The emerging role of flexible bronchoscopy in pediatrics

Advanced Diagnostic and Therapeutic Bronchoscopy in Pediatrics

Advanced diagnostic and therapeutic flexible bronchoscopy in children is a rapidly evolving field. Recent advances in technology and awareness of indications, risks, and benefits by pediatric providers have greatly increased the use of advanced techniques in children. This review highlights advanced diagnostic procedures including assessment of endobronchial lesions, mediastinal/hilar masses, and peripheral lung nodules as well as therapeutic techniques for restoring airway lumen patency, managing persistent air leaks, and treating tracheoesophageal fistulas in children as well as the potential to spare these patients more invasive procedures.

Flexible bronchoscopy in pediatric lung transplantation

Pediatric lung transplantation represents a treatment option for children with advanced lung disease or pulmonary vascular disorders who are deemed an appropriate candidate. Pediatric flexible bronchoscopy is an important and evolving field that is highly relevant in the pediatric lung transplant population. It is thus important to advance our knowledge to better understand how care for children after lung transplant can be maximally optimized using pediatric bronchoscopy. Our goals are to continually improve procedural skills when performing bronchoscopy and to decrease the complication rate while acquiring adequate samples for diagnostic evaluation. Attainment of these goals is critical since allograft assessment by bronchoscopic biopsy is required for histological diagnosis of acute cellular rejection and is an important contributor to establishing chronic lung allograft dysfunction, a common complication after lung transplant. Flexible bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsy plays a key role in lung transplant graft assessment. In this article, we discuss the application of bronchoscopy in pediatric lung transplant evaluation including historical approaches, our experience, and future directions not only in bronchoscopy but also in the evolving pediatric lung transplantation field. Pediatric flexible bronchoscopy has become a vital modality for diagnosing lung transplant complications in children as well as assessing therapeutic responses. Herein, we review the value of flexible bronchoscopy in the management of children after lung transplant and discuss the application of novel techniques to improve care for this complex pediatric patient population and we provide a brief update about new diagnostic techniques applied in the growing lung transplantation field.

Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases

Objective

In children, pulmonary and cardiac diseases are closely associated, and their integrated evaluation is important. Flexible fiber-optic bronchoscopy (FFB) can be used for both diagnostic and therapeutic purposes in pediatric cardiac intensive care units (PCICU). The objective of this study was to evaluate the utility of FFB in children with congenital heart disease (CHD).

Materials and methods

A retrospective, descriptive study was conducted at a tertiary care center in pediatric patients who underwent FFB in PCICU over a period of 6 years (2012-2017).

Results

Total 71 bronchoscopies were done in 58 patients with CHD with median age and weight of 2.5 months and 3.4 kg, respectively. Total of 20 different cardiac lesions were present among patients who underwent FFB. While 38 (53.5%) and 30 (42.3%) procedures were performed in pre-op and postoperative patients, respectively, 3 intraoperative bronchoscopies were also performed. The main indications for FFB were persistent atelectasis (42/71), prolonged oxygen requirement (13/71), stridor (8/71), and suspected airway anomaly (6/71). Tracheobronchitis was the commonest bronchoscopy finding (51/71, 71.8%) followed by tracheobronchomalacia (27/71, 38.3%). Cause of stridor detected in 7/8 cases. Associated preoperative and postoperative respiratory complications were detected and necessary interventions were done. These included slide tracheoplasty (5/58), tracheostomy (5/58), antibiotic change based on bronchoalveolar lavage (BAL) cultures (11/71), and continued positive pressure ventilation (4/71). Nonconsequential complications were transient hypoxemia (10/71), bleeding (2/71), and transient bradycardia (1/71).

Conclusion

Bedside FFB is a safe and a valuable diagnostic tool that also helps in guiding interventions in children with cardiac diseases.

How to cite this article

Sachdev A, Chhawchharia R, Gupta D, Gupta N, Joshi R, Agarwal N. Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases. Indian J Crit Care Med 2020;24(5):340-343.

The Significance of Bronchoalveolar Lavage Fluid Cytology in Diagnosing Lung Infiltrates in Children

AIM

The aim of this research is to show why is it important in diagnosing children with lung infiltrates.

METHODS

Our study included 50 children with lung infiltrates during period 2005-2012, and was conducted on Pediatric Clinic of the University Clinical Center Sarajevo. We sent all cytological BAL analyses to the University Clinical Center Sarajevo. Cytology was performed by direct microscopy. BAL cytology was performed by the principle of sending samples for centrifuging, 12000 revolutions during a 10 min Shandon-cyto spin. Then the centrifuged sample is dried in the air during 1-2 hours, and is then dyed under the May-Grünwald-Giemsa staining, and analyzed under the Olympus BX41 microscope.

