Retrospective evaluation of a paediatric intensivist-led flexible bronchoscopy service

Flexible Fiberoptic Bronchoscopy in Non-ventilated Children in Pediatric Intensive Care Unit: Utility, Interventions and Safety

Objective

To study the utility of flexible fiberoptic bronchoscopy (FFB), and its effects on oxygenation and hemodynamics in children while on respiratory assist devices.

Materials and methods

The data of non-ventilated patients who underwent FFB during their stay in the PICU from January 2012 to December 2019 was retrieved from medical, nurses, and bronchoscopy records. The study parameters, demography, diagnosis, indication, and findings of FFB and interventions done after FFB, were noted, and also the oxygenation and hemodynamic parameters before, during and 3 hours after FFB.

Results

Data from the first FFB of 155 patients were analyzed retrospectively. About 54/155 (34.8%) children underwent FFB while on HFNC. About 75 (48.4%) patients were on conventional oxygen therapy (COT) before FFB. There were 51 (33%) patients who had received mechanical ventilation and were extubated successfully. The 98 (63.2%) children had primary respiratory diseases. Stridor and lung atelectasis were indications for FFB in 75 (48.4%) cases and the commonest bronchoscopic finding was retained secretions in the airways. Based on the FFB findings, 50 medical and 22 surgical interventions were done. The commonest medical and surgical interventions were changes in antibiotics (25/50) and tracheostomy (16/22) respectively. There was a significant fall in SpO₂ and a rise in hemodynamic parameters during FFB. All these changes were reversed after the procedure with no consequences.

Conclusion

Flexible fiberoptic bronchoscopy is a useful tool to diagnose and guide interventions in non-ventilated pediatric intensive care unit (PICU). There were significant but transient changes in oxygenation and hemodynamics with no serious consequences.

How to cite this article

Sachdev A, Gupta N, Khatri A, Jha G, Gupta D, Gupta S, et al. Flexible Fiberoptic Bronchoscopy in Non-ventilated Children in Pediatric Intensive Care Unit: Utility, Interventions and Safety. Indian J Crit Care Med 2023;27(5):358-365.

Pulmonary artery sling: An overview

Pulmonary artery sling is a rare childhood vascular tracheobronchial compression syndrome that is frequently associated with tracheal stenosis. Consequently, neonates or infants may present with critical airway obstruction if there is long segment airway narrowing and complete rings. Rapid diagnosis of this cardiac vascular malformation and evaluation of the extent and severity of airway involvement is essential to plan surgery, typically a slide tracheoplasty to relieve critical airway obstruction. Long term outcome can be excellent following surgical repair of the stenosed airway and reimplantation of the left pulmonary artery. In this review we focus on the embryology, diagnostic workup, airway investigations and management for this rare but challenging congenital condition.

Utility and safety of flexible fiberoptic bronchoscopy in mechanically ventilated children in pediatric intensive care unit

OBJECTIVES

To study the utility, safety, and effects of flexible fiberoptic bronchoscopy (FFB) on oxygenation status, ventilation parameters, and hemodynamics in mechanically ventilated children.

DESIGN

Retrospective study.

PATIENTS

Children aged >1 month to 18 years suffering from critical medical and surgical diseases.

RESULTS

First bronchoscopy data of 131 patients were analyzed. Indication, FFB findings, the microbiological yield from bronchoalveolar lavage, and medical and surgical interventions based on FFB results were recorded. Hemodynamic and ventilation parameters before, during, and 3 h after FFB were also captured. The majority of bronchoscopies were done for diagnostic purposes with a positivity rate of 90.8%. Retained mucopurulent secretion in the airways was the commonest finding in 60 patients. A cause for weaning or extubation failure could be identified in 83.3%. Post-FFB radiological resolution of atelectasis was seen in 34/59 (57.6%; p-value: 0.001) chest radiographs. Forty-seven medical and 25 surgical interventions were done depending on FFB and BAL findings. There was a significant drop in oxygenation parameters and a rise in heart rate during FFB (p-value: <0.0001). The peak inspiratory pressure, positive end-expiratory pressure, and mean airway pressure increased significantly during bronchoscopy (p value: <.0001) while patients were on pressure-regulated volume-controlled ventilation. All these changes reversed to pre-FFB levels. There were minor procedure-related complications.

