Dr. Alfin Vicencio focuses on Pediatric Interventional Bronchoscopy, sharing its history and how it has developed. He highlights current developments, including emerging instruments that increase the accessibility of this procedure. Specifically, Dr. Vicencio highlights the flexible cryoprobe and its numerous potential medical applications. He shares a vision of a bright future for Pediatric Interventional Bronchoscopy.
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Anthony uh asked me to speak a little bit about um what's cooking below the vocal chords. Um As Emily said, uh it's more of a mindset as far as this error digestive uh management program. But um uh I think that Anthony wanted me to expand a little bit about things that are going on uh within the lower airways and the lung pereny uh that might be relevant and I thought that it was a um might be a good opportunity uh because there's actually quite a lot going on these days. Um And a lot more that's going to be coming in the next couple of years. And specifically, I want to talk a little bit about um pediatric, advanced diagnostic and interventional bronchoscopy. Um I've labeled this talk, what, how and why and some of that will actually um come out uh bear out in the talk during the talk. Um This is my only dis disclosure. I am a consultant for ambu. So, what I'd like to try to do over the next 15 or 20 minutes um is uh listed here. Number one, I'd, I'd like to try to advance uh to define pediatric advanced diagnostic and interventional bronchoscopy. I realize that a lot of people here in the audience are not pulmonologists. Um So I'm trying to tailor this so that um people can get a little bit of a better view from from the pulmonary perspective. Um I want to provide a little bit of a historical perspective uh about the evolution of this discipline which is continuing to evolve uh based on the available technology these days. Um And specifically introduce um this crowd to some emerging techniques that may have implications for minimally invasive diagnosis and therapeutics uh specifically in the lungs. Um and the lower airways that will, will eventually be very, very relevant uh to the air air digestive programs. Um For those of you who are not pulmonologists um or even for those of you who are ent folks, um this is a flexible bronchoscopy. It's old one, I apologize. Uh The, the equipment we had back in, I think 2010, I think this was taken uh 2008. Um It wasn't as good, it's a little bit grainy. But um uh for those of you who have not uh necessarily seen a lot of flexible bronchoscopies, um This is what it looks like. It's actually quite a simple procedure. Um I'm, I'm going to spare you the, the anatomical uh landmarks of this, but basically, we're going in through all the portions of the lung. Um We are uh uh visually inspecting, um, all the way down to the segmental, uh, airways, uh, in a spontaneously breathing child. Uh, this did not happen to occur in the context of a, uh, triple scope. Uh, back then, we weren't really doing a lot of, uh, double or triple scopes. Um, but what you can see here is that it's quite easy. And, uh, I think one of the things that scares a lot of people from a pulmonary perspective is that uh we're sticking things in airways where people get nervous about that sort of thing. Um But uh bronchoscopy has come a long way and it's a very, very safe procedure. Uh that literally a complete visual examination can be done in about two minutes, um very, very safely. Um There are other procedures. Uh It's moving on here. This is the Broncho alveola lavage portion of it where uh this is where our, our anesthesiologists playfully say we're drowning our patient. Um uh But, but it can provide a lot of information about inflammatory counts, cell counts. Um uh and uh uh bacterial um uh microbiologic analysis and on occasion, we'll do things like um some simple instrumentation. Um In this case, we're getting a brush biopsy sample. So, what is interventional bronchoscopy? And I think um probably the best way to define interventional bronchoscopy is to actually look to our adult colleagues because interventional bronchoscopy in the adult realm has been actually around for 20 years. Uh Surprisingly, the AC GME did not recognize it as an approved subspecialty until probably about two or three years ago. This is the letter that uh one of the Bronchoscopy boards sent to the AC GME arguing that it should be under their realm uh for accreditation and uh they provide sort of a 50,000 ft view of what interventional bronchoscopy means in the adult realm. And I'm gonna read some of this to you. Interventional Bron. Uh Pulmonology is a subspecialty that focuses on the evaluation and management of thoracic diseases with a focus on minimally invasive diagnostic and therapeutic procedural skills. Beyond the scope of adult Pulmonary Medicine Fellowship requirements. I underlined that particular comment because that's where we start to get a big, big divergence in between the adult realm and the um uh pediatric realm. Uh Specifically, uh interventional pulmonology really came to be because of lung cancer. We don't have lung cancer in pediatrics. Um So already there's a, there's a little bit of a discrepancy as far as how we might define these disciplines um from the adult of pediatric patients. So they have a well-defined indications they're looking for lung cancer so they can treat it early. Um They have advanced procedural training. Remember in our adult populations, uh uh they are doing uh routinely things like transbronchial biopsies, needle aspirations, et cetera, et