Today I Scoped! #1

Hi there! 👋

Back in May, I promised a mid-June launch. Well... That was the plan, but time flew, and a lot has happened since.

If you’re starting out in pediatric interventional pulmonology, it’s easy to feel overwhelmed by the equipment, techniques, and procedures, and finding all the relevant, trustworthy content in one place isn’t easy.

That's the reason why we started a community driven scientific journal - Pediatric Interventional Pulmonology, which you should definitely visit. The journal is the flagship, but around it, we built an entire educational ecosystem, supported by an incredible global community.

I’ve come to really enjoy newsletters. Today I Scoped! combines that format with my love for writing and curating content, and I write it the way I would want a newsletter to be written for me - concise, relevant, and worth revisiting.
Each issue will share cases, pearls, and insights that you (we) can actually use in your clinical practice.

Spotlight Procedure

Cryo Recanalization for Pediatric Post-Intubation Tracheal Stenosis Case by Venkat Tummuru

Presentation: 8-year-old girl with severe stridor and SpO₂ 80% on room air, 10 days after extubation post-mechanical ventilation for snake envenomation. CT neck showed subglottic stenosis.

Procedure: Bronchoscopy under LMA revealed thick granulation tethering the vocal cords and narrowing the subglottis. Adhesions were released with cautery, granulation removed using a cryoprobe, subglottic area ablated, and topical mitomycin-C applied.

Outcome: Airway patency restored; extubated on table, discharged next day. Follow-up bronchoscopy at 10 days showed good lumen.

Editor’s Note (M.S.): This was an excellent case and well executed by Venkat. There is no single consensus on the best approach here. Prevention is always preferable. This was not the usual, isolated subglottic stenosis; it also had an anterior laryngeal web with thick cricoid lamina and posterior narrowing.
Some centers might refer this to ENT for laser treatment and keel placement, while others might manage it within interventional pulmonology. The procedure is not as straightforward as it appears, and different operators might choose different techniques. Venkat has a lot experience, and he executed it flawless, but in these cases, when the vocal cords are involved, there is a high risk of restenosis, no matter the technique (that is the reason why ENT's place a keel).

Tip: Be extremely careful when manipulating near the vocal cords. The risk of scarring and long-term voice changes, along with vocal cord paralysis, dislocation, and even perforation… is real.

DEEP DIVE: How Do You Treat Atelectasis? It Depends.

When I first started in pediatric interventional pulmonology, besides foreign body removal, I enjoyed treating atelectasis, especially obstructive atelectasis. If you see mucus, you just suction it.

But chronic, nonobstructive atelectasis? That’s a different challenge entirely.

The Problem

One common method is wedging the bronchoscope into a segment and doing lavages. But there’s the catch: an atelectatic lung segment is already surfactant-depleted, and lavage reduces it further. You need higher peak inspiratory pressure to reinflate it. If the patient has an underlying neuromuscular disease, they cannot generate the pressure.

Another approach is connecting air or oxygen through the suction port at ~2 L/min, and pressing as if suctioning. I dislike this because you can’t control the pressure, and risk creating a pneumothorax.

Our Solution

I work quite a lot in our NICU and work with ventilators all the time. The approach I adopted is based on this:

• Fixed maximum pressure, variable volume.

• Use the smallest scope for segmental insufflation.

• The pressure is controlled with a digital cuff manometer.

• Instill surfactant post-inflation to reduce collapse risk.

By wedging at the start of the lobe, we hypothesized that air would otherwise preferentially go to non-atelectatic lung (due to higher resistance of the atelectatic lung). Pressure-controlled segmental insufflation solved this.

Results: We published this approach in Pediatric Pulmonology, and after that we treated a dozen patients with no pneumothoraces and excellent outcomes in one session.

In the mean time we expanded it by using lung ultrasound for real-time monitoring, to reduce the need for x-rays, and to observe if any pneumothorax is created just after the procedure.

I am currently exploring the idea going even further - using bronchial branch tracing, by finding the exact location on the CT scan, and going subsegmental (or even deeper, if the patients size allows). Worked really good in a couple of patients.

However, I still don't know what the best treatment for chronic nonobstructive atelectasis is. Some of the questions that remain are the dose of surfactant, the timing of intervention or should I use a digital manometer or connect it to a ventilator and adjust the settings for lung recruitment like the Spanish group did.

Announcements

1. The journal Pediatric Interventional Pulmonology started a webinar series. So far two live events have been hosted, and two more have been planned for 2025:

   • Cryotherapy in Pediatric Airways

   • Management of Tracheoesophageal Fistula

2. Cincinnati Children's Bronchoscopic Cryotherapy Seminar on September 20, 2025.

Worthwhile Reading

1. Therapeutic Bronchoscopic Interventions for Non Foreign-Body Removal Indications in Children, Pediatric Pulmonology 2024

   Why read: One of the largest series of therapeutic bronchoscopic interventions for non-foreign body related indications in children

2. Role of Endobronchial Therapy in the Management of Primary Tracheo-Bronchial Tumors in Children, Pediatric Interventional Pulmonology 2025
   Why read: Endobronchial tracheo-bronchial tumors in children are extremely rare. The authors describe different techniques in the management of CAO caused by such type of tumors.

3. A novel technique of non-invasive ventilation: Pharyngeal oxygen with nose-closure and abdominal-compression-Aid for pediatric flexible bronchoscopy, Pediatric Pulmonology 2015
   Why read: PhO2 -NC-AC is a simple, safe and effective NIV technique for respiratory support and rescue during various pediatric FB procedures.

   Editor’s Note (M.S.): I tried this method many times, and it works wonders

That’s it for this issue of Today I Scoped! I hope you found something here that you can use in your next case

Your turn: Have a case, tip, or question worth sharing? Feel free to reply to this email. It might be featured in a future issue.

Until next time,

Matej