Introduction Pre-operative management of neonates with esophageal atresia and tracheoesophageal fistula (EA/TEF) requiring positive pressure ventilation (PPV) support is clinically challenging. This study evaluates the safety, feasibility and value of flexible endoscopy with noninvasive ventilation and sustained pharyngeal inflation (FE-NIV-SPI) in diagnosis and placing a naso-tracheo-fistula-gastric (NTFG) tube before surgery. Methods A retrospective study conducted from 2017 to 2020 in neonates with Type-C EA/TEF and respiratory distress, where FE-NIV-SPI performed with NTFG tube placement before surgery. Results Five neonates were collected, one with duodenal atresia and one with transposition of great artery. At FE-NIV-SPI, median body weight was 2,399 g and mean age was 15.2 hours. Four neonates yielded severe (>80% collapsed) tracheomalacia. With this FE-NIV, all tracheal, fistulas and esophageal lumens could clearly assess and manage. All fistulas were less than 8mm proximal to carina with mean orifice width of 5 mm. All NTFG tubes placed successfully after confirmed the EA/TEF. Three neonates had co-intubated with nasal endotracheal tube and 2 neonates had received nasal prongs PPV. Mean procedural time of FE-NIV was 13.6±4.5 minutes. All neonates received gastric decompression and feeding via NTFG tubes for mean of 11.4±18.2 days and had stable pre-surgical courses. No adverse associated complication noted. Conclusion FE-NIV-SPI technique enables safe and accurate measurement of EA/TEF anatomy and placing NTFG tube. It could avert emergent gastrostomy, aid gastric decompression, feeding, and ETT intubation, improve PPV, provide pre-surgical stabilization and identify the fistula location during the surgical correction.

Subject: Role of Impulse Oscillometry in Children with Airway Narrowing After Bronchoscopic Stent Implantation, a Pilot Observational StudyTzung-Lin Ou1, Chieh-Ho Chen2*, Chien-Heng Lin2* and Wen-Jue Soong 2,3,4,5*1Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan2Division of Pediatric Pulmonology, China Medical University Children’s Hospital, China Medical University, Taichung, Taiwan3 Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan4 Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan5 Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan* Correspondence:Corresponding Author: Chieh-Ho Chen, Chien-Heng Lin and Wen-Jue [email protected]: Impulse oscillometry, transbronchoscopic airway intervention, stent, obstructive lung disease, peripheral airway resistance, pulmonary function testTo the Editor,We would like to address the critical issue of congenital airway anomalies, encompassing tracheal stenosis, tracheomalacia, and tracheo-bronchomalacia, which pose life-threatening challenges. Patients afflicted with these conditions frequently exhibit respiratory distress, such as tachypnea, dyspnea, chest tightness, chronic cough, exercise intolerance, and audible breathing sounds. The risk of recurring pulmonary infections is associated with inadequate airway clearance, culminating in irreversible lung damage over time.Bronchoscopic airway stent placement emerges as an efficacious strategy for alleviating tracheo-bronchial obstructions. It demonstrates notable success in mitigating breathlessness, elevating quality of life, and enhancing survival rates, especially among adults with malignancies. However, the extension of this technique to pediatric populations remains underexplored, primarily due to concerns regarding potential complications, including hypoxia, laryngospasm, hemorrhage, and air-leak syndromes. Despite its clinical safety, the absence of established consensus or guidelines for bronchoscopy and airway stent implantation in infants and children persists (1).Nevertheless, evaluation of pulmonary function after airway stent implantation by spirometry might be challenging in pediatric population due to weak respiratory efforts, inadequate cooperation, and poor comprehension. This is where Impulse Oscillometry (IOS) comes into play. Grounded in the forced oscillation technique, IOS passively assesses airway resistance and alveolar reactance during tidal breathing. IOS is able to differentiate resistance of peripheral (small) airways from central (large) airways, thus aiding treatment planning for obstructive lung diseases. It encompasses parameters like respiratory impedance (Z), respiratory resistance (R), and respiratory reactance (X), which together provide a comprehensive analysis of airway function, assisting in the assessment of obstructive and restrictive lung diseases.

Introduction: Airway stent implantation may alleviate respiratory difficulties in pediatric patients with airway narrowing, yet its physiological changes in pulmonary function tests remain unknown. Our objective is to determine the aerodynamic changes after stent implantation by spirometry and impulse oscillometry in children with airway stent implantation. Methods: A retrospective chart review was conducted at China Medical University Children’s Hospital, Taichung, Taiwan between January 2019 and October 2022. Results: Four adolescents with successful stent implantation received impulse oscillometry examination (IOS) before and after BONA stent implantation. The results showed no significant reduction in total airway resistance (R5) (1.66±0.44 vs. 1.25±0.21, P = 0.10) or central airway resistance (R20) (0.74±0.21 vs. 0.70±0.11, P = 0.63). However, there was significant improvement in small airway resistance (0.92±0.36 vs. 0.56±0.27, P = 0.04) after stent implantation. Meanwhile, all patients had a positive bronchodilator test response in impulse oscillometry before and after stent implantation. Inhaled corticosteroids with long-acting beta-2 agonists were given to all four patients after stent implantation. Conclusions: IOS could be used as a non-invasive tool for monitoring pulmonary function after airway stent implantation. Peripheral airway resistance, but not total or central airway resistance, may be improved after airway stent implantation. However, chronic airway inflammation may remain and require long-term inhaled steroid with bronchodilator treatment.