RESULTS

Nosocomial pneumonia has occurred in 32% children, acquired pneumonia in 38%, and 30% children had a lung infiltrates. 6 (12%) of children were younger then 1 year old, 23 (46%) children were between 1 to 5 years, 14 (28%) of children were between 5 to 10 ages, and 7 (14%) of children were between 10-15 ages. The most of the changes in observed children took place on the right lung, 34%, while 26% occurred on the left side, 22% were normal and 18% changes have affected both lungs, right and left. Percentage of cells in cytological smear in children with BAL were: cylindrical cells 28%, lung macrophage 26%, lymphocytes 17%, detritus 17% and phlegm 12%. Erythrocyte sedimentation rate (ESR) in children with BAL was up to 10-52%, to 50-30%, while ESR after first hour was above 50-18 %.

CONCLUSION

Clinical parameters and local inflammation of the affected lobe are associated with positive bronchoalveolar cytology lavage findings.

Cardiovascular-associated tracheobronchial obstruction in children

Tracheobronchial compression of cardiovascular origin is an uncommon and frequently unrecognised cause of respiratory distress in children. The compression may be due to encircling vessels or dilated neighbouring cardiovascular structures. Bronchoscopy and detailed radiography, especially computed tomography and magnetic resonance imaging, are among the most powerful diagnostic tools. Few previous reports have addressed the relationship between bronchoscopic findings and underlying cardiovascular anomalies. The objective of this study was to correlate bronchoscopic and radiographic findings in children with cardiovascular-associated airway obstruction. A total of 41 patients were recruited for the study. Patients with airway obstruction were stratified on the basis of the aetiology of the cardiovascular structures and haemodynamics into an anatomy-associated group and a haemodynamics-associated group. In the anatomy-associated group, stenosis and malacia were found with comparable frequency on bronchoscopy, and the airway obstructions were mostly found in the trachea (71% of patients). In the haemodynamics-associated group, malacia was the most common bronchoscopic finding (85% of patients), and nearly all locations of airway involvement were in the airway below the carina (90% of patients). The tracheal compression was usually caused by aberrant systemic branching arteries in the anatomy-associated group. In the haemodynamics-associated group, the causal relationships varied. Tracheal compression was often caused by lesions of the main pulmonary artery and aorta, whereas obstruction of the right main bronchus was caused by lesions of the main pulmonary artery and right pulmonary artery. The causes of left main bronchus compression were more diverse. In summary, the bronchoscopic presentations and locations are quite different between these two groups.

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 for diagnosis and follow up of childhood endobronchial tuberculosis

BACKGROUND

In this study, our aim was to determine the clinical and bronchoscopic outcome of the endobronchial tuberculosis (ETB).

METHODS

Patients with suspected tuberculosis (TB) or TB patients with an inadequate response to 8 weeks of antituberculosis treatment were enrolled in the study.

RESULTS

Seventy patients were included to the study and 118 flexible bronchoscopies were performed. ETB was present in 33 (47%) patients. There was isolated compression in 14 cases, caseous lesions in 13, granuloma formation in 6, polypoid lesions in 2, adenopathy protrusion in 1, and mucosal erosion in 1 case. The mean duration of bronchoscopic resolution of endobronchial lesions was 5.50 +/- 2.74 months. Mycobacterium tuberculosis was isolated from gastric lavage in 10% and from bronchoalveolar lavage in 12.8% of 70 cases. When both of the procedures were performed concurrently, the isolation rate increased to 20%. Transient hypoxia resolving with nasal O2 was observed in 3 patients as a complication of bronchoscopy.

CONCLUSIONS

Bronchoscopy offered a safe and rapid means of confirming the diagnosis of ETB.