CONCLUSION

FFB was an important diagnostic and therapeutic tool for mechanically ventilated children and the results helped plan interventions. It was a safe procedure with transient reversible cardiopulmonary alterations.

The clinical application of flexible bronchoscopy in a neonatal intensive care unit

OBJECTIVE

Flexible bronchoscopy is widely used in infants and it plays a crucial role. The aim of this study was to investigate the value and clinical safety of flexible bronchoscopy in a neonatal intensive care unit.

METHODS

A retrospective analysis was performed on the clinical data of 116 neonates who underwent flexible bronchoscopy and the outcomes of 147 procedures. A correlation analysis was performed on the relationship between flexible bronchoscopy findings, microscopic indications, and clinical disease.

RESULTS

The 147 procedures performed were due to the following reasons: problems related to artificial airways, 58 cases (39.45%); upper respiratory problems, 60 cases (40.81%) (recurrent dyspnea, 23 cases; upper airway obstruction, 17 cases; recurrent stridor, 14 cases; and hoarseness, six cases), lower respiratory problems, 51 cases (34.69%) (persistent pneumonia, 21 cases; suspicious airway anatomical disease, 21 cases; recurrent atelectasis, eight cases; and pneumorrhagia, one case), feeding difficulty three cases (2.04%). The 147 endoscopic examinations were performed for the following reasons: pathological changes, 141 cases (95.92%); laryngomalacia, 78 cases (53.06%); mucosal inflammation/secretions, 64 cases (43.54%); vocal cord paralysis, 29 cases (19.72%); trachea/bronchus stenosis, 17 cases (11.56%) [five cases of congenital annular constriction of the trachea, seven cases of left main tracheal stenosis, one case of the right middle bronchial stenosis, two cases of tracheal compression, and two cases of congenital tracheal stenosis]; subglottic lesions, 15 cases (10.20%) [eight cases of subglottic granulation tissue, six cases of subglottic stenosis, one cases of subglottic hemangioma]; tracheomalacia, 14 cases (9.52%); laryngeal edema, five cases (3.40%); tracheoesophageal fistula, four cases (2.72%); rhinostenosis, three cases (2.04%); tracheal bronchus, three cases (2.04%); glossoptosis, two cases (1.36%); laryngeal cyst, two cases (1.36%); laryngeal cleft, two cases (1.36%); tongue base cysts, one case (0.68%); and pneumorrhagia, one case (0.68%). Complications were rare and mild.

CONCLUSION

Flexible bronchoscopy is safe and effective for diagnosing and differentiating neonatal respiratory disorders in neonatal intensive care units.

Impact of staffing model conversion from a mandatory critical care consultation model to a closed unit model in the medical intensive care unit

BACKGROUND

The intensive care unit (ICU) staffing model affects clinical outcomes of critically ill patients. However, the benefits of a closed unit model have not been extensively compared to those of a mandatory critical care consultation model.

METHODS

This retrospective before-after study included patients admitted to the medical ICU. Anthropometric data, admission reason, Acute Physiology and Chronic Health Evaluation II score, Eastern Cooperative Oncology Group grade, survival status, length of stay (LOS) in the ICU, duration of mechanical ventilator care, and occurrence of ventilator-associated pneumonia (VAP) were recorded. The staffing model of the medical ICU was changed from a mandatory critical care consultation model to a closed unit model in September 2017, and indices before and after the conversion were compared.

RESULTS

A total of 1,526 patients were included in the analysis. The mean age was 64.5 years, and 954 (62.5%) patients were men. The mean LOS in the ICU among survivors was shorter in the closed unit model than in the mandatory critical care consultation model by multiple regression analysis (5.5 vs. 6.7 days; p = 0.005). Central venous catheter insertion (38.5% vs. 51.9%; p < 0.001) and VAP (3.5% vs. 8.6%; p < 0.001) were less frequent in the closed unit model group than in the mandatory critical care consultation model group. After adjusting for confounders, the closed unit model group had decreased ICU mortality (adjusted odds ratio 0.65; p < 0.001) and shortened LOS in the ICU compared to the mandatory critical care consultation model group.

