Update on pediatric flexible bronchoscopy

Translational research in pediatrics III: bronchoalveolar lavage

The role of flexible bronchoscopy and bronchoalveolar lavage (BAL) for the care of children with airway and pulmonary diseases is well established, with collected BAL fluid most often used clinically for microbiologic pathogen identification and cellular analyses. More recently, powerful analytic research methods have been used to investigate BAL samples to better understand the pathophysiological basis of pediatric respiratory disease. Investigations have focused on the cellular components contained in BAL fluid, such as macrophages, lymphocytes, neutrophils, eosinophils, and mast cells, as well as the noncellular components such as serum molecules, inflammatory proteins, and surfactant. Molecular techniques are frequently used to investigate BAL fluid for the presence of infectious pathologies and for cellular gene expression. Recent advances in proteomics allow identification of multiple protein expression patterns linked to specific respiratory diseases, whereas newer analytic techniques allow for investigations on surfactant quantification and function. These translational research studies on BAL fluid have aided our understanding of pulmonary inflammation and the injury/repair responses in children. We review the ethics and practices for the execution of BAL in children for translational research purposes, with an emphasis on the optimal handling and processing of BAL samples.

Clinical features and management of aspiration of plastic pen caps

OBJECTIVE

To describe the clinical features of pen cap aspiration and removal techniques.

STUDY DESIGN

We retrospectively reviewed all children with a history of inhaling a pen cap who were referred to the ENT department, at Beijing Children's Hospital, between Jan 2006 and Dec 2010. Methods Clinical data was recorded, including patients' common information, physical examination, radiologic data and final outcome.

RESULTS

Data from 44 children, with a median age of 8.7 years of age (35 months to 12 years) and a male-female ratio of 7.8:1 were analyzed. The time between inhalation and diagnosis with extraction of the foreign body ranged from several hours to 6 years, but 75% (33/44) were seen within one week. 89% (39/44) had pen caps removed by rigid bronchoscopy under general anesthesia. Reverse grasping forceps were used in 62% of the cases and ordinary forceps in 38% of the cases (24/15, p<0.05). In 2 cases, the pen caps were coughed up. In 2 cases the FB was removed via a tracheotomy and in 1 case by thoracotomy.

CONCLUSIONS

Pen caps are an unusual foreign body in the airway, occurring frequently in school age children. Rigid bronchoscopy under general anesthesia with reverse grasping forceps was the most favorable method for extraction of pen caps, but open surgical approaches should be available.

What is the diagnostic value of flexible bronchoscopy in the initial investigation of children with suspected foreign body aspiration?

PURPOSE OF THE STUDY

The diagnosis and early bronchoscopic extraction of a foreign body (Fb) in children are life-saving measures. Many studies have described the manifestation of foreign body aspiration (FbA); however, only a few analyzed the role of flexible bronchoscopy in the diagnosis of FbA. The aim of this work is to define the indications of flexible bronchoscopy in the management algorithm of suspected FbA.

SETTING

This study was conducted at a tertiary referral University Medical Center with an outpatient clinic and a 20-bed pediatric emergency unit.

MATERIAL AND METHODS

Between January 2002 and July 2006 children referred with suspected FbA were included in this prospective study. Children with asphyxiating FbA requiring immediate rigid bronchoscopy, were excluded. If there was no convincing evidence of FbA, a diagnostic flexible bronchoscopy was performed under local anesthesia. In the case where a Fb was actually found, extraction was always performed by rigid bronchoscopy.

RESULTS

Seventy cases (median age: 2 years, males: 44/females: 26) were analyzed. Among the 19 children who underwent flexible bronchoscopy first, 7 (37%) had a Fb. Among the 51 who underwent rigid bronchoscopy first, 43 had a Fb and 8 (16%) had a negative first rigid bronchoscopy. Predictive signs of a bronchial Fb were a radiopaque Fb, foreign body aspiration syndrome (FbAS) associated with unilaterally decreased breath sounds or localized wheezing and obstructive emphysema or atelectasis.

CONCLUSION

In case of suspected FbA in children, the following management algorithm is suggested: rigid bronchoscopy should be performed solely in case of asphyxia, finding of a radiopaque Fb, or in the presence FbAS associated with unilaterally decreased breath sounds, localized wheezing and obstructive radiological emphysema, or atelectasis. In all other cases, flexible bronchoscopy should be performed first for diagnostic purposes.

