Day 2 Pulmonary Breakout Interventional Pulmonology R. Paul Boesch, DO, MS Assistant Professor, Pulmonary Medicine Mayo Clinic Children s Center
Interventional Pediatric Pulmonology or Pulm/ENT airway hybrid? Overtime developed practice that overlaps/merges with ENT, spanning disciplines Allows for richer airway expertise Improved efficiency vs competition Much of the following is also done by my adult pulmonary colleagues
In clinic flexible endoscopy Nasopharyngoscopy Evaluation of congenital stridor, OSA patients Screening of surgical patients for ENT (Or myself) Flexible tracheoscopy Immediate clinical evaluation for assessment of trach complications Adjunct to ventilator assessment
Rigid Bronchoscopy Pulmonologist maintains skills in rigid bronchoscopy ENT maintains skills in flexible bronchoscopy Aero working environment: natural mentoring Allows ability to fill in for one another
Foreign body removal Rigid instruments preferred in large majority of cases Sometimes need flexible Sometimes both One operator can do both or work together Pulmonary and ENT both able to perform makes it easier to have a pediatric provider on call, expands coverage
Foreign body removal Tools, tools,tools Flexible Forceps, Fogarty, Baskets, Snares, Cryoprobe Rigid Optical forceps: alligator, peanut, cups, rat tooth, cryoprobe
Flexible bronchoscopy Generally not preferred, sometimes necessary Peripheral access, less airway control Can t suction with device in channel 3 and 4 wire baskets FG 51D 3 prong grasping forceps FG 54D Rat tooth forceps FG 32L
More airway control Access limitations Better tool options Peanut forceps Rigid Bronchoscopy Less risk of pulverizing FB Alligators Angled Can pass flexible suction simultaneously
Great for: Balloon dilation Thin webs Touching up LTPs, slide tracheoplasties Dilating metallic stents To quickly gain control of emergent situations With or without incision, injection Not for: Absence of cartilage Weak or degraded structures
Balloon dilation Concept: Radial distending pressure without shear AcclarENT balloons High pressure non compliant airway balloons 5, 6, 7, 8.5, 10, 12, 14 mm Center balloon over stenosis Inflate to rated burst pressure for 2 minutes or desaturation Goal to dilate up to, but not beyond, size of cartilage skeleton of airway
Incision, injection, dilation
5 Weeks Post OP 6 Months Post OP
Management of granulation Suprastomal, intratracheal, intrabronchial Sphenoid punch Optical forceps Laser, Bugbee, flexible forceps for distal lesions Cryoprobe through larger scope
The boy likes to play in the toilet
Removal of tissue improved visualization AND provided identification of pathogen (Mycobacterium avium intracellulare)
Energy in the airway FiO2 30% Short controlled bursts Be aware of deep and distal penetration Bo not denude too much continuous mucosa
Endoscopic TEF closure When: Long skinny tracts best Proximal TEF better than distal Goals: De epithelialize tract Prevent airflow through tract Pressure occlude tract
TEF Closure
Stents Rarely a good idea (for benign disease) When used, best temporary Issues of size in children Silicone or wire mesh
Silicone stents Placed with rigid forceps Various lengths, diameters, Y stents Proximal edge cannot abut conus elasticus Migration Granulation (proximal and distal ends) No mucociliary clearance Biofilm formation
Silicone stents Indications Structural support for healing repair site Palliative bypass for obstructive lesion Intraluminal or compression Beware of potential to watermelon seed Cover a hole
Balloon expandable metallic stents The good Endoscopically guided Can be dilated to precise diameter Can be further dilated later Thinner wall than silicone stent Possibility for mucociliary clearance The bad Stent can be deformed Stent can fracture Challenging to remove Granulation tissue
Metal stents Indications Recalcitrant tracheal stenosis Goal: short term: 2 weeks 3 months Palliative bypass for obstructive lesion
Stent s best friend Drizzle into trach Drizzle onto gran Instill through bronchoscope Nebulize 1 ml Ciprodex + 1 ml NS
Supraglottoplasty Craniofacial abnormalities: Not assessable through direct laryngoscopy KTP laser through flexible bronchoscope 300 or 600 micron fiber 10 15 Watts Tedious Able to be suspended: Laryngeal instruments and operating microscope CO2 laser
Laryngomalacia Surgical intervention rarely needed <10% of cases of congenital LM Laryngomalacia Types: Congenital Stridor shortly after birth Late onset FTT/dyphagia at 2 5 years OSA at 4 10 years DOE with stridor in teenagers Neurologic variant Floppy larynx and redundant mucosa Worst response to supraglottoplasty
Supraglottoplasty Cold steel or laser Indications: Severe/continuous stridor with increased work of breathing Cyanotic episodes Obstructive sleep apnea Aspiration Failure to thrive Complications: Post operative aspiration Supraglottic stenosis Glottic stenosis
Supraglottoplasty Release aryepiglottic folds Often resect cuneiforms Rarely trim edge of epiglottis Maintain intact mucosa between cut surfaces Can do intubated or free breathing Conservative better than aggressive Goal usually to make better not perfect Extubate on table Observe overnight Swallow evaluation before discharge
How do you get there? More intervention: More possible rewards and more risk Need opportunity to embed yourself with Otolaryngology Adult interventional colleagues Start with cases likely to succeed Don t burn bridges Have a back up plan Understand your environment