Driving Patient Care and Research to Treat Pediatric Aerodigestive Disorders

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology-head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center in our Head and Neck Institute. You can follow me on Twitter @PaulCBryson, and you can get the latest updates from our institute by following @CleClinicHNI, that's @CleClinicHNI.

Today I'm looking forward to talking with my friend and colleague, Dr. Brandon Hopkins, Vice Chairman of Growth and Program Development in our Head and Neck Institute. Dr. Hopkins is also Assistant Professor and Section Head of Pediatric Otolaryngology-Head and Neck Surgery and Surgical Director of our Pediatric Center for Airway, Voice and Swallowing at Cleveland Clinic Children's. You can follow him on Twitter @otopeds_hopkins, that's @otopeds_hopkins.

Dr. Hopkins, welcome to Head and Neck Innovations.

Brandon Hopkins: It's delight to be here, Paul. Thanks for having me.

Paul Bryson: Well, it's our pleasure, really looking forward to highlighting some of your work and congratulations to the many programs and processes and research projects that you have going on in the system to improve our outcomes and improve the quality of life of our patients. I wanted to, can you start just by giving us some of your background for our listeners, where you're from, where you trained, how you got to Cleveland Clinic?

Brandon Hopkins: Sure, Paul. I'm from East Tennessee. My wife every year pulls me a little further north of the Mason Dixon line. It's been a good journey. I trained at East Tennessee State University for medical school, and then I spent five years in Cincinnati. I think that's probably where a lot of my kind of background in kind of aerodigestive care and complex upper airway anatomy kind of came from is my time in Cincinnati. That's what really sparked my interest from a pediatric standpoint.

I went to fellowship at UC Davis with the intent goal of expanding that airway knowledge to be able to do kind of bony work, mandible distractions, things beyond kind of standard pediatric airway care. Then I was fortunate enough to find a position here at Cleveland Clinic, almost is it nine years ago now. Time flies when you're having fun, for sure. We've almost, we're no longer early career faculty, Paul. We're currently in the gray senility of our mid-career.

Paul Bryson: No, I mean solidly mid-career, for sure. I also wanted to highlight just with your fellowship experience. I know you got to provide a lot of care and surgical care for patients with cleft lip and palate.

Brandon Hopkins: I mean, it was a really unexpected and amazing opportunity. I went out to California with the intent purpose of coming back to Cincinnati Children's and expanding kind of the breadth and scope that they provided. My goal was to come back and be very competent at bony anatomy.

Cincinnati's well known for their aerodigestive center and being able to cannulae people. The goal when I went out there was to kind of expand on that knowledge. It was that added bonus when I arrived there that so much of probably 50% of my training was in cleft cranial facial care and overseas mission work and that type of endeavor. It's been great to have that skill set and really kind of benefit from that, both from a skillset standpoint, but also the opportunities it provides on a yearly basis to go and work overseas and kind of show the world what we can do at Cleveland Clinic from a surgical standpoint's really great.

Paul Bryson: Our listeners specialize in many different fields across medicine. Can you give an overview of what conditions fall under pediatric aerodigestive disorders?

Brandon Hopkins: Our snazzy name here is PCAVS. Originally it was the Pediatric Cavaliers, P Cavs, but I think across the country, the overall name is am aerodigestive center. Children with complex upper airway anatomy, these children often suffer from breathing difficulties. They suffer from pulmonary issues. Along with that, it's GI issues.

Children have to do three things really well at the same time. They have to feed, they have to breathe and they have to swallow. Anytime one of those three systems is out of whack, it impacts the other three greatly. I think that there is a huge population of these children that have really complex needs and are kind of out of scope for a general pediatric population and really deserve and require team care, or they really slip through the cracks. They end up with tons of hospitalizations, ER visits and really bad things that can happen if you're not paying really close attention to them in a kind of organized way over time.

Paul Bryson: It's probably hard for patients and families to try to get all of the physicians together at the same time without sort of a team model.

Brandon Hopkins: I think that the burden for these families with kind of complex children, a lot of them were born premature with multiple organ systems involved. I mean, imagine for me to take time off to take my typically developing children to the pediatrician is a huge burden on my life. Many of these families have four, five, 10 appointments per week with multiple providers, physical therapists, speech pathologists, swallowing specialists, to be able to coordinate that all together as a parent is almost impossible. The only way that quality care gets delivered is if you can put the providers in the same place at the same time. I think that's what the theory of aerodigestive care really kind of centers around.

