Flexible fiberoptic endoscopy for airway problems in a pediatric intensive care unit

A Quantitative Analysis of Smartphone-Based Endoscopy and Video Tower Endoscopy

OBJECTIVES

Examine the differences between traditional tower-based endoscopy (TBE) and smartphone-based endoscopy (SBE) using objective measures of cost, setup time, and image quality.

METHODS

Cost analysis study and randomized single-blinded prospective trial was performed at a tertiary academic health center. Twenty-three healthcare providers, 2 PA-C, 9 residents, 2 fellows, 10 attendings varying in practice from 1 to 27 years were a part of the study. Actual cost analysis was used for purchase of the Karl Storz video tower system and the Save My Scope smartphone-based endoscopy system for cost analysis. For setup time, providers entered a room and were randomized to set up either an SBE or TBE system and timed from room entry to a visible on-screen image. A crossover was then performed so all providers performed both setups. For image discernment, standardized photos of a modified Snellen's test were sent via text message to providers who were blinded as to which photo represented which system. Practitioners were randomized as to which photo to receive first.

RESULTS

Cost savings was 95.8% ($39,917 USD) per system. Setup time for the smartphone system was 46.7 seconds less than video tower system on average (61.5 vs 23.5 seconds; P < .001, 95% CI: 30.3-63.1 seconds). Level of visual discernment was slightly better for SBE over TBE, with reviewers able to identify Snellen test letters at a size of 4.2 mm with SBE versus 5.9 mm with TBE (P < .001).

CONCLUSIONS

Smartphone-based endoscopy was found to be cheaper, quicker to set up, and to have marginally better image quality when transmitted via messaging than tower-based endoscopy, although the clinical significance of these visual differences are unknown. If appropriate for their needs, clinicians should consider smartphone-based endoscopy as a viable option for viewing and collaborating on endoscopic images from a fiberoptic endoscope.

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.

Accuracy of stridor-based diagnosis of post-intubation subglottic stenosis in pediatric patients

OBJECTIVE

To assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis.

METHOD

Children who required endotracheal intubation for >24h were included in this prospective cohort study. Children were monitored daily and underwent flexible fiberoptic laryngoscopy after extubation. Those with moderate-to-severe abnormalities underwent another examination 7-10 days later. If lesions persisted or symptoms developed, laryngoscopy under general anesthesia was performed. Patients were assessed daily for stridor after extubation.

RESULTS

A total of 187 children were included. The incidence of post-extubation stridor was 44.38%. Stridor had a sensitivity of 77.78% (95% confidence interval [95% CI]: 51.9-92.6) and specificity of 59.18% (95% CI: 51.3-66.6) in detecting subglottic stenosis. The positive predictive value was 16.87% (95% CI: 9.8-27.1), and the negative predictive value was 96.15% (95% CI: 89.9-98.8). Stridor persisting longer than 72h or starting more than 72h post-extubation had a sensitivity of 66.67% (95% CI: 41.2-85.6), specificity of 89.1% (95% CI: 83.1-93.2), positive predictive value of 40.0% (95% CI: 23.2-59.3), and negative predictive value of 96.07% (95% CI: 91.3-98.4). The area under the receiver operating characteristic (ROC) curve was 0.78 (95% CI: 0.65-0.91).

CONCLUSIONS

Absence of stridor was appropriate to rule out post-intubation subglottic stenosis. The specificity of this criterion improved when stridor persisted longer than 72h or started more than 72h post-extubation. Thus, endoscopy under general anesthesia can be used to confirm subglottic stenosis only in patients who develop or persist with stridor for more than 72h following extubation.

Flexible Fiberoptic Bronchoscopy in the Intensive Care Unit

For the past 20 years, flexible fiberoptic bronchoscopy (FOB) has been shown to be an important procedure in the diagnosis and management of patients in intensive care units (ICU). In adults, FOB is used therapeutically to remove retained secretions and to correct atelectasis not improved by conservative means. In the pediatric population, however, FOB is mainly used to diagnose tracheal disease in critically ill children. The principal risks of FOB are hypoxemia and dysrhythmias; hemor rhage and pneumothorax may occur as a result of biopsy procedures. In competent hands, these adverse compli cations of FOB are minimal. Although rigid bronchos copy remains pivotal in most pediatric bronchoscopic procedures, massive hemoptysis, foreign body removal, and laser therapy for occluding tumors of the upper airway, flexible FOB has an increasingly important role in the diagnosis and management of these disorders.

