Boesch, Richard P

AbstractIntroductionAdvanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS‐TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4‐9].MethodsWe sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States.ResultsWe received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0‐5 years age group. Among our respondents, 31% self‐identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows.DiscussionThis is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

AbstractObjectiveChildren frequently present with chronic cough, recurrent respiratory infections, and dysphagia. These symptoms are poor predictors of significant inflammatory lung disease, such as from chronic aspiration. Bronchoalveolar lavage (BAL) is the gold standard for identification of lung infection and airway inflammation but is expensive and requires sedation. Chest X‐rays (CXR) are inexpensive, low‐radiation tests that do not require sedations and can document findings associated with infectious or inflammatory lung disease. The accuracy of CXR to predict or exclude infectious or inflammatory lung disease has not been directly evaluated and is unknown.MethodsRetrospective cohort of all pediatric patients who underwent FFB with BAL within 2 weeks of a CXR. Blinded CXR images reviewed for findings consistent with inflammatory disease by two senior pediatric radiologists. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for CXR to identify significant inflammation and/or infection on BAL were calculated.ResultsThree hundred and forty‐four subjects included. Two hundred and sixty‐three had positive CXR (77%), 183 had inflammatory BAL (53%), and 110 had infection (32%). The sensitivity of CXR changes for BAL inflammation, infection, and either inflammation or infection was 84.7, 90.9, and 85.3, respectively. The PPV of CXR was 58.9, 38.0, and 59.7. The NPV of CXR was 65.0, 87.5, and 66.3.ConclusionsAlthough CXR are inexpensive, do not require sedation, and are of low radiation dose, the ability of an entirely normal CXR to exclude active inflammatory or infectious lung disease is limited.

Objectives/HypothesisThis study defines essential data elements to be recorded during an aerodigestive “triple endoscopy” to form the foundation of a standardized multicenter registry and to clearly define measurement of each consensus item.Study DesignModified Delphi process.MethodsModified Delphi consensus with six survey rounds. Twenty‐four expert pediatric otolaryngology, pulmonology, and gastroenterology aerodigestive clinicians from eight large academic pediatric aerodigestive programs formed the Delphi panel. After achieving consensus through the Delphi process, outside validation was performed at 2019 national Aerodigestive Society conference. Consensus, near‐consensus, or exclusion was obtained for each proposed data element. Concordance was then measured between expert panel conclusions and validation group conclusions.ResultsOverall response rate was 94.4%. 73/167 proposed items reached consensus in six domains (flexible bronchoscopy, bronchoalveolar lavage, microdirect laryngoscopy and bronchoscopy, esophagogastroduodenoscopy with biopsies, and esophageal impedance and pH probe). Measurement of all items was defined; classification/grading systems were selected for 11 items. Validation group endorsed importance of 82/167 data items; compared to expert consensus, overall, inclusion, and exclusion concordance rates were 94.5%, 98.7%, and 90.9%.ConclusionTriple endoscopy is a central component of aerodigestive care. This study identifies and defines data elements to be recorded for all triple endoscopy procedures. The list is of usable length, and clear definitions were created for all items, with explicit classification/grading systems selected for 11 items. Face validity was confirmed with an independent multispecialty sample of aerodigestive providers. This consensus provides the foundation for a triple endoscopy registry but also is immediately applicable to standardize clinical documentation in aerodigestive care.Level of Evidence5 Laryngoscope, 132:2251–2258, 2022

AbstractAimPersistent or recurrent wheezing is a common indication for flexible bronchoscopy, as anatomic and infectious or inflammatory changes are highly prevalent. We sought to evaluate the prevalence of anatomic, infectious, and inflammatory disease in a cohort of children undergoing flexible bronchoscopy for wheezing or poorly controlled asthma.MethodsWe retrospectively reviewed all children <18 years old who underwent flexible bronchoscopy at our center from October 29, 2012‐December 31, 2016 for the primary or secondary indication of wheezing (persistent, frequently recurring, or atypical) or poorly controlled asthma.ResultsA total of 101 procedures were identified in 94 patients, aged 3 months to 18 years. Potential anatomic causes for wheezing identified in 45.7% of patients and inflammatory changes in 49.5% of procedures. This included the identification of a laryngeal cleft in 17% for which half required medical or surgical management. Tracheobronchomalacia was the most commonly identified anatomic lesion. Thirty children from this cohort had poorly controlled asthma. Among this subgroup, 54% had increased neutrophils on BAL and 30% had an anatomic contributor to wheezing, including one with a laryngeal cleft. Based on findings from flexible bronchoscopy, management changes made in 63.8% of patients. This included medication changes in 54 and surgical intervention in 9.DiscussionWe conclude that transnasal flexible bronchoscopy has high yield in children with recurrent, persistent, or atypical wheezing and those with poorly controlled asthma. Laryngeal cleft has a reasonably high prevalence that warrants specific evaluation in this population.