Abstract
Dr. Wood, you are often described as the father of pediatric flexible bronchoscopy. What were the main challenges in developing this technology for use in children back in the 1970s?
The first challenge was purely technical—getting the instruments built. I was first exposed to flexible bronchoscopy in 1972, when I was at the National Institutes of Health (NIH), shortly after the first instrument was brought to the United States in 1971. It was fairly big, about 6 mm in diameter. When I began using these early flexible scopes, I was dealing with teenagers and young adults, and the size did not make too much difference. The conventional wisdom at that time was that you could not use a flexible instrument in a child younger than about 10 years of age.
In 1974, I went to Rainbow Babies & Children's Hospital in Cleveland, Ohio, for a pulmonary fellowship, and I was doing flexible bronchoscopy in adolescents and young adults with cystic fibrosis, primarily for research purposes. Shortly after I arrived there, Olympus Corporation came out with a flexible scope that was 3.5 mm in diameter. It had no operating channel, so it was very limited in its utility. It was intended to be used as a flexible telescope to be passed through a rigid bronchoscope, so you could “look around the corner.” I got one, and one day I took some Teflon tubing, about the size of an intravenous needle, and attached it to the outside of the scope. I discovered that I could do reasonable bronchoscopy in children as young as about 18 months.
I published the first paper on pediatric flexible bronchoscopy after I attended the first World Congress of Bronchology and presented my experiment with this instrument. Shortly thereafter, I went to Olympus in New York and asked them to make a pediatric bronchoscope. They thought I was insane! Why would anyone ever want to do flexible bronchoscopy in a child? I heard nothing more for a couple of years, until one day, in the fall of 1978, I got a very apologetic phone call from Olympus asking if I would be willing to test a prototype. My career changed abruptly! For the next nearly three years, I had the only prototype of this instrument. Olympus was shocked by what I was able to do.
So were my colleagues, and this presented the second major challenge, which was political. I went to the American Broncho-Esophagological Association meeting in the spring of 1980. The audience was comprised of otolaryngologists and adult pulmonologists. I presented my experience with 200 children under the age of six years and said that this would be a very useful instrument and technique. In response, one of the leading pediatric otolaryngologists at that time went to the microphone and said, “This is the most distressing paper I have ever heard in my entire life. Flexible bronchoscopy is nothing more than medical voyeurism. Doing this in children is the grossest of medical malpractice.”
I hate to say that there is still some of that attitude out there today. I have worked very hard over the years to develop collegiality and cooperation, and one of the main reasons I came to Cincinnati 11 years ago was to join forces with the field of otolaryngology and try to put an end to that kind of attitude, and to demonstrate that the two disciplines and their techniques and instruments are complementary, and that 1+1 can equal 3, or 4, or even 5.
The third challenge I would mention was teaching others how to use the instrument. Until we had a pediatric flexible bronchoscope, very little was known about pediatric bronchology, about the airways and their abnormalities. I had a colleague who came to me in 1981 and asked me to train him to use the instrument. He had just finished a three-year fellowship in pediatric pulmonary, and after he had worked with me for several months he said that he had felt somehow illegitimate because everything he could do with the lungs was indirect. He could look at their shadows on a chest x-ray and guess what they might mean, he could listen to the sounds of the lungs through the chest wall and try to guess what they meant, and he could measure airflow in and out of the lungs and try to guess what that meant. If he was lucky, he could collect something that had been coughed out, hope it came from the lungs, and analyze it. But now, he could see the lungs, sample the lungs, and touch and feel the lungs. “Now,” he said, “I feel like a real pulmonologist.”
Did the early pediatric flexible bronchoscope, besides allowing you to see the lungs, also allow you to take samples?
Yes, that was a critical part of the technology. The initial prototype was 3.5 mm in diameter and had a working channel of about 1.2 mm in diameter. There has been very little change in the overall design since that time.
What fortuitous opportunities did you encounter in the early days and, more recently, what has helped to advance this technology?
In early 1980, I was approached by a good friend who invited herself to come and learn how to do bronchoscopy. I didn't have any better sense than to say, “C'mon!” She brought a friend with her, and I gave these two ladies two weeks of my life. I realized afterwards that I couldn't do that for anyone else. I thought that maybe if I organized a course and brought everyone that was interested together at one time, I could train more people. To my amazement, 30 years later, this course is still going strong. It has evolved over the years from a two-day course to a four-day course. It has always been intensely hands-on. I feel strongly that this is not something you learn by having somebody tell you how to do it.
