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.