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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 85-87

Airway management of transbronchial lung cryobiopsy: What is different in a paediatric patient?

1 Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India

Date of Submission22-Feb-2020
Date of Acceptance29-Apr-2020
Date of Web Publication30-Aug-2020

Correspondence Address:
Dr. Rakesh Garg
Room No 139, First Floor, Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_7_20

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Various modalities such as cryoprobe-transbronchial lung biopsy (TBLB)/transbronchial lung cryobiopsy (TBLC) have been described for lung biopsy procedure. However, anaesthetic concerns related to periprocedural planning for paediatric TBLC have not been previously reported in the literature as clinical experience with paediatric TBLC is just evolving. The airway and general anaesthetic management of TBLC in a 12-year-old girl is described. TBLC in a child requires rigid bronchoscopy under general anaesthesia by an experienced endoscopist who, along with the anaesthesiologist, is alert all the time to keep the peak airway pressures low to avoid barotrauma.

Keywords: Anaesthesia, children, cryoprobe-transbronchial lung biopsy, transbronchial lung cryobiopsy

How to cite this article:
Agarwal S, Garg R, Madan K, Hadda V, Mohan A. Airway management of transbronchial lung cryobiopsy: What is different in a paediatric patient?. Airway 2020;3:85-7

How to cite this URL:
Agarwal S, Garg R, Madan K, Hadda V, Mohan A. Airway management of transbronchial lung cryobiopsy: What is different in a paediatric patient?. Airway [serial online] 2020 [cited 2020 Nov 24];3:85-7. Available from: https://www.arwy.org/text.asp?2020/3/2/85/293968

  Introduction Top

Lung biopsy is often required for establishing a definitive diagnosis for various diffuse parenchymal lung diseases. Various modalities have been described for lung biopsy procedure. Cryoprobe-transbronchial lung biopsy (TBLB)/transbronchial lung cryobiopsy (TBLC) has emerged as one of the acceptable and safe techniques for performing lung biopsy in adults. Literature is however scarce for similar procedures among children. TBLC is a bronchoscopic technique of obtaining larger tissue specimens than conventional TBLB, thereby yielding more definitive diagnosis.[1],[2] It avoids the complications associated with surgical biopsy such as longer hospital stay, air leak and other morbidities.[3] A protected airway is recommended, preferably using a rigid bronchoscope or an endotracheal tube, and general anaesthesia is usually required.[4] However, anaesthetic concerns related to periprocedural planning for paediatric TBLC have not been previously reported in the literature as clinical experience with paediatric TBLC is just evolving. We describe the anaesthetic management for TBLC in a 12-year-old girl performed under general anaesthesia.

  Case Report Top

A 12-year-old girl weighing 30 kg presented with a 2-month history of breathlessness, fever and dry cough. She was evaluated at another facility and started empirically on antitubercular therapy. During treatment, she developed pneumothorax for which an intercostal drain was inserted which was later removed after adequate lung expansion. The computed tomographic scan of the thorax showed homogenous ground-glass opacities with interstitial thickening in lungs, few small air cysts and peripheral bronchiectasis. A differential diagnosis of hypersensitivity pneumonitis, sarcoidosis or non-specific interstitial pneumonia was considered. TBLC was planned for definitive tissue diagnosis.

