Multidisciplinary approach to paediatric aerodigestive disorders: A single‐centre longitudinal observational study

Abstract

Aim: Aerodigestive clinics (ADCs) are multidisciplinary programmes for the care of children with complex congenital or acquired conditions affecting breathing, swallowing and growth. Our objective was to describe the demographic, clinical, etiological and investigational profile of children attending the inaugural ADC at a tertiary paediatric centre in Queensland. Methods: Children referred to the ADC at Queensland Children's Hospital from August 2018 to December 2019 were included. Data on clinical, growth and lung function parameters, bronchoscopy and upper gastrointestinal endoscopy findings, thoracic imaging and comorbidities were retrospectively analysed. Results: Fifty-six children (median (range) age 4 years (3 months-15 years); 18 female) attended the ADC during this 17-month period. Forty-six (82%) children had previous oesophageal atresia with tracheo-oesophageal fistula; 43 of these were type C. Previous isolated oesophageal atresia, congenital diaphragmatic hernia and congenital pulmonary malformation were the underlying disorder in three (5%) children each, with one child having a repaired laryngeal cleft. Vertebral Anal Tracheo Esophageal Renal Limb anomalies (VACTERL)/Vertebral Anal Tracheo Esophageal renal anomalies (VATER) association was seen in 21 (38%) children. Growth was adequate (median weight and body mass index z-score −0.63 and −0.48, respectively). Thirty-four (61%) children reported ongoing wet cough, with 12 (21%) requiring previous hospital admission for lower respiratory tract infection. Fourteen (25%) had bronchiectasis on computed tomography chest and 33 (59%) had clinical tracheomalacia, apparent on bronchoscopic examination in 21 patients. Dysphagia was reported in 15 (27%) children, 11 (20%) were gastrostomy feed-dependent and 5 (9%) had biopsy-proven eosinophilic oesophagitis. Conclusion: High proportion of children attending the ADC have ongoing respiratory symptoms resulting in chronic pulmonary suppuration and bronchiectasis. Potential benefits of this model of care need to be studied prospectively to better understand the outcomes.

Gastrointestinal factors associated with risk of bronchiectasis in children

“…We did not find a significant relationship for aspiration in the present cohort, but it is possible that this is related to our older pediatric population, where swallowing dysfunction associated with developmental immaturity may have been outgrown 35 . Other groups have reported increased incidence of bronchiectasis in aerodigestive center populations and therefore the underlying conditions commonly seen in this population might put these patients at increased risk 12 …”

“…With the growth of multidisciplinary aerodigestive centers, many patients with persistent pulmonary symptoms undergo triple airway endoscopy as an initial part of their workup before consideration of chest CT 49 . This approach commonly includes flexible bronchoscopy with bronchoalveolar lavage and the results are typically interpreted in the multidisciplinary aerodigestive context 8,12–14 . Prior studies have shown an association between bronchiectasis and BAL neutrophil count and the results our ROC analysis are similar 24,50,51 .…”

“…In particular, no prior studies have examined the gastrointestinal risk factors contributing to bronchiectasis; however, with the development of aerodigestive programs, the role of the gastroenterologist in multidisciplinary care has become more central to the diagnosis and management of these patients 12–14 . One of the primary diagnoses considered is swallowing dysfunction with resultant aspiration which has been shown to play a role in pediatric and adult bronchiectasis 8,15 .…”

“…10,11 In particular, no prior studies have examined the gastrointestinal risk factors contributing to bronchiectasis; however, with the development of aerodigestive programs, the role of the gastroenterologist in multidisciplinary care has become more central to the diagnosis and management of these patients. [12][13][14] One of the primary diagnoses considered is swallowing dysfunction with resultant aspiration which has been shown to play a role in pediatric and adult bronchiectasis. 8,15 Other diagnoses are also critical to consider including upper gastrointestinal dysmotility and gastroesophageal reflux disease (GERD) since these conditions can have significant symptom overlap and are commonly considered in children with bronchiectasis.…”

Flexible Bronchoscopy Diagnosis of Uncommon Congenital H-type Tracheoesophageal Fistula, Dual Fistulae, Bronchoesophageal Fistula, and Recurrence of Fistula in Children

“…We have adopted a multidisciplinary model of care including pulmonology, gastroenterology, surgery, speech therapy, physiotherapy, respiratory scientists, and clinical nurse practitioners. 42 As with any diagnostic procedure, the sensitivity will be dependent on the skill of the proceduralist. We acknowledge that the positive TEF identification rate may be more dependent on the expertise and procedural dexterity of the bronchoscopist compared with the radiologic techniques.…”