Ryne Simpson

Introduction: The Pediatric Mechanical Ventilation Society is a collaboration of pediatric pulmonologists with a focus on pediatric chronic home invasive ventilation (PCHIV). Since the initial discharge on PCHIV is not always directed by pediatric pulmonologists, we sought to understand how this variability between centers impact adherence to American Thoracic Society (ATS) guidelines for PCHIV. Methods: A survey was distributed to pediatric pulmonologists across multiple platforms inquiring about discharging practices for PCHIV and adherence to six of the nine ATS recommendations for PCHIV. Two subgroups were created based on common practices — discharge by pediatric pulmonologists from a non‐ICU unit (pulmonary group) and discharge by ICU team from an ICU unit (ICU group). Results: A total of 107 surveys were completed, 90 from the US. Among the US centers, the ATS recommendations with lowest adherence were offering ongoing education to caregivers and the utilization of standardized criteria for discharge. Despite better adherence, the requirement of two caregivers for discharge was often made an exception for. When comparing the pulmonary and ICU groups, the number of annual discharges ( p < 0.001), caregiver length of training ( p = 0.003), and the utilization of standardized discharge criteria ( p = 0.04) were significantly different. Discussion: Our study demonstrates variable adherence to expert consensus recommendations outlined by the ATS. A significant proportion of PCHIV patients were discharged directly from the ICU and by ICU teams. Practice variability was evident between institutions and discharging teams; therefore, the identification of barriers to guideline implementation and multidisciplinary collaboration is paramount to optimizing care.

Objectives: Low molecular‐weight hyaluronic acid (LMW‐HA) is produced by the degradation of high‐molecular‐weight hyaluronic acid at the pulmonary interstitium and alveolar epithelium by reactive intermediates following lung injury. We aimed to investigate the role of bronchoalveolar lavage (BAL) LMW‐HA as a biomarker of pediatric chronic pulmonary aspiration (CPA).Methods: Single‐center prospective comparison of LMW‐HA presence in BAL in pediatric Aerodigestive patients with and without CPA undergoing clinically indicated bronchoscopy. Pediatric pulmonologists diagnosed CPA based on video‐fluoroscopic swallowing evaluation.Results: Fifteen children (mean age 6.1 years, male predominance at 73%, and 53% with CPA) were enrolled. Children with CPA have comparable baseline characteristics (age, sex, and race), but their BAL had higher white blood cell count, higher neutrophil percentages, higher bacterial culture positivity rates, and lower macrophage percentages than those without CPA. The two groups were comparable in sex, BAL lymphocyte percentages, eosinophil percentages, red blood cell counts, and lipid‐laden macrophage positivity. Detection of BAL LMW‐HA in the BAL had a 100% specificity and 88% sensitivity for CPA diagnosis. BAL protein levels were higher in the CPA group and in participants with positive LMW‐HA.Conclusions: We suggest BAL LMW‐HA as a potential novel biomarker of pediatric CPA with high specificity and sensitivity. BAL LMW‐HA is not detectable in subjects without CPA and is associated with increased BAL protein levels.

Introduction: Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) are frequently performed in children with known or suspected aspiration, however, the additive value of FB in conjunction with direct laryngoscopy and rigid bronchoscopy (DLB) has not been previously quantified. This study details the common endoscopic/cytological findings and associated management impact of FB and BAL in pediatric Aerodigestive patients undergoing combined airway evaluation (FB and DLB) for oropharyngeal dysphagia.Materials and Methods: A retrospective chart review was performed in children <3 years of age followed through a large Aerodigestive center undergoing outpatient, combined airway endoscopy for dysphagia. Patient and procedural characteristics, endoscopic and BAL findings, and management metrics were collected and analyzed. A secondary analysis evaluated the association between endoscopic findings and medication changes.Results: Ninety-one procedures (median patient age, 15 months) were identified. All procedures included both FB and DLB, and just over half (52.7%) included esophagogastroduodenoscopy. Common endoscopic findings included bronchitis (73.6%), adenoidal hypertrophy (31.9%), and tracheomalacia (10.8%). BAL cytology frequently identified neutrophilic inflammation (mean 39.6% neutrophils [interquartile range 6.5%-71%)]. Cultured pathogens commonly included Streptococcus viridans (46.6%), Hemophilus influenzae (36.3%), Moraxella catarrhalis (30.1%), and Streptococcus pneumoniae (25.0%). FB and BAL results contributed to clinical decisions in 65 of 91 (71.4%) patients. Endoscopically-diagnosed bronchitis (odds ratio [OR] 7.27, 95% confidence interval [CI] 2.4-21.99) and tracheomalacia (OR 5.79, 95% CI 1.20-27.85) were significantly associated with increased odds of medication adjustments following FB.Conclusion: In pediatric Aerodigestive patients undergoing combined airway evaluation for oropharyngeal dysphagia, FB and BAL are high-yield and clinically impactful procedures.