Abstract
The multidisciplinary aerodigestive care model allows a coordinated and efficient approach to patients with complex airway and swallowing disorders. Careful patient selection and a structured approach are essential to the success of this approach, as are the involvement of key providers within a culture of collaboration. Early data suggest that, as with coordinated approaches to other complex pediatric conditions, the aerodigestive model is both effective and efficient, providing high-value care.
Keywords
aerodigestive model, multidisciplinary, coordinated care, value
Historical Perspective
While multidisciplinary coordinated care is rapidly becoming the norm for complex patients and diseases, the Cincinnati Children’s Hospital Medical Center aerodigestive model was a pioneering example of this approach. The development of the Cincinnati aerodigestive program was an outgrowth of advances made in the care of premature and critically ill infants, in which significantly increased survival rates led to children presenting with subsequent problems arising from either their underlying conditions or their management. Many children, particularly those with a history of prolonged endotracheal intubation or pulmonary disease, were tracheotomy-dependent and in need of airway reconstruction. Other patients required the care of multiple subspecialists in fields, including otolaryngology, pulmonary medicine, gastroenterology, and surgery. Beyond their anatomic and physiologic problems, many of these children also had functional problems such as oral aversion, feeding difficulty, and aspiration. As a result, these patients presented multiple challenges: complex diagnostic and therapeutic needs, associated social and financial health care burdens placed on their families, and the need for ongoing care across a range of specialties.
In this context, it was essential for involved pediatric subspecialties to develop a model for the delivery of efficient, unfragmented care built on constant communication between specialists and families, longitudinal tracking and follow-up of patients, and coordinated scheduling of appointments, diagnostic tests, and procedures. Since the development of this model at the Cincinnati Children’s Hospital Medical Center, it has spread across the country and around the world, with other leading pediatric and adult hospitals adopting very similar approaches to children with complex aerodigestive disorders.
In view of this success, the objective of this section is to provide the reader with more detail regarding the structure of the coordinated aerodigestive care model. We also describe criteria by which we select children who might benefit from this horizontally integrated approach to medical and surgical care.
Patient Selection
Selection criteria for inclusion of patients in an aerodigestive care program vary between centers. Some centers, particularly those with patients traveling long distances frequently for visits, have developed specific criteria to assist pediatricians and other referring providers in deciding whether a patient might benefit from referrals that could involve significant travel and financial costs. This approach allows patients to avoid visits that may not provide benefit and allows involved specialists to focus on those patients to whom they might offer the most benefit. Other centers have elected to use less specific criteria, improving access for many patients but increasing the number of referrals that may not lead to a comprehensive treatment plan.
Regardless of the specifics of each aerodigestive program, certain characteristics and diseases serve to define “typical” aerodigestive patients ( Table 75.1 ). The reader will notice that these components cover a wide spectrum of patients with interrelated symptoms and pathologies. The pathologies may be congenital, acquired, or a combination of the two.
| Category | Common Symptoms/Complaints | Common Etiologies |
|---|---|---|
| Airway | Stridor/noisy breathing Dyspnea with exertion Cyanosis “Dying spells” Tracheostomy/ventilator dependence Voice problems | Airway stenosis Laryngomalacia Tracheomalacia Extrinsic airway compression Vocal fold hypomobility/immobility Vocal fold scarring Nasal obstruction (in neonates and infants) |
| Pulmonary | Supplemental oxygen requirement Ventilator dependence Frequent respiratory infections | Bronchopulmonary dysplasia Aspiration Bronchiectasis Chest wall abnormalities Primary ciliary dyskinesia Immunodeficiency |
| Gastrointestinal and swallowing | Oral aversion Poor feeding Choking Aspiration Dysphagia | Functional swallowing disorders Neurologic/neuromuscular diseases Laryngeal cleft Tracheoesophageal fistula Vocal fold disorders Eosinophilic esophagitis Reflux Esophageal stricture Esophageal dysmotility Poor gastric emptying Cricopharyngeal disorders |
| Sleep apnea | Central sleep apnea Obstructive sleep apnea | Multiple |
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