Transcript

TRANSCRIPT PODCAST: Pediatric Bronchoscopy

TRANSCRIPT PODCAST: Part 2, D217126, 2021-06

TRANSCRIPT PODCAST: Welcome to this Erbe group podcast produced by our Medical insights studio. In today’s episode our Clinical Application Manager Dr. Niklas Froemmel is talking to Dr. Erik Hysinger, Assistant Professor in the Department of Pediatrics at Cincinnati Children’s Hospital. Dr. Hysinger is a board-certified pediatric pulmonologist who has received the Best in Pediatrics award by the American Thoracic Society (ATS).

TRANSCRIPT PODCAST: In the last episode, Dr. Hysinger discussed general aspects of bronchoscopic procedures for pediatric patients and use of cryotechnology for treatment of foreign body aspiration and emergent recanalization in critically ill patients.In this episode he will be discussing his rationale for debulking granulation tissue using cryotechnology as opposed to other modalities and the role this technology plays for palliation of central airway tumors.

Niklas: You have told me in an earlier conversation that you are also treating granulation tissue bronchoscopically. And let me maybe go to this as prevention is always better than treatment. Which patients are under risk for such granulation tissue and how can you prevent its formation?

Erik: Sure. Well, actually, so you mentioned the granulation tissue, we were just doing a case of this last week for a young lady who's had really a very difficult time with formation of granulation tissue. The kids that I see granning the most are going to be patients that have long term needs for trachestomies and long term needs for ventilation. That's probably the most common area that we see. And we can see it from anything from suction trauma to problems with the cuffs, creating damage to the tissue or from the tracheal tube itself, rubbing into the mucosa and creating inflammation distally. Another place where we've seen this has been in patients that are having endobronchial stents. Oftentimes similar processes.

Erik: The presence of the metal in the airway was usually the reason ... stents. The presence of the metal is resulting in irritation of the tissue and frequently can get completely obstructed. So that's another place where we've had good use for it. There is a little bit of patients that we've had this with using for lung transplants and trying to make sure we maintain the anastomotic site. But fortunately, lung transplants a fairly rare thing to have to do in children. So we don't have a lot of those, but it does happen on occasions. But the bigger issue or the patients that have chronic tracheostomies and ventilation and also chronic stents in the airway.

Niklas: Would you say that the formation is more frequent as compared to adults?

Erik: Probably. I'm not aware of anything that's directly comparing that. But at the same token, children are going to have smaller airways. They're going to be more vulnerable to irritation, suction trauma, things along that line, in particular with some of our kids that have unusual congenital airway problems.

Erik: They can be more prone to developing airway damage related to intubation or chronic trache use or suction trauma. This is probably more common in kids, but I'm not aware of anything that specifically compared to the two. Certainly it's something that we end up having to deal with, not terribly infrequently, unfortunately.

Niklas: You already mentioned the vulnerable mucosa in children, so any treatment would mean manipulation. What should the optimal treatment for granulation tissue be capable of?

Erik: Well, I think the first thing is to try to treat it as to prevent the granulation tissue from forming in the first place. And so especially for kids that are trate making sure that the track is well positioned, that it's well seeded, is now back while your front walling that people are using appropriate suction technique. Many people will suction children the same way that we use suction in adult which can cause trauma to the airway and there needs to be carbonate. Really pretty great care needs to be taken to not do that. So prevention I think is the first thing that we need to be able to do. If we're going to have to do something that is more interventional for granulation, it's already formed. Ideally, we can do something that's going to be quickly done and it's not going to cause any pain for the kids. We will trust medication therapies and those don't work trying to do things endoscopically that are going to put the kid at minimal risk and try to prevent their grant from reforming when it does happen. It's going to be a key for us.

Niklas: Where in the therapeutic algorithm would you integrate cryo technology? So what's the benefit of it?

Erik: So in terms of timing of using cryotherapy for granulation, I would say first thing, try to prevent it from forming. So using appropriate suction technique, positioning your tricks or other devices that may be in the airway, positioning that optimally so that you're not getting formation of granulation tissue would be step one. If that's not going to be effective. We will often try some medical therapy, steroid drops or Superdex drops things along that line. If in that point we haven't had good success in alleviating the granulation tissue. That's usually the time at which I would start doing endoscopic intervention, trying to remove the obstructive tissue from the granulation.

