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BackTable / ENT / Podcast / Transcript #5
Podcast Transcript: Pediatric Tracheostomy: The Long Game
with Dr. Romaine Johnson
Dr. Romaine Johnson talks us through the challenges of pediatric tracheostomy care and the importance of building high reliability tracheostomy teams. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Dr. Johnson’s Introduction to Otolaryngology and Path to Pediatric Airway Surgery
(2) Pediatric Tracheostomy vs Adult Tracheostomy
(3) Counseling and Multidisciplinary Collaboration in Airway Management and Tracheostomies
(4) Building an effective Airway and Tracheostomy Team
(5) Management of the Pediatric Airway and Tracheostomy Patients
(6) Additional Considerations in Pediatric and Adult Tracheostomy Patients
(7) Management of Tracheoesophageal Fistulas in Airway Patients and Role of Antibiotics
(8) Pearls from Dr. Romaine Johnson: Bet on Yourself
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[Gopi Shah MD]
Hello, everybody, and welcome back to the BackTable ENT Podcast. I'm your host, Gopi Shah, here with my cohost, Ashley Agan.
[Ashley Agan MD]
Hey, y'all.
[Gopi Shah MD]
And we have a special guest with us today, Dr. Romaine Johnson. Dr. Johnson did his residency at Baylor. He was a Cincinnati fellow for pediatric ENT. Then went on and got his master's in public health, and has been at UT Southwestern at Dallas Children's. He's our main airway surgeon at Dallas Children's. He's our airway guru. So welcome to the show, Dr. Johnson. We're so happy to have you today.
[Romaine Johnson MD]
Well, thanks for having me. It's really great to be here and to talk to you all about a lot of good stuff.
(1) Dr. Johnson’s Introduction to Otolaryngology and Path to Pediatric Airway Surgery
[Gopi Shah MD]
Yeah, so we're going to be talking about tracheostomies, pediatric, maybe some adult tracheostomies, quality and how to get a program going, and how to keep it so that it's a safe, successful program for trachs. First, Dr. Johnson, do you want to just tell us a little bit about your practice and your interest and how it got started into pediatric airway, airway surgery trachs?
[Romaine Johnson MD]
Sure, sure. So, I grew up in Philadelphia, and that's where I spent most of my young life and also where I went to medical school. So, during my third year of medical school, the first rotation was general surgery, and that was kind of one of the power rotations. You did 12 weeks, you're on-call every fourth night.
[Gopi Shah MD]
Right.
[Romaine Johnson MD]
But the way they had it arranged was you spent your first month doing a subspecialty month, and I actually wanted to be a psychiatrist. I tell the president of the Psych Club, the student psych club.
[Gopi Shah MD]
Wow.
[Romaine Johnson MD]
And there were a lot of African Americans, psychiatrists in Philadelphia. They had little monthly dinners, and I would go to the dinners. And I was very active. Then, during that first month of my rotation in general surgery, I did ENT.
[Gopi Shah MD]
Wow.
[Romaine Johnson MD]
That was it. I was like, "Oh, my God. I love this specialty." And then, of course, I had never really heard about ENT in terms of what it was about. So then, I asked some of the other students who were on the rotation with me, and then you get that kind of reality check where it's like, "Hey, hey, you do know this is one of the most competitive specialties out there." That's why it's so much fun. You didn't think it was just going to be easy like, "Oh, man. I did not realize that."
So I had to kind of step my game up, and I was very fortunate. During my fourth year, I sat down with ... He's the Triological chair now for the committee. He's a committee chair. His name is Dan Dressler at Boston, but at that time, he was in Philadelphia at Drexel. And he kind of sat me down, and he basically said, "Romaine, you got a good chance of not matching."
[Ashley Agan MD]
Oh, gosh.
[Romaine Johnson MD]
"And you're going to have to strategize to match." And he said, "You're only doing one airway rotation, that's not enough. You need to do another one." Of course, he tells me this in July. And then, ENT was in early Match, we matched in January. And so July is really late in the game to get in a way rotation.
