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Scott Webb (Host): The Pediatric Aerodigestive and Airway Reconstruction Team at Stanford Children's Health, one of the busiest pediatric airway centers in the US, works together to streamline all parts of patient care, constantly striving to provide the best outcome for each patient. And joining me today in this panel discussion are Dr. Douglas Sidell, Associate Professor of Otolaryngology and Director of Lucile Packard Children's Hospital Center for Pediatric Voice and Swallowing Disorders and Pediatric Aerodigestive and Airway Reconstruction Center. And I'm joined by Dr. MyMy Buu. She's a Clinical Associate Professor of Pediatrics Pulmonary Medicine at Stanford School of Medicine. This is Health Talks from Stanford Children's Health. I'm Scott Webb. I want to thank you both for joining me today. Dr. Sidell, I'm going to start with you. What is aerodigestive medicine and how is it different from a more typical approach to patient care?

Douglas Sidell, MD (Guest): Well, aerodigestive medicine involves the coordinated care of children with medical or surgical problems that involve the airways, which would include the voice box and trachea otherwise known as the windpipe, as well as the lungs. It also involves systems like the gastrointestinal tract, which would include things like the esophagus, stomach and the intestines. It also addresses nutritional issues associated with these problems, as well as the mechanics and the therapies that are associated with voice production and feeding and swallow function. So, as you can imagine, just hearing all of that, covering all of these items is a pretty tall order, but the important thing to remember, and really what this clinic, I think is all about, is that these issues can be very, very much related. You know, rarely do we have an isolated issue with only one system where it makes sense to ignore everything else.

Unfortunately, patients who have these types of medical issues, they require a lot of specialists, many different docs, and that means it requires multiple clinic visits and they may need to undergo multiple diagnostic studies or even procedures or surgery in the operating room. This can be difficult for patients and their families. And it comes at the cost of lost days at school or lost days at work for parents and the potential for communication breakdown, not just between two different doctors, but between the patient and the physician. And so it can be downright frustrating and confusing for parents. The Aerodigestive and Airway Reconstruction Center at Stanford Children's Health tries to internalize all of this care by combining all specialists for each child under one roof. And this allows for coordinated clinic visits with all providers, the appropriate review and ordering of diagnostic studies and when needed a combined approach to care in the operating room.

And this has been shown in the literature to reduce the number of times that each child requires an anesthetic. It's known to save time away from school and work. And it's been demonstrated to improve our ability as physicians and care practitioners to correctly diagnose and to treat these aerodigestive disorders. And throughout the entire process, the patient remains a central focus, as they should be. And both parents and their families remain an essential component of the decision-making process. So, they're in this with us and we're in it with them as a team.

Host: I love that. I love that team approach. And Dr. Buu, I want to bring you in. What types of patients or diagnoses are seen at the Pediatric Aerodigestive Center?

MyMy Buu, MD (Guest): So, we see a whole range of different conditions, starting first with the airway problems. So, what that means is problems with the larynx or the voice box, to the trachea, or also known as the wind pipe and these abnormalities can be seen in children when they're born with it, or it can be acquired through their lifespan too.

And so the symptoms that patients may encounter are noisy breathing or difficulty breathing, and some of the conditions include airway narrowing such as subglottic stenosis, trachealmalacia, bronchomalacia. There can also be abnormal airway connections, such as tracheal esophageal fistula, or patients who have devices in their airway, such as a tracheostomy.

So, those are some of the airway issues that we see, and we also will treat children with lung problems, such as chronic cough, chronic respiratory insufficiency, or shortness of breath or difficulty breathing, or for children who have recurrent respiratory infections. And then for the esophagus and gastroesophogeal region, we also see children who have allergic eosinophilic esophogitis or gastroesophageal reflux.

And then for the parents, the symptom that you'll see in your child is swallowing disorders or difficulty eating or difficulty with gaining weight. These are just a snapshot of the various things we see. And, in addition, as a team, we also will optimize patients for airway or lung surgery or other surgeries that can involve the airway or the esophagus.

Host: And Dr. Sidell, you mentioned earlier, sort of everybody under one roof and the benefits to patients and families. So, how many specialties are involved in the care of a typical aerodigestive patient?

