Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center

Tracheobronchomalacia is common in children with primary ciliary dyskinesia-A case note review

BACKGROUND

The estimated prevalence of tracheobronchomalacia (TBM) in children is about 1:2100. Prevalence of intrathoracic malacia is higher in children with chronic lung disease such as bronchiectasis and cystic fibrosis (CF) and may contribute to increased morbidity.

OBJECTIVE

To determine the prevalence and assess clinical features of tracheomalacia (TM), TBM and bronchomalacia (BM) in patients with primary ciliary dyskinesia (PCD).

METHODS

We performed a retrospective case-note review of all children with a confirmed or highly likely diagnosis of PCD attending Oslo University Hospital between 2000 and 2021. We selected those who had undergone flexible fiberoptic bronchoscopy (FB) and in whom the presence of TBM was assessed. We retrieved demographic and clinical data, including airway symptoms, PCD-diagnostic criteria, indication for bronchoscopy, the presence of lobar atelectasis, microbiology and the descriptive and unblinded video-recorded results of FB. Complications occurring during and after bronchoscopy were noted.

RESULTS

Of 71 children with PCD, 32 underwent FB and were included in the review. The remaining 39 were included for TBM prevalence calculation only. Median age at FB was 6.0 years (3.1-11.9). Twenty-two children (69%) had intrathoracic airway malacia. Four (13%) had isolated TM, seven (22%) had TBM, and 11 (34%) had isolated BM affecting either main (n = 4) or lobar bronchi (n = 7) (LBM), including four with associated lobar atelectasis. FB related complications, one major, 12 minor, were documented in 13 children (41%).

CONCLUSION

We found a high prevalence of TBM among children with PCD undergoing FB. This may represent a significant comorbidity and have implications for patient management.

Flexible and Rigid Bronchoscopy for Critically Ill Children on Extracorporeal Membrane Oxygenation

BACKGROUND

We aim to describe our experience with bronchoscopy to diagnose and relieve tracheobronchial obstruction in anticipation of decannulation in children on extracorporeal membrane oxygenation (ECMO) support.

METHODS

A retrospective cohort study of children on ECMO between 1/2018 and 12/2022.

RESULTS

A total of 107 children required ECMO support during the study period for cardiac (n = 48, 45%), pulmonary (n = 38, 36%), or cardiopulmonary dysfunction (n = 21, 20%). Thirty-seven (35%) patients underwent 99 bronchoscopies while on ECMO. Most (76%, n = 75) experienced no improvement or worsening of chest radiography 24 hours following bronchoscopy. Clinical improvement in tidal volumes 48 hours after the first bronchoscopy was noted in 13/25 patients with available data (p = 0.05). Adverse events were seen in 18 (49%) patients who underwent bronchoscopy, including pneumothorax (n = 8, 22%), pneumonia (n = 7, 19%), pulmonary hemorrhage (n = 6, 16%), and sepsis (n = 5, 14%). ECMO courses were longer (25.4 ± 37.2 vs 6.1 ± 8.8 days, p < 0.0001) and more likely to be complicated by pneumonia (p = 0.0004) and sepsis (p = 0.047) in patients who underwent bronchoscopy compared with those who did not. Adverse events following bronchoscopy were associated with the number of bronchoscopies (p = 0.0003) and the presence of obstructive materials but not with the type of bronchoscopy or indication for ECMO. Mortality rates were similar between patients who underwent bronchoscopy and those who did not.

CONCLUSION

Children requiring bronchoscopy represent a subset of the sickest children on ECMO. Bronchoscopy may provide benefit in children with persistent cardiopulmonary failure who could not otherwise be decannulated. Adverse events are associated with the number of bronchoscopies and the presence of obstructive material.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4134-4140, 2024.