But the internet was pretty new then, so I went to the school library and I got on the internet. I had done some outcomes research as a post-baccalaureate after college at the University of Pennsylvania, and I kind of interested in that. So, I went to the academy's website, and they had some names there of people who where doing outcomes research in laryngology. And I was like, "Oh, that's interesting."
So, one was in Saint Louis and one was in Boston. Then one was in Houston. I was like, "Well, I don't really want to go to Boston, and I don't want to go to Saint Louis. Houston, okay." It's like Philadelphia apparently, or it's like a big city like Philly. So, I emailed the guy, and he said, "Oh, absolutely. Come on down and do an away rotation." And that person was Michael Stewart, who now chair at Cornell.
And so that kind of, I went there and I just kind of knocked it out the park and I matched at Baylor. And then I think it was during my third year at Baylor, my PGY3, that's when you do your children's rotation, and then I had already become very friendly with a pediatric laryngologist there. There are only three there at the time. But I was very friendly with them and in fact, Dr. Freidman who, I came into the OR one day and I don't know res nurse, she said do this, but I did. I came to the OR one day and I said "Hey, Dr. Freidman is it okay if I call you Ellen? I feel like we're pretty good friends.
And I called her Ellen. And so I called Dr. Zulig, Dr Zulig, and I called Dr. Geononi, Dr Geononi, but I called Ellen, Ellen. But I really enjoyed the rotation and then something kind of clicked about halfway through that rotation. And I think we were doing an airway and the anesthesiologist kind of said, "Hey man, you were really good at that. What you just did. The whole case went so smoothly, I can't believe it." And then I was like, "Yeah, I enjoy it, It's fun."
And so that's what drove me to want to do pediatrics and pediatric airway. And then, I matched at Cincinnati, obviously. And to kind of round the story up, after I was in Cincinnati, I was looking at jobs and I was looking at Baylor, and I was looking at UT Southwestern. And I thought UT Southwestern, the job was a little bit better in terms of the type of cases I would get to do. And so I wind up choosing to come here because I thought that may be a little bit more important at the moment to make that choice.
[Gopi Shah MD]
Well, what's great for me is that, Dr. Johnson was my fellowship director, has been my mentor, my friend, truly my sponsor, the person that pretty much I do what he tells me. And it's kept me afloat for the last seven years and not just afloat, but successfully swimming, I feel so fortunate to have you, as my partner and my friend.
[Romaine Johnson MD]
Thank you.
(2) Pediatric Tracheostomy vs Adult Tracheostomy
[Gopi Shah MD]
Yeah, no, so all right, so let's get into it. Let's get into tracheostomy and I think for me, so in residency, I was in a program where we just did six months. And when you come into your fellowship, all of a sudden, you jumping in to the Children's Hospital world, the peds world, and I didn't realize just the nuances between major differences actually, between pediatric and adult tracheostomy not just obviously the surgeries, but in terms of care and management. Just tell us about the members of our trach team I guess, on the peds side. Who are the players or what do you need to have... How do you build a successful trach team? And what does that really mean?
[Romaine Johnson MD]
So you raised an interesting point, when you talked about the differences between the adult world and the pediatric world. And I'd had a thought that one of the big differences is that, so in the adult world, when you place a tracheostomy in a patient, kind of the end of life right? They've had a stroke, or they have a major health event, and now they're in the hospital on a vent. And that's cardiac surgery or something like that, and they need a trach. But they're usually older, and they're sicker and a lot of times they wind up going to rehab, and you never really, you don't follow along those patients long term.
Where in pediatrics, it's often the beginning. So they're doing their trach when they're six months old, nine months old, a year, almost 80% of the trachs we do at children's, they're under a year. And the average time it takes to decannulate a child is two and a half years. So I'd say the median time is at least two and a half years, but only about 30% of our patients ever get the trach out. About 15% pass away, so the majority of patients where you put a tracheostomy tube in, they keep the trach throughout their childhood.