Dr. Sidell: That's a great question. And you know, this can vary like so many things from patient to patient, but there are at least two. But more frequently, three or four providers involved and depending on the child's condition and or the question we're really trying to answer, a single patient may have as many as six specialists working to evaluate or treat them in that clinic visit. Our clinic consists of three pulmonologists or lung specialists, three otolaryngologists also known as the ENTs and we're specialists with advanced airways. We have three GI docs, the gastroenterologists. We also have a registered dietician or nutritionist, three speech language pathologists who have special training in voice and swallowing disorders. And we have two pediatric general surgeons with extra training in minimally invasive endoscopic techniques.

And we've got an entire team of coordinators in the clinic, including two advanced practice providers, a registered nurse, and two administrative coordinators. And you know, the bottom line with all of this is that it ensures that when you need anyone on your child's team, you really call this single number and we have this specialized team.

It's not different people, every time. We have the same core team. You don't talk to a random provider, but instead you talk to the people who you know, and trust on your child's care team. So, this can be very helpful along the way.

Host: Yeah, very helpful. And you use that word there, a such a key word in medicine is trust, especially when you're dealing with children and families and Dr. Buu, how do I know if my child should be referred to the Aerodigestive Center?

Dr. Buu: Yeah. So our center sees children from near and far. And so we see patients in our local Bay area community, but we'll also patients in the California or the neighboring states, because we provide expertise in these aerodigestive and airway disorders. And so the referrals can actually come from a child's primary care provider, or a child specialist that is local to them.

But we also will get referrals from families as well. And so if you are listening to this and you feel like your child or your patient has some of these disorders that may need further investigation, then you're welcome to send an inquiry to our program coordinator, through our aerodigestive website. And we'll help you review the case and see if your child or patient would be by our aerodigestive team to help with diagnosis or evaluation, and come up with a care plan.

Host: That sounds great. And Dr. Sidell, you mentioned the team and this team approach, and it sounds like an amazing team of experts there for patients and families to work with and get to know and to trust. So, how does your team decide what evaluation a child needs?

Dr. Sidell: Well, this is often a complex process, but as I alluded to in one of my prior explanations, you know, we work to internalize any of this extra work to make the process as smooth as possible for the patient. And in order to decide what evaluation your child may need, we use what's commonly referred to as an intake process and in this process, an advanced practice provider or nurse will call the family and discuss the medical, surgical and family history pertinent to their care, as well as any diagnostic studies or therapies that a child may have had in the past.

So, we bring all of this together. We then distribute this information among the entire team who reads through it and provides feedback with regard to any additional studies that might be needed in the clinic or in clinic procedures to consider. And then the patient receives a personalized itinerary for the visit and we coordinate all the studies and procedures for the patient based on this input from the team. I think this streamlines the care process quite well. And it's done with careful consideration by all providers involved in the child's care. And so there's no room for real repetition. We've talked about the patient even before we've met them under most circumstances, and we're ready for anything that may come up during that clinic visit.

And another thing I want to mention that builds on what Dr. Buu was mentioning in her previous answer to your question. You know, we see patients near and far and many times patients aren't anywhere close to us. You know, we see patients who are coming from other countries, around the world, as well as across our own country. And this intake process where we actually gather a lot of this information before the child arrives is really important. And it makes that visit to our center very, very efficient.

Host: Yeah. And I want to follow up you talking about the intake and sort of getting to know that the children, the patients before they're actually physically there under that roof that we discussed. Are you doing virtual visits or is there any sort of the screening intake that can be done virtually or maybe just on the phone?

Dr. Sidell: We do actually have virtual visits and we use them frequently for our follow-up visits or just for interval check-ins with the patients. And I think this has been something that has come up over the last two years that has really enhanced our ability to follow patients and to respond to them. And, you know, it's quite surprising how much information you can gather over a virtual visit.

That being said, before we were doing virtual visits, we were also doing very well with just the telephone. You know, talking to somebody saying, hey, what's going on? How can I help you? And actually knowing the patient ahead of time and having that patient know you, it makes all the difference in the world.

Host: I'm sure it does. And just getting used to the sound of each other's voices and that trust factor that we discussed and Dr. Buu, how does the team work with our existing care teams? You know, for a lot of patients, I'm sure it's difficult. They have their primaries and the docs and nurses they're used to seeing, and then they get referred to specialists like yourself and your team there. How does that integration work? How do you work with those existing care teams?