Measuring Pediatric Bronchoscopy Outcomes Using an Electronic Medical Record

RATIONALE

Bronchoscopy procedures should be tracked for safety, quality improvement, and federal regulations.

OBJECTIVE

The aim of this study was to develop and test a method for evaluating flexible bronchoscopy use and outcomes using the electronic medical record (EMR) system in current clinical use at a large children's hospital.

METHODS

We created a custom bronchoscopy procedure note for our EMR system (Epic Systems Corporation) to track demographics, bronchoscopist, coordinated procedures, and outcome. Unplanned outcomes in children were defined as a disposition (admission to the hospital or elevation of care) after flexible bronchoscopy that differed from the preoperative plan. Readmissions to the hospital and emergency visits within our hospital system were also tracked electronically. Unplanned outcomes and readmissions were evaluated by a bronchoscopy quality team.

MEASUREMENTS AND MAIN RESULTS

Over 2.5 years, we tracked 1,297 bronchoscopic procedures performed on 1,161 patients (60% male, 78% American Society of Anesthesiologists class 2 or 3, mean age 5.5 yr [range, 0.02-40 yr]). Overall, 27 unplanned outcomes occurred (2.1%). The risk of unplanned outcomes did not appear to be different between procedures performed by a trainee with faculty oversight and those performed by a faculty member alone. Patients with multiple same-day procedures were more likely to have unplanned outcomes (21 of 27 [78%], P = 0.004) than were patients who had flexible bronchoscopy alone. The relative risk (RR) of having an unplanned outcome was not different from flexible bronchoscopy alone in the subset of patients with multiple procedures coordinated through our multidisciplinary aerodigestive clinic (RR 0.7; 95% CI, 0.1-3.4). The risk of unplanned events was significantly elevated in children with coordinated procedures scheduled outside the aerodigestive group (RR, 5.8; 95% CI, 2.4-14.5). Ten patients (<1%) were readmitted or seen urgently within 1 week; three of these unplanned outcomes were attributed to complications of the bronchoscopy.

CONCLUSIONS

An EMR system may be used to track procedural outcomes. Unplanned outcomes after flexible bronchoscopy were infrequent at our institution. Children who underwent multiple procedures had unplanned outcomes more often; however, the subset of children who underwent coordinated procedures through our multidisciplinary aerodigestive clinic did not demonstrate this increased risk.

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.

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.

Comparison between rigid and flexible laser supraglottoplasty in the treatment of severe laryngomalacia in infants

OBJECTIVE

Traditionally, laser supraglottoplasty for the treatment of severe laryngomalacia (SLM) is via rigid endoscopy (RE). Potassium-titanyl-phosphate (KTP) laser fiber can pass through a flexible endoscopy (FE) and cauterize tissue. This study is designed to evaluate and compare clinical variables between these two techniques in the treatment of SLM in infants.

METHODS

A retrospective study includes four-year period of consecutive infants who received laser supraglottoplasty. In the first two years (2006-2007), conventional RE CO(2)-laser with general anesthesia and endotracheal intubation were used. In the latter two years (2008-2009), a novel technique of FE KTP-laser with intravenous sedation, nasopharyngeal oxygen and a noninvasive respiratory support (if indicated), without any artificial airway was used immediately after the diagnostic FE. After laser surgery, infants were followed for three months. Clinical variables were analyzed and compared.

RESULTS

A total of 57 infants (27 in RE group, 30 in FE group) were enrolled. Basic variables were similar between both groups. Clinical improvement was comparable with 88.9% and 93.3% in the RE and FE groups, respectively. There are no significant differences in mean number of laser surgery, major complications, duration of post-laser respiratory support and hospitalization days, body weight percentile between the two groups. However, the durations of waiting time, operation, ET intubation and total hospital days were significantly less in the FE group.

CONCLUSIONS

FE technique has similar success rate but more convenient and cost-effective than the RE technique. It may to be a practical alternative therapy for infants with SLM.

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.