Approach to the patient with Childhood Interstitial and Diffuse Lung Disease

Childhood Interstitial and Diffuse Lung Disease (chILD) encompasses a group of rare, chronic lung disorders in infants and children with overlapping clinical features but diverse etiologies. The clinical presentation of chILD is of chronic or recurring respiratory signs and symptoms, often including increased work of breathing and hypoxia, with diffuse radiographic abnormalities on chest imaging. Recognition can be challenging since some clinical features overlap with those of more common pediatric respiratory diseases including asthma and recurrent viral infections, among others. chILD should be considered as an underlying diagnosis when a patient's respiratory symptoms seem disproportionate to the clinical scenario and/or persist. The diagnostic process involves multiple steps and is tailored to the individual patient. Nearly all children will undergo imaging and pulmonary function testing, many will undergo bronchoscopy with bronchoalveolar lavage, many will receive genetic testing, and some will require lung biopsy. Treatment includes preventive care, evaluation for comorbidities, pharmacotherapy according to diagnosis, and ongoing disease surveillance, including revisiting genetic and histopathologic results as new clinical information becomes available and as our understanding of these rare disorders improves. The purpose of this review is to provide a broad approach to the diagnosis and management of patients with chILD.

Unveiling the impact of airways: A comparative analysis of oropharyngeal and nasopharyngeal airways in painless fiberoptic bronchoscopy

Background

This study compared the efficacy of oropharyngeal airways (OA) and nasopharyngeal airways (NA) in maintaining oxygenation during painless fiberoptic bronchoscopy (PFB) in patients sedated with remimazolam besylate.

Methods

Two hundred and fifty-two patients were randomized to the OA or NA group. Remimazolam besylate was used for anesthesia induction and maintenance in both groups. We measured and recorded several physiological parameters, including mean arterial pressure, heart rate and oxygen saturation (SpO2), at various time points: before anesthesia (T1), after anesthesia induction (T2), immediately after the bronchoscope reached the trachea (T3), during the procedure (T4), and 5 min after transfer to the post-anesthesia care unit (T5). The incidence and frequency of hypoxemia, minimum SpO2 during the procedure and patient awakening time after flumazenil administration were also recorded. Additionally, the relationship between minimum SpO2 and body mass index (BMI) was investigated.

Results

Patients in the NA group experienced a higher incidence of hypoxemia compared to the OA group. Patients in the OA group maintained higher SpO2 levels at T3 and had a higher minimum SpO2 during the procedure than the NA group. Furthermore, a significant negative correlation was observed between minimum SpO2 and BMI. Following flumazenil anesthesia reversal, nearly 97 % of patients awakened within 1 min.

Conclusions

This study suggests that OA may provide a better safety profile than NA by preserving respiratory function during PFB.

Assessment of risk factors for adverse events in analgosedation for pediatric endoscopy: A 10-year retrospective analysis

OBJECTIVES

Data regarding the occurrence of complications specifically during pediatric anesthesia for endoscopic procedures is limited. By evaluating such data, factors could be identified to assure proper staffing and preparation to minimize adverse events and improve patient safety during flexible endoscopy.

METHODS

This retrospective cohort study included children undergoing anesthesia for gastroscopy, colonoscopy, bronchoscopy, or combined endoscopic procedures over 10-year period. The primary study aim was to evaluate the incidence of complications and identify risk factors for adverse events.

RESULTS

Overall, 2064 endoscopic procedures including 1356 gastroscopies (65.7%), 93 colonoscopies (4.5%), 235 bronchoscopies (11.4%), and 380 combined procedures (18.4%) were performed. Of the 1613 patients, 151 (7.3%) patients exhibited an adverse event, with respiratory complications being the most common (65 [3.1%]). Combination of gastrointestinal endoscopies did not lead to an increased adverse event rate (gastroscopy: 5.5%, colonoscopy: 3.2%). Diagnostic endoscopy as compared to interventional had a lower rate. If bronchoscopy was performed, the rate was similar to that of bronchoscopy alone (19.5% vs. 20.4%). Age < 5.8 years or body weight less than 20 kg, bronchoscopy, American Society of Anesthesiologists status ≥ 2 or pre-existing anesthesia-relevant diseases, and urgency of the procedure were independent risk factors for adverse events. For each risk factor, the risk for events increased 2.1-fold [1.8-2.4].