Paul Bryson: With this large spectrum of organ systems that are connected, what are some of the other specialties that you collaborate with in the PCAVS?

Brandon Hopkins: I think that we have a really robust team. I think one of the things that makes our team a little different around the country is we like to think of ourselves as a medical home. A lot of places are really focused on what is your surgical problem and how can we address that and then move you back to your home institute.

I think we have a little broader scope and have a coordination of pediatric laryngology head and neck surgery, pediatric pulmonary, the pediatric GI team. That's the center of most aerodigestive programs. But I think our scope is expanded a little bit where we also include speech language pathology, nutrition. We also have the physical medicine and rehabilitation team. We have access to complex sleep from a medical standpoint for these children. Then we pull in developmental pediatrics, our down syndrome clinic. We really are the hub of the wheel for a lot of these complex kids that see multiple providers.

Paul Bryson: You mentioned some of the surgeries. What are some of the more innovative surgeries that take place in the center that you're passionate about being a part of?

Brandon Hopkins: This population is really interesting because you have such a wide range of patients. We have some patients who are again typically developing, but have a very specific complex airway problem that can be addressed with a specific surgery, whether that's glottic level stenosis in a two year old where we can provide an endoscopic graft, a surgery where we can make these children sleepy, place a graft, wake them up either the same day or two or three days later, and their problem's fixed and they can go home and they really don't need further ongoing care. That's one end of the spectrum.

The other end of the spectrum is a child who maybe is wheelchair bound has cerebral palsy and is tracheostomy dependent for this patient. For this patient and this family, optimizing their quality of life may not be removing their tracheostomy tube or having them be typically developed. In those children, it's really how can we optimize their quality, the family's quality of life? How can we make their care as straightforward and safe for the family? How can we help them get to Disney World, travel, enjoy life with their family, enjoy life with their kids? For those families, that may be surgeries that decrease drooling, surgeries that decrease reliance on mechanical ventilation and interventions in coordination with our speech team and our pulmonary team to get these children speaking. Just because our children are on ventilators doesn't mean that they can't speak and want to communicate. It may even mean partnering with our ear surgeons to be able to provide cochlear implants and hearing care to optimize the sensory input from the world.

I think that each child that comes through this clinic is approached as an individual and what interventions, whether it's surgery or medical, can be done to optimize that child and kind of help them reach their potential, whether it's from a surgical standpoint, from my standpoint, or whether it's a medical intervention.

Paul Bryson: That focus on individualized care I think's really important and I think very appealing to patients and their families. As a patient or a family visits with the center or interfaces with the center, what can they expect? What does that visit look like? Then I guess the next level would be for any colleagues or caregivers that are listening to the podcast, what about a provider that might refer to the center? What can they expect for their patient?

Brandon Hopkins: I think that the input to the center is there usually referral that gets identified and screened either by our nurse coordinator or our nurse practitioner who helps manage this population. Then they try to provide white glove service to these families where they call, there is usually a virtual visit, some type of encounter where there's an intake taken. These families are really assessed from a standpoint of what are your primary concerns and what can we really help you with? What are your goals? Is your goals to have a trach removed? Is your goal to feed? Is your goals to eat by mouth or maybe to enjoy a trip? How do we travel with this child who has a ventilator and a tracheostomy? We want to take a family vacation.

The first step is identifying what are the primary goals? Once that happens, then we bring families in either in an in-person visit, or sometimes we even have now transitioned to virtual visits for these team meetings where they actually don't have to leave. Maybe we can do them from Virginia. Maybe we can do them from Pennsylvania, Kentucky, other parts of the country, and we can give that team approach.

Then during that visit, they will meet one of our providers on a one-on-one standpoint, the pulmonary team, the GI team, nutrition, all these different teams that are involved, including social work, who really is one of the key members of the team from a diversity and a social economics kind of resource standpoint, providing making sure family have all the resources that they need. Then they'll meet all of their providers.

Then before the team, before the meeting, we actually all review that abstract together. We look at it as a group, meet the family. Then after the family has kind of met all these team members, we come back together at the end of the day or over lunch, and we review them as a group. Then we kind of put together a plan of care with input from the family in terms of what the next step is.

