Today I Scoped! #2

Hi there! 👋

Time really does fly, and with everything going on lately, I didn’t find a moment to write a proper newsletter article. Still, I wanted to take a moment to thank you all for the positive feedback after launching Today I Scoped!

Several of you reached out after the last issue regarding atelectasis treatment, and we even managed a few patients together — which was amazing to see in practice.

In today’s episode of Today I Scoped! we are going to talk about central airway obstructions (CAO)!

Spotlight Procedure

Management of a large tracheal tumor with electrocautery by Joseph Tinku.

Presentation: A 15-year-old male patient presented with progressive dyspnea over six months, worsening to orthopnea and stridor in recent days. Initially misdiagnosed as asthma, a CT scan revealed a well-defined, endoluminal, polypoid tracheal lesion.

Procedure: Under rigid bronchoscopy, a flexible scope was introduced to perform snare electrocautery. The tumor was extracted with cryotherapy, and the base was coagulated, and cryonecrosis was induced.

Outcome: Airway patency was fully restored, and the tumor completely removed.

Editor’s Note (M.S.): Central airway obstruction (CAO) is a life-threatening emergency that demands immediate intervention. Cases like Joseph’s are rarely demonstrated online, which is why this one deserves to be in our spotlight.

There are many ways to manage such obstructions: snaring, laser, cryo, or coring, and the choice depends on what tools are available. Regardless of the method, you must always control for two (+) critical scenarios:

1. Bleeding - Prepare for possible massive endobronchial bleeding. Maintain suction and coagulate early. Be ready for temporary loss of visualization.

2. Obstruction - Dislodged tumor fragments can behave like foreign bodies, worsening the blockage.

3. A combination of those two complications.

Personally, I often use a diode laser. I start with lower frequencies to coagulate the lesion, minimizing potential bleeding, then proceed to evaporate and core it. For large tumors, this may not be the best option, since it takes time. But not all can be easily snared. Some colleagues apply topical or intralesional adrenaline to further reduce bleeding.

But anyway, cases like these do require significant experience.

DEEP DIVE: Total CAO caused by a blood clot

A while ago, I treated a patient with complete tracheal obstruction due to a blood clot - a rare late complication of tracheostomy.

Tracheostomies are designed to ensure safe ventilation, but in this case, the tube itself wasn’t functioning because the obstruction was below the tracheostomy.

The Problem

There are several problems with this:

• A non-functional tracheostomy tube

• A blood clot too soft for grasping or suction (I like to think of it like trying to remove pudding from an airway)

• A narrow, fresh stoma might to collapse

• A rapidly desaturating patient

Our Solution

I treated this as a foreign body problem.

Our goal: ensure ventilation below the clot.

We approached from above, using an LMA, advancing to the tracheostomy site. We pulled the tube just to the stoma edge for partial ventilation. Then, using a cryoprobe, we froze the clot and extracted it above the tracheostomy tube, restoring airway patency.

After repeating the maneuver a few times, we reinserted the tube and reestablished ventilation. Finally, we removed the suprastomal foreign body safely.

Results: We published this approach in Pediatric Pulmonology for others to try out this approach if needed.

Announcements

How much do you know about Virtual Bronchoscopy and Peripheral Navigation?

We’re developing new content, including a dedicated course, on this underused but powerful diagnostic tool. Stay tuned for updates and early access.

Worthwhile Reading

1. Bronchoscopic Lung Insufflation and Surfactant Instillation for Post-Cardiac Surgery Atelectasis in a Neonate

   Why read: Related to the last newsletter, Patrick Stafler and colleagues published a modified version of atelectasis treatment using a NeoPuff device, with amazing results. It includes a video demonstration!

2. Extracorporeal life support-assisted airway foreign body extraction in an infant: The story of Indian Esperanza, first reported case from India
   Why read: I personally do not have access to ECMO. I am really proud of Hari’s team, who are the leaders in adult IP, for managing this case.

✉️ Guest Writers Joining In

Over the past few weeks, several of you have reached out with the idea of contributing as guest writers, and I absolutely love that! 

Today I Scoped! was always meant to be a shared space for pediatric interventional pulmonology stories and real-world experiences.

If you've managed an interesting case or have a technique worth sharing, I'd love to feature it. Just send me a short note or draft and we'll polish it for publication.

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.

Of course, feel free to share the newsletter with colleagues who are interested in our field!

Until next time,

Matej