So if you put a trach in a child who's six months old, or a year old, oftentimes, you're going to be following them until they're an adult, if you practice that long. And I do now I'm starting to see more the kids that I've trached, 2010, 2008, they're starting to age out. So I think that you raised that very interesting point in terms of the perspective of tracheostomy, it really is a long term care issue. So you're dealing with a long horizon of how do you manage this child with the tracheostomy as opposed to the adult that they're probably, you're going to see him once or twice if ever after you put the trach in. And so how do you build the team? I think you have to a lot of people involved. So-
[Gopi Shah MD]
And it sounds like you have an inpatient and outpatient right? Because you bring up long term and so like you said, a lot of those, it's not just getting them out of the hospital, but then taking care of them for years after.
[Romaine Johnson MD]
So the first challenge is really trying to decide who needs a trach? Or what quality of life, whose quality of life will benefit from a tracheostomy. Because clearly, there's some children who you shouldn't put a trach in. But that gets in sort of the ethical dilemma of do you do it, do you not do it? We often wind up doing it. But so that's the first thing. So having someone who can go and evaluate the patient, and really determine, okay, is this patient a good candidate for a tracheostomy?
So in our team, it's a nurse. She goes to the patient's bedside, examines the patients, and she reviews the charts, and she also talks to the family. And she gets a feel for okay, is this a good situation? And will this improve the quality of this child's life? Because sometimes the answer is no, we really need to talk about other ways to deal with those life issues. And so that's the first person you need on the team. Someone who can go look at the chart, not from like the resident perspective, I think the residents just go and they look at the neck and they decide, okay, is the patient on anticoagulation medications and can you safely do the trach? But the nurse or if it's an APP, and another thing like a physician assistant, you need someone to help you determine initially, is this a good candidate for the long run?
[Gopi Shah MD]
Right.
(3) Counseling and Multidisciplinary Collaboration in Airway Management and Tracheostomies
[Romaine Johnson MD]
And then the other thing, so that's one of the big components. So the other, once you decide to place to trach, and actually there's more to it, which we can talk about if you want, but let's say you go through the process, you decide where you're going to place a tracheostomy. So now for our team, we have another nurse who primarily works on the inpatient side, and she does a lot of the teaching. She really spends time with the family, helping them and guiding them to learn how to take care of a child with the tracheostomy too. Because there's a lot involved, obviously, an adult, you can put them in a nursing home, you can put kids in nursing homes too, but for most kids, they're going to go home, so you have to have families trained to take care of the child. So she does that.
And then we also have a respiratory therapist. And so the respiratory therapist is there, can help teach them how to do a vent. Like what steps are needed to manage their child on a vent. He can help them how to understand suctioning and just delivering respiratory medications and things like that. And then those three individuals, they primarily work on the inpatient side. And so one of them, her name is Rebecca Brooks. She also does some outpatient stuff, too. So she has an outpatient clinic, that helps bridge the gap between inpatient and outpatient. But on the inpatient side is mostly those three individuals working together to provide care for the children. And then we have Ashley Brown, who's our speech therapist. She does inpatient work too, but not as much as the other three. And what she does on the inpatient side is she kind of makes sure that, one that the child is receiving speech therapy services, and feeding services, learning how to eat, as well as seeing whether or not they're a good candidate for one way valve usage. So we can work on some communication, if the child has the ability to communicate.
[Gopi Shah MD]
And all the teaching starts before the trach is even placed, for I mean, a week to 10 days before...
[Romaine Johnson MD]
So the initial counseling session, that is some teaching, but the actual teaching in terms of like how to do a trach change, how do you suction trach, that starts the day the trach is placed.
[Gopi Shah MD]
Okay.
[Romaine Johnson MD]
And then goes forward. And we actually have concepts, we have journey maps, where it'll show the families, these are all the steps that you need to go through in order to successfully go home or to a rehab center with a tracheostomy. And so usually, it takes us, if a kid is doing well, it'll take about three weeks to finish the journey map.
[Gopi Shah MD]
And so I assume that in the beginning, when you're creating this team, that there's a lot of time commitment from your standpoint, getting things going. But now I assume at this point, it kind of that the team works pretty independently and comes to kind of for tough situations or how do you interface with the team? How regularly, what does that look like?
