The diagnostic role of triple endoscopy in pediatric patients with chronic cough

Aerodigestive evaluation of pediatric patients with chronic aspiration

OBJECTIVE

To evaluate the effectiveness of coordinated endoscopy with otolaryngology, pulmonology, and gastroenterology in diagnosing and managing chronic aspiration in pediatric patients.

METHODS

We reviewed our REDCap Pediatric Aerodigestive Database for patients with chronic aspiration who underwent coordinated endoscopy between January 2013 and July 2023. Patient demographics, comorbidities, operative findings, interventions, and outcomes were reviewed.

RESULTS

Forty-nine patients were identified with a diagnosis of aspiration. Their mean (SD) age was 28 (36) months (range 1.2-163 months) with more than half of the patients younger than 24 months. The most common findings noted on combined endoscopies were laryngeal cleft (n = 30), positive bacterial culture (n = 18), positive viral PCR (n = 17), and active reflux-induced esophagitis/gastritis (n = 9). Patients with a positive bacterial culture were associated with a history of recurrent pneumonia (p = 0.009). There were no other significant associations between endoscopy findings and patient demographics, co-morbidities, or symptoms. Twenty-five (51 %) had multiple abnormalities identified by at least 2 different specialists at the time of endoscopy and 6 patients (12 %) had abnormalities across all three specialists.

CONCLUSION

Coordinated endoscopy should be considered in pediatric patients presenting with aspiration on MBS or non-specific symptoms suggestive for chronic aspiration for comprehensive diagnosis and management.

Carbon Footprint Reduction Associated With Multidisciplinary Pediatric Airway Clinics: A Program Evaluation Study

Objective

Health care is a significant contributor to the climate crisis. Multidisciplinary clinics (MDC) may reduce carbon emissions by combining multiple appointments into one. This is the first program evaluation study to quantify the carbon footprint associated with multidisciplinary pediatric airway clinics.

Study Design

Retrospective.

Setting

Children's Hospital at London Health Sciences Center, London, Canada.

Methods

Pediatric airway MDC allows patients to see otolaryngology and respirology in one appointment. The carbon and financial savings (Canadian Dollars) of all patients attending the MDC from January 1, 2018 to December 31, 2022 were calculated. Patient postal codes and institutional parking rates were inputted into the CASCADES carbon accounting tool. Total distance was divided into unsustainable (vehicles) and sustainable (transit, walking, cycling) transportation to calculate carbon emissions. Travel costs included cost/kilometer for vehicles (maintenance, license/registration, insurance, fuel) and costs/ride for transit.

Results

A total of 560 MDC appointments for 300 patients saved 77,785 km. Total carbon emissions saved from travel averted was 16.21 tonnes. The total carbon emissions saved, minus public transit, was 15.60 tonnes. Using the Natural Resources Canada Greenhouse Gas Equivalencies Calculator, 16.21 tonnes are approximately equivalent to 5 passenger vehicles, 6906 L of gasoline, 3.8 homes' energy, and 10.8 homes' electricity use for one year, 36.6 barrels of oil consumed, and 675 propane cylinders. Travel costs of $28,891.83 (no parking), $30,519.40 ($4 minimum parking fee), or $33,774.55 ($12 maximum parking fee) were saved.

Conclusion

MDC effectively reduced carbon emissions and offered patients financial savings. Similar models can be adapted across institutions to help mitigate climate change.

Triple endoscopy and recurrent croup in children: A single aerodigestive center experience

OBJECTIVE

To determine the utility of triple endoscopy (combined direct laryngoscopy, bronchoscopy (DLB), flexible bronchoscopy with bronchoalveolar lavage (FB + BAL), and esophagogastroduodenoscopy (EGD)) in the diagnosis and management of patients with recurrent croup (RC), and to identify predictors of endoscopic findings METHODS: A retrospective chart review was performed of pediatric patients (age <18 years) with RC evaluated by triple endoscopy at a tertiary care pediatric hospital from 2010 to 2021. Data including presenting symptoms, airway findings, BAL and EGD with biopsy findings were collected.

