Interventional pulmonology: The new horizon in pediatric pulmonology

Pediatric interventional pulmonology science is considered a new field in children’s lung science and has progressed significantly in recent years. This progress has been not only in new methods but also in the invention of tools and necessities needed for the special age of children. Many interventional methods in children have been copied from their use in adults, but due to the special conditions of children and the significant difference in the anatomy and physiology of the airways, many subtle changes have been made in them. Now it seems that the speed of manufacturing and the availability of the required equipment have exceeded the number of trained pediatric lung specialists to perform such interventions, which indicates the necessity of training experienced pediatric interventional bronchoscopists. Interventional methods are now used by pediatric pulmonologists, pediatric surgeons, otolaryngologists, anesthesiologists, and sometimes intensivists. However, it seems that pediatric pulmonologists have a smaller proportion of the mentioned doctors. A bronchoscope is the main tool for performing such interventional techniques. In general, there are two types of bronchoscopes: rigid and flexible. Rigid types require deep anesthesia and should be performed only in the operating room, but flexible bronchoscopes, in addition to being more maneuverable, can be performed in bronchoscopy suits outside the operating room and even at the patient’s bedside, with minimal need to use sedation drugs and anesthesia. Although rigid bronchoscopes can only be inserted orally, there are several ways to enter the flexible bronchoscopes into the airways, including the nostrils, oral, and through artificial tubes such as endotracheal tube and tracheostomy tubes, which also can prevent in some circumstances, the more complicated and invasive procedures. Although rigid bronchoscopy is still used as the gold standard, such as when airways need to be kept open or to maintain hemostasis, flexible types are now considered a good alternative in some situations. Bronchoscopic interventions are used for both diagnostic and therapeutic purposes. Diagnostic indications can include visual anatomical and dynamic examinations of airways, as well as taking pathobiology samples from respiratory tracts and even lung tissue. Bronchoscopy indications for diagnostic proposes can include: the presence of any acute, chronic, or recurring symptoms such as coughing, choking, gagging, apnea, stridor, wheezing, shortness of breath, infections, and inflammations, persistent and recurrent atelectasis, difficult extubation, and pulmonary hemorrhage. These methods are now more specific to clarify important clinical conditions that have received little attention in infants in recent years, such as pharyngomalacia, aspiration syndrome, airway malformations, and children’s interstitial lung diseases. Diagnostic bronchoscopy will not only prevent the imposition of high diagnostic expenditures but also lessen the occurrence of complications caused by the disease itself or the use of undesirable methods in patients. Moreover, they are more convenient, effective, and reliable strategies in this age. Pathobiological samples can be obtained with a wide spectrum of techniques such as bronchoalveolar lavage, airway brushing, tracheobronchial, and even lung and lymph node tissue biopsies. Samples can be taken with a special biopsy device through the working channel of the flexible bronchoscope. In recent years, newer techniques that are currently used in adults, such as cryobiopsy, have been successfully used in the pediatric age groups. Concerning therapeutic procedures, bronchoscopes have high capabilities with low side effects and can be used in different conditions. Among their most common proven effectiveness, the removal of foreign objects from children’s airways can be mentioned. Flexible bronchoscopes also have a high ability to open blocked airways due to various congenital stenoses (webs) or acquired strictures (tumors, mucosal plugging, and endobronchial blockages causing persistent and recurrent atelectasis due to the inflammatory process or infections such as tuberculosis) and even bronchoscopy-assisted airway intubation in difficult intubation situations. Such treatments can be performed by using various types of equipment such as balloons, lasers, electrocautery knives, cryotherapy, argon plasma coagulation, and silicone, metal, and biodegradable stents. Fortunately, most of the published articles indicate a low complication rate for pulmonary interventions which are usually minor and transient. The most common type of these complications are physiological complications (such as transient hypoxia during bronchoscopy and, fever and cough after the procedure). Mechanical complications (such as laryngospasm, tracheo-bronchospasm, vocal cord injury, pulmonary derecruitment and atelectasis, pneumothorax, and bleeding) can also occur. Anesthetic and bacteriological complications are also reported. It is clear that with sufficient experience, modern equipment, and an experienced treatment team, all these complications can be minimized. The undersupply of well-designed randomized clinical trials in pediatrics renders interventional pulmonary procedures without many globally accepted standard guidelines. One way to overcome this problem and standardize such practices is to publish more reports on most multicenter studies at the national and international levels. Also, the centers that have significant activity in this regard should be identified to train more interested doctors. Of course, these pieces of training should be based on well-designed guidelines. Developing a communication infrastructure between pediatric pulmonologists from different centers in the form of designing social networks and organizing national and regional workshops could be a pathway to the medical training needed to carry out such measures. Meanwhile, regional associations can play a very important role in creating educational convergence. Financial support and sponsorship Not applicable. Conflicts of interest There are no conflicts of interest.