I am very pleased that most of the faculty that has helped me teach this course has been with me for more than 25 years. It's like adult camp for us. We love to teach! Over the years, we have trained physicians from more than 75 countries. We have had to learn about and teach about the kinds of things you find in the lungs. Why do you want to do bronchoscopy, what are you looking for, and what are you going to find? It has been a very gratifying experience.
So there was a lot of serendipity involved. When I went to the NIH in 1972, quite frankly, pulmonary was not on my radar screen. The only bronchoscopy I had ever seen performed was a rigid procedure that was done to remove a foreign body. It was done with no anesthesia and it was brutal. But at the NIH, I was working in the cystic fibrosis program, and shortly after my arrival, one of my adult patients developed left upper-lobe atelectasis. After two weeks, I was not making any progress with his treatment and I asked the adult pulmonary people if they had any suggestions. They wanted to bronchoscope him, to which I replied, “Oh no you won't!” But they explained that they had a new device, a flexible fiberoptic bronchoscope. And I watched as they sprayed the patient's nose and throat with lidocaine, put the bronchoscope through his nose and into his lung, pulled out a big plug of mucus, removed the scope, and said goodbye as the patient got up and walked back to his room. I remember thinking, “Wow, what a research tool this could be.”
A few weeks later, I was in an elevator in the clinical center and I overheard two radiologists talking about having purchased one of these newfangled flexible bronchoscopes, which they intended to use to do bronchograms by injecting contrast material into the bronchi and then taking x-rays. After using it once, they decided it was way too complicated and would never use it again. I got off the elevator, went straight to the head of radiology's office, and walked out of his office the proud owner of a flexible bronchoscope.
I then had the problem of learning how to use it, and there was only one person who could teach me (the adult pulmonologist). So I would watch him do procedures, but there was no video in those days and I had no way of seeing what he was seeing. It was a struggle. Eventually, I went to one of my teenage patients with cystic fibrosis and I told him about this new instrument that I thought could help him by sucking a lot of mucus out of his lungs and leaving some antibiotic behind. I told him that I had never done this before, but I wanted to learn. He said, “Let's do it!”
Another fortuitous event occurred a few weeks later, when my mentor called to say that he was leaving the NIH in six weeks. For the next year and a half, I was the bronchoscopist at the NIH clinical center. All the adults who needed bronchoscopy came to me.
With regard to the other part of the question, what has helped advance the technology, we now have smaller, more useful instruments. They have better optical resolution and better performance overall. I have no personal connection to Olympus, but I think it is important to tell this story. Several years ago, I was in Tokyo visiting the world headquarters of Olympus. At dinner one evening, I asked the vice-president how many pediatric flexible instruments the company sold each year worldwide. He hesitated for a minute and then told me that Olympus would never be able to sell enough pediatric instruments to recoup its development costs. But, he said, as a corporation, Olympus is dedicated to making the best instruments it can for the benefit of the children on the planet, and that adult sales would take care of the bottom line. I think that is a magnificent corporate attitude, and over the past 30 years they have supported my postgraduate course by providing all of the instruments.
What mistakes were made in the early stages of developing and using pediatric flexible bronchoscopes?
I teach in three ways: by apprenticeship, by example, and, most powerfully I think, by telling my students about the mistakes I have made. One example of a mistake I made very early in my career was not getting my experience well organized, particularly prospectively, in preparation to publish my findings formally in the medical literature. For example, during the first year and a half that I had the prototype scope, I was involved in more than 100 bronchoscopies in children in the neonatal intensive care unit who had massive atelectasis. I began to realize that this was due to the fact that deep endotracheal suctioning was being done routinely in these neonates, and that the suction catheter was traumatizing the bronchial mucosa. I finally convinced the neonatologists to change their technique, and in the next year and a half I only had about three cases of atelectasis.
But I did not prospectively collect the data in such a way that I could write about it formally, so I lost some serious academic opportunities. Thus my message to young people is to pay attention to what you are doing and keep good records. The essence of academic medicine is that we learn from what we are doing and then we pass on what we have learned. I have passed on what I have learned about bronchoscopy primarily through teaching and through my course. I have published many papers, but not nearly as many as I could have. It amuses me when people come to my course, and a year or two later I see that they have published a paper reporting their experience with four, five, or six patients doing something I may have done 500 times (and never published). But I have gained great satisfaction from seeing my students do great things.
As Harry S. Truman said, “There is no limit to what one can accomplish if he doesn't care who takes the credit.”
What types of advances do you envision on the horizon for pediatric flexible bronchoscopy?
