Katherine Hart

142 statements · 4 topics · summaries given as host listed separately

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There's a lot of controversy about the timing of all of this, but really what it boils down to is if you have a child who's got ongoing respiratory symptoms, they're having aspiration, they're failing to thrive, they're having recurrent pulmonary infections, and they've failed all the other stuff, or in some instances before you even try all the other stuff, you operate on them.

quote · Aerodigestive / ENT

It doesn't matter if you do this in a mass closure technique or a layered closure technique, but the key is when you're done, you have to make sure that your edges are inverted.

quote · Aerodigestive / ENT

I always prefer to go with cold steel, especially on the minor ones, because it's more simple to set up, and you can't have a laser fire if you don't use the laser.

quote · Aspiration

When you compare conservative management. Other different therapies in either injection or surgical closure, get resolution over time in 51% of kids.

quote · Aspiration

When you look at injection laryngoplasty in this big group, they get improvement in symptoms in 2/3 of kids with resolution in 1/3.

quote · Laryngeal Cleft

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.

clinical · CHARGE Syndrome

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Katherine's statements about Aerodigestive / ENT 64 statements

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Aerodigestive Management of Pediatric Aspiration - FULL SHOW

Statement 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. Open

Statement Aspiration can be silent with no clinical indication, or obvious with coughing, choking, and sputtering. Open

Statement 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. Open

Statement Children with severe neurologic compromise regardless of etiology should be assumed to aspirate until demonstrated otherwise. Open

Statement 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. Open

Statement A single aspiration event of caustic substance can have lifelong consequences. Open

Statement 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. Open

Statement Four major groups aspirate: premature babies, those with neurologic disabilities, those with airway disease (anatomic, dynamic, or functional), and those with gastrointestinal disorders. Open

Statement Syndromes with significant swallowing dysfunction include CHARGE, Cri-du-chat, Möbius syndrome (cranial nerve abnormalities), and craniofacial defects like Pfeiffer, Crouzon, and Treacher Collins. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement Having a tracheostomy tube changes the dynamics of laryngeal elevation but most studies show it does not create aspiration. Open

Quotation It's not what you get in, it's how you get it out. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement Cuff tubes cannot stop aspiration because inflating the cuff enough to decrease leak causes unacceptable tracheal injury or dilation. Open

Statement 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. Open

Statement 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. Open

QUAD #20: Endoscopic Repair of Minor Laryngeal Clefts with Dr. Catherine Hart

Quotation This is a child. We had a really high index of suspicion had a cleft, and you can see there that that looks. Incredibly normal on that flexible bronchoscopy. Open

Statement A type 1 laryngeal cleft can appear normal on flexible bronchoscopy but be visible on rigid bronchoscopy using less sophisticated identification techniques. Open

Quotation And even here using the less sophisticated technique that we use to identify cleft in Cincinnati, you can see this kid's got a type 1 cleft. Open

Statement Combined flexible and rigid bronchoscopy evaluations are complementary and necessary to avoid missing laryngeal clefts. Open

Quotation So I think this really speaks to the importance of these combined evaluations that we do, and those two evaluations are truly complementary, and you miss stuff if you don't do them both. Open

Quotation There's a lot of controversy about the timing of all of this, but really what it boils down to is if you have a child who's got ongoing respiratory symptoms, they're having aspiration, they're failing to thrive, they're having recurrent pulmonary infections, and they've failed all the other stuff, or in some instances before you even try all the other stuff, you operate on them. Open

Statement Surgical indications for laryngeal cleft repair include ongoing respiratory symptoms, aspiration, failure to thrive, recurrent pulmonary infections, and failure of conservative measures (or in some instances before trying conservative measures). Open

Statement Mass closure or layered closure technique can be used for laryngeal cleft repair, but the key requirement is that edges must be inverted when finished. Open

Quotation It doesn't matter if you do this in a mass closure technique or a layered closure technique, but the key is when you're done, you have to make sure that your edges are inverted. Open

Statement Cold steel is preferred over laser for minor cleft resection because it is simpler to set up, faster, and eliminates the risk of laser fire. Open

Quotation I always prefer to go with cold steel, especially on the minor ones, because it's more simple to set up, and you can't have a laser fire if you don't use the laser. Open

Quotation That's why we typically do it this way, and it's just a heck of a lot faster. Open

Statement Closure is performed using interrupted sutures, typically PDS on an RB1 or P3 needle depending on child size. Open

Statement Postoperatively, children are observed overnight on the airway unit and resume their preoperative diet, which is continued until postoperative evaluation. Open

Statement Postoperative evaluation is typically performed 6 to 8 weeks after surgery and includes repeat video swallow study and repeat endoscopy to ensure healing. Open

Statement Failure of endoscopic cleft repair is not super common. Open

Statement Incomplete demucosalization at the apex can result in healing at the top but a gap remaining at the back. Open

Statement Layered closure technique (closing anterior and posterior portions separately) seems like more effort in minor clefts but is a more reasonable option for type 2 or 3 clefts to ensure good closure. Open

Quotation When you compare conservative management. Other different therapies in either injection or surgical closure, get resolution over time in 51% of kids. Open

Statement Conservative management (not surgery) achieves resolution over time in 51% of children with laryngeal clefts. Open

Quotation So by doing not nothing, but not doing surgery, you can still get improvement in a lot of patients. Open

Quotation When you look at injection laryngoplasty in this big group, they get improvement in symptoms in 2/3 of kids with resolution in 1/3. Open

Statement Injection laryngoplasty achieves improvement in symptoms in two-thirds of children and resolution in one-third. Open

Statement Complications of surgical cleft repair are often not terrible but include reports of laryngeal scarring, supraglottic infections, and lacerations. Open

Katherine's statements about Aspiration 39 statements

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