[Romaine Johnson MD]
So we have regular meetings. So we have a standard once a month meeting, where we sit down and we talk about all the issues related to the program. And then we can have any ad hoc meeting as we need. And then I share clinics with Rebecca Brooks and Ashley Brown, the speech therapist and the nurse who spans inpatient outpatient care. We have a multidisciplinary clinic. So I see them all the time. So you know, we have trach clinic just with kids who... We try to limit it to kids not on a vent. We have that twice a month. And then Rebecca Brooks also has her own clinic and I'm there at the same time, I have a feeding clinic and so when she's having a trach clinic, I'm in the feeding clinic, but I can be consulted for any patient.
And then we also have another multidisciplinary clinic. This clinic is at Cityville, which is a campus, up the street from the main hospitals, kind of across from the train station in Parkland. And that's our vent clinic. And so that clinic, they see a pulmonologist, these are all kids on a vent. They see a pulmonologist, they see me, the nurse, my nurse practitioner, my nurse assistant is there, I have my personal nurse there, our speech therapist is there, we also have our, there's a dietician, there's a respiratory therapist, it's a big group of people. And we see 10 to 14 patients twice a month in that clinic. And these are all vent dependent patients from all over the city.
So we have at least four or five trach clinics a month that are multidisciplinary. And so I meet often with them during those times. So there's a lot of communication and interaction and work. Yeah, they take care of a lot of the inpatient stuff, in terms of the consults and doing trach crowns and things like that. But yet, and still every time they write a note, they send it to me and I co sign it. If they need my help getting a patient scheduled for surgery, then I'll do it, that kind of thing. So there's still, even though we only meet once a month, there's a lot of interaction and meeting.
[Gopi Shah MD]
Yeah, that's awesome, I think multidisciplinary, I'm sure for those families that's such a huge convenience factor for them to be able to see multiple providers during one visit. And then on our side of it, I'm sure it's helpful to be able to be in a place where you can be more collaborative and see the people that are kind of working with the patient as well. What are some of the biggest pearls and pitfalls for people out there who are wanting to build their own trach team or who are looking into trying to establish multidisciplinary clinics?
(4) Building an effective Airway and Tracheostomy Team
[Romaine Johnson MD]
Well, I mean, where should I begin? I think the first thing is money, right? People don't work for free. So if, say you want a nurse and you want an advanced practice nurse or a PA to help you start this program, well, who pays your salary? And oftentimes they work for the hospital. And if they work for your practice, then that is taking them away from other clinical duties. And so one, you got to figure out a payment structure. Now we're fortunate that our practice is very busy. So we can afford to pay their salaries. But that's the first challenge. So you may have to rely on volunteerism.
So if you work at a big hospital, the hospital usually has a speech therapist who works for them, usually has a respiratory therapist, usually has nurses, or you can use your own nurse. So that's going to be the first big challenge just getting the personnel and making sure that there's a margin, there's money that they can be paid. And that It's not all voluntary.
[Gopi Shah MD]
And you have to get people that believe in it too. I mean, I feel like people, there's some attrition as well
[Romaine Johnson MD]
Yeah, and I agree.
[Gopi Shah MD]
It's difficult, it's hard work.
[Romaine Johnson MD]
I think usually you can find people who want to do it. Now keeping them can be the challenge. Because oftentimes you train them up and then, people leave. People get successful, they want a promotion or sometimes life circumstances. But I have found that since I've been here, usually we've been able to find people who are willing to do it. But that does change quite a bit in terms of the turnover. That's particularly on for the nursing in the clinic, because it can be challenging work.
They're very, I would say, every day, we get a call from a trach patient about something. And so I think with tubes and tonsils or ear infections, you get those phone calls. But they're probably a couple of times a week or it's very acute, like you just did a tonsillectomy and so you're getting a bunch of calls, but their routine like okay, your kid doesn't want to eat, okay, give him ice chips, but with the trach patients, again, they don't go away, you keep them for a long period of time. And so there is this cumulative effect. So you think like, oh, let me do, I want to do a lot of trachs and so you do 50 tracheotomies a year. Well, that means probably 30 of those patients aren't getting rid of their trachs. So that means the next year you've got now 60 trach patients and then the next year you got 90 trach patients and the year after that you got 120 trach patients. And so can you manage 120 trach patients? Can you imagine 240? So right now we have about 500 active trach patients.