I have seen two main changes in the instruments over the years: they have gotten smaller and the optical characteristics have gotten better. I do not see that a smaller bronchoscope than we currently have would even be useful. The instrument that I use most of the time now is 2.8 mm in diameter. There are few kids that cannot be bronchoscoped with that size instrument if you use the right technique. To develop a smaller instrument would require challenging the laws of physics, which we don't need to do.
I think we will see improved optics and changes in the fiberoptic nature of the scope. The adult scopes are now all video. Instead of having an image created by a fiberoptic bundle, there is a tiny video chip on the end of the scope. Until now, there has not been a video chip small enough to use in pediatric instruments. I believe that will come, and it will give us much higher quality images. Another advance, which is already emerging, is the increased use of bronchoscopy as both a clinical and a research tool. We still have a big educational gap in terms of letting physicians who are caring for children know why they should send these children for bronchoscopy. There is only one indication for a diagnostic bronchoscopy: if there is information in the lungs or airways of a child that is necessary for their care and is best obtained with a bronchoscope. I think many children could benefit from bronchoscopy, but they are never referred. Furthermore, I think there are still many pediatric pulmonologists who do not, in my not-so-humble opinion, fully appreciate the value of diagnostic bronchoscopy.
It is a procedure that takes time, and over the years I have had experience with physicians who would rather treat a child empirically for two or three weeks in the hospital before considering bronchoscopy. It should be the other way around. Bronchoscopy can give you a definitive diagnosis very early and guide therapy. I am hoping that the next generation of physicians will become increasingly aware of how useful it is. My radiology colleagues often tease me and insist that they can show me the anatomy of the lungs with a CT scan, create a three-dimensional reconstruction, and, in essence, do a virtual bronchoscopy. My response is “That's all good, but can you get me microbiological data that will tell me what bacteria are there and what antibiotics they are susceptible to? Can you tell me whether a patient is showing evidence of aspiration? Can you show me the airway dynamics?” Of course, they cannot. Radiology and bronchoscopy are complementary techniques; neither one can give us the entire picture in every patient. We need both.
On the horizon, I also see increased use of bronchoscopy for research. I believe that the days are long past when we can do adequate clinical research in children using questionnaires, x-rays, physical exams, and pulmonary function tests. We are now in the age of DNA and biochemistry, and we need specimens from deep within the lung.
There are certainly still limitations. We cannot do bronchoscopy for research on healthy kids, except in extremely limited circumstances. When there is potential benefit for a child who is enrolled in a research protocol that includes bronchoscopy, then we can justify it. A good example is young patients with cystic fibrosis. I have done a number of clinical studies in which I would not have typically done a bronchoscopy on a child at that time, but by enrolling the child in the clinical study, we obtained culture and cytological data that were immediately useful in guiding the patient's subsequent therapy. And many times the bronchoscopic findings were quite at variance with what had been expected clinically. In some cases, a child's lungs may have been grossly infected but no one realized it, and so the infection was not being treated. In other cases, a child was being treated for an infection when in fact the lungs were sterile.
Is reimbursement a limiting factor at present?
I do not perceive that to be a major limitation right now. I think that many pulmonologists believe bronchoscopy takes too much time to do. I am in an enviable position in that I average 15 to 20 procedures a week. So I go to the operating room and do multiple procedures in a day. I don't have to leave my office, go to the hospital, do one or two procedures, and then go back to the office. We have economy of scale at our hospital, and I am fortunate to be able to devote my time largely to doing this.
How would you describe the current level of expertise in the pediatric pulmonology community with respect to flexible bronchoscopy?
It is not nearly as high as I would like. Expertise evolves from a combination of formal training and on-the-job training. If you do not do a procedure often enough, you will not get good at it. Improving the level of overall expertise will be a slow, evolutionary process as people realize how important the technique is and begin to use it more.
Has the almost routine use of general anesthesia enhanced or limited your practice of bronchoscopy and that of others?
Good question! For many years, I was a traditional pediatrician and looked upon general anesthesia with a great deal of suspicion and skepticism. In the early years, I did my own sedation, which gave me total control over the timing, scheduling, and performing of the procedures. But as I have grown older, and hopefully wiser, I have come to appreciate that there is a great advantage to having another professional take the responsibility for this aspect of bronchoscopy. You cannot rely on just any anesthesiologist, however. You need extremely good mutual understanding, cooperation, and communication between the bronchoscopist and the anesthesiologist. Other than death of the patient, the most serious complication of diagnostic bronchoscopy is to do the procedure and get the wrong answer. If you use the wrong technique for sedation, it is very easy to get the wrong answer.