Objectives Flexible endoscopy (FE) assessed the whole approachable aeroesophageal (AE) tracks and changes of management in infants with severe bronchopulmonary dysplasia (sBPD). Methods A 10 years (2011-2020) retrospective study of sBPD infants who had FE with and without artificial airway in AE tracks. FE with noninvasive ventilation (FE-NIV) of pharyngeal oxygen with nose-close and abdomen-compression was supported. Data of found pathologies, changes of consequent management and therapeutic interventions were collected and analyzed. Results Total 42 infants enrolled. Two scopes of 1.8mm and 2.6mm were used. FE revealed 129 AE pathologies in 38 (90.5%) infants. Twenty-eight (66.7%) infants detected more than one lesion. In 35 (83.3%) infants with 111 airway lesions, bronchial granulations (28, 25.2%), tracheomalacia (18, 16.2%) and bronchial granulations (15, 13.5%) were the leadings. Fifteen (35.7%) infants had 18 esophageal lesions. No significant FE-NIV complication noted. FE findings resulted consequent changes of management in all 38 infants. Thirty-six (85.7%) infants involved respiratory care of pressure titrations (29, 45.3%), shorten suctioning depth (17, 26.6%), changed endotracheal or tracheostomy tube depth (10, 15.6%) and extubation (8, 12.5%). Twenty-one (50%) infants had 50 medication changes included add steroids, anti-reflux medicine, antibiotics and stop antibiotics. Eighteen (42.8%) infants had received 37 therapeutic FE-NIV procedures which included 14 balloon dilatation, 13 laser-plasty and 10 stent implantations. Seven (16.7%) infants had surgeries included 4 tracheostomies and 3 fundoplications. Conclusion FE-NIV can be a safe and valuable modality for direct visual assessment of AE pathologies which contributed subsequent changes of clinical management in sBPD infants.

OBJECTIVE: Sustained pharyngeal inflation (SPI) with pharyngeal oxygen and nose-close (PhO2-NC) can create positive peak inflation pressure (PIP) inside the pharyngolaryngeal space (PLS). This study measured and compared effects of four different SPI durations in the PLS. METHOD: In this prospective observational study, 20 consecutive infants aged less than 3 years, scheduled for elective flexible-bronchoscopy were enrolled. SPI was performed twice in four different durations (0, 1, 3 and 5 seconds) sequentially in each infant. PIP was measured for each SPI in the pharynx, and simultaneously took images at two locations of oropharynx and supra-larynx. Infants’ demographic details and PIP levels, lumen expansion scores and images of PLS were measured and analyzed. RESULTS: Twenty infants with 40 measurements were collected. The mean (SD) age and weight were 11.6 (9.1) months and 6.8 (2.4) kg, respectively. The measured mean (SD) pharyngeal PIPs were 4.1 (3.3), 21.9 (7.0), 42.2 (12.3) and 65.5 (18.5) cm H2O at SPI duration of 0, 1, 3 and 5 seconds, respectively; which showed significant positive association (p<0.001). At assigned locations, the corresponding PLS images also show significant increase in lumen expansion scores and number of detected lesions with increase in SPI duration (p<0.001). The mean (SD) study time was 5.7 (1.2) minutes. No study related complication was noted. CONCLUSIONS: SPI with PhO2-NC up to 5 seconds is a simple, safe and feasible clinical ventilation modality. It may provide enough PIP to expand the PLS and facilitate flexible-bronchoscopy performance in infants.

Sustained pharyngeal inflation (SPI) with pharyngeal oxygen and nose-close (PhO2-NC) can create positive inflation pressure (PIP) inside the pharyngolaryngeal space (PLS). This study measured and compared effects of different SPI durations in the PLS. Method: A one-year prospective study, 20 consequent infants whose age less than 3-year-old and scheduled for elective FB were enrolled. SPI performed in four different durations (0.0, 1.0, 3.0 and 5.0 seconds) consequently. Each infant did two cycles of SPI. Measured the PIP of each SPI in the pharynx, and simultaneously took images at three locations of oropharynx, supra-larynx and larynx. Data of infant’s demographics, PIP levels, space expansion scores and images were collected and analyzed. Results: Total 20 studied infants, the mean (SD) age was 11.6 (9.1) month-old, the mean (SD) body weight was 6. 8 (2.4) kg and the mean (SD) study time was 3.8 (1.1) minutes. The measured mean (SD) pharyngeal PIPs were 4.1 (3.3), 21.9 (7.0), 42.2 (12.3) and 65.5 (18.5) cmH2O at SPI duration of 0.0, 1.0, 3.0 and 5.0 seconds, respectively. Which showed positively and significantly (p<0.001) correlations. At these assigned locations, the corresponding PLS images also show significant lumen expansion correlated with the PIP. Especially, when there existed pathologic or occult lesions. No any study related complication was noted. Conclusions: SPI with PhO2-NC up to 5 seconds is a simple, safe and feasible clinical ventilation modality. Which could provide enough PIP to expand the PLS and benefit FB performance in infants.