CONCLUSION

The closed unit model was superior to the mandatory critical care consultation model in terms of ICU mortality and LOS among ICU survivors.

Pediatric flexible bronchoscopy in the intensive care unit: A multicenter study

INTRODUCTION

Flexible bronchoscopy (FB) is frequently used for assessment and treatment of patients with respiratory diseases. Our aim was to investigate the contribution of FB to diagnosis and therapy in children admitted to the intensive care units (ICU) and to evaluate the safety of FB in this vulnerable population.

METHODS

Children less than 18 years of age who underwent FB in the five neonatal and pediatric ICUs in Istanbul between July 1st, 2015 and July 1st, 2020 were included to the study. Demographic and clinical data including bronchoscopy indications, findings, complications, and the contribution of bronchoscopy to the management were retrospectively reviewed.

RESULTS

One hundred and ninety-six patients were included to the study. The median age was 5 months (range 0.3-205 months). The most common indication of FB was extubation failure (38.3%), followed by suspected airway disease. Bronchoscopic assessments revealed at least one abnormality in 90.8% patients. The most common findings were airway malacia and the presence of excessive airway secretions (47.4% and 35.7%, respectively). Positive contribution of FB was identified in 87.2% of the patients. FB had greater than 1 positive contribution in 138 patients and 80.6% of the patients received a new diagnosis. Medical therapy was modified after the procedure in 39.8% and surgical interventions were pursued in 40% of the patients. Therapeutic lavage was achieved in 18.9%. There were no major complications.

CONCLUSION

Flexible bronchoscopy is a valuable diagnostic and therapeutic tool in neonatal and pediatric ICUs and is not associated with major complications.

Postnatal impact of a prenatally diagnosed double aortic arch

BACKGROUND

A double aortic arch (DAA) is increasingly identified before birth; however, there are no published data describing the postnatal outcome of a large prenatal cohort.

OBJECTIVE

To describe the associations, symptoms and impact of prenatally diagnosed DAA.

METHODS

Retrospective review of consecutive cases seen at two fetal cardiology units from 2014 to 2019. Clinical records including symptoms and assessment of tracheobronchial compression using flexible bronchoscopy were reviewed. Moderate-severe tracheal compression was defined as >75% occlusion of the lumen.

RESULTS

There were 50 cases identified prenatally and 48 with postnatal follow-up. Array comparative genomic hybridisation (aCGH) was abnormal in 2/50 (4%), aCGH was normal in 33/50 (66%) and of those reviewed after birth, 13 were phenotypically normal. After birth, there was a complete DAA with patency of both arches in 8/48 (17%) and in 40/48 (83%) there was a segment of the left arch which was a non-patent, ligamentous connection.Stridor was present in 6/48 (13%) on the day of birth. Tracheo-oesophageal compressive symptoms/signs were present in 31/48 (65%) patients at median age of 59 days (IQR 9-182 days). Tracheal/carinal compression was present in 40/45 (88%) cases. Seven of 17 (41%) asymptomatic cases demonstrated moderate-severe tracheal compression. All morphologies of DAA caused symptoms and morphology type was not predictive of significant tracheal compression (p=0.3).