An anesthesiologist's primary goal is to have a patient who is immobile, has a controlled airway, and who does not respond to whatever the surgeon is doing. But many times in pediatric bronchoscopy, the important diagnostic finding is abnormal airway dynamics. If the patient is not breathing spontaneously or is sedated too deeply, I cannot see the dynamics, and I will get the wrong answer.
I encountered some serious opposition from anesthesiologists early on. They had no idea what I was trying to do. I would tell them that I am going to violate nearly every principle that they hold near and dear—that the bronchoscopist and not the anesthesiologist must own and control the airway. So we are inherently in conflict, and we must have effective communication before, during, and even after the procedure to ensure the patient's safety and comfort and to get the right answer.
Throughout your early education and training, what factors or events led to your interest in pediatric pulmonology and to your introduction to flexible bronchoscopy? How did your career path evolve?
During my senior year in high school, I decided that I would go into medical research—to complete college, spend three years on a PhD, four years on an MD, followed by internship and residency, and then two years at the NIH. I had no intention whatsoever of doing clinical medicine. My interest in medicine was purely academic and scientific, and I was actually frightened out of my mind of having to assume responsibility for patients. After completing my PhD, I went back to do my third year of medical school. Late in the year, I did a pediatrics rotation and I awoke one morning with the startling recognition that I was going to become a pediatrician. I couldn't believe it! I still did not want to take care of patients; my interest in pediatrics at the time was purely academic.
I was particularly interested in metabolic disease, so I went to Stanbury's textbook The Metabolic Basis of Inherited Disease and there I found cystic fibrosis. At about that time, I was applying for a position at the NIH, and one of the openings was in Paul diSant'Agnese's cystic fibrosis lab. I was accepted and, after two years of residency, I went to the NIH. I made two important discoveries while I was there. First, I learned that dealing with dying patients (one of the things I had been most frightened of) turned out to be one of the most satisfying things I could do, and I became very good at it. In those days, with cystic fibrosis patients, you had to deal with that a lot. Second, I was also exposed to Dr. Marvin Sackner and his colleagues from Mount Sinai Hospital at the University of Miami, Florida, who were using the flexible bronchoscope to measure the rate of mucus clearance from the lungs. I invited them to come to the NIH, and together we did a study on mucociliary transport in cystic fibrosis patients. As a result, I was able to start my fellowship as the Principal Investigator of my own NIH grant.
Another serendipitous, and tragic, event took place within a year of beginning my fellowship at Rainbow Babies & Children's in Cleveland. The chief of otolaryngology, Dr. Walter Maloney, who was one of the giants of the ENT field, suddenly died. This was before I had begun to do any work in small kids. For the rest of my time there, the hospital had no real staff otolaryngologist, and certainly none in pediatric otolaryngology. So there was a kind of vacuum; no one to teach or guide me, and I had to learn on my own. It was a time of great discovery and a lot of fun, but I wonder, in retrospect, what might have happened if Dr. Maloney had lived and how it might have changed the course of my career.
As airway management has been one of your main areas of interest, based on your historical perspective, how have you seen the management of airway problems in children change over the course of your career?
Overall, I think there has been a dramatic improvement in awareness, particularly on the part of pediatric pulmonologists. The number of pediatric otolaryngologists has also increased. In the late 1970s and early 1980s, a pediatric otolaryngologist was a rare breed. Furthermore, I have seen substantial improvements in instrumentation since the first prototype flexible bronchoscope, as well as steady improvement in rigid instrumentation.
Additionally, there has been dramatic improvement in the surgical techniques for dealing with the pediatric airway. One of the reasons I came to Cincinnati was to work with Dr. Robin Cotton, a pediatric otolaryngologist who is the father of airway reconstructive surgery in children. We do 250 to 300 major airway reconstructions a year here, which is probably about equivalent to the total number done in the rest of the country. We have also trained many people to go out into other the parts of the country and do this as well.
In your view, how has closer collaboration between pulmonary physicians and surgeons impacted the care of children with airway malformations?
I am proud to say that between Dr. Cotton and his colleagues and me and my colleagues, we have established at this institution a very strong tradition of multidisciplinary/interdisciplinary cooperation in managing children's airway problems. Having both an otolaryngologist and a pulmonologist evaluate a patient independently and together has paid enormous dividends. This has contributed to another major area of improvement, which relates to practice patterns and taking advantage of the complementary aspects of the two disciplines.