CONCLUSIONS

This study identifies multiple factors that increase the rate of adverse events associated anesthesia-based endoscopy. Combined gastrointestinal procedures did not increase the risk for adverse events while combination of bronchoscopy to gastrointestinal endoscopy showed a similar risk as bronchoscopy alone.

[Safety of modified T-piece resuscitator versus nasal cannula oxygen in electronic bronchoscopy for infants: a prospective randomized controlled study]

OBJECTIVES

To optimize the oxygen therapy regimens for infants with pulmonary diseases during bronchoscopy.

METHODS

A prospective randomized, controlled, and single-center clinical trial was conducted on 42 infants who underwent electronic bronchoscopy from July 2019 to July 2021. These infants were divided into a nasal cannula (NC) group and a modified T-piece resuscitator (TPR) group using a random number table. The lowest intraoperative blood oxygen saturation was recorded as the primary outcome, and intraoperative heart rate and respiratory results were recorded as the secondary outcomes.

RESULTS

Compared with the NC group, the modified TPR group had a significantly higher level of minimum oxygen saturation during surgery and a significantly lower incidence rate of hypoxemia (P<0.05). In the modified TPR group, there were 6 infants with mild hypoxemia, 2 with moderate hypoxemia, and 1 with severe hypoxemia, while in the NC group, there were 3 infants with mild hypoxemia, 5 with moderate hypoxemia, and 9 with severe hypoxemia (P<0.05). The modified TPR group had a significantly lower incidence rate of intraoperative respiratory rhythm abnormalities than the NC group (P<0.05), but there was no significant difference in the incidence rate of arrhythmias between the two groups (P>0.05).

CONCLUSIONS

Modified TPR can significantly reduce the risk of hypoxemia in infants with pulmonary diseases during electronic bronchoscopy, and TPR significantly decreases the severity of hypoxemia and the incidence of respiratory rhythm abnormalities compared with traditional NC.

Diagnostic yield of bronchoscopy in children with leukemia or post hematopoietic stem cell transplant

BACKGROUND

The utility of bronchoscopy with bronchoalveolar lavage (BAL) in immunocompromised children is not well understood. We aim to describe the bronchoscopy diagnostic yield and complications and to investigate factors associated with diagnostic yield.

METHODS

This is a single-center, retrospective cohort study of 60 children with leukemia or post-hematopoietic stem cell transplant who had a bronchoscopy with BAL between 2017 and 2021. Comparisons were done with regression analysis.

RESULTS

Of the 60 bronchoscopies performed, 46 (77%) revealed diagnostic information: 39 (65%) identified a pathogen, 14 (23.3%) found secretions/mucus plugging, and 6 (10%) found pulmonary hemorrhage. BAL results changed antimicrobial therapy in 27 (45%) cases. Bronchoscopies were performed in the intensive care unit (27/60) or operating room (33/60), with the former having a higher diagnostic yield (96% vs. 60%, p = 0.001). Half (50%) of bronchoscopies found a new infectious diagnosis. Respiratory symptoms (n = 58, 97%), supplemental oxygen use (n = 39, 65%), and antibiotic use (n = 56, 93%) before bronchoscopy were all common. The median volume of fluid instilled during bronchoscopy was 1.3 mL/kg (interquatile range [IQR]: 0.7, 2.6). None of these factors were associated with the diagnostic yield. Complications were rare and minor with only one child having self-resolved bleeding and four children, previously in room air requiring a nasal cannula. For the 27 (45%) children on mechanical ventilation when the bronchoscopy was performed, there was no difference in ventilator settings pre- and post-bronchoscopy.

CONCLUSION

Bronchoscopies with BAL are useful, safe, and important in the diagnostic management of pulmonary complications in this cohort of children.