Flexible fiber-optic laryngoscopy in the first hours after extubation for the evaluation of laryngeal lesions due to intubation in the pediatric intensive care unit

OBJECTIVE

To evaluate the feasibility and safety of using fiber-optic laryngoscopy in the first hours after extubation for the early diagnosis of laryngeal lesions in infants and children in the pediatric intensive care unit and describe the findings of such approach.

METHODS

Patients 0-4 years old who had undergone endotracheal intubation for longer than 24h were included in the study. Exclusion criteria were history of laryngeal symptoms, current intubation or tracheostomy, craniofacial malformations, or a poor prognosis according to the medical team responsible for the patient. Exams were performed in the pediatric intensive care unit in the first 8h after extubation; the patient was at the bedside and did not receive sedation. The fiber-optic laryngoscope was used to obtain images of the larynx. Minor complications were: saturation decrease not below 85% and rapid recovery, and minor nasal bleeding. Severe complications were: bradycardia and laryngospasm that required intervention. Images were evaluated by a blinded examiner, and findings were classified as mild and unspecific (edema and hyperemia), or specific, such as laryngomalacia and glottic granulation and subglottic ulceration and granulation. Results were expressed as means and standard deviations when the variable had a normal distribution, and as median and interquartile ranges for asymmetric data.

RESULTS

Forty-one patients, mean age 2.7 months (interquartile range 1.5-6.1), were included in the study. Fiber-optic laryngoscopy was performed between 40 min and 8h after extubation, and mean time was 4.9h (standard deviation=2.4h). Mean exam duration was 4.16 min (2.41-7.12 min; standard deviation=1 min). One patient (2.4%) had mild desaturation, a minor complication. No other complications were found. Thirty-five patients were available to 6-month follow-up and subglottic stenosis was found in 11.4%.

CONCLUSIONS

Fiber-optic laryngoscopy may be safely performed in the first hours after extubation, with few minor complications. It does not take long, but provides accurate information about the conditions of the supraglottic and glottic larynx. The subglottic region can also be visualized in most patients. This easily performed exam seems to be useful for the diagnosis of pediatric patients with acute laryngeal lesions due to intubation.

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.

The yield of flexible fiberoptic bronchoscopy in pediatric intensive care patients

STUDY OBJECTIVE

To evaluate the contribution of flexible fiberoptic bronchoscopy (FFB) and BAL to the clinical management of patients in a pediatric ICU (PICU).

SETTING AND DESIGN

A retrospective study based on medical records in a six-bed pediatric ICU of a tertiary care children's hospital serving as a referral center for airway surgery.

PATIENTS AND PARTICIPANTS

One hundred consecutive infants and children hospitalized in a PICU, who underwent FFB with or without BAL.

MEASUREMENTS AND RESULTS

One hundred fifty-five procedures were performed, for the following causes: search for airways anatomic pathologies (114 of 155 procedures, 74%), including 55 procedures during the perioperative period of airway surgery; treatment of atelectasis (35 of 155 procedures, 22.5%); and BAL (30 of 155 procedures, 19%). Thirty-five percent of procedures had more than one cause. Airway pathology was observed in 79 of 114 procedures (69%). Management changed from conservative to surgical in 44 of 114 procedures (39%). In airway surgery cases, reoperation subsequent to postoperative FFB took place in 35%. BAL results changed antimicrobial treatment in 15 of 30 cases, with clinical improvement in 10 of 30 cases (33%). Treatment of atelectasis was successful in 26 of 35 cases (74.3%). No procedure-related mortality, life-threatening complications, or significant changes in patient status occurred.

CONCLUSIONS

FFB is an important and safe procedure in very sick infants and children with a variety of respiratory diseases, and significantly contributes to their management. FFB should be considered to be a PICU staff expertise.

Evaluation of the upper airway

The evaluation of infants and children with upper airway obstruction always involves a history and physical examination, which in many cases allow a diagnosis to be made. Assessment of severity and response to treatment relies on subjective parameters. Flow-volume loop analysis is a rapid, simple and effective method of evaluating patients with upper airway obstruction non-invasively. Imaging studies are complementary to endoscopy, and include plain radiography as well as computed tomography and magnetic resonance imaging, with the latter two being increasingly used in the evaluation of the paediatric airway. The ultimate diagnostic test for evaluation of upper airway obstruction, however, is flexible endoscopy.