We have set up a multidisciplinary model here for children with complex airway and swallowing problems. We call it the Aerodigestive Center, which is being emulated on a smaller scale around the world. Many of the patients we see have been to multiple doctors who have each worked independently from each other. When we evaluate the patient and come out of the operating room, three or four of us sit down with the family; we are all singing the same song, we have been in the operating room together and seen the same things, and we have already discussed the case together. We give families a coherent, comprehensive, coordinated picture of what is going on with their child, and that is worth its weight in gold.
On a different topic, what do you see as some of the perils and pitfalls of management of a child with a tracheostomy?
This is a topic near and dear to my heart. The most important thing in managing a child with a tracheostomy is to maintain patency of the tube. Children die when their trach tubes become clogged. I had a very unfortunate experience some years ago in which a child came to my hospital after an automobile accident. The father had been killed, the mother was badly injured, and the child received a tracheostomy. Several weeks later, when the child's condition had stabilized, the grandparents begged me to transfer the child to where the mother was being treated. I talked to the people at the other hospital, and they agreed to train the family, so we transferred the child. Three months later, when the child did not show up for a clinic visit, I called the house and learned that the child had died the week before. One day she couldn't breathe, the grandparents couldn't clear the tube, and before they could drive the child to the hospital, she died. No one had trained the family how to change the trach tube or how to respond to an emergency.
I tell this story to the house staff that I lecture to every month on their pulmonary rotation. A plugged trach tube can be lethal. Monitoring children with tracheostomies is a huge problem. There are no electronic monitors that do the job properly. Either they are insensitive and do not give an alarm until it is too late, or they are so sensitive that the alarm goes off all the time and people quickly begin to stop paying attention to it. This is still a major issue, and if I could wave a magic wand and create something for kids with trachs, it would be an effective, efficient, nonintrusive, clinically useful, and reliable way of monitoring their trach status.
I am a huge believer in early tracheostomy. Too many kids are intubated for far too long, causing damage to the larynx that is beyond repair. The majority of children who have trachs have iatrogenic subglottic stenosis from being intubated too long. I would rather trach first and ask questions later. Clearly, my opinion is heavily biased because I don't see the successes, I only see the failures, but I have seen a lot of them.
How do you feel about the current movement toward “evidence-based medicine?” What are the main opportunities and limitations it offers?
Evidence is great, and we must pay attention to evidence that has been carefully developed. However, evidence is only as good as the most recent study. Next month there may very well be a different study with different results, and then the evidence changes. On the one hand, we have to stay abreast and aware of this, but in my teaching I try to teach principles rather than specifics. I try to teach about things that are not going to change over time.
Let me give you an example. We had a child six months of age come to our hospital who was wheezing, febrile, coughing, and had a runny nose and weepy eyes—clearly with a viral bronchiolitis. We had an evidence-based guideline that said not to do a chest x-ray in a child with bronchiolitis. Two months later the child came back, almost dead. No one had taken a chest x-ray or they might have discovered the four pennies stuck in the child's esophagus. The wheezing was caused not by the viral respiratory infection, but by compression of the trachea by the foreign bodies in the esophagus. The pennies eventually eroded through the esophagus, and the child developed mediastinitis and almost died.
The problem with evidence-based medicine is how we teach it. Our young physicians have to learn how to think, as well as how to read the guidelines. Too often they follow an evidence-based protocol and feel that relieves them of the responsibility of following up on the patient. But if you are going to follow an evidence-based protocol, you better be very sure that your diagnosis is correct and that you are using the right protocol! And you need to go back and look at your patient again.
Statistics do not apply to individuals. Evidence is statistical. Every patient is an individual, not a statistic. Patients either have a disease or they do not; they don't 32.8% have it! Evidence is only a guide, and while we need to use evidence, first and foremost we need to be physicians. Medicine uses science, but medicine is not science, it is an art. We have to pay attention to our patients. We must think.
What advice would you give young physicians who are completing their training in pediatric pulmonology?
I would give the same advice to any young physician: remember that the goal of medicine is the relief of human suffering. We are not doing a scientific experiment. Sometimes, the most powerful treatment we can give is a smile, a hand on the shoulder, or a receptive ear. Make patients feel that they are a respected part of the team. Second, I advise every physician to take some formal training in medical hypnosis. Words are incredibly powerful, and this training will make them much more aware of the power of words and of body language. People under stress are abnormally receptive to suggestion, and that suggestion can be given deliberately or, all too often, inadvertently. It can be positive or, all too often, negative. How you present information to people can have an unbelievably powerful impact on how they react to it. In my opinion, there is no excuse for any physician to interact with a patient without the patient in some way feeling better when the encounter is done.