Following an adequate period of fasting, the patient was shifted to the bronchoscopy procedure room. After attaching a 5-lead electrocardiogram, noninvasive blood pressure and pulse oximeter, a 22-SWG intravenous cannula was secured. Anaesthesia was induced with intravenous fentanyl 60 μg, propofol (using target controlled infusion with a target of 4 μg/mL) and atracurium 15 mg, and the lungs ventilated with 100% oxygen. Thereafter, under the guidance of direct Macintosh laryngoscopy, a rigid bronchoscope (Karl Storz, size 8.5 mm ID) was introduced by a pulmonologist into the trachea. The laryngoscope was removed once the bronchoscope was negotiated into the trachea. Anaesthesia was maintained using propofol (target-controlled infusion [TCI] at 3 μg/mL) and lungs ventilated manually using a closed dual-tube ventilator circuit with 100% oxygen through the side port of the rigid ventilating bronchoscope. Oxygen was delivered at 15 L/min and ventilation performed at a rate of around 15 breaths/minute. The flexible bronchoscope was then negotiated through the barrel of the rigid bronchoscope, and its tip was placed just proximal to the right secondary carina. Thereafter, a 5 Fr Fogarty balloon catheter was negotiated through the barrel of the rigid bronchoscope by the anaesthesiologist. Once the Fogarty catheter exited the barrel of rigid bronchoscope, the flexible fibrescope was used to guide it to the proximal right bronchus intermedius (just distal to the right secondary carina beyond the take-off of the right upper lobe bronchus). The position (right bronchus intermedius) was again confirmed by inflating the balloon with 1 mL of saline. The balloon was deflated once its position was confirmed. TBLC was performed using a 1.9 mm cryoprobe (inserted through the rigid bronchoscope barrel along with preexisting Fogarty catheter and flexible bronchoscope) from the right lower lobe, anterior and lateral basal segments. At the time of cryoprobe activation, ventilation was stopped and apnoeic oxygenation continued at 15 L/min. During these steps, anaesthesia was maintained with TCI using propofol. As soon as the lung biopsy specimen was extracted (which took around 15–20 s), the Fogarty catheter was inflated with 1 mL saline to achieve haemostasis by tamponade. Thereafter, ventilation was resumed manually keeping the peak airway pressure below 30 cm H2O to avoid the risk of barotrauma. During this period, the oxygen saturation remained between 94% and 98%. Lung ultrasound was performed to rule out a pneumothorax. After around 3 min of inflation of the Fogarty balloon, it was deflated and haemostasis was assessed under flexible bronchoscopy. Once haemostasis was confirmed, the Fogarty catheter was removed, followed by the removal of the rigid bronchoscope. A size 2.5 i-gel® was introduced to achieve airway control and continue manual ventilation. The TCI infusion of propofol was stopped and the residual neuromuscular blockade was antagonised using intravenous glycopyrrolate and neostigmine according to body weight. After adequate recovery from anaesthesia and neuromuscular blockade, the i-gel® was removed. The child was shifted to the recovery room for further observation.

The child had an uneventful recovery. Occasional bouts of cough were managed conservatively with budesonide nebulisation. Repeat ultrasound of the thorax to identify pneumothorax was done hourly in the postoperative period for the first 4 h. At the time of discharge from the postoperative ward, the child did not have a pneumothorax. The child was discharged from the hospital next day with follow-up in the paediatric pulmonary clinics.

  Discussion Top

A standardised technique for performance of TBLC in adults has been described. Based on differing anatomy and physiology of children, TBLC may have age-related concerns and higher complication rates.[5] Children have a lower functional residual capacity and a higher oxygen consumption, leading to faster desaturation during apnoea that is an inevitable component of this procedure.[6] This mandates apnoeic oxygenation at higher flow rates. Major concerns with TBLC include the risk of bleeding, pneumomediastinum and pneumothorax (with some studies reporting postprocedure pneumothorax in nearly one quarter of the subjects).[7] Paediatric patients may have a greater risk of pneumothorax and poor tolerance if pneumothorax occurs, because of a mobile mediastinum that may shift to the contralateral side even with less intrathoracic pressure.[8] Therefore, repeated lung ultrasound should be performed in all patients to identify pneumothorax early. It was a greater concern in our patient as there was a prior history of pneumothorax.

