To the Editor:
Cryotherapy has become an important aspect of pediatric interventional bronchoscopy. Through application of the Joule-Thompson effect, cryotherapy utilizes freeze-thaw cycles via rapid expansion of pressurized gas [1]. Bronchoscopic cryoextraction (i.e. using cryotherapy to remove material en bloc from the airway) has shown promise for the removal of large mucus plugs, obstructive thrombi, and foreign bodies in children [2, 3]. Although there are no reports of serious complications related to cryoextraction in children, the risk of hemorrhage is likely enhanced in coagulopathic patients, including those receiving anticoagulation for extracorporeal membrane oxygenation (ECMO) support. Because the bronchoscope and cryoprobe must be removed in tandem to extricate foreign material, there is a period of time when visualization of the airway is lost. As such, the ability to quickly address complications is hampered.
Sriprasart et al. described a 2-bronchoscope approach in adults undergoing cryobiopsy for undiagnosed interstitial lung disease (ILD) [4]. By utilizing an additional bronchoscope with a patent suction/instrumentation channel, this approach minimized time outside of the patient’s airway and facilitated prompt hemostasis following lung tissue removal. In this report, which we believe to be the first of its kind, we describe a similar technique performed in a pediatric patient undergoing cryoextraction of a massive airway thrombus secondary to prolonged ECMO support.