|Year : 2018 | Volume
| Issue : 3 | Page : 38-44
Pediatric interventional flexible bronchoscopy
Department of Pediatrics, Taipei Veterans General Hospital, National Yang-Ming University; National Defense Medical Center, Tri-Service General Hospital, Taipei; Neonatal and Pediatric Intensive Care Units, Children Hospital, China Medical University, Taichung, Taiwan
|Date of Web Publication||19-Oct-2018|
Neonatal and Pediatric Intensive Care Units, Children Hospital, China Medical University, No. 2, Yude Road, North District, Taichung
Source of Support: None, Conflict of Interest: None
Pediatric interventional flexible bronchoscopy (IFB) procedures are difficult to standardize because of a lack of consensus across different countries. The current literature are scant with retrospective case series or case reports in single center only. The main aim of IFB is to keep an enough and patent central airway lumen. The prerequisites are secure environment, skillful technique, appropriate instruments, clear airway vision, and maintenance of cardiopulmonary status of patients. Noninvasive ventilation (NIV) with pharyngeal oxygen with intermittent nose-closure and abdomen-compression or Soong's ventilation is the preferred method in the author's center as it provides a simple and reliable ventilation support during IFB. Pulmonologists should be trained in basic IFB procedures such as tracheobronchial intubation, bronchoalveolar lavage, balloon dilatation, laser ablation, cryotherapy, or even stent placement and maintenance. Pulmonologists should achieve and maintain high skill levels during their career. There is a rapidly evolving IFB role for in the intensive care units (ICUs) because of critical and cardiopulmonary compromised patients. IFB procedures require intense training and a multidisciplinary approach for patient care. With developing technology, the role of IFB is destined to grow. The IFB modality of using short-length bronchoscopes, supported with a NIV and ICU facilities is a viable, instant, and effective management in pediatric patients. Successful IFB could result in rapid weaning of respiratory supports in ICU without the need for transport to the operation theater and more invasive procedure.
Keywords: Bronchoalveolar lavage, bronchoscopy, child
|How to cite this article:|
Soong WJ. Pediatric interventional flexible bronchoscopy. Pediatr Respirol Crit Care Med 2018;2:38-44
| Introduction|| |
Pediatric bronchoscopy, with an expanding number of indications and applications, allows diagnostic and therapeutic procedures to be done. Conventionally, flexible bronchoscopy (FB) is limited for diagnostic usage only.,,, Most of the tracheobronchial (TB) therapies are carried out with rigid bronchoscopy (RB) or open surgery. Both require extensive resources such as transport to operation theater, operation room service, general anesthesia, and extracorporeal life support. All of them are complicated and risky, particularly in very small and/or sick children. Furthermore, RB itself may distort the airway anatomy and is inappropriate or even incapable of managing complicated and distal bronchial problems and lesions.,,,
FB allows inspection of the dynamics of the airway as it is often done with spontaneous breathing. With the development of better airway endoscope, pediatric interventional FB (IFB) is gaining wider acceptance. Both guidelines of the British Thoracic Society in 2013 and the American Thoracic Society in 2015 stated that there were limited applications of the IFB in pediatric field such as lavage, removal of secretion plugs, expanding collapsed lobes, and aiding endotracheal tube (ETT) intubation. IFB may still not be applicable to small infants because of their narrower airways, poor physiologic reserve, higher sedative risk, and different pulmonary disease entities. There were very few reports,, about the more challenging fields of laser therapy (LT), balloon dilatation plasty (BDP), metallic (balloon expandable) stent implantation, stent plasty, and retrieval. Potentially, effective IFB done in Pediatric Intensive Care Unit (ICU) can prevent in some circumstances, the more complicated and invasive procedures of RB, or open surgeries such as tracheostomy, laryngotracheal reconstruction, and TB plasty. IFB is particularly important to be developed in low-income countries in view of its significantly lower cost.
For more than two decades, the author has gradually developed and employed a simple, convenient, and less invasive IFB modality for children. The purpose of this article is to provide a review of the author's personal practice.
| Sedation and Local Anesthesia|| |
Pediatric IFB is an invasive procedure and potential high risk, especially in cardiopulmonary compromised children. Therefore, vital signs of heart rate, respiration, and pulse oximetry should be monitored continuously as well as intermittent (or continuous) blood pressure monitoring throughout the whole procedure. If possible, the intensive care facilities may be a preferred place for performing pediatric IFB.
