by Adam Kronish, MD (’22)
Pediatric Pulmonology Elective

Dear Hasbro Blogosphere, 

My May elective was scheduled to be pulmonology, where one of my goals for the elective was to learn more about the management of our patients with chronic respiratory problems, from children with moderate-to-severe asthma to those kids that are tracheostomy- and technology-dependent. I decided to focus on aspiration in pediatric patientslargely after the last patient I admitted to the pulmonology service as the yellow team intern in April.  In particular, I was daunted by the reconciliation of my patient’s medications and “airway clearance sick plan.”

Aspiration is the result of pathologic changes affecting children’s ability to protect their airway and subsequently from their own upper respiratory secretions or substances that they ingest. Though patients with anatomic problems with the upper airway/GI tract are at risk, over the past year I’ve found that more commonly we discuss aspiration in the context of patients with acute and chronic neuromuscular disorders (Guillain Barre syndrome, autoimmune or infectious encephalopathy, status epilepticus, cerebral palsies, severe hypotonia, etc.). This was the case with my patient on Yellow Team.

The rate of aspiration, especially “silent aspiration” may be as high as 80% in patients with complex chronic diseases (Tutor, 2020). They are at risk for aspiration pneumonia, which is a poly-microbial infection (most often with gram negative enteric and oral anaerobic bacteria). In pediatrics, coverage of anaerobes beyond coverage of gram negatives is associated with decreased length of stay and less likely respiratory failure (Thomson et al., 2019). 

Ways to prevent aspiration in these patients involve a multidisciplinary approach:

1) Speech-Language pathology helps with feeding modifications and swallow evaluation
2) Nutrition/Feeding teams help manage non-PO feeds (via NG, G- or J- tube) if needed
3) Medications or procedures may decrease salivation (glycopyrrolate, scopolamine, Botox, surgical ligation of ducts
4) Airway clearance with medications and devices 

I delved deeply into learning about airway clearance methods and divided the interventions into (1) those that mobilize secretions and (2) those that clear them. I watched many Youtube videos to better picture how these devices work physiologically (interestingly, the models for the videos are more often old men with COPD than children with neuromuscular disorders). I learned an alphabet of acronyms for clearance methods including PEP, IPV, CPT, CAD.Overall, I grew to appreciate the complexity of home-care for these patients. Families have to navigate and learn to properly administer these treatments at least twice daily and sometimes triple that if they are sick. Additionally, they have to coordinate with insurance and medical device companies for the cost and maintenance of these regimens.

Next time I get overwhelmed by the med rec of a “complex care patient” and their “sick plan”, I’ll take a moment, take a deep breath, and remember that however frustrating it may be for me to find the “Sick plan” documented in EPIC, these families have an exponentially more demanding time taking care of these children to prevent them from coming into the hospital. 

☺ Breathe easy ☺

*Positive Expiratory Pressure, Intrapulmonary Percussive Ventilation, Chest Physiotherapy, Cough Assist Device