For many of these families, I think the next step is what can we do to keep them out of the hospital or what can we do to move their plan of care forward? Whether that's an operative evaluation for planning for de-cannulation, which when we do that, we also approach as a team where we have the pulmonary team, the GI team and the surgery team all present. What makes our group, I think, different outside of the clinic standpoint and the medical home standpoint is we also combine many of the other procedures and needs that these family have during that one sedation. It's very common across the country to have what's called a triple scope where you have a flexible bronchoscopy, a rigid bronchoscopy, and an EGD, so flexible cameras in the airway, flexible cameras in the esophagus and rigid cameras in the esophagus.

At the Cleveland Clinic, we also add on or facilitate dental procedures, sedated hearing testings, cardiac echos, CT scans, MRIs, urology procedures, anything that will keep these families from having multiple trips to the OR, our scheduling team goes above and beyond to help try to coordinate that for the family so they don't have to make multiple trips to the OR throughout the year, which is not only hugely financially stressful, but also from a safety neurologic standpoint. Every time one of these children has a sedation, you run the risk of setting them back from a developmental standpoint.

Paul Bryson: That's a great point. The scheduling and the coordination, I mean, it's a real testament to the commitment of everybody on the team to make this happen for children and their families.

Brandon Hopkins: I mean, you've seen it in your own world. Trying to get two surgeons in the OR at one time sometimes can be like moving mountains. I think that one of the really blessings of the system is that we have had schedulers that have been given us grace and go out of their way to sometimes provide families with four, five, six, seven different surgeons or proceduralists in OR at the same time, which I think is unique to our program compared to other places.

Paul Bryson: I mean, solving the Rubik's cube and maybe not 45 seconds, but still very commendable.

Brandon Hopkins: Always work to do though. It could always be smoother.

Paul Bryson: For sure. Well, it's an exciting time of year for our field as the American Academy of Otolaryngology-Head and Neck Surgery annual meeting is taking place this week. Can you talk about some of the research that you and your team are presenting that you're enthusiastic about? Little gear change here.

Brandon Hopkins: No, I think it should be a great meeting. I think that I'm excited to, again, go back from a self plug standpoint and participate in the global tracheostomy kind of collaborative tracheostomy panel that we put together that really looks at what we can do from a global standpoint on adult tracheostomy care, but also mirrors what we're doing in the pediatric world. That panel's going to be great.

We have from a pediatric standpoint, lots of work being done on our otology team by Dr. Samantha Anne, from a cochlear implant and pediatric sensory general hearing loss standpoint. It's going to be great to see some of the work Joe Scharpf's doing on complex head neck cancer and invasive thyroid carcinoma. It's looking through some of the stuff that's being done. It's really great to be part of the team here at Cleveland Clinic that can push some of that stuff forward, so pretty excited.

Paul Bryson: Well, I'd recommend following Dr. Hopkins on Twitter this week, because he'll be sharing lots of insights on site at the meeting. As a reminder, you can follow him @otopeds_hopkins, that's @otopeds_hopkins.

Well, as we kind of wrap up this addition of Head and Neck Innovations, can any final take home messages for our listeners?

Brandon Hopkins: No. I mean, I think that the taking the long view here at the Cleveland Clinic, I've been involved in this for nine years and it's really exciting to see the growth of our aerodigestive program. We're really excited about the next phase of really better capturing data standardizing the way we do things here and then expanding that standardization out to other programs in the country. I think that just really trying to focus on the family's quality of life is our next step in our goal so it's a fun time.

Paul Bryson: Great. Well, I really commend you and the team's work with this group. It's been really great to see it grow over the nine years plus here. I've been impressed, the continued expansion of the group with other partners and other centers that are offshoots of the peak program.

Brandon Hopkins: No, I can't say, we can't thank you guys enough on the adult laryngology team, such great partners from Dr. Tierney, our laryngologist who's really was key in kind of bridging the tracheostomy divide from pediatrics to adults and the work that you put in and Emma has put in from a speech language pathology standpoint from the Pediatric Voice Center, partnering with Dr. Apache, these are all kind of growths out of their a digestive program, but couldn't be done without collaboration across the system, especially with your team. Thank you very much, Paul.

Paul Bryson: No, it's been our pleasure. It's really fun to watch.

Well, to learn more about our Cleveland Clinic Children's Center for Pediatric Airway, Voice and Swallowing Disorders, please visit clevelandclinic.org/pcavs, that's clevelandclinic.org/pcavs. To speak with a specialist or submit a referral to our Head and Neck Institute, please call 216.444.8500. That's 216.444.8500. Dr. Hopkins, thanks for joining Head and Neck Innovations.

Brandon Hopkins: Cheers.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org/podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic Head and Neck Institute experts on our consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.