Dr. Buu: Our main goal is to help our patients and to, you know, create a coordinated care plan. And so to do that, we really do want to maintain relationships with the patient's primary and local teams. And so while these patients travel from far away and we provide the expertise for their airway or aerodigestive disorders, we still need ears, eyes, and hands close to home in case of urgent situations, interval issues that come up between visits.

And so, our team will provide an overarching expertise for the airways, lungs, esophagus or swallowing, but we definitely still need that relationship with their primary team. And so we do that through letters, through coordinated communication. Our job is to create one message from our multidisciplinary team to create this package that we provide to the local teams. And we really want the primary care provider to be integral in this communication. And we really feel like that's a key component to our program, that we work with the local teams.

Host: Yeah, that's great to hear. And Dr. Sidell, let's just say my child is seen at the aerodigestive center and gets admitted to the hospital, unfortunately, does the team continue to see patients once they're are admitted?

Dr. Sidell: Yes, they do. Absolutely. We have an inpatient aerodigestive process and any aerodigestive patient who's admitted either in a planned or unplanned fashion, will be seen by our advanced practice provider for evaluation. And based on that assessment, we determine who on the team needs to be involved in the inpatient care. And this is important, because it really allows for the patients to see and be cared for by providers again, who they know and who's already been a member of their care and in doing so, I think this provides that extra level of comfort for patients and their families.

And it also eliminates any other relearning or new learning about a patient and their history that may otherwise be necessary for a new provider. And like Dr. Buu just alluded to, you know, we do rely on the care providers who are maybe on call or on service in the hospital. And part of our job is to bring the information that we have about the patient to those care teams so that they can do their job while they're in the hospital.

And so that we can do ours by representing the patient as a team and providing the information about many of the historical things that may have happened to this patient or in this patient's life up until the point where they're admitted.

Host: Yeah, yeah, and I just love that you're all working so well together. So seamlessly. I'm sure there are some hiccups and bumps in the road, but every attempt is made to really integrate and work well with existing care teams and be everything you can be for patients and families. It's really amazing. This has been an interesting conversation for sure.

As we wrap up here, last word to each of you, Dr. Buu, I'll start with you. What are your takeaways on the Pediatric Aerodigestive and Airway Reconstruction Team at Stanford Children's Health?

Dr. Buu: I'm really honored to be part of this team. I feel like as a lone pulmonologist, trying to see how the lungs interface with the airway interfaces with the esophagus, it's very difficult to be able to talk to colleagues, when we're in different silos. However, now with the Aerodigestive Center, we are all in one room together, talking together. It's actually one of the most fun experiences I have, during the week to get together with my colleagues and to learn from each other, to learn from our great patients who have such great stories and great lives and that we're trying to improve.

Host: I love hearing that, that, you know, doctors and nurses learning from the patients as well, it's a sort of really a two-way street, which is amazing. So, Dr. Sidell, last word to you, either about the center, about the work that you do, your team, anything else?

Dr. Sidell: I think that this is from the outside in, hard work and it's something where, you know, we wake up in the morning early and we go to sleep late. And at the end of the day, you know, you can look at it and say, well, how do we get all of this done? But I gotta say that the patients and the people that we work with on this team, they really make it easy.

They're the center of this. And they're the absolute reason why we do the work that we do. We love what we do because of them. And having this team, as MyMy mentioned is one of the most extraordinary things we can have in our careers. It is something that allows us to cross train between specialties.

We get to pick each other's brain right there on the spot. As an academic physician, my job is to also train residents, medical students, fellows. But thinking of a program where I can actually bring a fellow in to learn otolaryngology, where they get to be a part of a clinic where they can learn about gastroenterology, pulmonary medicine, voice, and swallow, and how that all integrates into disease. Taking care of some of the most complicated patients that there are. I think there's nothing like that in the world. And, I can't be more honored to be a part of this group and a part of our team here at Stanford Children's Health.

Host: That's great. And I know you're both honored and you both love your jobs, and it's been really interesting talking to you both and thank you for sharing your compassion, your expertise. It's an amazing center and amazing team, patients and families are in such good hands. So, thank you both. And you both stay well.

Dr. Sidell: Thank you very much.

Host: To learn more, check out our website at aerodigestive.Stanfordchildren's.Org. And if you found this podcast helpful, please be sure to tell a friend and subscribe, rate, and review this podcast and check out our entire podcast library for additional topics of interest. This is Health Talks from Stanford Children's Health.

I'm Scott Webb. Stay well, and we'll talk again next time.