The role of flexible fibreoptic bronchoscopy in evaluation of pulmonary diseases in children with congenital cardiac disease

BACKGROUND

Diseases of the lungs and airways can be life-threatening in patients with congenital cardiac disease. External compression, and tracheobronchomalacia, as well as pathology of the large airways, can cause respiratory symptoms such as wheezing, stridor, fever, and dyspnoea, along with producing difficulty to wean the patient from mechanical ventilation. A definite diagnosis may be achieved by fibreoptic flexible bronchoscopy.

AIMS

To characterize the patients who underwent bronchoscopy for respiratory diseases associated with congenital cardiac disease, and to evaluate the safety, total diagnostic rate, and diagnostic rate, which yielded alteration of treatment in this group of patients.

METHODS

We reviewed retrospectively the records of 39 patients with congenital cardiac disease associated with abnormalities of the airways who underwent 49 fibreoptic bronchoscopies between 1999 and 2004. The patients were evaluated with regard to rate of diagnosis, the rate of procedures that resulted in alteration of management, and the rate of complications.

RESULTS

Fibreoptic flexible bronchoscopy was safe, and contributed to a specific diagnosis in almost nine-tenths of the procedures. A specific diagnosis that resulted in treatment alteration was achieved in one-fifth of the procedures.

CONCLUSIONS

Fibreoptic flexible bronchoscopy has an important role in the evaluation of pulmonary abnormalities in patients with congenital cardiac diseases, and should be considered as an initial diagnostic tool that may guide the clinician with regard to the proper therapy.

Investigative bronchoprovocation and bronchoscopy in airway diseases

RATIONALE

Basic and clinical research strategies used for many lung diseases have depended on volunteer subjects undergoing bronchoscopy to establish access to the airways to collect biological specimens and tissue, perhaps with added bronchoprovocation in asthma syndromes. These procedures have yielded a wealth of important scientific information. Since the last critical review more than a decade ago, some of the techniques and applications have changed, and untoward events have occurred, raising safety concerns and increasing institutional review scrutiny.

OBJECTIVES AND METHODS

To reappraise these investigational methods in the context of current knowledge, the National Heart, Lung, and Blood Institute and the National Institute of Allergy and Infectious Diseases of the National Institutes of Health convened a working group to review these procedures used for airway disease research, emphasizing asthma and chronic obstructive pulmonary disease.

MAIN RESULTS

The group reaffirmed the scientific importance of investigative bronchoscopy and bronchoprovocation, even as less invasive technologies evolve. The group also considered the safety of bronchoscopy and bronchoprovocation with methacholine and antigen to be acceptable for volunteer subjects and patients, but stressed the need to monitor this closely and to emphasize proper training of participating medical research personnel. Issues were raised about vulnerable volunteers, especially children who need surrogates for informed consent.

CONCLUSION

This review of investigative bronchoscopy and bronchoprovocation could serve as the basis for future guidelines for the use of these procedures in the United States.

Successful bronchoscopic retrieval of Timothy grass from the airway

Aspiration of Timothy grass in the airway is a well-recognized cause of bronchiectasis, and management often requires pulmonary resection. The authors describe 2 cases of Timothy grass aspiration with established pulmonary infection that were successfully managed by bronchoscopic removal with subsequent improvement. Every effort should be made to accomplish this goal, and pulmonary resection should be considered a last resort in these cases.

Airway anomalies in children with Down syndrome: endoscopic findings

Down syndrome (DS) is the most common chromosomal anomaly in humans. Numerous congenital malformations associated with DS have been described. However, there are insufficient data available about airway anomalies. Our objective was to characterize the clinical presentation, frequency, and type of airway anomalies in a population of patients with DS. A retrospective evaluation of flexible bronchoscopies performed in 24 DS patients due to significant respiratory morbidity was compared to the findings in 324 non-DS patients during the same time period. The procedure was carried out under sedation, using an Olympus BF3C20 bronchoscope. The main indications for the procedure were atelectasis of the right upper lobe (12/24) and stridor (7/24). The most common associated conditions were congenital heart disease (12/24) and reactive airways disease (12/24). The most important endoscopic findings were: laryngomalacia (12/24), tracheomalacia (8/24), tracheal bronchus (5/24), and bronchomalacia (5/24). Only six patients had a normal examination. Multiple airway anomalies (>/=2) were a common finding in this series. We conclude that patients with DS and respiratory symptoms have a high incidence of airway anomalies compared to non-DS patients. The clinician should have a high index of suspicion for airway anomalies in DS patients with respiratory symptoms.