CONCLUSIONS

Genetic testing should be offered following detection of double aortic arch. Early signs of tracheal compression are common and therefore delivery where onsite neonatal support is available is recommended. Significant tracheal compression may be present even in the absence of symptoms.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Correlation of Symptoms with Bronchoscopic Findings in Children with a Prenatal Diagnosis of a Right Aortic Arch and Left Arterial Duct

A right aortic arch (RAA) with a left arterial duct (LAD) together encircle the trachea and have the potential to cause tracheobronchial compression and published guidelines recommend bronchoscopy in symptomatic patients. The aim of the study was to describe the incidence of tracheal compression in a cohort of prenatally diagnosed RAA and LAD. Retrospective review of clinical course and imaging of prenatal cases of RAA and LAD assessed with flexible bronchoscopy over an 11-year period. 34 cases of prenatally diagnosed RAA with LAD underwent bronchoscopy at median age of 9 months (range 0.4-123) of whom 11 had respiratory symptoms and 23 were asymptomatic. In the neonatal period, three cases demonstrated respiratory symptoms. An aberrant left subclavian artery (ALSA) was identified in 29 cases. Pulsatile tracheal compression was identified in 32/34 (94%) cases and two cases showed normal tracheal appearances. Significant tracheal compression (> 70% occlusion) was present in 25/34 (74%) cases of which 16 were asymptomatic. Significant carinal compression (> 70% occlusion) was identified in 14/34 (42%) cases, an ALSA was observed in 13/14. Surgical relief of a vascular ring has been performed in 27 (79%) cases at a median age of 15 months (range 0.6-128 months). At surgery, a fibrous remnant of an atretic left aortic arch was identified in 11/27 (41%) cases. Significant tracheal compression may be present in infants even without symptoms. If early relief of airway compression is to be achieved to promote normal development of tracheal cartilage, early bronchoscopy should be considered.

Safety and efficacy of rescue flexible bronchoscopic intubation using the Bentson floppy-tip guidewire via a supraglottic airway in critically ill children

Difficulty in tracheal intubation in paediatric intensive care patients is associated with increased morbidity and mortality. Delays to intubation and interruption to oxygenation and ventilation are poorly tolerated. We developed a safe and atraumatic tracheal intubation technique. A floppy-tipped guidewire and airway exchange catheter were placed to a pre-determined length under bronchoscopic guidance while oxygenation and ventilation was maintained via a supraglottic airway device (SAD). We performed a retrospective review of this technique on patients who were either known to have or who had an unexpected difficultly in intubation. We describe the safety and experience of this in a broad range of critically ill children. Thirteen patients, median (IQR [range]) (9.0 (5.0-10.0 [4.0-12.0]) kg and 15.4 (12.1-23.2 [3.3-49.7]) months) underwent emergency tracheal intubation using this technique, after unsuccessful attempts at intubation using standard laryngoscopy blades. All intubations were successful at the first attempt using this technique and no airway trauma or significant clinical deteriorations were recorded.

Critical airway obstruction in apparently asymptomatic neonates

Central airway obstruction (trachea and major bronchi) in neonates can be caused by malacia, stenosis, or compression by masses or vascular structures. These abnormalities may be present in the neonatal period but are typically not detected until at least 6 months of age. We present four patients (1.6-4.1 kg, 32-41 weeks gestation) with nonspecific symptoms (e.g., poor weight gain, difficulty weaning from CPAP) who underwent bronchoscopy in the neonatal period. Critical airway obstruction (>90%) was identified in these relatively asymptomatic neonates. We suggest a low threshold for investigation with bronchoscopy in high-risk neonates. Pediatr Pulmonol. 2017;52:E15-E17. © 2016 Wiley Periodicals, Inc.

Flexible bronchoscopy in children: Utility and complications

Background and objectives

The flexible bronchoscope has become widely used by pediatric pulmonologists as a diagnostic and therapeutic tool. Nevertheless, there are several gaps in our knowledge to help refine its use and reduce its complications. In this study, we aimed to evaluate the utility and complications of pediatric bronchoscopy.

Design and setting

We conducted a retrospective review of bronchoscopy cases between March 2006 and April 2015 at a tertiary care medical center (King Fahad Medical City). One-hundred forty nine patients were studied.

Patients and methods

We evaluated how bronchoscopy contributed to the patients' diagnosis, assessed the accuracy of bronchoalveolar lavage white blood cell count (BAL WBC) to differentiate between infectious and non-infectious conditions, assessed the ability of clinical factors to predict high risk of desaturation during bronchoscopy, and finally summarized the reported procedural complications.