[Gopi Shah MD]
Wow.
[Romaine Johnson MD]
We can imagine like every day, there's just a lot of phone calls.
[Gopi Shah MD]
That's what your epic inbox has like 50 messages.
[Romaine Johnson MD]
And so you kind of figure out what to do with those kids. But yeah, I think finding people, you have to have a nurse, you have to have a pair of respiratory therapists or a speech therapist, you have to have those components involved. And the other things that we don't have that we use a lot, at least they're not dedicated to the airway program, are social worker and case managers. Because you can imagine the social work situations can be profound if you have a family that lives on the third floor of an apartment building. And now they have a kid who's on a vent and in a wheelchair. How do you manage that? Do they have to move?
[Gopi Shah MD]
Yeah.
[Romaine Johnson MD]
How do you deal with transportation? And then just in case manager, just once, at least to get out the hospital, equipment issues, you want to make sure that all the equipment issues get settled in a timely fashion, so you can get them out sooner, or else that'll delay your discharge.
(5) Management of the Pediatric Airway and Tracheostomy Patients
[Gopi Shah MD]
So switching gears a little bit, you had mentioned earlier, we talked about only 30% of patients will be decannulated. And so a lot of these kids are going to grow up and still have trachs. And I've noticed in my general ENT practice, I've started to inherit patients who have had trachs since they were very young and continue to have trachs and just need to have an ENT to kind of help manage that with them. So what advice do you have for those of us who are inheriting pediatric trachs? Do we need to be upsizing them at a particular point? Is there anything different about how we manage our other trach patients? What pearls do you have?
[Romaine Johnson MD]
So I try to treat each child individually when it comes to tracheostomy. So we have a standard trach that we kind of put in when they're young, and then we'll upsize it appropriately. But once they get to about a four and a half, five tracheostomy tube, then I think it's basically on a case by case basis. If they're a kid who's like 16 and they still have a trach, probably they're either like a cranial facial child, who still has some craniosynostoses type issues, a small mandibles, small maxilla, something like that. And they still need more surgery. Or it's a kid who's kind of neuro devastated, and they've just had a trach for a long time and they're going to continue to have a trach.
For those kids, If the trach is stable, I just leave it alone, because usually there's not going to be much growth. I think that signs that suggest that you're going to need a new trach, things like trouble suctioning, the trach starting to fall out. If they feel like there's more obstruction, the one thing that I do notice in a lot of the adolescence who've had a trach since childhood, is that they start to develop scoliosis, if they're not moving around a lot. I mean that scoliosis causes the trachea to move with the spine and then it becomes more challenging to find a trach that fits them that kind of sits in the center of the lumen that doesn't have anterior irritation or back walling kind of thing. So those are the things I start to look at as they get older.
[Gopi Shah MD]
How do you manage that? I feel like we get those calls, I see it obviously, on the inpatient side. Maybe it's a 17 year old like that, or maybe a 10 year old like that, that now is inpatient for respiratory decompensation from a viral URI, and it's say, the trachs obstructive and there's so much scoliosis and positioning that makes a difference of when the trach is obstructive or not. And I find that sometimes I play the go shorter, go longer game. From your experience, how do you manage that? Because that can be, I feel like, it's hard to know what the right thing is sometimes for those kids?
[Romaine Johnson MD]
Yeah, no, I don't have a good answer. It's trial and error. And you try to find the best fitting trach that you can. Generally speaking, I think, going longer is the way to go as opposed to going shorter. I think going shorter, you tend to back wall more often. But sometimes, you go longer, and you get all the way to the carina…
[Gopi Shah MD]
Right.