Fibrobroncoscopia en el niño con ventilación mecánica

Fiberoptic bronchoscopy can be performed at the patient's bedside. This technique allows direct visualization of the upper and lower airways up to the segmental and subsegmental bronchi. Its most frequent indications are airway examination ot evaluate damage produced by toxins or the endotracheal tube, patency of the endotracheal tube and extubation failure. It is also used to obtain microbiological samples, facilitate intubation when difficult, aspirate airway sections or mucus plugs, perform bronchoalveolar lavage and administer drugs. With prior preparation, adequate monitoring and sedation, material according to the size of the patient and correct techniques, there are few complications. However, the procedure can produce trauma and obstruction of the airway, bronchial hemorrhage, barotrauma, loss of alveolar recruitment, bronchospasm, hypoxemia, bradycardia, and bronchopulmonary infection.

Airway obstruction in children with congenital heart disease: assessment by flexible bronchoscopy

We assessed the spectrum of airway disorders in children with congenital cardiac anomalies, and reviewed our experience in using flexible bronchoscopy for assessment of airway problems in this patient group. The clinical records, flexible bronchoscopic findings, and cardiac imaging results of pediatric cardiac patients who presented with either clinical or radiological signs of airway obstruction between 1992-1999 were reviewed. Flexible bronchoscopic assessment was performed with the patients under sedation and topical anesthesia, using one of two bronchoscopes, i.e., an Olympus BFN20 or Olympus BF3C20. Of a total of 52 patients, 33 had acyanotic cardiovascular lesions, the commonest being left-to-right shunts (61%), while 19 had cyanotic heart lesions, with right ventricular outflow obstruction being the commonest (63%). Twenty-seven patients had undergone either surgical or transcatheter interventions. The median age at bronchoscopic assessment was 6 months (range, 4 days to 6 years). None of the patients developed significant procedural complications. A definitive diagnosis was made in 48 (92%) patients, 8 of whom had abnormalities involving only the upper airways, 35 only the lower airways, and 5 both. Abnormalities of the upper airway included laryngomalacia (n = 6), subglottic stenosis (n = 3), pharyngeal collapse (n = 2), and 1 each of choanal stenosis and supraglottitis. Extrinsic compression was the commonest lower airway abnormality that was found in 27/40 patients (67%), with a predilection for the left main bronchus (18/27, 67%). The structures that caused extrinsic compression included dilated pulmonary arteries with or without left atrial dilation (n = 20), an anomalous aortic or pulmonary arterial course (n = 3), a dilated aorta (n = 1), and a shunt (n = 1), but were not obvious in 2 patients. Intrinsic lower airway abnormalities included bronchomalacia (n = 4), tracheal stenosis (n = 4), and one each of variant bronchial bifurcation and a pouch arising from the tracheal wall. Intraluminal mucus plugging of the lower airways occurred in the remaining 3 patients. Children with congenital heart disease are at risk of airway obstruction both before and after surgery. Flexible bronchoscopy, being safe and effective in diagnosing airway disorders in this patient group, should be considered as the first line of investigation.

Tracheobronchography and angiocardiography of paediatric cardiac patients with airway disorders

OBJECTIVE

We report our experience in combining tracheobronchography and angiocardiography in the assessment of a selected cohort of paediatric cardiac patients with problematic airway disorders.

METHODOLOGY

The clinical records of 11 patients who underwent 17 studies at a median age of 5.5 months (range 3 months to 10.8 years) were reviewed. Tracheobronchography and angiocardiography were performed under general anaesthesia using a non-ionic contrast agent. The findings were compared with those of flexible bronchoscopy and magnetic resonance imaging (MRI).

RESULTS

Seven patients had cardiac lesions associated with vascular anomalies potentially compressing the airway, while four had no identifiable aberrant or enlarged vessels. All examinations but one were performed without complications. Tracheobronchography demonstrated extrinsic vascular compression with secondary airway malacia in three (27%), intrinsic tracheobronchial stenosis in five (45%), and airway malacia in three patients (27%). Precise measurement of the airway calibre and real-time fluoroscopic monitoring facilitated transcatheter tracheobronchial interventions (six balloon dilations, three stent implantations) in four patients. In conjunction with angiocardiography, cine-tracheobronchography provided detailed information on the spatial relationship between vascular and airway structures in all patients; allowed dynamic assessment of airway malacia; and facilitated preoperative planning in six patients. In contrast, bronchoscopy failed to differentiate malacia from extrinsic compression in four patients (36%), while MRI, performed in six patients, was unsatisfactory in one due to a motion artefact and failed to diagnose airway malacia and extrinsic compression in three patients.