RESULTS

42 patients with RC underwent triple endoscopy were included. The mean age was 4.55±2.84 years old. The most common symptom was chronic cough among 19 (45%) patients, while 23 (55%) patients had gastrointestinal (GI) symptoms. Airway findings included tracheomalacia in 19, laryngeal cleft in 17, and subglottic stenosis in 11 patients. On EGD with biopsy, abnormal gross findings were present in 6 and abnormal microscopic findings in 18 patients, including 6 with histologic findings suggestive of gastroesophageal reflux and 5 with eosinophilic esophagitis. Seventeen (40%) patients had positive culture on BAL. No findings in patient histories significantly predicted presence of lower airway malacia, subglottic stenosis, or abnormal EGD findings.

CONCLUSIONS

Children with recurrent croup presenting to aerodigestive centers may not have any pertinent presenting symptoms that correlate with significant findings on triple endoscopy. Further work is needed to determine which children with recurrent croup may benefit from aerodigestive evaluation.

LEVEL OF EVIDENCE

Level 3.

Factors associated with eosinophilic esophagitis in an urban, tertiary care pediatric aerodigestive population undergoing triple endoscopy

BACKGROUND

Children with aerodigestive dysfunction often undergo triple endoscopy (flexible bronchoscopy, rigid direct laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) for diagnostic evaluation as well as screening prior to airway reconstruction. Prevalence and risk factors for eosinophilic esophagitis (EoE) in this population are poorly understood.

METHODS

A retrospective chart review was performed for pediatric patients, aged 0-21 years, who received a triple endoscopy with biopsy from January 1, 2015, to December 31, 2019, at the Children's Hospital at Montefiore (CHAM). Bivariate and multivariable analyses were used to compare the baseline characteristics between patients with and without EoE to assess for potential predictors of EoE.

RESULTS

Of the 119 cases included in the analysis, 16.0 % (19) received a histopathologic diagnosis of EoE following triple endoscopy. Patients with EoE were more likely to have a family history of eczema (p = 0.02) and a dairy-free diet (p = 0.02). Age, sex, history of environmental allergies, and recency of initiating oral diet were not significantly associated with increased odds of an EoE diagnosis.

CONCLUSIONS

A family history of eczema and a diet lacking allergenic foods, such as milk, may be associated with an increased risk of a future diagnosis of EoE in patients with aerodigestive dysfunction. Larger, multi-institutional studies are needed to identify early predictors of EoE.

Allergic rhinitis facts from an Irish pediatric population

Objective

Assessing the main allergens in the pediatric population from the largest urban area in the country.

Methods

Clinical letters of patients referred with possible allergic rhinitis (AR) were retrospectively reviewed over the past 5 years.

Results

Five hundred and fifty-five patients were included. Males suffer twice as often with AR than females and have high titers of allergens. House dust mites (44.7%) and grass pollen (29%) were the main allergens in our area, with 48% of patients sensitized to both allergens. Half of the patients had the diagnosis of AR confirmed with positive allergen-specific tests. For the other half, the diagnosis was based on a clinical assessment performed by a pediatric otolaryngologist.

Conclusions

Half of suspected AR children have environmental allergen sensitivity confirmed by testing, and a large number had a clinical diagnosis of AR after an otolaryngology consultation. Our findings can help clinicians to initiate AR treatment considering the most problematic allergens in the area.

Pediatric Aerodigestive Medicine: Advancing Collaborative Care for Children With Oropharyngeal Dysphagia

OBJECTIVES

Aerodigestive disorders encompass various pathological conditions affecting the lungs, upper airway, and gastrointestinal tract in children. While advanced care has primarily occurred in specialty centers, many children first present to general pediatric gastroenterologists with aerodigestive symptoms necessitating awareness of these conditions. At the 2021 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the aerodigestive Special Interest Group held a full-day symposium entitled, Pediatric Aerodigestive Medicine: Advancing Collaborative Care of Children with Aerodigestive Disorders. The symposium aimed to underline the significance of a multidisciplinary approach to achieve better outcomes for these complex patients.