[Romaine Johnson MD]
It's still really good. So you just go back a few millimeters and just see what happens. I do sometimes, we'll have talks with families about what is the long term prognosis for their child. You have to be honest with, like hey no one gets to live forever. And at some point, something's going to cause all of us to to move on. And for your child, that may mean that it's just respiratory function. It's just going to slowly fail. And is that so bad? And if the struggle is we're just constantly trying to find a trach that fits, and the reality is like yours, the scoliosis is so bad and the pulmonary function is so bad and we're just looking at sort of the end stage, do you want to continue to just trial and error? Or do you want to move toward hospice? Palliation?
[Gopi Shah MD]
I was going to say, when do you know to get palliative care involved for these kids?
[Romaine Johnson MD]
I think it's good. I mean, so let's go back to the beginning, that six month old kid who had a near drowning. And now the anoxic brain injury, the two year old. Has a near drowning, and they've had anoxic brain injury, and they've lost most of their function. And they're going to be vent dependent, G-TUBE dependent, from here on out, and there's probably little to no, there's not going to... So you start having these quality of life issues.
So how do you define quality of life for someone who can't eat or can't talk or can't walk, who can't breathe without a ventilator? But these are tough conversations to have, but we try to have those conversations with families and kind of just let them know, like, "Hey, you know, everybody's going to heaven. And sometimes you just have to let God's will be done." And obviously, not everyone believes in heaven, but I'm just using that language to say that we have to be able to talk to families about death and dying. And do it in a way that's empathetic, but also, lets them know, like, yeah your child had suffered a serious injury. And this is what you're looking at, would it be better to just not do any else? And a lot of families choose that option. And so I'll have that conversation at any time with any family.
[Gopi Shah MD]
And then I know we're very lucky, we're part of a big freestanding Children's Hospital, big academic center. And so, we have a close relationship with our pulmonary colleagues, with our NICU colleagues. And it seems like with that multidisciplinary team approach expanding, not just ENT, and everybody's on the same page, those outcomes in terms of inpatient outpatient care, complications, end of life issues have got to make that journey a lot smoother, and hopefully the best as possible, when you have all those hands involved in trying to make the child's care as the best it can be.
[Romaine Johnson MD]
Yeah, I agree.
(6) Additional Considerations in Pediatric and Adult Tracheostomy Patients
[Gopi Shah MD]
So to switch gears just a little bit in terms of managing pediatric trach patients, I feel like one of the common things, in the adult world too, is patients who have bleeding from their trach. And I'm just curious how do you manage that?
[Romaine Johnson MD]
Wow, so I was going to say, "Ah I hate bleeding." So those are the things that drive you crazy. So bleeding from the trach, secretions around the trach, granulation tissue, wound problems, every day there's a new wound you have to deal with. So bleeding from a trach, we actually have a pulmonary sick plan that talks about secretions. And so we kind of have a green, yellow, red. So green, kind of their usual not a lot of secretions, everything's great. Yellow, maybe a little bit of increased secretions, maybe bleeding just with suctioning. And for that we kind of just tell them, "Hey, don't suction as much, maybe if you think it's due to suctioning, use more saline, use more breathing treatments, keep an eye on things." But then any heavy bleeding and the family can't decide what that is, are persistent bleeding, we always tell them to come in. And we just look, I think you have to look, you just don't know what it is. Anyone who's got bleeding from the trach-
[Gopi Shah MD]
When you say you have to look...
[Romaine Johnson MD]
Oh, so you bring them into the clinic and then you can do a tracheoscopy. When you put the flexible scope through the tracheostomy tube and you look to see if it's like suction trauma or back walling and causing granulation tissue. Those are the two big things. Sometimes you can see tracheitis and inflammation. And so if you see anything that gives you a diagnosis, then obviously you treat it and you go from there. Now if you don't see anything, if it's completely normal, then you have to decide, are you going to do a bronch in the operating room or not. Typically, I won't do it, unless it's persistent and we still don't have an answer.
So if they come into the clinic and they've had some bleeding, and we don't see anything, and everything seems fine, I'll say we'll just keep an eye on it. And then if it doesn't get better, then we'll do a bronchoscopy. But that's the way I manage bleeding.
