Introduction

Interventional pulmonology (IP) is an excitingeld that has continued to evolve and innovate since its introduction [1]. IP has been de ned as the art and science of medicine related to the performance of diagnostic and invasive therapeutic procedures that require additional training and expertise beyond that required in standard pulmonary medicine training programs [2]. Over the years, IP has continued to grow both in regard to practitioners and the literature base.

The question of IP in pediatrics, or a pediatric population, remains an interesting one. Since the majority of the standard IP’s practice is largely based in advanced malignancy, the interaction or “need” for interaction is generally less, mainly related to pediatric cancers involving the airways and thorax, fortunately not as common as

N. Silvestri

Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD, USA

L. B. Yarmus

Interventional Pulmonology, Division of Pulmonary Disease and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA

C. R. Gilbert (*)

Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA, USA

Center for Lung Research in Honor of Wayne Gittinger, Seattle, WA, USA

e-mail: christopher.gilbert@swedish.org

in adults. Additionally, the standard IP’s training program remains in adult medicine (internal medicine residency, pulmonary and critical care fellowship, interventional pulmonology fellowship). The need and/or potential of exposure to the pediatric population can vary widely in this type of training including the potential for never seeing a patient less than 18 years of age in the entire training timeframe. A somewhat different issue may arise during pediatric pulmonology fellowship training. Pediatric pulmonology fellowships remain limited to those completing pediatric residencies. During fellowship training, pediatric pulmonologists are taught bronchoscopy; however, data suggest that the training is variable and there remain no objective requirements for their procedural training [3, 4]. Current requirements expect trainees to “demonstrate competence in performing bronchoscopy,” but there are no clear standards in place per current American College of Graduate Medical Education Requirements. A recent survey of pediatric pulmonology training programs reported the average graduating fellow had completed 89 fexible bronchoscopies with a range of 10–200, illustrating the variation in exposure for pediatric practitioners [5].

While the difference in exposure between the training programs is likely directly related to the lower “demand” in the pediatric population, recent innovations have been made to increase the “supply” of training exposures for both cohorts to gain competency in pediatric interven-

tional procedures. Some researchers and educators have begun replicating the pediatric airway with three-dimensional (3D) reconstruction of computed tomography (CT) scans of the airway of infants and children for trainee bronchoscopy practice [6]. Others have been able to replicate the respiratory cycle using four-dimensional (4D) dynamic CT airway protocols and have constructed tracheobronchial trees that represent pediatric airways. This technology may offer the ability to introduce pathologies to the simulations such as tracheobronchomalacia and subsequent stent placement training [7]. With models, some training programs have been able to educate both pediatric and adult providers in pediatric IP and could close the experience gap between clinicians [8].

Complex Problems

and Multidisciplinary Approaches

Similar to many issues in medicine, patients with complex problems often require complex solu- tions—which are likely better served within a multidisciplinary evaluation. Since many issues encountered by IP are complex (airway and pleural disease), IP commonly works with other physicians from anesthesia, intensive care medicine, otolaryngology, pulmonology, and thoracic surgery on a daily basis. This type of model is often in place at many institutions, and many IP physicians are familiar with the processes of multidisciplinary evaluation and management of patients. Additionally, review of the available literature appears to describe that multidisciplinary care of pediatric patients with central airway obstruction (CAO) already occurs [3], however is often reported within the surgical literature (otolaryngology, thoracic, or pediatric surgery). There appears to be limited data on pulmonologists (pediatric or adult) performing therapeutic airway interventions within the pediatric population [9], except perhaps the plethora of data during foreign body removal.

The Pediatric Airway

While many general principles related to airway management are the same regardless of age and size, there are some distinct differences physicians must be aware of for both patient safety and procedural feasibility. Preoperative airway evaluations including a patient history and physical examination, as well as a review of any previous history of airway dif culties from the medical record and from parents/guardians are required. When evaluating newborns and infants, a maternal and perinatal history is often appropriate. When encountering children with congenital or malformation syndromes, a thorough understanding of their de ned and potentially unrecognized manifestations remains essential for appropriate procedural and anesthetic planning [10]. The utilization of a multidisciplinary approach and open dialogue between all team members, especially pediatric anesthesiologists, intensivists, surgeons, and pulmonologists, have often been helpful in pre-, intra-, and post-­ procedural planning.

Signi cant head and neck changes occur during normal child growth that affect airway anatomy and access. Initially, children have large heads with small, immobile mandibles. However, over time, head size proportions decrease and the mandible becomes larger and mobile. Additionally, the tongue becomes smaller in proportion to the airway, the epiglottis decreases, and the location of the glottic opening changes. In smaller children, the cricoid cartilage remains the smallest diameter of the airway (as opposed to adults in which the glottic opening is the smallest); therefore an instrument that passes through the glottic opening may not pass further into the trachea [11].

Airway diameter remains an extremely important consideration for procedural planning and selection of appropriate equipment. Utilization of the ventilating rigid bronchoscope for safe airway control and numerous interventions is relatively common in adults. However, despite the