ideal candidates are <40 years old, within 1-2 years of injury, with known injury location. — Sandra Stinnett summarizing the discussion [Ep 1 · 72:46](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4366)
- Open cleft repair is reserved for failed endoscopic repairs (some type 2s and type 3s), type 4 clefts (cervical approach), and type 4 long clefts (which present anesthetic challenges requiring double lumen tube, single lung ventilation, ECMO, or bypass). — Sandra Stinnett summarizing the discussion [Ep 1 · 129:02](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7742)
- Type 4 long laryngeal clefts have very high mortality rate hovering around 50%, and families must be counseled about this before attempting repair. — Sandra Stinnett summarizing the discussion [Ep 1 · 129:46](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7786)
- Esophageal atresia is a rare birth defect where a part of the esophagus, the tube connecting the mouth to the stomach, is missing. — The host summarizing a resource [Ep 3 · 0:00](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=0)
- All babies born with esophageal atresia should be treated at a specialist center with appropriate expertise and a dedicated multidisciplinary team. — The host summarizing a resource [Ep 3 · 0:40](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=40)
- Because saliva, secretions and food cannot flow into the stomach in esophageal atresia, the baby is at risk of aspiration, which is fluid entering the lungs. — The host summarizing a resource [Ep 3 · 0:55](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=55)
- A replogle tube is placed through the mouth or nose into the esophagus to suck out all fluids, preventing leakage into the airway and thus preventing aspiration. — The host summarizing a resource [Ep 3 · 1:10](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=70)
- The replogle tube enables giving the baby pleasant oral experiences and developing swallowing skills. — The host summarizing a resource [Ep 3 · 1:30](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=90)
- With the replogle tube in place, parents may be able to give the baby a small taste of breast milk before esophageal repair using a pacifier or dummy. — The host summarizing a resource [Ep 3 · 1:40](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=100)
- In rare circumstances when the baby needs a delayed repair, sham feeding may be helpful. — The host summarizing a resource [Ep 3 · 1:55](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=115)
- In sham feeding, a baby's feed is provided orally but sucked out by the replogle tube while the baby receives food directly into the stomach through a gastrostomy tube. — The host summarizing a resource [Ep 3 · 2:05](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=125)
- Sham feeding can help the baby associate oral feeding with milk entering the stomach. — The host summarizing a resource [Ep 3 · 2:20](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=140)
- A lactation consultant or support worker will support parents to bond with the baby, discuss feeding options and support with breastfeeding. — The host summarizing a resource [Ep 3 · 2:28](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=148)
- A specialized swallowing therapist can assess the baby's swallowing and feeding, and if necessary, offer ongoing specific therapy and advice. — The host summarizing a resource [Ep 3 · 2:38](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=158)
- A nutrition therapist will ensure that the baby meets all nutritional requirements to support optimal growth. — The host summarizing a resource [Ep 3 · 2:48](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=168)
- For the first year after surgery, an outpatient review including a nutritional assessment is recommended to take place every 3 months. — The host summarizing a resource [Ep 3 · 2:58](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=178)
- From the first year onward, nutritional assessments are recommended to occur every 2 years until transition to adult care. — The host summarizing a resource [Ep 3 · 3:10](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=190)
- Lifelong follow-up is now recommended for those born with esophageal atresia. — The host summarizing a resource [Ep 3 · 3:20](https://qa.library.globalcastmd.com/watch/care-and-nutrition-in-esophageal-atresia-an-ernica-animation-for-parents-and-fam-7604?t=200)

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