cetera where that's not really under the realm of of most pediatric Pulmonary Fellowship programs. Uh And, and perhaps more importantly, especially nowadays is the, the dedicated equipment that they have that has been developed in order for them to get um uh minimally invasive. Some of these m minimally invasive procedures done uh in pediatrics as Emily will know and some of the other people who might be in the pulmonary realm in the in the audience, uh We're dealing with a bunch of rare conditions. Um There's a relative lack of procedural training. Most um pediatric pulmonologists are trained in flexible bronchoscopy from a visual diagnostic standpoint and perhaps bronchial alveolar lavage, but something as routine in the adult population as transbronchial biopsies, probably two thirds of the programs don't a um of the training programs and pediatrics don't actually have access to that. Um And, and again, perhaps, most importantly is the lack of dedicated equipment. Um We need small equipment to get out into the periphery of the lung and up until very very recently that has not been present. Um The first statement that came out uh in about pedia specifically pediatric interventional bronchoscopy uh wasn't until 2017. And even that, that was it, it was a, it was a um consensus statement uh out of the uh the European Respiratory Society. Um And all it did was comb the literature and found a bunch of case reports, small case series and some of what's listed up here are certain things that people had done. Um leading up to this publication, they were typically done in isolation, various institutions across the world and almost nothing that appears on this list is actually listed as standard of care even today. So it's a whole bunch of different things, people figuring out ways around problems and, and, and that's really um what, what makes it very, very difficult to define what is advanced um pediatric bronchoscopy. So at this point in time, I usually like to switch gears a little bit and, and just give a historical background of how it evolved for me. Um If you go around the country around the world and you know, poll 15 advanced or, or interventional pediatric pulmonologist, they're probably gonna have a lot of parallels to the story that I'm gonna tell you here, but also probably some important differences. So this is really just my own story. And it started with actually an ent physician by the name of Sanjay Parek, who um I was a year or two out of fellowship. He approached me and he said, listen, I, I think I really need your help with some of the complex cases. And he was one of these ent folks who not only um allowed me to come into his or to help with joint procedures, but really encouraged it. And he said there are certain things that I want to do that I'm gonna need your help with. Um There were three principles over the next eight years when we were working together that probably drove some of the procedures that we had created. Uh And they're listed here and I'm gonna go one by one. Most of the time back then, this was 20 years ago. Uh It was, it was simply driven by necessity a little bit of innovation and honestly, some improv um this is not the first foreign body that I've taken out, but it's representative of some of the ways that we approach some of these problems. Um This happened to be a 14 year old boy playing with a pin in his mouth, went down his lung and went very, very far down. Nobody else could reach it. Um Again, the first time that I did something like this had never done it in fellowship. And somebody said, hey, listen, we're gonna be there, we need you to go down there and get this out. Or else this kid's gonna get his, his, his uh his chest cut open uh in order to get this thing out. Now, once that was successfully done, then it allowed us to start thinking about other lesions that were difficult to access with traditional rigid equipment uh by flexible, even though some of the equipment that we were using was not specifically designed for the pediatric airway. Um But as those skills became a um acquired uh confidence began to grow, not only in doing these procedures uh ourselves, but uh they became recognized among our ent colleagues and our IC U colleagues and our floor colleagues that, hey, maybe we can approach this in a different way. Uh And then lastly, there was the um issue of no. So this is just a video of um an airway lesion that was inaccessible um by rigid bronchoscopy that we had to debulk. I'm not gonna play the whole video there. Um uh equipment uh as I had mentioned before has been historically, the, the, the main limiting factor. Um I'm old enough that uh I remember when we had big scopes with very, very small channels that we really couldn't do much with. Um eventually those scopes got smaller, the outer diameters got smaller, the channels got bigger. So it allowed us to actually do a lot more things with them even though technically, we were not trained to do them. I think that an underappreciated uh technological advance was actually the application of the laryngeal mask airway because it allowed a relatively stable airway. Um It allowed repeated passage, repeated and easy passage of bronchoscopes uh that were larger than, than could fit through a corresponding and a tracheal tube. Uh And it allowed a lot more intervention. And these days we have some other uh fancy tools that I'll, I'll discuss a little bit more in detail and subsequent slides. But what I've listed up here is the uh flexible cryoprobe and the um radio uh endobronchial ultrasound probe. So I want to pause again and um