key: cord-0932564-ljyw3o0n authors: Ferraro, Valentina Agnese; Baraldi, Eugenio; Stabinger, Diana; Zamunaro, Andrea; Zanconato, Stefania; Carraro, Silvia title: Pediatric flexible bronchoscopy: A single‐center report date: 2021-05-18 journal: Pediatr Pulmonol DOI: 10.1002/ppul.25458 sha: f0bef2a5c73206a31fe3205061f82f89e7b79261 doc_id: 932564 cord_uid: ljyw3o0n INTRODUCTION: Pediatric flexible laryngotracheal bronchoscopy (FB) is an integral part of diagnostics and treatment at tertiary pediatric respiratory centers. AIM: FBs performed between 2013 and 2018 at our Pediatric Allergy and Respiratory Medicine Unit of the Department of Women's and Children's Health at Padua University were examined in terms of the indications, findings, and adverse events. MATERIALS AND METHODS: The electronic medical records of pediatric patients who underwent FB at least once between 1 January 2013 and 31 December 2018 were considered. Patients' clinical data, indications for FB, anatomical findings, information derived from bronchoalveolar lavage (BAL) and bronchial brushing, and possible adverse events were analyzed. RESULTS: There were 447 pediatric FBs performed in 428 patients (aged from 1 month to 18 years) for diagnostic purposes (92.4%), to clear secretions (3.6%), or to monitor a known condition (4.0%). The main indications were recurrent lower respiratory tract infections (LRTI, 32.2%) and chronic wet cough (9.4%). Lower airway malacia was the most common abnormal finding in these two groups (36.1% and 28.6%, respectively). BAL bacterial culture was positive in 55 children (39.6%) with recurrent LRTI and in 25 (59.5%) with chronic wet cough, being Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis the microorganisms most commonly isolated. FB proved a safe procedure and was well tolerated. CONCLUSIONS: Pediatric FB is an essential tool at our tertiary pediatric respiratory center. It helps establish the anatomical conditions underlying several chronic respiratory conditions and any correlated microbiological findings, with a significant impact on further patient management. Pediatric flexible laryngotracheal bronchoscopy (FB) is a highly versatile and effective diagnostic and therapeutic tool with an important role in pediatric respiratory medicine. 1 It was first described in 1968 2 and applied in the pediatric population 10 years later. 3, 4 Nowadays, FB is an integral part of the management of neonates, infants, and children with various lung and airway diseases. 5 International recommendations on pediatric FB have been published by the European Respiratory Society (ERS) 6 and the American Thoracic Society 7 and describe the indications, the facilities, and equipment needed for the procedure, care of the instruments involved, techniques, and suggestions for sedation and patient management. FB was performed in a dedicated bronchoscopy suite, using Olympus bronchoscopes with outside diameters of 4.1 or 2.8 mm. Patients were placed under deep sedation/analgesia with intravenous midazolam, propofol, and/or ketamine. All treatments were administered with intravenous bolus (not with continuous infusion) and children could maintain ventilatory function, without external ventilatory support. Lidocaine was used as a topical anesthetic. All FBs were recorded. During the procedure, intrapharyngeal oxygen supplementation was provided for all patients. All FBs were performed by two of the present authors (E. B., who has 25 years of experience, and S. C. with 5 years of experience). Airway malacia was diagnosed on visual inspection of the airway's shape and dynamics during spontaneous breathing. Malacia was defined as a collapse of at least 50% of the airway lumen. 10, 11 Routine BAL fluid studies included differential cell counts and microbiological analyses. No endobronchial or transbronchial biopsies were performed, no foreign body was extracted, and none of the FBs were emergency procedures (which are managed by ear nose and throat specialists in operating rooms). For the present study, FB-related adverse events were classified as mild or severe, the latter including desaturation <80% or <90% if associated with laryngospasm/bronchospasm, severe hypotension, pulmonary and/or endobronchial bleeding, need for mechanical ventilation, need for admission to the intensive care unit, need for cardiopulmonary resuscitation and/or death. 12 Indications and findings were expressed in absolute and relative terms. The study was approved by the Ethics Committee of Padua General Hospital (Protocol No. 0048862). Persistent wheezing: wheezing in preschool-age children that persists in spite of the anti-asthma therapies administered. 16 Severe asthma is asthma that requires Step 4 or 5 treatment (e.g., high-dose ICS/LABA), to prevent it from becoming "uncontrolled," or asthma that remains "uncontrolled" despite this treatment. 17 Stridor is a variably high-pitched respiratory sound, usually heard on inspiration, that indicates the narrowing of the larynx and/ or (extrathoracic) trachea. 18 The retrospective analysis concerns 447 pediatric FBs performed in 428 patients aged from 1 month to 18 years. The indications for FB are listed in Table 1 . Results are grouped according to the indication for the exam. Table 2 . Prompted by a clinical suspicion of primary ciliary dyskinesia (PCD), 75 patients underwent bronchial or nasal brushing to analyze ciliary ultrastructure using transmission electron microscopy (TEM). Ultrastructure analysis of the nasal/bronchial respiratory mucosa with TEM was performed in 28 patients with chronic wet cough, and anomalies suggestive of PCD were found in 3, the sample was not evaluable in 5, and a normal ultrastructure was found in 20. Airway anatomy was normal in all cases, and no blood was found in the upper respiratory or lower respiratory tracts in four, while one with idiopathic hemosiderosis had visible active bleeding. The mild adverse events encountered were one case of urticaria after propofol administration (an 11-year-old male with severe asthma), treated with chlorphenamine and systemic steroids; nine cases of transient cough and/or stridor during the FB, which had been indicated for wheezing (in three children), laryngotracheal cough (in three), severe asthma (in two) and stridor (in one). The following four severe adverse events during or immediately after the FB were recorded. -A 14-year-old female who underwent FB for stridor experienced laryngospasm with desaturation (SatO 2 < 90%), and was treated with nebulized epinephrine, systemic steroids, and increased oxygen supplementation. -An 8-year-old female who underwent FB for recurrent respiratory infections had bronchospasm with several episodes of desaturation (SatO 2 < 90%) during the procedure, and was treated with albuterol, bag-mask ventilation, and increased oxygen supplementation. -A 4-year-old male who underwent FB for tracheal cough developed respiratory distress with bronchospasm and desaturation (SatO 2 < 90%), and was treated with albuterol, systemic steroids, bag-mask ventilation, and increased oxygen supplementation. FB is recommended for children with persistent, frequently recurring or atypical wheezing to examine the underlying anatomy. 