Chronic pulmonary aspiration (CPA) in children is an important cause of recurrent pneumonia, progressive lung injury, respiratory disability and death. It is sporadic, intermittent and variable, and often occurs in children with complicated underlying medical conditions and syndromes that produce symptoms indistinguishable from CPA. For most types of aspiration there is no gold-standard diagnostic test. The diagnosis of CPA is currently made clinically with some supporting diagnostic evaluations, but often not until significant lung injury has been sustained. Despite multiple diagnostic techniques, the diagnosis or exclusion of CPA in children is challenging. This is of particular concern given the outcome of unrecognised progressive lung injury and the invasiveness of definitive therapies.Although new techniques have been introduced since the 1990s and significant advances in the understanding of dysphagia and gastro-oesophageal reflux have been made, characterisation of the aspirating child remains elusive.

Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients.

Bronchiectasis is highly prevalent in children with CPA and its presence in young children demonstrates that it can develop rapidly. Early identification of bronchiectasis, along with interventions aimed at preventing further airway damage, may minimize morbidity and mortality in patients with CPA.

Corresponding author's email: Paul.Boesch@cchmc.orgPressure ulcers are commonly acquired in pediatric institutions and are a key indicator of standard and effectiveness of care. Rationale:Pressure ulcers are associated with pain, infection, and length of hospitalization. Tracheostomy tubes cause pressure ulcers by creating a constant pressure interface with further disruption of skin integrity due to wetness from sweat and respiratory secretions. We recognized a high rate of tracheostomy-related pressure ulcers (TRPU) in our ventilator unit and instituted a quality improvement program to develop and test potential interventions for TRPU prevention. We condensed them into a clinical bundle, and then implemented it into standard clinical practice.The setting was an 18-bed multidisciplinary unit within an academic children's hospital, whose primary mission is transition of Methods: children requiring invasive mechanical ventilation to home. All tracheostomy-dependent patients from July 2008-August 2010 were included. TRPU stage, description, number of days each TRPU persisted, and bundle compliance were recorded in real time. All TRPU were staged by a wound-care expert within 24 hours. The intervention model utilized a rapid-cycle, Plan-Do-Study-Act (PDSA), framework for improvement research. The interventions identified for incorporation into the TRPU-prevention bundle included the following: Skin Braden Q risk assessment and full body skin assessments daily, and device assessments every 8 hour shift, assessment:Moisture-free Hydrophilic polyurethane foam under tracheostomy to wick moisture from the skin surface, device interface:Pressure-free device "extended" style tracheostomy tubes in children with anatomy in which the neck was not clearly exposed in the neutral position interface: (figure 1). Figure 1 Fit of standard vs. extended-style tracheostomy tube in ventilated infant. Note the crowding of the ventilator circuit in the neck with focal pressure of the adapter edge against the sternum. This is the site of 72% of the TRPU that developed during the study period.Over the study period there were 717 patients and 8770 trach days evaluated; 22 TRPU were identified. There was a significant Results: decrease in the rate of patients who developed a TRPU from 8.1% during the baseline period, to 2.6% during bundle development, and 0.5% after the bundle was implemented (figure 2). The percentage of trach days affected by a TRPU decreased from 12.5% to 0.4% between baseline and implementation periods. There was a marked difference between standard and extended tracheostomy tubes in TRPU occurrence (3.7% vs 0%, P=0.035) and days affected by a TRPU (6% vs 0.2%, P<0.0001). Figure 2

Education and ongoing assessment of skin integrity and the use of devices that minimize pressure at the tracheostomy-skin interface effectively reduce TRPU even among a population of children at high risk. These interventions can be integrated into daily workflow and result in sustained effect.

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5. Laryngoscope, 2018.