Fig. 38.10  Silicone Y-stent placement for malignant disease. (a) Endoscopic view of mass located in the distal trachea and proximal right mainstem. (b) Initial attempts at

tumor destruction with APC probe coating tumor surface. (c) Back table preparation of Y-stent prior to placement. (d) Endoscopic view from within tracheal limb of Y-stent

Endobronchial Valves

Alveolar-pleural stula and persistent air leak remains a serious clinical problem with increased morbidity and mortality [71]. Air leaks appear commonly related to underlying parenchymal lung disease and thoracic surgery. Adult data suggest endobronchial valve (EBV) placement has utility in the treatment of prolonged air leak [71– 73] and emphysema [74, 75]; however, the data in pediatrics remain limited (Fig. 38.11). A case

report describes successful EBV use in an 18-year-old patient with cystic brosis and recurrent pneumothorax to avoid pleurodesis while awaiting lung transplantation [76]. Additionally, a case series of four pediatric patients (age range: 16 months to 16 years) described successful EBV use in the setting of bronchopleural stula related to empyema and recurrent pneumothorax related to barotrauma [77]. No signi cant complications related to valve placement were identi ed within these reports.

Fig. 38.11  Endobronchial valve. A 16-month-old male with persistent air leak after ventilator barotrauma. (a) Chest radiograph demonstrating multiple chest tubes in

place. (b) Bronchoscopic view post-placement of a unidirectional endobronchial valve

Bronchial Thermoplasty

Bronchial thermoplasty (BT) is an endoscopic treatment available to adults with severe persistent asthma undergoing maximal medical therapy but still suffering from persistent symptoms [78]. BT attempts to alter smooth muscle mass of lobar and segmental bronchi by delivering heat energy to these airways via a radiofrequency generator. Initial data support the global reduction in smooth muscle mass [79], as well as further clinical studies demonstrating quality of life improvements [80] and decrease in mean hospital days at one year post treatment [81]. However, all the current data remain in adults, and these authors are currently unaware of any literature within the pediatric population. The evaluation of BT with the pediatric population appears to be mainly retarded by a self-imposed manufacturer moratorium and remains unclear if and when this will move forward. As of 2021, FDA approval for BT remains in patients 18 years of age and older.

Pediatric IP and the COVID-19

Pandemic

We would be remiss if we did not comment on the pandemic that has caused some of the most widespread interruptions to the modern health care system. While the morbidity and mortality of Coronavirus Disease-2019 (COVID-19) in the pediatric population is astronomically less than their adult counterparts, many children have contracted the virus and its severity and clinical course can be wide ranging [82]. Bronchoscopy has no role in the diagnosis, and, in children, it has a very limited role in the management of acute disease [83]. Unfortunately, given the widespread nature of the disease it is safe to say that some patients may come to require intervention during an acute infection or after infection resolution. Recent recommendations for bronchoscopy in pediatric patients follow many of the same tenets as what guide us in the adult population. First, all patients undergoing bronchoscopy

should undergo risk strati cation for the procedure, i.e., if the case is urgent (obstruction, foreign body), semi-urgent (mucous plug removal or respiratory sample collection), or elective (chronic cough evaluation, etc.) [84]. Second, it is recommended that any patient undergoing bronchoscopy be screened for illness. Third, if the procedure must go forward, the team performing the procedure must wear proper personal protective equipment with proper training on donning and dof ng the personal protective equipment [85]. Finally, the procedure should be performed in a well-ventilated or negative pressure suite. Flexible bronchoscopy is preferred to rigid bronchoscopy if possible, and, if possible, single-use fexible bronchoscopes would be optimal. Techniques such as use of non-invasive ventilation masks with an opening for a bronchoscope or having patients wear masks for as much as allowed have been suggested to minimize aerosolizing virus [84]. Minimizing cough refex has also been suggested to minimize exposure to health care workers. While performing procedures in actively infected patients is suboptimal and will pose some risk to health care workers, as the pandemic has dragged on it is becoming more likely that we will have to continue to adapt care for infected patients. Risk mitigation strategies should continue to be utilized and developed in order to continue to care for our patients and protect ourselves as health care workers.

Discussion

Our review suggests that there is literature to support increasing utilization of IP expertise within the pediatric population for complex thoracic and airway management problems. The current use of IP expertise within pediatrics appears relatively underutilized, likely the result of inertia in the medical elds and the current satisfaction and/or acceptance of management paradigms. It remains unclear regarding the clinical impact of additional support by mainly adult trained IP within the pediatric world of medicine; however, initial reports from the literature appear encouraging. Additionally, as the care of many complex pediat-

ric patients is multidisciplinary, the potential collaboration remains exciting and likely vital to the advancement of the eld and care of these patients.

Conficts of Interest  NS, LBY, and CRG have no conficts of interest related to this article.

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