Airway microbiota correlated with pulmonary exacerbation in primary ciliary dyskinesia patients

IMPORTANCE

PCD is a rare disease characterized by productive cough, rhinitis, and recurrent infections of the upper and lower airways. Because the diagnosis of PCD is often delayed, patients receive more antibiotics, experience a heavier financial burden, and have a worse prognosis; thus, it is very important to identify the pathogeny and use the correct antibiotic. In this large single-center study of PCD microbiota, we identified an outline of the bacterial microbes from the respiratory tract; furthermore, we found that the microbiota diversity in pediatric sputum was richer than that in pediatric BALF through sequencing, indicating a heterogeneous community structure. The microbiota diversity and richness were lower during pulmonary exacerbation than during pulmonary stabilization. A significantly higher abundance of Pseudomonas had a moderate distinguishing effect for lung exacerbation, which attracted more attention for the study of Pseudomonas therapy in pediatric patients with PCD.

Foreign body aspiration in children - being safe and flexible

PURPOSE OF REVIEW

Anesthesia for foreign body removal in children can be quite challenging. Even though rigid bronchoscopy is considered the gold standard for foreign body removal, there is increasing evidence for successful foreign body removal using flexible bronchoscopy. This review discusses the recent implications for flexible bronchoscopy for the purpose of foreign body removal and will compare these findings to rigid bronchoscopy.

RECENT FINDINGS

During the last few years, several observational studies on foreign body removal by flexible bronchoscopy have been published, with promising results.

SUMMARY

Flexible bronchoscopy is a feasible and safe method for removing aspirated foreign bodies in children. In order to improve patient safety during the procedure, it is necessary for a pediatric anesthetist and a pediatric pulmonologist to work closely together. The anesthetist can take care of the administration of the anesthetic and maintenance of the vital functions, and the pulmonologist can carry out a safe and fast bronchoscopy. In the case of foreign body removal by flexible bronchoscopy, the anesthesiological procedure of choice should be general anesthesia with controlled ventilation via a laryngeal mask.

Flexible bronchoscopy in pediatric patients with Down syndrome: A case-control study of the indications, findings, and complications

BACKGROUND

Children with Down syndrome (DS) often undergo flexible bronchoscopies (FB) due to common respiratory symptoms.

OBJECTIVE

To examine the indications, findings, and complications of FB in pediatric DS patients.

METHODS

A retrospective case-control study on FB performed in DS pediatric patients between 2004 and 2021 in a tertiary center. DS patients were matched to controls (1:3) based on age, gender, and ethnicity. Data collected included demographics, comorbidities, indications, findings, and complications.

RESULTS

Fifty DS patients (median age 1.36 years, 56% males) and 150 controls (median age 1.27 years, 56% males), were included. Evaluation for obstructive sleep apnea and oxygen dependence were more common indications among DS (38% vs. 8%, 22% vs. 4%, p < 0.01, respectively). Normal bronchoscopy was less frequent in DS compared with controls (8% vs. 28%, p = 0.01). Soft palate incompetence and tracheal bronchus were more frequent in DS (12% vs. 3.3%, p = 0.024, 8% vs. 0.7%, p = 0.02, respectively). Complications were more frequent in DS (22% vs. 9.3%, incidence rate ratio [IRR] 2.36, p = 0.028). In DS, cardiac anomalies (IRR 3.96, p < 0.01), pulmonary hypertension (IRR 3.76, p = 0.006), and pediatric intensive care unit (PICU) hospitalization before the procedure (IRR 4.2, p < 0.001) were associated with higher complication rates. In a multivariate regression model, history of cardiac disease and PICU hospitalization before the procedure, but not DS, were independent risk factors for complications with an IRR of 4 and 3.1, respectively (p = 0.006, p = 0.05).

CONCLUSION

DS pediatric patients undergoing FB are a unique population with specific indications and findings. DS pediatric patients with cardiac anomalies and pulmonary hypertension are at the highest risk for complications.