CONCLUSIONS

Tracheobronchography is relatively safe in paediatric cardiac patients. Combined tracheobronchography and angiocardiography, a less operator-dependent imaging modality compared to bronchoscopy and MRI, delineated the airway and vascular anatomy in detail; facilitated preoperative planning; and permitted transcatheter tracheo-bronchial interventions. The dynamic capability of tracheobronchography supplements that of flexible bronchoscopy and MRI in the diagnosis of airway malacia.

Pediatric bronchoscopy

Diagnostic flexible endoscopy for pediatric respiratory diseases is performed in many centers. Technical advances have resulted in performance of interventional bronchoscopies, and new diagnostic indications are being explored. Indications with documented clinical benefit include congenital or acquired progressive or unexplained airway obstruction. Pulmonary infections in immunodeficient children who do not respond to empirical antibiotic treatment may be diagnosed by bronchoscopy and bronchoalveolar lavage (BAL). The potential usefulness of bronchoscopy and BAL for managing chronic cough, wheeze, or selected cases with asthma or cystic fibrosis requires further study. The use of transbronchial biopsies (TBB) is established in pediatric lung transplantation. The role of TBB in the diagnosis of chronic interstitial lung disease in children remains to be determined. For a number of interventional applications, rigid endoscopy is required, and pediatric bronchoscopists should be trained in its use. Complications in pediatric bronchoscopy are rare, but severe nosocomial infection or overdosing with local anesthetics has occurred. The issues of quality control, video documentation, interobserver variability of findings, and educational standards will have to be addressed in the future as bronchoscopy use becomes less restricted to only large pediatric pulmonary units.

Ultrastructural examination of bronchial biopsy specimens from children with moderate asthma

BACKGROUND

Few studies have evaluated the asthmatic airway in childhood. The aim of this study was to assess the histopathological changes occurring in the bronchi of children with moderate asthma using light and electron microscopy.

METHODS

Bronchial biopsy specimens from 10 children with moderate asthma (seven boys) of mean (SD) age 9.3 (3.8) years (range 5-14) were examined by light and electron microscopy. Patients had not had a respiratory infection for at least one month and they had not been treated with steroids or sodium cromoglycate for four weeks before the study. Bronchoscopy was performed under general anaesthesia using a Karl Storz rigid paediatric bronchoscope. Biopsy materials were stained with uracyl acetate and lead citrate and evaluated under a Zeiss-10 electron microscope and light microscope.

RESULTS

The most important finding was thickening and hyalinization of the basement membrane in nine patients. The ciliated epithelial cells showed loss of cilia in some cases. Overactive fibroblasts were consistently found. Six patients had degranulating mast cells and lymphocyte infiltration in the submucosa. Eosinophils were seen in only one biopsy sample.

CONCLUSION

Children with moderate asthma develop bronchial inflammation similar to the reaction observed in adults. However, in our study the inflammation was rich in lymphocytes rather than eosinophils.

Bronchoalveolar lavage

Bronchoalveolar lavage is a technique for sampling the epithelial lining fluid of the respiratory tract. Analysis of cellular and non-cellular components of returned fluid has the potential to provide valuable information about airways inflammation. Because of the invasive nature of the investigation, there are few conditions for which repeat sampling can be justified. Bronchoalveolar lavage has been used to study immune mechanisms in cystic fibrosis, interstitial lung diseases and asthma. This article reviews the usefulness of BAL assessments for lung inflammation in paediatric practice.

[Role of endoscopy in the diagnosis of respiratory distress]

In acute respiratory distress, bronchial endoscopy is useful to determine the nature of dyspnea: inspiratory dyspnea in laryngeal abnormalities and obstructions; mixed inspiratory and expiratory dyspnea in extrinsic and intrinsic compressions of the tracheobronchial tree; overall, foreign bodies. Moreover, it allows the evaluation of the lesions in bronchial contusions, tracheobronchial burns and hemoptysis. Flexible (fiberoptic) and rigid endoscopy are complementary methods. Bronchoalveolar lavage is useful in the microbiological investigation of pneumonias developing in immuno compromised children.

[Tracheobronchial foreign bodies]

Forty cases of children with an inhaled foreign body (FB) are reviewed over a three-year period. Clinical data, radiologic findings and complications are detailed. The nature and size of FBs are also reported. Diagnosis and management are discussed according to the most recent studies in the literature. Diagnostic flexible bronchoscopy is a useful first step when the diagnosis is unclear (i.e., choking history, unexplained respiratory symptoms), but FB removal is usually not possible during this procedure. Extraction is performed via the rigid bronchoscope under general anesthesia. However, FB could be removed with the flexible bronchoscope in five children in our study. Diagnosis and removal of an inhaled FB are required as quickly as possible in order to prevent respiratory sequelae (bronchiectasis). Prevention is based upon information to be given to families, but to the medical community as well, which often minimizes the seriousness of inhalation hazards.