Flexible fiberoptic bronchoscopy in children with heart diseases: a twelve years experience

In children, cardiac diseases and respiratory disorders are tightly linked entities whose evaluation should be performed integrally. Flexible fiberoptic bronchoscopy (FB) presents a diagnostic and therapeutic role by assessing the airway anatomically, dynamically, and through the performance of several procedures. The present study describes our experience on FB assessment in children with congenital and acquired cardiac diseases, providing a characterization of the principal demographic and clinical features. Records of 72 patients under 14 years (mean age 21 months) with heart diseases, corresponding to 104 FB performed between January 1993 and October 2004 were reviewed. The principal cardiac diseases were left-to-right shunt (51.9%), followed by right-to-left shunt (17.3%) and miscellaneous cardiopathies (8.7%). The main indications for FB assessment were study of atelectasis (35%), stridor (14%), and pneumonia (14%). Airway malacias, as a group, were the commonest finding, represented mainly by left main bronchus malacia (24%). The second most common finding was stenosis by extrinsic compression, and among these, 75% corresponded to left main bronchus compression. Sixteen different types of clinically meaningful utilities were obtained. No mortality was reported and in only one procedure was there a major complication, which was easily managed. We concluded that FB is an important and safe diagnostic-therapeutic tool in the health care of neonates, infants, and children with a variety of cardiac diseases.

Retrospective evaluation of a paediatric intensivist-led flexible bronchoscopy service

OBJECTIVE

To demonstrate the diagnostic yield, therapeutic role and safety of flexible bronchoscopy via an intensivist-led service in critically ill children.

DESIGN

Retrospective chart review.

SETTING

Regional paediatric intensive care unit.

MEASUREMENTS AND RESULTS

One hundred forty-eight flexible bronchoscopies were performed by two intensivists on 134 patients (median age 16.5 months) over a 2.5-year period. Eighty-eight percent of patients required mechanical ventilation, and 22% were receiving inotropes. Case mix included general (n = 77), cardiac surgery (n = 18), cardiology (n = 13), ear-nose-and-throat surgery (n = 17), oncology (n = 8) and renal (n = 1). The indication for bronchoscopy was defined a priori according to one of four categories: suspected upper airway disease (n = 32); lower airway disease (n = 70); investigation of pulmonary disease (n = 25); and extubation failure (n = 21). Bronchoscopy was generally performed soon after PICU admission, at a median time of 1.5 days for the former three categories, and 4 days for extubation failure group. A positive yield from bronchoscopy (diagnosis that explained the clinical condition or influenced patient management) was present in 113 of 148 (76%) procedures, varying within groups from 44% (pulmonary disease) to 90% (extubation failure). Ten percent of patients developed a fall in oxygen saturations > 20% during the procedure and 17% required a bolus of at least 10 ml/kg of 0.9% saline for hypotension.

CONCLUSIONS

Critically ill patients with respiratory problems may benefit from a PICU-led bronchoscopy service as the yield for positive bronchoscopic finding is high, particularly for upper airway problems or extubation failure.

Broncoscopia flexible en el niño: indicaciones y aspectos generales

There is considerable interhospital variability in the practice of flexible bronchoscopy in children. The present report aims to provide some recommendations that are supported by the Spanish Society of Pediatric Pulmonologists. We review the indications, contraindications, equipment, setting and personnel involved in flexible bronchoscopy, as well as the pre-procedure preparation of the patient, medications, post-procedure monitoring, complications, care and maintenance of instruments, and informed consent. These recommendations may be adopted, modified or rejected according to clinical needs and constraints.

Should bronchoscopy be performed in the evaluation of suspected pediatric pulmonary tuberculosis?

BACKGROUND

Pulmonary tuberculosis (PTB) infection in children is difficult to diagnose.

OBJECTIVE

To evaluate the effectiveness of fiberoptic bronchoscopy in the diagnosis of PTB.

METHODS

Four hundred twenty-two children underwent bronchoscopic evaluation. The study population was composed of 80 children (study group) who were suspected of having PTB and 342 children with chronic cough or recurrent/persistent pneumonia (control group). Videotape reviews of each bronchoscopy were correlated with the results of smears and cultures.

RESULTS

The majority of children in the study group (54 of 80 children) were new immigrants from Ethiopia, while most of the control group (323 of 342 children) were born in Israel. Among patients in the control group, physical anomalies such as laryngotracheomalacia were more common among children in the control group (105 of 342 children) compared with those in the study group (5 of 80 children; p < 0.03). In the study group, external compression of the right main bronchus, usually at the entrance, was more common (32 of 80 children) compared with the control group (6 of 342 children; p < 0.001). Cultures from BAL fluid revealed Mycobacterium tuberculosis in 3 of the 80 children from the study group compared with 2 children from the control group (p < 0.08). The children with positive cultures from the control group had external compression of the right main bronchus that had been documented by bronchoscopy.

CONCLUSION

Bronchoscopy in children with suspected PTB has a low yield and does not significantly aid bacteriologic confirmation. External compression at the entrance to the right main bronchus is suggestive of PTB infection.