QUAD #16 - Flexible Bronchoscopy in Management of Slide Tracheoplasty Patients - Sara Zak
With Dr. Sarah Zack · hosted by Dr. M. Goddy · StayCurrentMD
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What the experts said
At Cincinnati Children's, pulmonologists perform the majority of flexible bronchoscopy, though this is not standard practice elsewhere.
Flexible bronchoscopy is indicated at every point in patient care for slide tracheoplasty: preoperatively, intraoperatively, and postoperatively.
Infection can increase risk for dehiscence complications postoperatively after slide tracheoplasty.
BAL is always obtained preoperatively before slide tracheoplasty at Cincinnati Children's.
In a case of an 11-month-old with trisomy 21 and complete tracheal rings, supraglottoplasty and adenotonsillectomy were performed before slide tracheoplasty due to large tonsils, pharyngomalacia, curling epiglottis, and obstructive arytenoids.
Intraoperative bronchoscopy can help with intubation and ensure correct tube position, especially in children with congenital issues that make exposure difficult.
Intraoperative bronchoscopy can identify figure-8 deformities and leaks at the anastomotic site.
Life-threatening complications can occur after slide tracheoplasty procedures.
A bronchoscopy cart can be quickly brought to the ICU without moving the patient to evaluate the repair site.
Postoperative bronchoscopies are commonly done on younger children, those with heart disease, those on bypass, and those with prior airway surgeries, but nothing is published about this.
135 thoracic slide tracheoplasties were performed at Cincinnati Children's between January 2010 and September 2021.
The most common indication for slide tracheoplasty was complete tracheal rings, followed by acquired or congenital tracheal stenosis and tracheoesophageal fistula.
The mean age at time of slide tracheoplasty was 2.5 years.
The majority of slide tracheoplasties were performed on cardiopulmonary bypass.
21% of slide tracheoplasty patients had a preoperative tracheostomy.
28% of slide tracheoplasty patients had prior airway surgery that did not include preoperative tracheostomy.
Just over a third of slide tracheoplasty patients had underlying genetic conditions like trisomy 21, CHARGE syndrome, or VACTERL.
About a third of slide tracheoplasty patients were premature at the time of the procedure.
38 of 135 slide tracheoplasty patients required at least one urgent postoperative flexible bronchoscopy.
The mean postoperative day for urgent bronchoscopy was day 3, most commonly on day 1.
Children requiring urgent postoperative bronchoscopy were younger (just under 1 year, range 2 days to 8 years) compared to those not requiring bronchoscopy (mean 2.5 years, range 2 weeks to 20 years), a statistically significant difference.
No patient older than 8 years required an urgent postoperative flexible bronchoscopy in this dataset.
Smaller, sicker children and those with prior airway interventions are more likely to have postoperative complications after slide tracheoplasty.
Understanding risk factors for postoperative complications can help ensure the right team is in place, counsel families on expectations, and potentially modify preoperative or intraoperative management.
The most important factor is having someone skilled with the bronchoscope who knows what they are looking at and how to handle complications.
There is no standard practice for how to incorporate flexible bronchoscopy into airway procedures.
Preoperative BAL results help select perioperative antibiotic therapy.
Intraoperative bronchoscopy can assess the anastomotic site without putting tension on the trachea, either with chest open or closed.
ENT surgeons at Cincinnati Children's have pulmonology join in pretty much every post-op evaluation in the operating room.
About 60% of slide tracheoplasty patients were male.
Most common associated conditions were congenital heart disease including ASD, VSD, pulmonary artery slings, and other congenital lesions.
Congenital heart disease, need for positive pressure ventilation (invasive or noninvasive), and history of prior airway surgery were associated with requiring urgent postoperative bronchoscopy.