this is a movie, I think it was 1996 somewhere in the mid nineties, Jurassic Park. I don't know if anybody's seen it but uh the uh the II I like this movie in the context of this, of this talk. Uh It had a really cool scientific principle, you know, DNA, they're getting it out of um prehistoric mosquitoes and bringing back an extinct species. So very, very cool some consequences that were unintended. Bunch of people got eaten in during the movie. So, one of the themes of this movie is just because you can, doesn't necessarily mean you should. Um And we do recognize that that when we're doing some of these procedures, uh especially 20 years ago, it's something that wasn't highly accepted uh because there wasn't a whole lot of blueprint of how to correctly do them. Um So that really does beg the question that even now is this something that we should be doing? Uh And I'm gonna tell a couple of reasons why I think we should. So probably the best example that I have had in my career and this happened actually a long, long time ago, probably 15 years ago or so. Uh But this was a child who was born with one lung. Um And what you can see on one of the x rays is that because of the shift in the media thin and that was expected from, from a child who had one lung uh the left mains and Bronchus takes almost a 90 degree turn, um, turn and, and sure enough, this kid came in at about a year and a half of life with a foreign body that had wedged itself all the way distally in that left Main Bronchus. When I arrived at the bedside, there were three a nt folks that I worked with very closely sweating, profusely trying to get their equipment past that, that 90 degree um uh uh turn emo was being activated and, and the K CO2 was 100 and 20. Um This was actually the only way that we could actually get this kid out and avoid an emo running this kid and perhaps save this kid's life. Um importantly, uh this was done long enough ago that it wasn't easy to get um airway retrieval baskets um that were designed for pediatrics. That's actually a urology stone retrieval basket that I just happened to know where they were ran to the or and got that. Now, this is a dramatic example of how interventional pediatric pulmonology might be beneficial to some patients. But we're not going to design a specific discipline based on one case that probably I'm never going to see in my entire life. However, this was also recognized in the European Respiratory Society statement that Pediatric Interventional bronchoscopy after they had combed the literature for all of these case reports and case series admitted that, that, that this discipline may significantly limit morbidity, not only from a particular disease state, uh but also from more invasive procedures. In the case of that patient ECMO run uh open chest, et cetera, et cetera. Um These days, the applications um are being driven by the equipment availability. Um And I think that's actually kind of an interesting concept where uh it's sort of like the movie field of dreams. If you build it, then they will come where where in pediatric pulmonology, nothing is specifically designed for our use and for for use in our patients. But but people around the world have actually started to apply certain things that have been introduced to figure out how they can help patients. Uh Probably the one that has made the most impact recently is the flexible cryoprobe. Now you and G I and ent and everything, this might not be such a big deal to you. It was a very big deal when the 1.1 millimeter probe came out because now we could use that and essentially any pediatric patient on a flexible bronchoscope, uh I apologize for the self um citation here, but this was uh uh I, I feel I felt so important about, about this particular introduction of piece of equipment that um uh that I just had to put this up. And, and the reason is is that um the reason that I believed at the time that this was really going to spur the the discipline of pediatric interventional bronchoscopy was it was clinically useful, it was safe, it was easy to apply. Um And um for those business people in the room, it came at a modest price tag and, and all of those things together. Uh over the past couple of years, this is really, really um started to gain a lot of interest um in, in pediatric pulmonary circles. Uh Here's a couple of examples of what this device can be used for. Um the bigger photos. Uh our patient with polyangiitis um and uh recurring airway lesions that was actually on a lung transplant list, uh be uh because she had been failing um normal things like balloon dilations and, you know, uh intralesional steroids, et cetera and, and, and, you know, we would bring this child back every 3 to 4 months and, and start buzzing and deitz some of this tissue with these cryoprobe. Uh Mike Rothschild's in the in the room right now. And you might recognize some of the, the, the photos of a kid who had recurrent um some subglottic stenosis where we had to, where we applied the cryer probe. And actually uh got that to be a little bit more patent. And uh the patient in the lower right hand corner was a congenital web. So it has a lot of applications like this um uh without risks of airway fires and things like that. Um Here's two other, there's something a principle called cryo adhesion. It's very, very similar uh to sticking your tongue on a frozen metal pole. Uh Again for the ent folks in the room. Um Yes, that is a foreign body. Um uh No, we did not go in there by ourselves. Ent was with us, but the first pass with the, with a rigid scope, some pieces started to break off