High flow nasal cannula versus standard low flow nasal oxygen during flexible bronchoscopy in children: A randomized controlled trial

BACKGROUND

Hypoxemia is the most frequent complication of fiberoptic bronchoscopy (FB) in children. Guidelines recommend oxygen supplementation and conventional nasal prongs (NC) are used for this purpose. The aim of this study was to evaluate if the use of high-flow nasal cannula therapy (HFNC) in children undergoing FB result in a lower incidence of hypoxemia than standard oxygen administration.

METHODS

Patients aged 1 month-16 years undergoing elective FB were included in a prospective randomized controlled, nonblinded, single-center clinical trial and randomly assigned to receive oxygen via NC or HFNC. Patients' baseline characteristics were recorded pre-bronchoscopy. The primary outcome was oxygen desaturation during the procedure defined as saturation less than 94%.

RESULTS

An intention to treat analysis for 53 patients receiving NC and 51 receiving HFNC, showed HFNC patients were less likely to have hypoxemia than were NC patients (p = .011), with an absolute risk reduction of 0.27 (95% confidence interval [CI]: 0.08-0.45) and a number needed to treat of 3.75 (95% CI: 2.22-12.04). Moderate hypoxemia (SpO₂  ≥ 90% and <94%, and <60 s) was observed significantly less often with HFNC than with NC (p = .012). Severe hypoxemia (SpO₂  < 90% and >30 s) was not different between groups. Patients undergoing bronchoalveolar lavage (BAL) presented fewer desaturations with HFNC (p = .0003).

CONCLUSIONS

HFNC offers optimized oxygenation during elective FB with a significant reduction in desaturations and can be considered for oxygen administration, especially when BAL is performed.

Pediatric flexible bronchoscopy: A single-center report

INTRODUCTION

Pediatric flexible laryngotracheal bronchoscopy (FB) is an integral part of diagnostics and treatment at tertiary pediatric respiratory centers.

AIM

FBs performed between 2013 and 2018 at our Pediatric Allergy and Respiratory Medicine Unit of the Department of Women's and Children's Health at Padua University were examined in terms of the indications, findings, and adverse events.

MATERIALS AND METHODS

The electronic medical records of pediatric patients who underwent FB at least once between 1 January 2013 and 31 December 2018 were considered. Patients' clinical data, indications for FB, anatomical findings, information derived from bronchoalveolar lavage (BAL) and bronchial brushing, and possible adverse events were analyzed.

RESULTS

There were 447 pediatric FBs performed in 428 patients (aged from 1 month to 18 years) for diagnostic purposes (92.4%), to clear secretions (3.6%), or to monitor a known condition (4.0%). The main indications were recurrent lower respiratory tract infections (LRTI, 32.2%) and chronic wet cough (9.4%). Lower airway malacia was the most common abnormal finding in these two groups (36.1% and 28.6%, respectively). BAL bacterial culture was positive in 55 children (39.6%) with recurrent LRTI and in 25 (59.5%) with chronic wet cough, being Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis the microorganisms most commonly isolated. FB proved a safe procedure and was well tolerated.

CONCLUSIONS

Pediatric FB is an essential tool at our tertiary pediatric respiratory center. It helps establish the anatomical conditions underlying several chronic respiratory conditions and any correlated microbiological findings, with a significant impact on further patient management.

Multislice spiral computed tomography can independently predict the bronchoscopy results of children with bronchitis (pneumonia) suspected caused by bronchial foreign bodies

BACKGROUND

Multislice spiral computed tomography (MSCT) playsa vital role in the diagnosis of bronchial foreign bodies in children. Bronchitis (pneumonia) can be caused by bronchial foreign bodies in children, which need to be diagnosed and treated by bronchoscopy. To understand the application of MSCT in children with bronchitis (pneumonia) suspected to be caused by bronchial foreign bodies, the clinical data of 162 children were analyzed retrospectively.

METHODS

The clinical data of 162 children with bronchitis (pneumonia) suspected to be caused by bronchial foreign bodies were collected, including sex, age, course of the disease, auscultation, chest X-ray, MSCT, bronchoscopy, among many others. Univariate logistic regression analysis analyzed the above other items, taking the finding of foreign bodies in bronchoscopy as the outcome index. The key variables of univariate analysis are included in multivariate logistic regression analysis to determine the independent influencing factors of bronchoscopy results.