For achieving smooth and successful procedures of IFB, appropriate procedural sedation is necessary. It is accomplished with combination of various agents of sedatives, analgesics, or anesthetics. In the author's pediatric bronchoscopy team, intravenous midazolam (0.3–0.5 mg/kg), ketamine (0.5–2.0 mg/kg), and atropine (0.01 mg/kg, maximum 0.4 mg) are recommended. Topical upper and lower airways anesthesia was achieved with 2% lidocaine. Additional dosages of above agents or even intravenous muscle relaxant (succinylcholine 1–2 mg/kg/dose) may also be used as needed to keep patient quiet, motionless, or to induce apnea at the critical moment of the procedures such as balloon inflating to deploy the stent, laser ablation at critical sites. During these iatrogenic apneic or critical periods, the following respiratory support should be optionally recommended.
| Respiratory Support|| |
During the IFB in children, the most common concern is that the FB and/or accomplished instruments themselves may obstruct the limited airway lumens and impair ventilation. In addition, intraluminal manipulation is also challenging particularly in those with cardiopulmonary compromise and anatomic abnormalities. A crucial element leading to success in performing IFB is to ensure adequate airway patency, oxygenation, ventilation, and circulation as well as keeping clear FB vision, when patients are under heavy sedation with possible drug-induced apnea.
In the author's practice of preparation of FB, patient's respiratory support could be provided by a novel noninvasive ventilation technique, pharyngeal oxygen with intermittent nose-close and abdomen-compression, or “Soong's ventilation”, which has been used in this IFB team for more than 20 years. It provides both inspiration and expiration support by simple maneuver. Details of this technique were reported previously.,, Briefly, a continuous, heated, and humidified pure oxygen flow (1.0 L/kg/min, maximal 10 L/min) is supplied through a nasopharyngeal catheter to fill the upper airway cavity. An optional maneuver of assist inspiration and expiration was performed as follows. (1) Infant's mouth was firmly closed with the endoscopist's dominant hand. (2) Inspiration was assisted by nose-closure accompanied with cricoid pressure. (3) Expiration was assisted by release of nose and cricoid maneuver with simultaneous abdomen-compression. The above assisted ventilation cycle was performed as needed at a rate of 5–20 cycles/min. Endoscopist performs both the FB and nose-closure (release) maneuver, whereas an assistant delivers the abdomen-compression (release). This method obviates the need for any artificial ventilation bag, mask, airway tube, or mechanical ventilator. There is no upper limit of age or body weight for the effectiveness of Soong's ventilation. Contraindications of Soong's ventilation include significant pharyngeal trauma or basal skull fracture.
Soong's ventilation allows a less crowded upper airway in the absence of facemask and ETT that means more space for the FB and other intervention instruments. The endoscopist controls the rhythm and intensity of the ventilation to eliminate hypoxia and hypercarbia while simultaneously getting a more dynamic and comprehensive inspection of the airway. Additional advantage of using Soong's ventilation is the optional expansion of both upper and low airway lumen with positive inspiratory pressure allowing a more accurate diagnosis of airway lesion, like laryngeal cleft, tracheal malacia or fistula. Previous piglet study and case series,,,,,,,,,,,, demonstrated that it could effectively support and rapidly correct hypoxia, hypercapnia, and bradycardia, even during complicated pediatric IFB procedures.
| Flexible Bronchoscopes and Interventions|| |
FB is more readily available than RB as well as providing a better dynamic inspection of the upper and lower airway. FB can be performed in the bedside with appropriate support. It is an indispensable tool for pre- and postsurgery evaluation. Many pulmonologists prefer to insert FB through a face mask, ETT, or laryngeal mask airway. However, these devices limit the agility of the FB, size of intervention instrument, and the visual field. The author also found it better to deploy accessories side by side with the endoscope, thus allowing a wider choice of instruments that might not pass through the working channel of pediatric bronchoscope [Figure 1].,
In IFB, short working lengths (25 cm to 36 cm) scopes such as Olympus HYF-V, ENF-VQ, ENF-V2 and ENF-VT2, outer diameter range from 3.2 to 5.0 mm, with or without working channel, are preferred in small size children by the author. All FBs are inserted through the nostril except in those of severe nasal stenosis.
| Procedures of Pediatric Interventional Flexible Bronchoscopy|| |
Many pediatric IFB procedures have been reported [Table 1]. Currently, the majority of pediatric IFB are performed by pediatric pulmonologists or otolaryngologists who must have received proper training in the neonatal and pediatric intensive care as well as IFB techniques. This strategy has also been emphasized by Kohelet et al.
|Table 1: Considering procedures for pediatric interventional flexible bronchoscopy|
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Flexible bronchoscopy-assisted airway intubation
Conventional airway intubation technique by direct laryngoscopy can be difficult if not impossible in situ ations that preclude the proper approach and exposure of the larynx or when there is a tracheal problem. In this scenario, FB-assisted intubation will be needed. Examples of such situations were listed in [Table 2]. FB-assisted intubation allows simultaneous examination of airway lumens. Under FB guidance, the tip of ETT is adjusted to avoid impinging on airway lesion, thus ensuring a patent ventilation pathway.
|Table 2: Indications for flexible bronchoscopy-assisted airway intubation|
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An appropriate outside diameter, from 2.2 to 5.0 mm, of FB may be used as a visual and introducing guide. The FB can be threaded through an, at least 1 mm larger, inner diameter ETT. Both outer surfaces of the endoscope and the ETT should be prelubricated before doing insertion. The tip of FB should protrude beyond the ETT tip for correct directing. It is important to note that this assisted airway intubation could easily damage the FB due to lack of proper training.
