Discussion:
Bronchoscopic cryotherapy has become increasingly prevalent within pediatric pulmonary medicine. This has been largely due to the development of smaller cryoprobes more suitable for use in children [1, 2]. Nevertheless, cryotherapy does have potential for harm, and adequate care must be taken to ensure the safety of the patient [5]. This case highlights some of the drawbacks associated with cryoextraction (namely loss of airway visualization and inoperative suction channel) and offers a solution similar to what has been described by a center performing cryobiopsy in adults with ILD.
The 2-bronchoscope approach described here does not, in theory, require 2 separate pulmonologists. The authors describing the initial technique only utilized a bronchoscopist and an assistant. It is assumed that the authors had separate modalities for viewing each bronchoscope which would obviate the need for ‘disconnection-reconnection’ mentioned in this paper. Because our case occurred in the pediatric intensive care unit, there was not enough physical space for 2 separate mobile carts (in addition to the endoscopy cart, both ECMO and continuous renal replacement therapy circuits were present). Although a single proceduralist would have likely sufficed, we believe there was benefit in having 2 physicians share the workload and discuss the case in real-time. As an example, utilizing 2 providers allowed for intermittent cleaning of the bronchoscope and cryoprobe (a potentially time-consuming process due to friction associated with insertion/removal of the 1.9 mm probe in a 2.0 mm channel) while preserving suction capabilities and airway visualization. For these reasons, if qualified staff are available, we would recommend having more than 1 bronchoscopist present for this technique.
Although this report focuses primarily on the technical aspects of the case, the overall performance of bronchoscopic cryotherapy should not go unrecognized. As was previously mentioned, numerous time-consuming and unsuccessful attempts at thrombus removal were made prior to cryoextraction. This case illustrates another promising example of the recent advances within pediatric interventional bronchoscopy. As innovative medical therapies continue to make their way into the pediatric realm (e.g. a 1.1-mm flexible cryoprobe has been recently developed by Erbe), opportunities for novel approaches and techniques will continue to present themselves.