Niklas: When you perform cryo extraction of such granulation tissue, and you would need to give an advice to a colleague who wants to perform this for the first time, what kind of patient and what kind of,

Niklas: let's say, lesion by position or by morphology would you recommend him to do in a first case?

Erik: Well, I think trying to do it. And if you turn in the first time, using older patients with bigger airways is usually the best place to begin with. It's just technically it's an easier thing to be able to do bronchoscopy in general. The kids were grand that I had that have really the crime has really shined for me, have been children that have had problems with recurrent granulation tissue and particularly granulation tissue that's obstructing a significant fraction of the airway. So really greater than 50 percent would be where I would start to think about that, especially if it's in the trachea, because that's the point at which most of the kids will tend to start complaining of more shortness of breath or wheezing or just difficulty breathing in general. So that's probably the place that I would start with, is more proximal tissue and bigger kids that have significant airway obstruction.

Niklas: What else would I need to observe when I perform a cryo extraction of granulation tissue?

Erik: I think you need to make sure that the probe is going to be where you want to go. So, again, visualizing that you're actually hitting the granulation tissue with the probe and not some of the surrounding healthy mucosa is going to be an important thing to make sure that we're doing and being able to remove the tissue in block. Once tissue comes out I think it's very important to get back into the airway quickly as well. Make sure that we haven't created any significant problems with bleeding. Candidly, with doing cryo extraction for granulation tissue had really been quite pleased with the lack of bleeding that I've seen with removing tissue that way. I have done a lot of work with removing granulation tissue with forceps in children and it is typically quite challenging. And bleeding is often quite a major problem. And I just haven't seen that with doing cryo extraction in kids. I also think it's important and will typically spend some time doing devitalization of the tissue or doing devitalization around the site that I just did the tissue extraction with trying to prevent granulation from reforming and had some pretty significant success with that. We were mentioning earlier, I was working with a patient this past week, and she had developed precrime granulation tissue probably about every two to four weeks, actually, and it would become obstructive within about a month. And we spent some time, I guess it was about a year and a half ago now, giving her her first treatment with cryotherapy. And she just now came back for having some more granulation before and then about a year and a half later. So I think adding devitalization to the tissue can be quite useful as well.

Niklas: You mentioned the devitalization aspect of cryotherapy, so repeated freeze and thaw cycles. How long and how often would you freeze when having the intent to devitalize?

Erik: So typically what I've done is if there's tissue that I'm trying to devitalize, usually using between 20 and 30 second freeze cycles, I do have some colleagues who have done up to a minute of doing freezen cycles and really just trying to go around the entire area that's involved that we're trying to devitalize the tissue. Once I have done that, I'm usually bringing the patient back within probably two weeks. Maybe within a week, depending on how the patient has been doing and the extent of the work that we are doing and repeating it, I've typically found it takes usually two cycles of treatment to be able to get the result that I'm really looking for. I certainly see improvement within one. But usually it's taking two, sometimes three. I don't think I've had anybody where I've needed to do more than three for acute management with some of the patients that are more tenuous and not necessarily waiting that week or two may be coming back in a couple of days to see how things are going to be. Usually a week or two has been about right for most of my patients so far.

Niklas: When we talk about devitalization, I think we should also mention debulking of airway lesions, which is not only interesting for granulation tissue, but also for other tumors that can require cryo extraction. So to be debulked, which tumors do you frequently see in children that require a debulking with cryo technology?

Erik: Well, fortunately, tumors in the airway is really pretty rare in kids. So I don't know that I would say that there are any that we see frequently, but there certainly are airway tumors, primary airway tumors that we do deal with in children. One area that is used cryo for has to really just to open up an airway in an acute setting has been things like carcinoid tumors or inflammatory myelofibrosis, trying to open up the space and help kids be able to be more comfortable until they can get to more definitive surgery.

