While diagnostic flexible bronchoscopy can be used for the evaluation of the airway in children, advanced diagnostic, therapeutic, and interventional bronchoscopy has largely been limited to adult patients, particularly those with lung cancer. The small size of the pediatric airway and large size of advanced bronchoscopic equipment, have made these techniques difficult to implement in children.

Advancements in interventional bronchoscopy are helping to overcome these obstacles. And Cincinnati Children’s Division of Pulmonary Medicine is leading the charge in making these procedures more accessible to children.

“We’re using the latest technology and equipment to perform cutting-edge procedures,” says Gregory Burg, MD, assistant professor and pediatric pulmonologist in the Department of Pediatrics. “We’re fortunate that our institution supports forward thinking and is willing to take on these new technologies and devices to help us move the field forward and provide better care for our patients.” Alongside fine-tuning procedures for patients, these investments also are contributing to training the next generation of pediatric pulmonologist.

A Sizeable Program

While many centers nationwide perform pediatric bronchoscopy procedures, Cincinnati Children’s is one of the most prolific programs. Each year, providers perform approximately 3,000 flexible bronchoscopies for more than 1,200 children. This volume is double, or even triple, as many as other institutions, Burg says.

Still, some patients require more complex procedures, says Erik Hysinger, MD, MS, associate professor and pediatric pulmonologist in the Department of Pediatrics. These interventional techniques include endobronchial valves, endobronchial ultrasound guided biopsy (EBUS), cone beam computed tomography (CBCT) guided biopsy, and cryotherapy.

Throughout the year, he says, Cincinnati Children’s pulmonologists complete roughly 50 of these advanced procedures. On average, they perform approximately four each month.

Making Advanced Procedures Child-Size

While pediatric cases can be just as complex as adult ones, it’s important to remember that children are not little adults, Hysinger says. Instead, they frequently need treatments tailored to their smaller size.

“Some facilities will send pediatric patients to adult hospitals with adult interventionalists. That can work fine, but in many cases these providers aren’t familiar with the child’s disease process or airway management—those things that are individual to kids,” he says. “At Cincinnati Children’s, we’re unique in our ability to do all of these procedures in house with all the support necessary to care for these complex patients.”

To meet the needs of these children, multidisciplinary teams have collaborated closely to develop and design pediatric-friendly techniques for several interventional bronchoscopy procedures.

• Endobronchial valves: Our providers recently implemented a new, less invasive technique for managing persist airway leaks. After placing a patient under conscious sedation or general anesthesia, we use a combination of an airway balloon, suctioning via the bronchoscope, and possibly contrast injection with fluoroscopy to locate the leak. Once the air leak location is identified, we use a calibrated balloon to determine the correct valve diameter to close the leak and implant the valve with another catheter. Roughly six weeks after the leak stops, we remove the valve.
  
  
• EBUS: This advanced diagnostic procedure is frequently used to sample mediastinal masses related to inflammation, infections, and cancer. In this procedure, we use a bronchoscope with an ultrasound transducer to identify lymph nodes or lesions in the chest that are outside of the airway. Then, we use real-time ultrasound guidance to obtain needle biopsies.  Our gastroenterologists occasionally borrow this equipment for similar gastrointestinal system interventional procedures with young patients.
  
  
• CBCT:  We developed this advanced diagnostic procedure to sample peripheral lung nodules with our colleagues in interventional radiology. While in our state-of-the-art hybrid operating room, we capture a chest CT to identify the mass.  Using 3D fluoroscopic guidance to take biopsies with maximum yield and minimal risk, we display a virtual rendering.
  
  
• Cryotherapy: Our division has been a trailblazer with this technique. It uses pressurized liquid nitrous oxide passed through a probe to freeze tissues or objects to negative 50° Celsius. The freezing processes allow the probe to stick to and remove foreign bodies, such as blood clots and mucus plugs obstructing the airway. We use a similar process to biopsy and debulk airway tumors. Most recently, our team launched a small pilot study to investigate whether this technique feasibly can be used to safely and effectively perform lung biopsies.

Preparing the Next Generation of Pediatric Pulmonologists

With our leading-edge technologies and equipment, we go beyond delivering the highest level of patient care available to maximize outcomes and minimize risk. We also leverage these resources to offer extensive training to our pulmonology fellows.

“Our trainees now routinely finish fellowship having performed between 300 and 400 bronchoscopies each,” says Burg, one of the pulmonary medicine fellowship program co-directors. “This is well above the old standard of 50 procedures. So, our fellows certainly get the exposure and experience to learn more about bronchoscopy than you could imagine coming into fellowship.”

In fact, the division recently expanded its training options, launching the only pediatric bronchoscopy fellowship in the country. It’s a one-year program that just accepted its second trainee.

But our educational efforts extend beyond internal fellowship programs. Our pulmonologists also have partnered with the American Thoracic Society, the European Respiratory Society, and the American Association for Bronchology and Interventional Pulmonology to lead courses on interventional bronchoscopy techniques in children.

“We’re joining with these adult groups that are leading the charge on interventional bronchoscopy to develop a pediatric interest group that will ensure we’re confirming safety, efficacy, and competency as we advance these procedures for children across the country and the world,” Hysinger says.

Ultimately, Burg says that through our use of the most advanced, up-to-date technologies and our commitment to intense training, Cincinnati Children’s continuously demonstrates a dedication to outstanding patient care and patient quality of life.

“We are a program dedicated to adapting interventional pulmonary techniques to pediatric patients and proving the safety and efficacy of techniques that are already well established in adults,” he says. “Overall, we’re simply trying to learn what our best options are, minimize risks to our patients and get them home quicker and healthier.”