METHODS

The symposium brought together leading experts to highlight the growing aerodigestive field, promote new scientific and therapeutic strategies, share the structure and benefits of a multidisciplinary approach in diagnosing common and rare aerodigestive disorders, and foster multidisciplinary discussion of complex cases while highlighting the range of therapeutic and diagnostic options. In this article, we showcase the diagnostic and therapeutic approach to oropharyngeal dysphagia (OPD), one of the most common aerodigestive conditions, emphasizing the role of a collaborative model.

CONCLUSIONS

The aerodigestive field has made significant progress and continues to grow due to a unique multidisciplinary, collaborative model of care for these conditions. Despite diagnostic and therapeutic challenges, the multidisciplinary approach has enabled and greatly improved efficient, high-quality, and evidence-based care for patients, including those with OPD.

Characterization of combined endoscopies and aerodigestive care: An analysis of utilization and financial feasibility

BACKGROUND

Aerodigestive care is one model of multi-disciplinary care, which is a valuable tool for both providers and patients. Aerodigestive care models are associated with improved outcomes, reduced anesthesia exposure, reduction in hospital admissions, and fewer days of missed work or school. This is the first study to explore national usage and cost trends in combined endoscopy utilization to identify gaps in care and the potential for financial resource optimization.

METHODS

Data from the Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Sample (KID) was used from 2016 and 2019. Diagnoses and procedures were identified using ICD-10 codes, for patients with hospital length of stay less than 1 day. Demographic data were identified, and survey-weighted means and proportions were computed. Bivariate comparisons were made using Rao Scott Chi-Square tests. National estimates of charges were computed with discharge weights, developed using the American Hospital Association (AHA) universe.

KEY RESULTS

White, high-income patients, and those at urban teaching hospitals received the greatest proportion of combined endoscopic procedures. The cost/charges associated with combined endoscopies are less than for separate gastrointestinal (GI) or airway only endoscopies combined. However, combined procedures comprise a smaller share of national aggregate cost.

CONCLUSIONS

National utilization trends highlight racial and socioeconomic disparities and suggest differences in access based on hospital characteristics, despite the reduced cost/charges of the combined procedure. For patients with a need for combined aerodigestive procedures, there appears to be a cost-savings opportunity to increase efforts for combined procedures at the level of the clinician or hospital.

Characterization of Eosinophilic Esophagitis in Infants and Toddlers

OBJECTIVES

The objective of this study is to determine demographic and clinical characteristics of infants and toddlers <2 years with eosinophilic esophagitis (EoE) and to assess treatment response in this rarely studied pediatric age group.

METHODS

Retrospective study of children <2 years diagnosed with EoE at a single center from 2016 to 2018. EoE was defined by ≥15 eosinophils per high power field (eos/hpf) on at least 1 esophageal biopsy. Demographics, symptoms, and endoscopic findings were collected via chart review. EoE treatment [proton pump inhibitor (PPI), swallowed steroids, dietary restriction, or a combination] and treatment responses on all follow-up endoscopies were reviewed, with remission defined as <15 eos/hpf.

RESULTS

Forty-two children ages 1.3 ± 0.4 years underwent 3.8 ± 2.3 endoscopies over 3.6 ± 1.7 years of follow-up. Thirty-six children (86%) were male, and comorbidities included atopy (86%), reflux (74%), and a history of cow's milk protein allergy (40%). Common symptoms were feeding difficulties in 67% of patients (with gagging or coughing with feeding in 60% and difficulty with progression to pureed or solid foods in 43%), vomiting (57%), and coughing/wheezing (52%). Of the 37 patients with follow-up endoscopies, 25 (68%) had histologic remission. There was an effect of therapy type on histologic response ( P = 0.004) with the best responses seen on combinations of diet/steroids or diet/PPI and the worst response seen on PPIs alone. All patients showed improvement in ≥1 symptom at the time of first follow-up endoscopy.

