Alex J. Katz

Background: Bleeding is a well-recognized complication in flexible bronchoscopy, especially with advanced procedures. Oxymetazoline is a topical vasoconstrictor often used to reduce or treat bleeding in the nares and airways. Methods: A retrospective cohort study was conducted on pediatric patients undergoing flexible bronchoscopy from 2015 to 2025. Language processing was used to analyze bronchoscopy-related procedures, and mixed-effects logistic regression models were used to compare blood pressure, heart rate, and rescue medication use in cohorts that were exposed to nasal, endobronchial, and no oxymetazoline. Results: A total of 2874 patients (41% female, mean age: 5.8 y) underwent 3978 bronchoscopies, 66 (2%) of which were exposed to endobronchial oxymetazoline and 1039 (26%) to nasal oxymetazoline. Endobronchial oxymetazoline was associated with higher systolic blood pressure ( β =5.73; 95% CI: 2.48-8.98; P =0.00067), diastolic blood pressure ( β =3.68; 95% CI: 1.41-5.96; P =0.0016), and lower heart rate ( β =−6.91; 95% CI: −10.84 to –3.00; P =0.00054). These effects were more pronounced when bleeding was reported. Endobronchial oxymetazoline was associated with increased bradycardia (OR: 1.92; 95% CI: 1.09-3.40; P =0.024), but not with increased rescue medication use (OR: 0.69; 95% CI: 0.38-1.24; P =0.21). Conclusion: Endobronchial and nasal oxymetazoline use during pediatric flexible bronchoscopy is associated with a mild increase in blood pressure and a decrease in heart rate, although it is well-tolerated and appears to be safe without an increased need for clinical intervention.

Rationale: Cryotherapy and its diagnostic analogue, cryobiopsy, are emerging techniques via bronchoscopy with a wide range of clinical applications. While the use of cryotherapy and cryobiopsy has been established in adult pulmonary medicine, pediatric data describing the indications, procedural specifics, outcomes, and complications are limited. Objective: To describe the indications, procedural specifics, outcomes, and complications of cryotherapy and cryobiopsy use in pediatric bronchoscopy. Methods: A multicenter retrospective observational study was conducted at five pediatric hospitals in the United States. Patients aged 0 to 21 years who underwent cryotherapy or cryobiopsy via bronchoscopy between January 2017 and January 2025 were included. Results: A total of 317 cryotherapy and cryobiopsy procedures were performed in 187 patients (median age 10 [3, 15] years; 44% female). The most common indication was cryoextraction (50%), followed by cryorecanalization (38%) and cryobiopsy (17%). The 1.1 mm cryoprobe was used in 57% of cases. Cryoextraction was at least partially successful in 95% of procedures, with the most common use being removal of blood clots (57%). Cryorecanalization was at least partially successful in 93% of procedures. The use of cryobiopsy has grown the most over the last two years. Cryobiopsy yielded successful histopathologic evaluation in 96% of biopsies with 73% diagnostic yield. Bleeding was the most common complication of cryotherapy occurring in 35% of cases, with 96% being Grade I or II. No pneumothorax was observed. Other complications were rare. Conclusions: Cryotherapy and cryobiopsy via bronchoscopy in pediatrics have been increasingly utilized, demonstrating high success and favorable safety profile. The introduction of the 1.1 mm cryoprobe has facilitated its broader application to pediatrics. Bleeding was the most common complication but was generally mild in the context of the selected cases at specialized centers.

Introduction: Air leak is a common complication of necrotizing pneumonia in critically ill children. Severe air leaks impact effective oxygenation and ventilation, oftentimes necessitating multiple thoracostomy tubes and extracorporeal support. Endobronchial valves (EBV) are a minimally invasive intervention to control air leak that may expedite de-escalation of care for critically ill children with necrotizing pneumonia. Methods: A retrospective case series was conducted on patients at the Children's Hospital of Philadelphia who were hospitalized in the pediatric intensive care unit, required extracorporeal membrane oxygenation (ECMO), and underwent placement of one or more EBVs for air leak from July 2023 through August 2024. Results: Six patients, median age 12 years (range 18 months to 18 years), were hospitalized for necrotizing pneumonia complicated by severe air leak and required ECMO. The most common etiology was a viral infection with bacterial co-infection. The median number of EBVs placed per patient was five. The median total time on ECMO was 10 days, with a median duration of 3.5 days after valve placement. The median duration of antibiotic therapy was 47 days (range 24 to 126 days). One patient had a contralateral pneumothorax after valve placement, and another died due to progression of multiorgan failure that began before EBV placement. The five surviving patients were discharged from the hospital, weaned from all respiratory support, and their valves were removed without complication. Conclusion: Endobronchial valves are a feasible intervention for severe air leak in critically ill children with necrotizing pneumonia and may expedite liberation from ECMO.