Pediatric fiberoptic bronchoscopy with a laryngeal mask airway

BACKGROUND AND OBJECTIVES

Bedside flexible fiberoptic bronchoscopy (FFB) with sedation has been recognized as a diagnostic modality in children. In certain circumstances, general anesthesia with endotracheal intubation is advocated. This study evaluates the usefulness of the laryngeal mask airway (LMA) as an alternative to endotracheal intubation during pediatric FFB.

DESIGN, SETTING, AND PATIENTS

Between July 1995 and June 2000, we studied 92 children (51 girls; age range, 1 through 15 years) in the operating theater of a major tertiary children's hospital. The LMA was used in children with atelectasis, diffuse infiltrates, and those who required BAL under general anesthesia. The size of the LMA was chosen to accommodate a bronchoscope appropriate for the child's weight and age.

RESULTS

Procedures were well tolerated, no complications were observed, and oxygen saturation exceeded 95% in all patients. Major findings included mucoid impaction and purulent bronchial secretions, and BAL was successfully accomplished in all individuals.

CONCLUSIONS

Diagnostic BAL or extraction of mucous plugs should be accomplished with optimal control of the airway under general anesthesia. The use of the LMA during FFB is safe, provides excellent patient comfort, and should be utilized as an alternative to endotracheal intubation.

Development of an ultrathin fiberscope with a built-in channel for bronchoscopy in infants

Flexible fiberoptic bronchoscopy (FFB) is of great importance for diagnostic and therapeutic purposes in pediatric respiratory management. However, lack of a built-in channel in commercially available ultrathin fiberscopes has limited its usefulness in neonates and infants. Bronchoscopic procedures, including suctioning, BAL, bronchography, and selective drug injection have instead been performed by temporary extubation followed by mask ventilation. However, such techniques are not suitable for repeated FFB and are open to considerable risks, especially in critically ill patients. In this context, we developed a directable ultrathin fiberscope with an external diameter of 2.7 mm and a 0.8-mm internal diameter built-in channel. This prototype fiberscope, the XPF27, is useful during spontaneous ventilation and can be inserted through a 3.5-mm or larger endotracheal tube. The XPF27 was utilized for 55 FFB procedures and allowed suctioning, BAL, bronchial toileting, and bronchography in 16 critically ill children without complications. We conclude that XPF27 is useful for pediatric FFB despite its limited flexibility, visual field, and resolution.

Congenital stridor

Fifty-two infants and children with stridor were examined. The median age was 5 months and the boy/girl ratio was 2:1. Fiberoptic bronchoscopy was performed when other diagnostic methods had failed to establish the origin of stridor. The most common cause of stridor was laryngomalacia, which was found in 34 children (65%). The most common form of laryngomalacia was due to large, floppy arytenoid cartilages; this was observed twice as often as other forms of laryngomalacia and boys suffered from this abnormality more than twice as often as girls. Children with laryngomalacia had significant weight (24%) and height (8%) deficits in comparison with the normal healthy population (P < 0.001). In all but four patients with laryngomalacia, blood gases were within normal limits. In 18 children (35%) stridor was not caused by laryngomalacia. This group showed significant etiologic heterogeneity. However, identification of the cause of stridor in these patients is important because specific treatment can be offered and prognosis depends on the type and cause of the anatomical and functional abnormality present.

Usefulness of miniature flexible fiberoptic bronchoscopy in children

A miniature flexible fiberoptic bronchoscope (FFB) (Olympus BF-N20) (2.2 mm diameter) was applied to 53 children (20 female subjects) ranging in age from 3 months to 15 years (mean, 4.19 years). Most common indications for bronchoscopy included stridor or weak cry and persistent wheezing or cough unresponsive to inhaled bronchodilators, chest physiotherapy, steroids, and antimicrobial agents. There were no complications. In 38 children (71.6 percent) it was diagnostically useful, particularly for the investigations of upper airway obstruction (66 percent). In 22 children (41.5 percent) it provided guidance for surgical interventions. The instrument was particularly useful during its application in infants with severe upper airway obstruction who otherwise would require open rigid-tube bronchoscopy in the operating room. It was of limited value when excessive bronchial secretions obstructed the view of the working field for which a bronchoscope with a built-in suction channel was needed. It is concluded that this miniature FFB is a useful diagnostic tool in infants and children particularly for obstructed upper airways but has limited applications in children with peripheral airway disease. The 2.2-mm bronchoscope may have its greatest advantage in preterm neonates and intubated infants, where the small glottic or endotracheal tube size renders the 3.5-mm bronchoscope useless.