CONCLUSIONS

EoE should be considered in young children with feeding difficulties, vomiting, or respiratory symptoms. All patients improved clinically with standard medical or dietary interventions, however there is dissociation between clinical and histologic response with only 2 of 3 patients achieving histologic remission.

Gastrointestinal factors associated with risk of bronchiectasis in children

OBJECTIVE

To evaluate gastrointestinal (GI) risk factors for bronchiectasis in children. We hypothesized that upper GI tract dysmotility would be associated with increased risk of bronchiectasis.

STUDY DESIGN

Subjects in this retrospective cohort study included those evaluated for persistent pulmonary symptoms in the Aerodigestive Center at Boston Children's Hospital who underwent chest computed tomography (CT) between 2002 and 2019. To determine gastrointestinal predictors of bronchiectasis, baseline characteristics, comorbidities, enteral tube status, medications received, gastroesophageal reflux burden, adequacy of swallow function, esophageal dysmotility, gastric dysmotility, and neutrophil count on bronchoalveolar lavage (BAL) were compared between patients with and without bronchiectasis. Proportions were compared with Fisher's exact test and binary logistic regression with stepwise selection was used for multivariate analysis. ROC analyses were utilized to compare BAL neutrophils and bronchiectasis.

RESULTS

Of 192 subjects, 24% were found to have evidence of bronchiectasis on chest CT at age 7.9 ± 0.5 years. Enteral tubes (OR 5.77, 95% CI 2.25-14.83, p < 0.001) and increased BAL neutrophil count (OR 5.79, 95% CI 1.87-17.94, p = 0.002) were associated with increased risk while neurologic comorbidities were associated with decreased risk (OR 0.24, 95% CI 0.09-0.66, p = 0.006). Gastroesophageal reflux was not found to be a significant risk factor. Neutrophil counts >10% had 72% sensitivity and 60% specificity for identifying bronchiectasis.

CONCLUSIONS

Enteral tubes were associated with significantly increased risk of bronchiectasis but gastroesophageal reflux was not. Providers should consider obtaining chest CT to evaluate for bronchiectasis in children found to have unexplained elevated BAL neutrophil count.

The Role of Pediatric Gastroenterologists in the Evaluation of Complex Aerodigestive Disorders

PURPOSE OF REVIEW

Children with aerodigestive disorders frequently have concerns regarding difficulty breathing, swallowing, and growing. In this review, we explored the role of pediatric gastroenterologists in the evaluation of complex aerodigestive disorders and the overall approach to these often-challenging patients.

RECENT FINDINGS

Pediatric gastroenterologists evaluate children with aerodigestive concerns ranging from dysphagia and gastroesophageal reflux to complex congenital abnormalities such as esophageal atresia. Diagnostic tools, such as multichannel intraluminal impedance-pH monitoring, are used for diagnosing gastroesophageal reflux and assessing the correlation with symptoms. Endoscopic evaluation, and in some complex cases, with therapeutic dilations may also be performed. Gastrointestinal dysmotility evaluation with manometry studies are also being increasingly utilized. Multidisciplinary aerodigestive programs can provide a coordinated approach to children with complex airway, pulmonary and gastrointestinal tract disorders. A pediatric gastroenterologist's expertise and specialized skills not only offer many diagnostic tools for these complicated medical cases but are also important in long term medical management.

A multi‐disciplinary approach to chronic cough in children

Objectives

(1) To highlight the important causes of chronic and recurrent cough in children. (2) To discuss multidisciplinary approach to management of chronic/recurrent pediatric cough.

Methods

Review of scholarly articles, guidelines, expert panels via PubMed and Google Scholar.