[Gopi Shah MD]
And is there ever a role for CT angiogram in that?
[Romaine Johnson MD]
Hmm, rarely. So I think the times that we've done it was when we've seen anterior erosion of the trachea, and you can tip it, it is almost always been the sort of the kids in the wheelchair, who are not walking around and start to develop trachs that don't fit very well and you'll see the erosion. And even the times that I've seen the erosion, I've only seen one sort of near fistula like the anti trach wall got completely eroded and you could see the innominate on scope.
[Gopi Shah MD]
Like, that's not a good scope. I like my blood pressure. Is your blood pressure okay? What were your vitals at that time?
[Romaine Johnson MD]
And he had a huge tracheocutaneous, no, actually his trach went in, I guess I shouldn't give too much detail, but it went into a false trach. And it basically eroded in the false trach and it kind of went into the mediastinum. And it caused the second pocket, which was basically rubbing right up against the innominate, you could see it, it was clear as day. So yeah, that was a near miss. But besides that, I think I've only seen one other time where we got in a CT angio and it was pretty obvious that this was a severe injury, and there was bleeding and he looked and you could see that there was erosion. But besides that, I don't think I've ever done it.
[Gopi Shah MD]
You talked about anti erosion. What do you do about those post erosions? Cuff injuries?
[Romaine Johnson MD]
Put in a longer trach. They usually heal. Now sometimes, if you damage the back wall, that can be a problem. But again, even in those kids, they tend to be kids who, they're not going to get decannulated. So you can just watch it. But yeah, I just put in a longer trach and often it will heal once you put in a longer trach.
(7) Management of Tracheoesophageal Fistulas in Airway Patients and Role of Antibiotics
[Gopi Shah MD]
How often do you see tracheoesophageal fistulas from the cuff or from placement?
[Romaine Johnson MD]
I've seen it once, maybe twice, it's pretty rare. I think it's more common in adults, probably because, one, they're almost all of them used the cuff, and it's an air cuff, you can really, we use something called, we use sterile water for our cuffs. So we don't use a shyly ear cuff. Most of our kids have either Tracho or Bivona. And they use a sterile water. So you can only put so much sterile water in there, usually about five. And so I think that can cause erosion, but it's not like this huge air cuff where you're just going to just crush everything.
And then also those kids tend not to have like a NG tubes, especially those rigid NG tubes. Most of them have G tubes, so there's not something rubbing up against. So that's why I have only seen it twice, It's pretty rare. Now we've now had some tracheal diverticula and things like that but once we basically put in a longer trach and allow it to heal, this heals up.
[Gopi Shah MD]
And you just take them back for a DOB two, three weeks later? How do you...?
[Romaine Johnson MD]
Yeah, just take them back, two weeks to four weeks later, take a look and yeah, they tend to heal up. It's amazing. Even when you false track, if you put in a new trach, and you go through that posterior wall and it gets in a false track, you take it out and you put it back in the right spot, that injury will heal. It's just that, that back wall thins I think because they're so soft, that's just muscle and as membranous, it just tends to heal. Now anything's possible. I'm sure if you go to like some places, they'll be like no, no, no I saw one where everything was gone. But I think it's pretty rare.
[Gopi Shah MD]
Yeah. Do you ever use Ciprodex or any sort of topical jobs down the trach for bleeding or irritation?
[Romaine Johnson MD]
All the time. All the time. Tracheitis, especially I think it works best for granulation tissue. So if you have a little bit of granulation tissue at the tip of the tracheostomy tube, you know four drops of Ciprodex twice a day works like a charm.
[Gopi Shah MD]
How long do you usually keep him on for?
[Romaine Johnson MD]
10 days. The same as for tympanostomy tube otorrhea. Well I guess it's a little bit longer than seven days. So I think I used to go seven to 10 days something like that.
[Gopi Shah MD]
Cool.
[Romaine Johnson MD]
Some kids have been on longer. Some kids are on maintenance. And like tracheitis especially.