Erik: In certain cases, actually having tissue knowledge from a crowd debulking and sending that off to pathology can actually prevent having to do larger surgeries, such as wedger sections. And you can manage the airway with a combination of chemotherapeutics and really just maintaining the airway lumination, as some colleagues of mine in Philadelphia have been working on that currently. The other place that I've used tumors to try to pull out or just masses in the airway, papilloma ptosis, the crowd has worked really quite well there. Those tend to come off very easily. And as opposed to trying to use laser therapy to be able to remove that tissue, which creates a lot of concerns about aerosolizing the papilloma and also potential risk for airway fires. The cryo really seems to prevent both of those problems. And histoplasmosis has been another place where I have had some really nice success. We had one patient that had about a 70 percent decline in lung function in the span of about twenty four hours. And she had debulking using cryo and almost instantaneous return to normal lung function. Really, things were quite well. So several instances where you can do it and really have had very good success removing tissue from young kids airways.

Niklas: Lucky for the young lady that she recovered so quickly, actually. What would be your rationale, when would you debulk so when would you freeze and pull, and in which patients would you rather devitalize? How do you differentiate between that?

Erik: I think frequently doing a combination of both, honestly. The debulking, I think, is going to be the most important when you have very large amounts of airway lumen that´s being occluded. So if I have an entire bronchus that has been completely obstructed, trying to recanulate that bronchus by removing tissue is, I think, really critical for making patients have more comfort and be less short of breath. And things of that nature often will be doing devitalization at the same time, once the larger obstructive lesion has been done or has been removed, trying to make sure that we don't have regrowth of whatever was causing the obstruction of the airway lumen to begin with and make sure we keep the patients feeling well and not having shortness of breath.

Niklas: In case you have a well vascularized lesion, for example, carcinoid tumor, how do you deal with cryo debulking in these cases? Are there any precautions that you need to, manage a bleeding that might occur? How do you handle this?

Erik: Sure. And I think that is critical if you're going to be removing stuff from a pediatric airway. You need to be prepared to deal with the complications that may occur. I think actually, step one is knowing that this is, in fact, a tissue and not a hemangioma. Having a CTA before you're removing tissue can be really critical in children, because one of the more common masses we're going to see in airway is a hemangioma. And if you try to pull in a hemangioma, you will invariably regret it. If, in fact, it's not a hemangioma and you're dealing with other forms of airway tumor, I think having preparation for being able to deal with bleeding is still really important. So common things that we will use topical vasoconstrictors, particularly Afrin and epinephrine will have on hand and ready to go to be able to instill through the bronchoscope. Iced saline can be something else that's really quite useful. And I will say I have not had to use much beyond that at this point with the work that we've done. That said, always be prepared to intubate the contralateral lung or intubate beyond the lesion as well to make sure that we maintain airway if we're still having difficulty. I think that's something that's critical to be prepared to do.

Erik: And fortunately, if we're having a flexible bronchoscope in the airway, the ability to secure the opposite side or to secure the airway distal to a tumor. You have the right equipment already in the airway and ready to go. So I think being prepared is a very good choice. And then also making sure that, you know what you're pulling on, not pulling on something that's really likely to cause significant hemorrhage.

Niklas: All right. Thank you very much, Erik, for giving us a glimpse into your really rich experience in pediatric bronchoscopy, I know this is only touching a very little part of what experience that you have in this still young discipline. And I hope this is also interesting for our listeners to learn more about this evolving field. Thank you very much.

Erik: Uh, Niklas, I appreciate the invitation and certainly look forward to continuing to try to advance the field of the pediatric bronchoscopy and see what we can do to better support our kids and try to deal with some of the complications that seem to increasingly occur as we get better and better at saving young kids lives.

Erik: Granulation tissue easily forms in the pediatric airway as a result of irritation and inflammation of the mucosa. Preventing such conditions is always better than treating them. When it comes to bronchoscopic intervention, the combined capacity which cryotechnology has to debulk and devitalize tissue helps the physician obtain sustainable therapeutic results. Fortunately, tumors of the airways are quite rare in pediatric patients. Cryodebulking combines the capacity to evaluate tissue histopathologicaly and define the most appropriate and ideally gentler treatment option. In cases of papilloma, aerosolization of cells is not a concern when cryotechnology is employed. Keep up this great work saving children's lives.Thank you, Dr. Hysinger, for sharing your experience, which will be beneficial for other bronchoscopists as well and Niklas for being here today. Stay tuned for our upcoming episode about cryotechnology.

Erik: Thank you for listening to our medical insights podcast, a podcast by the Erbe group. To get further information and view our terms and conditions, please visit our website at www.erbe-med.com.