Conclusion

Chronic cough (CC) in children is mainly attributed to persistent bacterial bronchitis, asthma, nonspecific cough, and gastroesophageal reflux disease (GERD) symptoms. A multi‐disciplinary approach is cost‐effective and aids with earlier diagnosis and appropriate treatment. Congenital or acquired narrowing of the subglottis is the leading ENT cause for recurrent croup (RC) in children. Laryngeal cleft‐type 1 is commonly seen in children with recurrent aspiration and CC. Children are usually referred to pulmonologists for wet cough not responding to treatment. Eosinophilic esophagitis (EoE) and GERD should be considered in the differential diagnosis of CC in children with both respiratory symptoms and failure to thrive.

Level of Evidence: 2a

Anesthesia for pediatric rigid bronchoscopy and related airway surgery: Tips and tricks

Bronchoscopy-guided diagnostic and interventional airway procedures are gaining in popularity and prominence in pediatric surgery. Many of these procedures have been used successfully in the adult population but have not been used in children due to a lack of appropriately sized instruments. Recent technological advances have led to the creation of instruments to enable many more diagnostic and therapeutic procedures to be done under bronchoscopic guidance. These procedures vary significantly in their length and invasiveness and require vastly different anesthetic plans that must be easily adapted to situational and procedural changes. In addition to close communication between the anesthesiology and procedural teams; an understanding of the type of procedure, anesthetic requirements, and potential patient risks is paramount to a successful anesthetic. This review will focus on new rigid bronchoscopic procedures, goals for their respective anesthetic management, and unique tips and trick for how to maintain adequate oxygenation and ventilation in each scenario.

Perioperative respiratory adverse events in children undergoing triple endoscopy

OBJECTIVES

Children with aerodigestive disorders often have many of the reported risk factors for development of perioperative respiratory adverse events. This study sought to evaluate the incidence of such events in this group of patients undergoing general anesthesia for "triple endoscopy" (flexible bronchoscopy with bronchoalveolar lavage, rigid laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) and to identify any patient-specific or procedure-specific risk factors associated with higher incidence of perioperative respiratory adverse events.

METHODS

We performed a retrospective chart review of children 18 years or younger who underwent triple endoscopy as part of an aerodigestive evaluation. Data collected from medical records included: preoperative polysomnography, symptoms of acute respiratory illness, medical comorbidities, demographics, postoperative hospital or intensive care unit admission, and all respiratory events and interventions in the perioperative period. Patient-specific and procedure-specific factors were investigated via univariate analysis for any correlations with perioperative respiratory adverse events.

RESULTS

Of the 122 patients undergoing triple endoscopy, 69 (57%) experienced a perioperative respiratory adverse event. We found no difference in the incidence of perioperative respiratory adverse events among children with documented lung disease compared with those with no lung disease (OR: 0.89, p = .8 95% CI: 0.43, 1.8), and no significant difference between those children who had a respiratory illness at the time of surgery, 1-2 weeks prior, 3-4 weeks prior, and those with no preceding respiratory illness. A higher percentage of males had a perioperative respiratory adverse event, compared with females (OR: 2.7, p = .01 95% CI: 1.3, 5.09).

CONCLUSION

Patients undergoing triple endoscopy for evaluation of aerodigestive disorders at our institution experienced perioperative respiratory adverse events at a rate of 57%.

Development of a Multidisciplinary Aerodigestive Program: An Institutional Experience

We share our experience on the implementation of a multidisciplinary aerodigestive program comprising an aerodigestive team (ADT) so as to evaluate its feasibility. We performed a retrospective chart review of the patients discussed at the monthly ADT meetings and analyzed the data. A total of 98 children were referred to the ADT during the study period. The number of cases increased steadily from 3.5 cases per month in 2019 to 8.5 cases per month in 2020. The median age of patients was 34.5 months, and 55% were male. Among the chronic comorbidities, neurologic disease was the most common (85%), followed by respiratory (36%) and cardiac (13%) disorders. The common reasons for consultation were suspected aspiration (56%), respiratory difficulty (44%), drooling/stertor (30%), regurgitation/vomiting (18%), and feeding/swallowing difficulty (17%). Following discussions, 58 patients received active interventions, including fundoplication, gastrostomy, laryngomicrosurgery, tracheostomy, and primary dilatation of the airway. According to the questionnaire of the caregiver, the majority agreed that the main symptoms and quality of life of patients had improved (88%), reducing the burden on caregivers (77%). Aerodigestive programs may provide comprehensive and multidisciplinary management for children with complex airway and digestive tract disorders.