There are reports of TBLC being performed without the use of a protected artificial airway.[9],[10] However, it is recommended that airway protection (ideally using a rigid bronchoscope) be performed in all patients as there is always a risk of airway bleeding and possible airway loss.[11] The presence of a rigid bronchoscope allows removal of the cryoprobe avoiding accidental contact with other structures, thereby increasing procedure safety.[12] It also allows faster access to the biopsy site for assessment and for isolation of the contralateral lung if massive bleeding was to occur.[13] The risk of slippage of the occlusion balloon, leading to loss of control over bleeding, may be greater if a rigid bronchoscope is not used. Although the TBLC procedure has been well standardised for adults, sufficient experience is not available for children at present.[14]

We conclude that paediatric TBLC is feasible, but endoscopic surgeons and anaesthesiologists need to be well aware of the special age-related concerns of airway management and be prepared to handle such potential complications in this age group. TBLC in a child requires rigid bronchoscopy under general anaesthesia by an expert bronchoscopist, and the peak airway pressure should be kept low during ventilation to avoid barotrauma as chances of pneumothorax are high in this procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given consent for images and other clinical information to be reported in the journal. The guardian understands that the name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Babiak A, Hetzel J, Krishna G, Fritz P, Moeller P, Balli T, et al. Transbronchial cryobiopsy: A new tool for lung biopsies. Respiration 2009;78:203-8.  Back to cited text no. 1
Casoni GL, Tomassetti S, Cavazza A, Colby TV, Dubini A, Ryu JH, et al. Transbronchial lung cryobiopsy in the diagnosis of fibrotic interstitial lung diseases. PLoS One 2014;9:e86716.  Back to cited text no. 2
Nguyen W, Meyer KC. Surgical lung biopsy for the diagnosis of interstitial lung disease: A review of the literature and recommendations for optimizing safety and efficacy. Sarcoidosis Vasc Diffuse Lung Dis 2013;30:3-16.  Back to cited text no. 3
Dhooria S, Agarwal R, Sehgal IS, Aggarwal AN, Goyal R, Guleria R, et al. Bronchoscopic lung cryobiopsy: An Indian Association for bronchology Position Statement. Lung India 2019;36:48-59.  Back to cited text no. 4
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Madan K, Mittal S, Gupta N, Hadda V, Mohan A, Guleria R. Cryoprobe transbronchial lung biopsy: How we do it? Lung India 2018;35:520-2.  Back to cited text no. 5
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Madan K, Mehta S, Gupta N, Hadda V, Mohan A, Guleria R. Pneumomediastinum and extensive subcutaneous emphysema after cryoprobe transbronchial lung biopsy. Ann Am Thorac Soc 2016;13:2101-3.  Back to cited text no. 7
Kuo PY, Nong BR, Huang YF, Chiou YH. Primary spontaneous pneumothorax in children: A literature review. Pediatr Respirol Crit Care Med 2018;2:25-31.  Back to cited text no. 8
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Griff S, Schönfeld N, Ammenwerth W, Blum TG, Grah C, Bauer TT, et al. Diagnostic yield of transbronchial cryobiopsy in non-neoplastic lung disease: A retrospective case series. BMC Pulm Med 2014;14:171.  Back to cited text no. 10
Dhooria S, Sehgal IS, Bal A, Aggarwal AN, Behera D, Agarwal R. Transbronchial lung biopsy with a flexible cryoprobe during rigid bronchoscopy: Standardizing the procedure. Lung India 2016;33:248-9.  Back to cited text no. 11
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Kropski JA, Pritchett JM, Mason WR, Sivarajan L, Gleaves LA, Johnson JE, et al. Bronchoscopic cryobiopsy for the diagnosis of diffuse parenchymal lung disease. PLoS One 2013;8:e78674.  Back to cited text no. 12
Lentz RJ, Taylor TM, Kropski JA, Sandler KL, Johnson JE, Blackwell TS,et al. Utility of flexible bronchoscopic cryobiopsy for diagnosis of diffuse parenchymal lung diseases. J Bronchology Interv Pulmonol 2018;25:88-96.  Back to cited text no. 13
Eber E, Antón-Pacheco JL, de Blic J, Doull I, Faro A, Nenna R, et al. ERS statement: interventional bronchoscopy in children. Eur Respir J 2017;50:1700901.  Back to cited text no. 14


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