Topical lidocaine exaggerates laryngomalacia during flexible bronchoscopy

In 156 infants and children referred for flexible fiberoptic bronchoscopy (FFB) we examined the larynx before and after application of 2% lidocaine solution to see what effect topical anesthesia might have on laryngeal function. All patients received midazolam and nalbuphine intravenously. Using blinded, randomly re-recorded key segments of the original video recordings of bronchoscopy, we used an empirical scoring system (Table 2) to grade signs of laryngomalacia on a scale of 0 to 8 points before and after application of the lidocaine solution. This score was based on the magnitude of collapse of the arytenoids and folding of the epiglottis during inspiration. Topical lidocaine was more likely to result in an increase in signs of laryngomalacia than in a decrease in such signs (p < 0.0001). Younger patients were more likely to have signs of laryngomalacia before topical anesthesia (odds ratio, 1.83). In a group of 10 additional patients, selected for history and physical findings consistent with laryngomalacia, application of a normal saline solution had no effect on the laryngomalacia score, but application of 2% lidocaine solution to the larynx resulted in a significant increase in this score (p < 0.001). Thus, this study has clearly demonstrated that topical anesthesia in infants and children undergoing FFB exaggerates the findings commonly associated with laryngomalacia. Because overestimation of these findings might lead to unnecessary treatment, it is important to examine the larynx and contiguous structures before applying topical anesthesia.

Pediatric flexible bronchoscopy under conscious sedation: nursing considerations for preparation and monitoring

Flexible bronchoscopy provides a powerful tool to evaluate pulmonary abnormalities in the pediatric population. Nursing involvement may range from age-appropriate preparation of the patient and family to administration of conscious sedation agents. Meticulous nursing assessment of the child, family, and environment facilitates identifying and meeting client needs related to flexible bronchoscopy. Preparation of the physical environment as well as physiological and psychological preparation of the child increase the likelihood of a positive experience. By increasing their familiarity with the procedure, sedation strategies, and monitoring standards, nurses increase the probability of safe and successful flexible bronchoscopic evaluations.

Fatal pneumococcal sepsis following flexible bronchoscopy in an immunocompromised infant

A 5-month-old boy who suffered from a leukocyte chemotactic defect underwent flexible bronchoscopy for persistent right upper lobe atelectasis and tachypnea. Ten hours after the procedure he developed fulminant sepsis, and he died 16 hrs after bronchoscopy. Streptococcus pneumoniae (serotype 23) grew from the bronchoalveolar lavage fluid and from the blood culture taken during the sepsis work-up. We, therefore, suggest administering prophylactic antimicrobial therapy immediately following bronchoscopy to immunosuppressed children, even when an acute respiratory infection is not suspected, in order to prevent bacteremia and sepsis.

The diagnostic value of bronchoalveolar lavage in immunocompetent children with chronic diffuse pulmonary infiltrates

We have investigated the diagnostic value of (BAL) in 29 immunocompetent children (ages 1 month to 18 years) with chronic diffuse pulmonary infiltrates on chest radiograph who presented for evaluation over a 3-year period. The median age at the time of the BAL was 20 months with a range of 1-210 months. Positive results (1) diagnostic of a primary disorder; (2) consistent with a diagnosis; or (3) diagnostic of a secondary disorder, were obtained in 20/29 patients (13 with a single positive BAL finding and 7 with more than one finding). BAL was diagnostic of a primary disorder in only 5 patients (17%) with aspiration detected in 3 and infection in 2. The differential diagnosis was narrowed in 15 patients by the presence of lymphocytosis, neutrophilia, or eosinophilia. A secondary disorder was uncovered in 8 patients. Negative results were obtained in 9 additional patients. We conclude that BAL provided useful information in children with chronic diffuse infiltrates, but its ability to determine the primary cause was limited.

The airway endoscopy mask: useful device for fibreoptic evaluation and intubation of the paediatric airway

A mask is presented which allows the administration of 100% oxygen, inhalational anaesthetics, continuous positive airway pressure and intermittent positive pressure ventilation during diagnostic airway endoscopy and difficult intubation with a fibreoptic bronchoscope in paediatric patients. The mask is particularly useful in small or critically ill patients. It may also have its place in teaching situations.