RESULTS

Among the 162 patients, 70.4% were male, with the largest proportion of children aged 1-2 years (55.6%). The course of the disease of 98 cases (60.4%) was over14 days. A total of 111 cases (68.5%) showed positive auscultation, 110 cases (67.9%) showed positive chest fluoroscopy, 155 cases (95.7%) showed bronchial foreign bodies with MSCT, and the foreign bodies of 140 cases (86.4%) were removed by bronchoscopy. Univariate analysis showed that the course of the disease, chest auscultation, and MSCT were all correlated with the results of bronchoscopy. However, multivariate analysis showed, after adjusting the two factors of chest auscultation and chest fluoroscopy, the course of the disease (OR =6.01, 2.36-15.29, P<0.001) and MSCT (OR =95.64, 5.62-1,628.40, P<0.002) could still independently predict the results of bronchoscopy.

CONCLUSIONS

MSCT can independently predict the results of bronchoscopy in children with bronchitis(pneumonia) suspected to be caused by bronchial foreign bodies.

Ibuprofen does not prevent postbronchoscopy fever in children undergoing broncho-alveolar lavage

BACKGROUND

Fiber-optic bronchoscopy (FOB) of the lower airways is a routine examination performed for investigating varying respiratory complaints in children. A common side effect is a transient high fever on the day of the FOB. Such episodes are usually unrelated to an infectious process but may cause clinical uncertainty and parental anxiety. We have previously shown that a single dose of systemic dexamethasone significantly reduces the rate of fever postbronchoscopy (FPB).

RESEARCH QUESTION

To prospectively analyze the effect of a prophylactic dose of ibuprofen upon the FPB.

STUDY DESIGN AND METHODS

Children presenting for elective FOB and broncho-alveolar lavage (BAL) were randomized, in a double-blind fashion, to receive a single dose of ibuprofen syrup 10 mg/kg or placebo prior to the procedure. Parents were contacted the next day to record the presence or absence of fever.

RESULTS

Sixty-one children were included in the final analysis. Thirty-one children were in the treatment group and 30 in the placebo group. FPB occurred in 40 children (65%). There was no difference in the rate of FPB between placebo (63%) and treatment (67%) groups (P = .717). Fifty (82%) children had a positive BAL culture. Among them, 38 had FPB (76%) compared with only 2 of 11 (18%) of those with negative culture (P = .00026, relative risk 4.18). About 80% of positive cultures grew Haemophilus influenza. There was no significant difference between the number of BALs with a positive culture between the treatment and placebo groups (87% vs 77%, P = .35).

CONCLUSION

FPB occurs in around twothirds of children when BAL is performed. Fever occurred significantly more frequently when BAL culture is positive. A single standard dose of the nonsteroidal anti-inflammatory drug ibuprofen administered before a FOB does not prevent FPB.

Construction of a Risk Prediction Model for Fever After Painless Bronchoscopy

Background

The aim of this study was to construct a risk prediction model for fever after painless bronchoscopy.

Material/Methods

A total of 188 patients were included, and a self-designed data collection form was used. By collecting relevant clinical data of patients before, during, and after the painless bronchoscopy, the influencing factors were analyzed through univariate analysis, and multiple logistic regression analysis was performed to construct the prediction equation, which was tested by ROC curve analysis.

Results

Of the 188 patients undergoing painless bronchoscopy, 49 had postoperative fever, and the incidence rate was 26.0%. The prediction probability model was: P=e^x/1+e^x, where e is the natural logarithm, X=−4.337+0.020×(CRP)+1.014 (whether the examination time was greater than 30 minutes)+1.912×(whether remifentanil was used during anesthesia)+1.514×(whether nausea or vomiting occurred during surgery or during recovery). The prediction sensitivity and specificity were 78.26% 76.72%, respectively.

