Sedation for pediatric bronchoscopy

Safety and efficacy of ketamine sedation for infant flexible fiberoptic bronchoscopy

OBJECTIVE

To describe our experience with ketamine sedation during infant flexible fiberoptic bronchoscopy.

DESIGN

Retrospective chart review. Infants were sedated with midazolam and ketamine with or without fentanyl. The sedation regimen, final procedure performed, procedure duration, and complications were recorded. Complication rates between infants <or= 6 months or > 6 months of age and between infants with upper vs lower airway symptoms were compared by chi(2) test with a contingency table.

RESULTS

Fifty-nine procedures were performed in 55 patients aged 6.1 +/- 3.1 months (mean +/- SD). Sedation was achieved with ketamine and midazolam (n = 30) or ketamine, midazolam, and fentanyl (n = 29). Bronchoscopy with BAL was performed in 44 patients and bronchoscopy alone in 3 patients. In 11 patients, severe upper airway obstruction and/or anomalies prevented subglottic passage of the bronchoscope. One patient could not be adequately sedated. There were no major complications. Minor complications occurred in 14 patients (23.7%), most commonly mild hypoxemia (n = 9). Brief central apnea developed in three patients. Complication rates were unaffected by age or indication for bronchoscopy.

CONCLUSIONS

Infant flexible fiberoptic bronchoscopy can be safely and effectively performed using ketamine sedation. Complications, especially mild hypoxemia, appear more common in infants, likely due to smaller airway diameter. Regardless of the sedative(s) used, additional vigilance is required when performing bronchoscopy in this population.

Use of Nasopharyngoscopy in the Evaluation of Children With Noisy Breathing

STUDY OBJECTIVE

To evaluate the practice of using nasopharyngoscopy without routine fiberoptic bronchoscopy for children presenting to a pediatric pulmonary practice with nonspecific noisy breathing.

DESIGN

Retrospective chart review. Records of patients who underwent nasopharyngoscopy between January 1, 1990, and December 31, 1999, were reviewed. Follow-up was obtained by office records and direct contact with the patient's family and/or primary care physician.

SETTING

Academic, tertiary care facility.

RESULTS

Eighty-one children who underwent upper airway endoscopy to evaluate noisy breathing consistent with extrathoracic lesions were identified. One child had two evaluations separated by years for differing complaints, making a total of 82 procedures. Stridor was the chief complaint in three fourths of the children. Half of the children with stridor were found to have laryngomalacia. Long-term follow-up was available for 75 of 81 children, with median follow-up of 6 years (range, 1 to 13 years). No medical problems related to missed airway lesions developed in any infants initially evaluated using nasopharyngoscopy.

CONCLUSIONS

Nasopharyngoscopy without lower airway endoscopy can be used safely for the initial evaluation of noisy breathing in infants and children provided excellent follow-up is available.

The safety and quality of endobronchial biopsy in children under five years old

BACKGROUND

Little is known about the airway pathology of wheezing disorders in infants and preschool children, partly owing to the difficulty of undertaking invasive studies in this age group. The safety of endobronchial biopsy and the quality of biopsies obtained were reviewed in infants and preschool children.

METHODS

Case notes of children under five years of age who underwent bronchoscopy and endobronchial biopsy were reviewed. The safety of the procedure was compared in a control group matched for weight and age, undergoing bronchoscopy without endobronchial biopsy. A consultant histopathologist assessed biopsy quality.

RESULTS

33 patients (mean age 31 months, range 4 to 59) underwent bronchoscopy and endobronchial biopsy, and were matched with 33 controls (mean age 28 months, range 3 to 52). There was no significant difference between groups in the number, type, or severity of complications occurring during or after the procedure. Biopsies from 30 of the 33 subjects could be assessed. Reticular basement membrane was identified in all 30; inflammation could be assessed in 26; areas of smooth muscle were present in 23.

CONCLUSIONS

In a group of preschool children undergoing bronchoscopy under general anaesthetic, performance of endobronchial biopsy carried no extra risk. The quality of biopsies obtained was usually sufficient to allow an assessment of remodelling and inflammation.

[Factors associated with complications caused by bronchoscopy in pediatric patients]

BACKGROUND

Although the role of flexible bronchoscopy as an important diagnostic and therapeutic tool in pediatric medicine has been demonstrated, the procedure can cause complications which should be foreseen by the bronchoscopist. However, no precise information is available about the factors associated with the presence of such complications.

OBJECTIVE

To determine the incidence of complications caused by bronchoscopy in pediatric patients and the factors associated with their presence.

MATERIAL AND METHOD

This was a retrospective cohort study which reviewed the records of patients aged between 1 month and 18 years who had undergone bronchoscopy between January 1 and December 31, 2002. The presence or absence of several variables considered predictive of postbronchoscopy complications was recorded in each patient.

RESULTS

After adjustment for the method used to access the airway, age less than or equal to 3 months was the only independent factor associated with the presence of complications (odds ratio = 8.19; 95% confidence interval, 1.61-41.55; P=.01).

CONCLUSIONS

We conclude that patients 3 months old or younger are at greater risk of presenting complications after bronchoscopies performed under general anesthesia. Consequently a risk-benefit analysis should be carried out for patients in this age group, and the possibility of performing the procedure under sedation should be considered.

Bronchoscopy in paediatric intensive care

Bronchoscopy is a highly versatile technique in the context of intensive care and has many potentially valuable indications. Safety is of paramount importance and the risks in critically unstable patients are correspondingly greater than in more stable children. The main contraindication to bronchoscopy is if it will provide no useful information. The procedure is obviously more risky in children with severe hypoxia, uncontrolled bleeding diathesis, cardiac failure or severe pulmonary hypertension. Monitoring should include at least oxygen saturation, blood pressure (ideally by continuous, invasive monitoring) and preferably capnography. Indications for bronchoscopy in paediatric intensive care include endobronchial toilet, sometimes instilling recombinant human DNAase even in children who do not have cystic fibrosis; checking tube patency and position; assisting in a difficult intubation or tube change; achieving the selective intubation of a main bronchus; the diagnosis and management of ventilator-associated pneumonia or the ventilated, immunocompromised host; the assessment of lobar collapse or focal hyperinflation; airway stent assessment; assessment of stridor on extubation and the diagnosis of any associated disease. New iatrogenic complications are also likely to be discovered. The procedure is very safe if performed by experienced operators with back-up from doctors skilled in airway management and the monitoring of sick children.

Anesthesia for tracheal and endobronchial interventions

Tracheal and endobronchial interventions constitute a wide variety of procedures offering unique challenges in perioperative airway management and ventilatory support. Elective or emergent anesthetic management is individualized according to underlying airway pathology, coexisting disease, and patient age. This review explores recent literature and reports on relevant advances in anesthetic care.

Anesthesia for diagnostic procedures

Anesthetists and other providers are seeing an increased demand for sedation or anesthesia for challenging patients undergoing diagnostic procedures. Regardless of the specialty of the provider, proper attention must be paid to patient evaluation, monitoring, and drug dosage. The present review summarizes recommendations regarding sedation, as well as recent literature on sedation and anesthesia for endoscopy, radiology, pediatric oncology procedures, and pediatric electroencephalography.