Results

We found pediatric bronchoscopy was a crucial diagnostic (confirming, ruling out, and discovering unexpected diagnosis) and therapeutic tool. The accuracy of BAL WBC counts is poor (AUC (95% CI) = 0.609 (0.497–0.712)); however, using two cutoff values (≤10 WBCs (sensitivity = 84.44% and specificity = 29.27%) to rule out, and ≥400 WBCs (sensitivity = 33.33% and specificity 81.49%) to rule in infection) helped in early differentiation between infectious and non-infectious conditions. From the factors that we test, none we found predictive of desaturation. The most common procedural complication was desaturation (pooled incidence (95% CI) = 13 (8–19)%) followed by cough, mild airway bleeding, and spasm.

Conclusions

Flexible bronchoscopy is an important and relatively safe diagnostic and therapeutic tool in pediatric medicine, and utilization of this service should be encouraged after a careful consideration of which patient needs this procedure and a rigorous estimate of its pros and cons.

Utility of flexible fiberoptic bronchoscopy for critically ill pediatric patients: A systematic review

AIM

To investigate the diagnostic yield, therapeutic efficacy, and rate of adverse events related to flexible fiberoptic bronchoscopy (FFB) in critically ill children.

METHODS

We searched PubMed, SCOPUS, OVID, and EMBASE databases through July 2014 for English language publications studying FFB performed in the intensive care unit in children < 18 years old. We identified 666 studies, of which 89 full-text studies were screened for further review. Two reviewers independently determined that 27 of these studies met inclusion criteria and extracted data. We examined the diagnostic yield of FFB among upper and lower airway evaluations, as well as the utility of bronchoalveolar lavage (BAL).

RESULTS

We found that FFB led to a change in medical management in 28.9% (range 21.9%-69.2%) of critically ill children. The diagnostic yield of FFB was 82% (range 45.2%-100%). Infectious organisms were identified in 25.7% (17.6%-75%) of BALs performed, resulting in a change of antimicrobial management in 19.1% (range: 12.2%-75%). FFB successfully re-expanded atelectasis or removed mucus plugs in 60.3% (range: 23.8%-100%) of patients with atelectasis. Adverse events were reported in 12.9% (range: 0.5%-71.4%) of patients. The most common adverse effects of FFB were transient hypotension, hypoxia and/or bradycardia that resolved with minimal intervention, such as oxygen supplementation or removal of the bronchoscope. Serious adverse events were uncommon; 2.1% of adverse events required intervention such as bag-mask ventilation or intubation and atropine for hypoxia and bradycardia, normal saline boluses for hypotension, or lavage and suctioning for hemorrhage.

CONCLUSION

FFB is safe and effective for diagnostic and therapeutic use in critically ill pediatric patients.

Use of flexible bronchoscopy in pediatric patients receiving extracorporeal membrane oxygenation (ECMO) support

INTRODUCTION

Critically ill children treated with extracorporeal membrane oxygenation (ECMO) support frequently have respiratory complications amenable to evaluation by flexible bronchoscopy (FB). The safety and efficacy of FB in this setting has not been well described in children.

METHODS

Retrospective analysis of 153 FBs in 79 children treated with ECMO at a single institution from 2000 to 2008. Demographic data, clinical findings, and complications were obtained. Chest radiographs reports were evaluated prior to and following FB. Physiologic variables were compared prior to and following FB.

RESULTS

Seventy-nine patients underwent FB on ECMO [58 veno-venous (VV) and 21 veno-arterial (VA) ECMO], with 153 total FBs performed. Indications for FB included clearance of tenacious airway secretions (n = 118, 77%), or evaluation of suspected secondary infections with bronchoalveolar lavage (n = 26, 17%). Two patients also had surfactant instillation following secretion removal. FB was performed a median 5 days following cannulation for ECMO (range 2-14 days). Most common findings included thick secretions (n = 77, 50.3%), mucoid secretions (n = 15, 9.8%), and mucopurulent secretions (n = 28, 18.3%). No deterioration in radiographic lung findings was described post-FB. FB was not associated with any significant change in heart rate, systemic blood pressure, or temperature. No significant changes in ECMO pump flow rate or sweep gas flow was seen during or after FB. Cannula dislodgement, inadvertent extubation, fever, pneumothorax, or intraprocedural hypoxemia was not reported. Fifty-three FBs (35%) resulted in blood-tinged secretions from the endotracheal tube post-FB, which resolved spontaneously. Three patients received high frequency oscillatory ventilation (HFOV) following FB in association with mild hemorrhage.