Conclusions

Use of this risk prediction model of fever after painless bronchoscopy can improve the recognition of people at high risk of postoperative fever, and it has good ability to guide clinical nursing observation and early screening of fever after painless bronchoscopy.

An apple a day won't keep the doctor away: presentation, treatment, and outcome in pediatric apple aspirations

INTRODUCTION

Foreign body (FB) aspiration is a frequent and preventable source of morbidity and mortality, especially in children under 4 years of age. Few comprehensive studies exist on presentation and outcome of apple aspirations in children.

METHODS

In a retrospective analysis of bronchoscopy records of a tertiary medical care center from January 2007 to August 2019, we identified pediatric cases of suspected apple aspirations.

RESULTS

A total of 11 suspected apple aspirations were identified (observation time 12.7 years, n = 5858 bronchoscopies, n = 226 interventions due to suspected FB aspirations in total). The mean age of patients was 24 months (standard error mean, 7 months; range, 8-83 months), and 6 out of 11 cases (55%) were male. Bronchoscopy confirmed apple aspiration in n = 6/11 cases (55%). In n = 2/11 cases (18%), a bite of the apple was located in the esophagus causing significant tracheal narrowing, and in n = 3/11 cases (27%), no FB was found. In all cases of airway FB identification, extraction was successful. Hypersalivation was associated with esophageal FB location, whereas persistent cough, stridor, or dyspnea were associated with airway FB location. Outcomes ranged from complete reconstitution 1 day after bronchoscopy in most cases to hypoxemia with severe brain damage in one patient.

DISCUSSION

This analysis shows that apple aspirations are not entirely uncommon in children and may lead to disastrous complications. Typical signs of airway location are persistent cough, stridor or dyspnea, whereas hypersalivation may point toward an esophageal location. In each case of suspected apple aspiration, timely bronchoscopy with possible FB extraction should be performed by an experienced team.

Validation of a computerized scoring system for foreign body aspiration: An observational study

OBJECTIVE

The diagnosis of foreign body aspiration (FBA) is challenging. In a previous study, we developed a computerized scoring system (CSS) to support decision-making. In the present study, we aimed to validate it on a further cohort.

STUDY DESIGN

In this observational study, 100 children referred to the emergency department of a tertiary pediatric hospital for suspected FBA and treated according to standard protocol, were assigned a probability score using the CSS, between 0 and 1 (0, very low probability; 1, very high). The diagnosis of FBA was based on bronchoscopy, and if discharged without bronchoscopy, determined via telephone questionnaire, 4 to 6 months after discharge, supplemented by clinical re-evaluation and bronchoscopy, if respiratory symptoms persisted.

RESULTS

Thirty-five out of 100 children (35%) underwent bronchoscopy with 12 of 35 (34%) positive for FBA. Sixty-five patients were discharged without bronchoscopy and completed a telephone questionnaire. Seven patients required clinical re-evaluation for persistent respiratory symptoms, in two out of them, additional bronchoscopies were performed and were negative. The CSS median probability score was 0.94 in patients with FBA, as compared to 0.73 in patients without FBA (P = .007). The CSS area under the receiver operating curve was 0.74. At a probability score threshold of 0.6, the sensitivity and specificity were 100% and 41%, respectively.

CONCLUSION

The present validation study suggests a high sensitivity of the CSS for the identification of FBA in children. We suggest that it might aid decision-making with regard to the need for bronchoscopy in children presenting to the emergency room.

Less invasive surfactant administration: a word of caution

Surfactant is a cornerstone of neonatal critical care, and the presumed less (or minimally) invasive techniques for its administration have been proposed to reduce invasiveness of neonatal critical care interventions. These techniques are generally known as less invasive surfactant administration (LISA) and have quickly gained popularity in some neonatal intensive care units. Despite the increase in the use of LISA, we believe that the pathobiological background supporting its possible clinical benefits is unclear. Similarly, it is unclear whether there are any ignored drawbacks, as LISA has been tested in only a few trials and some physiopathological issues seem to have gone unnoticed. Active research is warranted to fill these knowledge gaps before LISA can be firmly recommended. In this Viewpoint, we provide an in-depth analysis of LISA techniques, based on physiological and pathobiological factors, followed by a critical appraisal of available clinical data, and highlight some possible future research directions.