33, 34 Previous studies demonstrated that nearly one in two such children have central airway malacia. 28 BAL analysis can also provide useful information in children with severe asthma, helping to elucidate the asthma endotype. 40 Unfortunately, this analysis was unreliable in most of our severe asthma patients because the BAL procedure was conducted while they were treated with high doses of steroids. From a safety standpoint, FB was well tolerated by most of our patients with severe asthma: only 4 (10.3%) had mild adverse events and none had any severe adverse events. Although pediatric bronchoscopy is known to be a generally safe procedure, serious and even fatal adverse events have been described, related mostly to patients' diseases before the procedure. 12 Today pediatric pulmonologists strive to understand their patients' potential risk factors for FB-related adverse events, to prevent their occurrence. 43, 44 Adverse events can certainly be minimized if each patient's indications and clinical status are carefully examined, and appropriate anesthesia and monitoring during the procedure is assured. 43 In our setting, patients underwent a complete assessment the day before undergoing FB, and the procedure was postponed if their clinical status could not ensure a safe procedure (if they showed signs or symptoms, for instance, of acute infection, acute bronchospasm, or fever). FBs were performed in deep sedation with children breathing spontaneously throughout the procedure. During and after sedation/ analgesia, patients were monitored in a dedicated room to promptly manage any possible adverse events. In conclusion, flexible laryngeal and tracheal bronchoscopy is an essential tool at our tertiary pediatric respiratory center. In most cases, it helps establish the anatomical condition underlying a number of chronic respiratory disorders and possibly correlated microbiological findings, with a significant impact on patients' further management. FERRARO ET AL. | 2639 Pediatric bronchoscopy Flexible bronchofiberscope Pediatric flexible bronchoscopy Applications of flexible fiberoptic bronchoscopes in infants and children Flexible fiberoptic bronchoscopy in pediatric practice Flexible endoscopy of paediatric airways Official American Thoracic Society technical standards: flexible airway endoscopy in children Use of the paediatric bronchoscope, flexible and rigid, in 51 European centres Pediatric flexible and rigid bronchoscopy in European centers-availability and current practice Tracheomalacia and bronchomalacia in children: incidence and patient characteristics ERS statement on tracheomalacia and bronchomalacia in children Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center Recurrent lower respiratory tract infections in children Management of children with chronic wet cough and protracted bacterial bronchitis: CHEST guideline and expert panel report CHEST Expert Cough Panel. Managing chronic cough as a symptom in children and management algorithms: CHEST guideline and expert panel report Global Initiative for Asthma-GINA International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma Assessment and causes of stridor ERS guidelines on the diagnosis and treatment of chronic cough in adults and children ERS statement on protracted bacterial bronchitis in children Microbiology of bronchoalveolar lavage fluid in children with acute nonresponding or recurrent community-acquired pneumonia: identification of nontypeable Haemophilus influenzae as a major pathogen Bronchoalveolar lavage in children. ERS Task Force on bronchoalveolar lavage in children Bronchoscopic evaluation of unexplained recurrent and persistent pneumonia in children Children with chronic wet or productive cough-treatment and investigations: a systematic review Are airways structural abnormalities more frequent in children with recurrent lower respiratory tract infections Bronchoscopic findings in children with chronic wet cough Protracted bacterial bronchitis in young children: association with airway malacia inflammation and bronchoalveolar lavage culture in children with persistent respiratory symptoms Predictors of time to cough resolution in children with chronic wet cough treated with antibiotics after bronchoscopy Protracted bacterial bronchitis: the last decade and the road ahead Prospective characterization of protracted bacterial bronchitis in children Detecting respiratory viruses in children with protracted bacterial bronchitis Official American Thoracic Society Clinical Practice Guidelines: diagnostic evaluation of infants with recurrent or persistent wheezing Flexible airway endoscopy in children Trans-nasal flexible bronchoscopy in wheezing children: diagnostic yield, impact on therapy, and prevalence of laryngeal cleft Tracheobronchomalacia in wheezing young children poorly responsive to asthma therapy Inhaled foreign bodies in children: a global perspective on their epidemiological, clinical, and preventive aspects Pediatric tracheal and endobronchial tumors: an institutional experience Vascular rings Bronchoscopy in severe childhood asthma: irresponsible or irreplaceable? Challenges in managing difficult-totreat asthma in children: stop, look, and listen Severe complications of bronchoscopy Complications of flexible bronchoscopy in children: prospective study of 1,328 procedures Flexible bronchoscopy in children: utility and complications Pediatric flexible bronchoscopy: a single-center report The authors declare that there are no conflict of interests. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.