Update on pediatric flexible bronchoscopy

Technological advances in flexible bronchoscopy have expanded the clinician's ability to diagnose and treat pulmonary disease in children. During the neonatal period, flexible bronchoscopy has contributed to the understanding of the incidence and factors responsible for acquired airway lesions. The ability to selectively collect lower airway secretions has contributed to the care of immunocompromised patients with new pulmonary infiltrates. New therapies may use the flexible bronchoscope to specifically target lower airway tissues of interest. Because of the breadth of both current and future applications, most pediatricians will require a working familiarity with the benefits of flexible bronchoscopy in their patients.

Complications of rigid laryngo-bronchoscopy in children

Twenty-five complications (of which 2 were lethal) occurred in 1332 rigid laryngo-bronchoscopies performed under general anesthesia in the Sophia Children's Hospital during an 8 year period (1982-1990). The nature and circumstances of these complications were studied retrospectively. Important intraoperative complications were hemorrhage and cardiac arrhythmia; postoperative complications were intoxication and respiratory complications. Three risk factors: tetralogy of Fallot, biopsy/drainage, and extraction of an aspirated foreign body appeared to be significantly associated with complications. The results of this study were compared with those reported in studies of rigid and flexible laryngo-bronchoscopies in children.

J-shaped catheter for endobronchial aspiration of right upper lobe bronchus during rigid bronchoscopy in pediatric patients

A J-shaped suction catheter was tailored to facilitate aspiration of the right upper lobe bronchus during rigid bronchoscopy in pediatric patients. This suction catheter was used successfully in three patients.

Serum lidocaine concentrations in children during bronchoscopy with topical anesthesia

To evaluate the safety of topical lidocaine anesthesia in children undergoing bronchoscopy, we determined SLC in 15 children aged 3 months to 9.5 years during flexible fiberoptic bronchoscopy. A total lidocaine dose of 3.2 to 8.5 (mean +/- SEM = 5.7 +/- 0.5) mg/kg was administered to nose, larynx and bronchial tree over 9 to 45 (mean +/- SEM = 20 +/- 2.7) minutes. No complication occurred during the procedure. Peak SLC were 1-3.5 (mean +/- SEM = 2.5 +/- 0.2) micrograms/ml. The Vd beta was 1.79 +/- 0.19 L/kg, the t1/2 beta was 109 +/- 12 minutes, and the total body clearance 12.2 +/- 1.1 ml/min/kg. Peak SLC correlated well with the dose expressed as mg/kg (r = 0.59, p less than 0.025), and even better when related to body surface area (r = 0.63, p less than 0.01). Lidocaine doses up to 8.5 mg/kg proved safe and resulted in therapeutic SLC in our patients. Lidocaine dose up to 7 mg/kg appears to be safe provided that it does not exceed an upper limit of 175 mg/m2 and is gradually administered over a minimum of 15 minutes. Doses of 7-8.5 mg/kg appear to be safe when administered over longer periods.

Bronchoscopy in the critical-care unit

To determine the diagnostic and therapeutic usefulness as well as safety of flexible fiberoptic bronchoscopy (FFB) in patients admitted to the critical-care unit (CCU), we conducted a review of all such procedures done in our CCU from 1985 to 1988. A total of 129 patients underwent 198 FFB, of which 76% were in mechanically ventilated patients. FFB was done for diagnostic purposes in 87, for therapeutic purposes in 93, and for both reasons in 18. Of the 71 diagnostic FFB performed for cultures, 27 (38%) were positive but only 18 (25%) influenced patient management. An additional 25 FFB were helpful in making therapeutic decisions even though the cultures were negative. Ten of 13 FFB performed for evaluation of airways and 1 of 3 done for hemoptysis were helpful. Of the 90 FFB done because of retained secretions, 37 (41%) showed mucous plugs or significant secretions, but clinical improvement was noted in only 17 (19%). Overall, FFB contributed substantially to patient management in 82 of the 198 procedures (41%). Seven patients had transient complications, but no deaths occurred. We conclude that FFB is safe and can be helpful in the CCU setting.