Clinical Characteristics of and Risk Factors for Fever after Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Retrospective Study Involving 6336 Patients

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic for mediastinal and hilar lymphadenopathy/mass. This study investigated fever incidence and associated risk factors after EBUS-TBNA in 6336 patients who underwent EBUS-TBNA at Asan Medical Center from October 2008 to February 2018. Bronchoscopists evaluated participants’ medical records for fever the 24 h following EBUS-TBNA. Patients were placed in either a Fever group (n = 665) or a non-Fever group (n = 5671). Fever developed in 665 of 6336 patients (10.5%) with a mean peak body temperature of 38.3 °C (range, 37.8–40.6 °C). Multivariate analysis revealed that fever-associated risk factors after EBUS-TBNA are older age (adjusted OR 0.015, 95% CI (0.969–0.997), p = 0.015), bronchoscopic washing (adjusted OR 1.624, 95% CI (1.114–2.368), p = 0.012), more than four samples of EBUS-TBNA (adjusted OR 2.472, 95% CI (1.288–4.745), p = 0.007), hemoglobin levels before EBUS-TBNA (adjusted OR 0.876, 95% CI (0.822–0.933), p < 0.001), CRP levels before EBUS-TBNA (adjusted OR 1.115, 95% CI (1.075–1.157), p < 0.001), and a diagnosis of EBUS-TBNA tuberculosis (adjusted OR 3.409, 95% CI (1.870–6.217), p < 0.001). Clinicians should be aware of the possibility of fever after EBUS-TBNA because it is common. Additional, prospective, large-scale research should assess the need for prophylactic antibiotics for EBUS-TBNA.

Pediatric Pulmonology Year in Review 2018: Rare lung disease, neuromuscular disease, and diagnostic testing

Pediatric Pulmonology publishes original research, case reports, and review articles on topics related to a wide range of children's respiratory disorders. In this article, we highlight the past year's publications in the topic areas of rare lung diseases, respiratory complications of neuromuscular disorders, and diagnostic testing, as well as selected literature in these areas from other journals.

Towards developing a valid scoring tool for bronchitis during flexible bronchoscopy

BACKGROUND

A valid bronchoscopic scoring tool for bronchitis would be useful for clinical and research purposes as currently there are none in children. From 100 digitally recorded flexible bronchoscopies (FB), we related the various macroscopic features to airway neutrophil % to develop a FB-derived bronchitis score (BScore_exp ). We aimed to develop a FB-derived bronchitis tool.

METHODS

FB recordings for six visualised features: secretions (amount and color) and mucosal appearance (erythema, pallor, ridging, oedema) based on pre-determined criteria on a pictorial chart were assessed by two physicians independently, blinded to the clinical history. These features were used to obtain various models of BScore_exp that were plotted against bronchoalveolar lavage (BAL) neutrophil % using a receiver operating characteristic (ROC) curve. Inter- and intra-rater agreement (weighted-kappa, K) were assessed from 30 FBs.

RESULTS

Using BAL neutrophilia of 20% to define inflammation, the highest area under ROC (aROC) of 0.71, 95%CI 0.61-0.82 was obtained by the giving three times weightage to secretion amount and color and adding it to erythema and oedema. Inter-rater K values for secretion amount (K = 0.87, 95%CI 0.73-1.0) and color (K = 0.86, 95%CI 0.69-1.0) were excellent. Respective intra-rater K were 0.95 (0.87-1.0) and 0.68 (0.47-0.89). Other inter-rater K ranged from 0.4 (erythema) to 0.64 (pallor).

CONCLUSION

A repeatable FB-defined bronchitis scoring tool can be derived. However, a prospective study needs to be performed with larger numbers to further evaluate and validate these results.