Patient-Reported Outcomes and Blood-Based Parameters Identify Response to Treatment in Eosinophilic Esophagitis

BACKGROUND

Noninvasive methods to assess treatment response in eosinophilic esophagitis are needed.

AIMS

Our aim was to determine whether a blood-based biomarker panel centered on immune parameters could identify histologic response to treatment in eosinophilic esophagitis patients.

METHODS

A pilot study involving adult patients with active eosinophilic esophagitis recruited at two Ear, Nose, Throat clinics in Sweden was designed. The patients (n = 20) donated blood and esophageal biopsies and filled in three questionnaires before and after a 2-month course of topical corticosteroids. Blood samples were analyzed for absolute levels of granulocytes and T cells and the fractions of eosinophils expressing 10 different surface markers by flow cytometry. All data were analyzed by multivariate methods of pattern recognition.

RESULTS

Multivariate modeling revealed that a combination of 13 immune parameters and 10 patient-reported outcome scores were required to create a model capable of separating responders (n = 15) from non-responders (n = 5). Questions regarding symptoms of esophageal dysfunction and capacity to eat certain foods from two of the questionnaires were discriminatory in the multivariate model, as were absolute counts of T cells, eosinophils, and eosinophil expression of activation markers and cell adhesion molecules.

CONCLUSIONS

A combination of blood-based immune parameters and directed questions may prove helpful to monitor response to treatment, perhaps reducing the need for repeat endoscopies in eosinophilic esophagitis patients in the future.

Should computed tomography and bronchoscopy be routine examinations for chronic cough?

Chronic cough is a common symptom of many diseases. Guidelines on cough from different countries recommend chest X-ray as the first-line examination. However, as compared to computerized tomography (CT), chest X-ray is insensitive in the diagnosis of many diseases. We speculate that CT is more helpful in excluding the causes of long-term cough, such as bronchial tumors and pulmonary interstitial diseases, which prevents patients from receiving unnecessary examinations and diagnostic treatments for chronic cough. In addition, a single chest CT is safe and affordable in some regions. Therefore, chest CT may be recommended as a first-line examination for patients with chronic cough. In addition, although bronchoscopy is employed as a further examination for chronic cough, it plays an important role in the diagnosis of chronic cough, especially in rare bronchial diseases such as amyloidosis and foreign body inhalation. Induced sputum cytology was not accepted as a necessary examination for chronic cough, but it becomes a first-line examination until physicians recognize that non-asthmatic eosinophilic bronchitis is a common cause of chronic cough. Therefore, we speculate that the roles of chest CT and bronchoscopy in the identification of causes of chronic cough are increasingly important; in some regions, or for patients suspicious for uncommon causes of chronic cough, CT and bronchoscopy are recommended as first-line examinations.

Proton Pump Inhibitors in Children: the Good, the Bad, and the Ugly

PURPOSE OF REVIEW

The evidence supporting or contesting the prescription of proton pump inhibitors (PPIs) for children and updates on side effects are reviewed.

RECENT FINDINGS

PPIs remain an important therapeutic option for esophagitis and gastritis. However, recent studies demonstrate no benefit when prescribing PPIs for chronic cough, infantile reflux, asthma, or functional gastrointestinal disorders. Recent studies suggest adverse effects on microbiome diversity and immune function, resulting in increased rates of gastrointestinal infections, bone fractures, and atopic disorders. PPIs influence a variety of cell types within the in the innate and adaptive immune systems. PPI prescriptions in children may be indicated for select conditions; however, multiple side effects and immune effects have been described. While most of these side effects are rare and mild, some studies suggest enduring adverse effects. Future studies to elucidate the mechanism behind some of these immune and infectious complications will be beneficial.