The team in the Esophageal and Airway Treatment (EAT) program at Johns Hopkins All Children’s Hospital are leaders in diagnosing and treating esophageal, airway and thoracic problems – conditions that are complex, often rare, and often misunderstood.

A new publication, led by Carlos Muñoz, M.D., a pediatric anesthesiologist on the EAT team, details the evolution of the team’s innovative method for treating tracheobronchomalacia, and how adapting anesthesia to accommodate new monitoring techniques during surgery has enabled the team to better meet the needs of patients with complex cases.

Muñoz and his co-authors, who included physicians from Johns Hopkins All Children’s in St. Petersburg, Florida, and Boston Children’s Hospital, published “Anesthesia for Posterior Tracheopexy in Pediatric Patients,” in the journal Anesthesia & Analgesia in October 2024.

Tracheobronchomalacia is an excessive collapse of the trachea (known commonly as the windpipe) or the bronchi (the airways that lead to the lungs) while breathing. The article reviews anesthesia-related challenges in performing what is called the posterior tracheopexy procedure – which is a newer but increasingly common surgery to treat tracheobronchomalacia – and the novel anesthesia techniques Muñoz has developed to meet those challenges. The article serves as a guide to other centers in how to approach these types of cases.

As Muñoz explains, a gas-based anesthesia would typically be used during surgeries. Early on in developing better treatments for tracheobronchomalacia, the surgeons wanted to be able to view the airway from the inside during the entire course of the surgery. This would mean inserting a camera into the airway where there was already tubing to administer anesthesia.

“I searched through the literature to see what else was available to use, how we could modify what we have and look for alternative anesthetics to keep patients asleep and pain free,” Muñoz says, noting they had to consider things like the length of the surgery (typically several hours) and minimizing complications like hypotension (or low blood pressure), which can be a risk in surgeries of that length of time.

They also wanted to be able to more directly monitor the vocal cords during surgery, to reduce the risk of injury to the vocal cords. The vocal cords are the bands of smooth muscle tissue behind the larynx, or voice box. Since they are muscle, this meant further modifying the anesthesia to no longer use muscle relaxers.

They now use a combination of medications – narcotics and anesthetics – administered intravenously to keep patients safely asleep during surgery, while using bronchoscopy as a means for the surgeons to continually monitor the patient’s airway via video during the surgery. Bronchoscopy is a means of using a thin, lighted tube to look directly into the airway through the nose or mouth. It is typically used as a diagnostic procedure, in which the camera is only in use for a few minutes. 

“Now we were doing them continually for three, four, five hours,” Muñoz said of using bronchoscopy during surgeries. “This had never been done before in pediatric patients.”

“An expert and safe anesthesia plan is absolutely critical for successful airway operations,” says Jason Smithers, M.D., head of the EAT program at Johns Hopkins All Children’s, and a leader in innovation and expertise for pediatric thoracic surgery. “Carlos and his specialized anesthesia team have been at the forefront of our innovative process for developing better strategies to tackle these challenging problems.”

Muñoz credits much of this innovation to strong collaboration among the EAT team. Muñoz came to Johns Hopkins All Children’s from Boston Children’s. There he was part of the esophageal and airway treatment team, founded by Russell Jennings, M.D., a pioneer of pediatric surgical procedures for malformed esophageal and tracheal conditions who is now a pediatric surgeon for the EAT program at Johns Hopkins All Children’s.

Muñoz, Jennings and Smithers have continued their close collaboration at Johns Hopkins All Children’s, a collaboration that extends to the entire EAT team and makes a difference for patients. The team was doing “a lot of things nobody had done before,” Muñoz says. “We sought ways to keep patients safe and move the field forward.”

The highly specialized team includes providers beyond the surgical team who have knowledge, training and expertise in complex airway conditions – including four dedicated anesthesiologists, CRNAs, and a specialized nursing team with a comprehensive understanding of the surgery and different stages of recovery and follow up care.

“It’s safer for patients, and parents and families get to know who will be taking care of their kids,” Muñoz says.

“Reliable success in patients with complicated problems requires a high-performance, well-integrated experienced team,” Jennings says. “We are fortunate to have developed such a team here at All Children’s with experienced specialists in every specialty focused on improving the lives of these very complex patients – nursing, anesthesia, thoracic (EAT) surgery, cardiac surgery, plastic surgery, gastroenterology – resulting in some of the best outcomes in the world for the airway and esophageal patients we treat. Achieving these lofty goals can only occur with visionary hospital leadership and enthusiastic administrative support. We are lucky to have the entire hospital behind the efforts to help these children and families.”

Teamwork and communication are paramount, according to Muñoz. “People say, that’s so trite – but it isn’t,” he says. Especially for infant patients whose airways need complex repairs, having a team that’s in lock step is essential, he says.

“These were cases that were rare and far between; these are complex patients and long surgeries. A lot of people are reticent in doing them, but I’ve always liked challenging cases,” Muñoz says. “Taking care of these patients, I could offer them all my expertise to make it safer for them.”