because that nut had actually been in there for about three weeks. Um But what you can see here is that um uh it's fairly easy um to extract some of these tissues that might be uh a either slippery um to grass as the as you saw with that big mucus plug. Uh but also uh things that might be too distal uh to be easily reached by traditional rigid equipment. Uh This is actually a fairly recent patient um with a very, very distal airway tumor uh that these are admittedly rare, but a lot of times uh these kids are actually going to surgery and getting part of their, their lungs chopped out. In this case, we were able to actually reanalyze that airway and get a specific diagnosis and then um have AAA more appropriate the uh chemotherapeutic option. So we were able to save this kid a lobectomy. Um and finally, transbronchial cryo biopsies. Um The importance of transbronchial cryo biopsies are that uh it's a minimally invasive um method for obtaining lung tissue. Uh because the probe freezes the alveolar tissue, you actually get a good sample without crush artifacts. So this is something that we believe is going to be much, much more prevalent um in the next decade from a diagnostic standpoint. Um I love cryotherapy but it's not, it's really literally, it, this is, I've always wanted to use this, the cryotherapy, the tip of the iceberg ha ha ha. But um uh the uh uh this has become my favorite slide, but really, that's sort of what what spurned the um the the acceptance of of interventional bronchoscopy in the past five years or so. But there's a whole lot more going on beneath the surface that I think is going to be very exciting and contributory to a lot of a programs. Um just very, very briefly, this, we've got some fancy navigational tools out there. This is the radial ultrasound probe that in the middle you can in real time locate distal lesions, stick a needle in it or put a bi a set of biopsy forceps in it and get a diagnosis uh to in this case help to um uh give more appropriate antibiotic coverage for a patient on chemotherapy. And that and that lesion in the uh in the right middle lobe um navigational equipment is getting pretty fancy. Um These are 3d images um where uh not only can you locate where exactly you're supposed to put the needle to get an optimal sample, but also to avoid blood vessels. Um So Emily's probably looking at this and saying, hey, listen, I can get to the left upper lobe very, very easily. I don't need that fancy piece of equipment, but again, that green dot is showing us where we're going to get our maximum um uh output. And then if you see a little bit of that pink tinge uh about two millimeters below that, that's a blood vessel. So it really, really enhances the safety of this stuff as well. So over the past 20 years, um this is sort of what I've observed uh from, from an advanced bronchoscopy standpoint is number one, I think the clinical utility has always been there. It's always been there, it's always going to be there. I think that there's been a lot of interest um and some gaining experience across the country. Um The equipment and technology is no longer the limiting factor. There's a lot of equipment available right now um for our, our use. Uh And because of that then better safety and effi efficacy profiles are now available. Um I think the pie in the sky that we're looking for now is education and training. Um It's not something that is um built in to the vast majority of pediatric pulmonary programs. But what we're hoping is that we're gonna be able to put some platforms together where uh many more people can start learning some of these techniques. Uh This is just a brief example over the past couple of years of what we've done, I've worked with colleagues from University in Cincinnati and, and the Children's Hospital of Philadelphia. Um, and we've run several courses either out of the American Thrust Society or independently, uh, to get people some hands on experience. And these are some of the pictures that you see with some of the models so that people can really, really feel what it, what it, um, uh, what it, uh what, what it's like to actually do some of these procedures. Actually, Emily was uh a hands on instructor for our first course that we ran in 2022. I don't, I don't think I have your picture up there Emily. But um and we're starting to organize now. Um you know, we're, we're, we, we, I just came from Germany as Anthony said, uh and we were running a three day course there um that was attended from people all over the world and in partnership with the American Academy, uh American Association of Bronch and Inter Interventional Pulmonology, the American Thoracic Society and the European Respiratory Society. Uh We're now starting to actually gather a lot of momentum for this discipline. So I just want to end by saying that um um again, I think that the clinical applications already exist. I think they've been here for a long, long time and we just needed to figure out a way to, to, to help um implement some of these, some of these um procedures. Um I I the lack of pediatric equipment is, is, is not a hindrance anymore. Uh or, or certainly not much less of a hindrance than it was 20 years ago. Uh And it's continuously improving. Uh And I think that the the future really shows that minimally invasive approaches, not only to diagnosis but also um treatment of lower airway. Um issues are going to add a completely new component to air digestive programs. So, with that, um I'm gonna hold questions, is that correct? And um and then, and then I will take the time to introduce our next speaker.