CONCLUSIONS

FB is a well-tolerated and safe procedure in critically ill pediatric patients on ECMO. FB may have a diagnostic as well as therapeutic benefit in such patients.

Flexible bronchoscopy as a valuable diagnostic and therapeutic tool in pediatric intensive care patients: a report on 5 years of experience

OBJECTIVE

To evaluate the clinical role of flexible bronchoscopy (FB) in pediatric and neonatal intensive care units (ICUs).

DESIGN

A retrospective review of all patients receiving FB procedures between January 2005 and December 2009.

SETTING

Pediatric and neonatal ICUs of a tertiary care multi-disciplinary teaching hospital located in northern Taiwan.

PATIENTS

A total of 358 ICU patients (223 males) who received 725 FB procedures.

MEASUREMENTS AND MAIN RESULTS

The medical records were reviewed and analyzed. Mean age for the first time FB was 35.7 (±48.9 SD) months old and 68.2% of them were <3 years old. Among them, unexplained retraction or tachypnea (32.0%) and stridor (20.1%) were the two leading indications for FB. The positive finding rate of FB was 87.2%, with airway malacia (47.8%) being the most common, especially in patients <3 years old. Positive lesion sites were approximately equally distributed between the upper (51.1%) and lower (50.6%) airways. Concomitant findings in the esophagus were found in 15.4% of the patients. There were 518 interventional FBs (71.4%, 518/725 procedures) which were performed on 201 (56.1%, 201/358) patients; FB-aided endotracheal intubation (180/518, 34.7%) and laser therapy (109/518, 21.0%) were the two leading techniques used. No patient suffered from any long-term complications or mortality associated with the FB procedures.

CONCLUSIONS

FB is a safe and valuable diagnostic and therapeutic tool for patients in pediatric and neonatal ICUs.

Flexible bronchoscopy in pediatric intensive care

OBJECTIVE

To define the benefits of a flexible bronchoscopy (FB) service in a Paediatric Intensive Care Unit (PICU).

DESIGN

Review of the first 200 FBs undertaken in a large PICU.

SETTING

Large cardiac and medical PICU in the United Kingdom, also providing extra-corporeal life support.

PATIENTS

129 patients (78 males, 51 females, median age 9.9 months, median weight 4.6 kg) underwent FB from August 1990 to June 2003.

INTERVENTIONS

Broncho-alveolar lavage (BAL) as indicated at time of bronchoscopy.

MEASUREMENTS

Basic patient parameters were identified, including ventilation modes and diagnoses. FB findings were correlated with microbiology results.

MAIN RESULTS

The majority of the FBs were diagnostic (161 of 200). 114 of these were undertaken to exclude underlying airway abnormalities and 47 to aid the diagnosis of pneumonia. Therapeutic procedures including bronchial stenting, directed surfactant instillation and broncho-alveolar toileting were undertaken in 39 cases. 68% of the diagnostic FBs were deemed to be abnormal. 16% had significant extra-luminal airway obstruction. 24% had new findings of airway anomalies. 14.5% of the FBs showed endo-tracheal tube misplacement. Positive microbiological results which altered or confirmed changes in patient management occurred in 46.1% children who had BAL specimens cultured. 80 of the FBs were undertaken whilst the children were receiving extra-corporeal life support. Only one FB procedure was ceased because of patient instability.

CONCLUSION

There is a high yield of positive findings from undertaking FB both anatomically and microbiologically. FB should be seen as a routine diagnostic and therapeutic tool in paediatric intensive care.