[Gopi Shah MD]
And so long as everything else looks good, it's safe to use it. Just like people use Flonase every day, they can use their Ciprodex every day?
[Romaine Johnson MD]
I mean, if it's not safe, I guess it's such a rare thing for someone to be on Ciprodex. It's hard to pick up any, and remember, these are sick kids too. So I don't know, but it seems pretty safe. I mean, we've used it for 20 years now, probably. And I haven't, maybe some people have had some allergies, maybe, but it's not even something I think about that. Usually the family would tell me like, oh, he has a Ciprodex allergy. Oh okay, well, then, I guess we won't use Ciprodex.
(8) Pearls from Dr. Romaine Johnson: Bet on Yourself
[Gopi Shah MD]
Well, do you have any final pearls things? Just from all of the experience that you've had. Final words of wisdom or things that everybody should at least know this?
[Romaine Johnson MD]
Wow. Everyone should at least know them. Well, I think so I'll take it a different way. So I think that you should always bet on yourself, that you can be better. And that you can solve complex problems, particularly if they're kind of human relation problems. Often what happens is you find yourself in a work environment, where there's conflict, and there's people working against each other and butting heads. And that's the reason why you have systemic error in something like tracheostomy patients. You'll find that there's just people who, that's the way they do trachs or no one takes the care of people with tracheostomy seriously or you don't think anybody wants to make things better.
And I would say that that's not true. I think, wherever you are, if you really set out to make positive change, positive change will happen. There's this book called the, what is it? The Alchemist. And in part of it, he says, "The whole universe works with you, if you're pursuing kind of your personal legend." I think if you're pursuing something positive, and you're trying to make a real significant impact on your work environment, on whatever it is, I do think the universe aligns and works with you. And so that would be my final piece of advice to everyone.
[Gopi Shah MD]
I think that's beautiful.
[Ashley Agan MD]
And I think you're such a great example Dr. Johnson of someone who's obviously followed their passion and who is thriving and it sets a great example for all of us.
[Romaine Johnson MD]
I appreciate it.
[Gopi Shah MD]
Yeah, no, we look up to Dr. Johnson thank you so much for coming on.
[Romaine Johnson MD]
Thank you. Thanks for inviting me.
[Gopi Shah MD]
Yeah, if people want to connect with you or reach out to you on social media can you tell them where.
[Romaine Johnson MD]
I'm on Twitter @rfjohnson77. And obviously my email address for the university is romaine.johnson@utsouthwestern.edu.
[Gopi Shah MD]
And you also have a YouTube channel is that correct?
[Romaine Johnson MD]
That's true. I do. I have a YouTube channel.
[Gopi Shah MD]
I've changed the way I do Supraglottoplasty. After looking at what your YouTube I'm like, "Oh, I don't need to grab anything. I'm just going to barely touch it with the micro grater okay."
[Romaine Johnson MD]
I think it's just you look on my name Romaine Johnson and you'll find my YouTube channel. And I try to post mostly procedures but I also am a member of the Harry Barnes society, which is the, it's the otolaryngology section for the National Medical Association. It's primarily African American physicians, but it's all over the diaspora. We have people from Canada and West Africa and the Caribbean, and I mean, even like Al Merati and Ron Cooper Smith, they're members and they're obviously not African American. So anybody can join it's for allies and it's all post we have a virtual grand round series. So I also will post the grand rounds from those series as well. So yeah, come check out my YouTube channel.
[Gopi Shah MD]
And for people that enjoy journal articles, Dr. Johnson probably is been publishing at least five to eight articles a year for the last five to-
[Romaine Johnson MD]
With your help, with your help.
[Gopi Shah MD]
That's because you're a kind mentor. Keep me swimming. So but yeah, a heavy hitter when it comes to the academic contribution as well. So all right, well, thank you everybody for tuning in and joining us. Awesome guest today. I learned a ton. We'll see you guys next time on BackTable ENT.
Podcast Contributors
Dr. Romaine Johnson
Dr. Romaine Johnson is a practicing ENT and Associate Professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2020, September 4). Ep. 5 – Pediatric Tracheostomy: The Long Game [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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