Endotracheal (bronchial) biopsy
The use of endobronchial biopsy forceps (or brush) through FB to get specimen in TB lumen is feasible for pediatric patients. The technical limitations of obtaining enough and usable samples through small working channels reduce the usefulness of this procedure. The largest study to date demonstrated the safety of this procedure. This may have advantage over conventional bronchoalveolar lavage (BAL), especially in the diagnosis of primary ciliary dyskinesia, tuberculosis, and granulomatous disorder in TB tree. It appears that neither significant bleeding nor pneumothorax is serious risk in this procedure.
Foreign body retrieval
Airway foreign bodies in children often result in significant morbidity and life-threatening emergency that makes the early recognition and prompt retrieval essential. There is general agreement in published guidelines that bronchoscopy should always be performed in a child with a history of choking, even without respiratory symptoms and/or radiological findings.
Conventionally, FB is mainly used for diagnostic purpose and RB for retrieval., However, RB requires specialized facilities that may prevent timely management in emergencies and is not applicable for compromised upper airway, restricted cervical motion, and distal airway approach. In children with a history of choking, a preceding FB reduces the rate of negative RB., There is growing evidence that FB can be used as both diagnosis and removal tool, either alone,, or in combination with a RB. FB coupled with grasping forceps, wire baskets, or cryoprobe resulted in varying success rates, after securing the airway and ventilation. This modality can save time, labor, and medical cost. In difficult cases, when FB and RB retrievals failed, more invasive open surgical approach is needed.
BAL is a diagnostic procedure used for recovering cellular and noncellular components of the epithelial lining fluid of the alveolar and bronchial airspaces. It usually is performed by injecting prewarmed sterile normal saline through a syringe into the working channel of a FB which has already been wedged into a target bronchus, irrigated, and then suctioned into a sputum trap and sent for studies. The targeted lobe depends on the radiological or endoscopic information. The amount of lavage sterile saline is usually 2–4 aliquots of equal volume (10 ml/aliquot in <6 years of age, 20 ml/aliquot in >6 years of age). Others suggest 1.0 ml/kg body weight for up to 20 kg and 20 ml/aliquot for heavier children. After each instillation, enough air must be injected to empty the dead space of the working channel. In general, BAL is considered acceptable if more than 40% of the total instilled saline is recovered and the lavage fluid contains epithelial cells. The residual saline is absorbed by the lymphatics.
The major application of BAL is the diagnosis of TB infection (particular in immunocompromised children), chronic interstitial pulmonary disease, chronic aspiration, and therapeutic and research applications. BAL has also a major role in the mucus plug removal and alveolar proteinosis. Children with persistent and massive atelectasis can be successfully managed with selective lavage with saline, mucolytics, or DNAse. The worldwide increase in the use of BAL in children has established its role in diagnosis, therapy, follow-up of childhood lung diseases, and research.
BAL, in general, is a well-tolerated and safe procedure. Cough, transitory wheeze, and pulmonary infiltrates might occur and usually resolve within 24 h., Severe bleeding, TB perforation, mediastinal emphysema, pneumothorax, and cardiac arrest are extremely rare. Contraindications to the BAL include bleeding disorders, severe hemoptysis, and severe hypoxemia that persist despite oxygen supplement.
Laser therapy (LT)
Lasers produce a beam of monochromatic, phased, and collimated light that can induce tissue vaporization, coagulation, hemostasis, and necrosis. Biological effects depend on the wavelength emitted by the laser source. There are several types of lasers that are currently used in pediatric IFB: carbon dioxide, neodymium: yttrium-aluminum-garnet, potassium-titanium-phosphate, and diode lasers. Among them, the diode laser is most suitable in pediatric upper and TB airways.,, A low power range (5–6 W) can transmit through a thin (200–600 um) flexible fiber through the inner channel (>1.0 mm) of FB.
FB-LT should be performed under appropriate procedural sedation, with or without muscle relaxation, to avoid inaccurate targeting due to movement. There is general agreement that specific safety measures must be addressed during the procedure: protective glasses are required; fractional inspired oxygen must be <0.5 before firing the laser beam to diminish the risk of airway ignition; smoke should be suctioned out from the airway; and any flammable material in the operative field should be removed to protect against ignition. Despite the limited information available, indications for FB-LT procedures in the pediatric airway appear to be increasing such as debulking the TB lumen lesion (tumor or cyst), dislodging incarcerated foreign bodies and laryngoplasty for laryngomalacia. There are no well-established criteria in pediatric yet, and each procedure should be considered on an individual basis. After the LT debulking, balloon dilation plasty is usually needed to optimize the size of the lumen.
Cryotherapy is an evolving diagnostic and therapeutic tool used during FB. The cryogen is liquid carbon dioxide or nitrogen. Through rapid freeze-thaw cycles, cryotherapy causes cell death and tissue necrosis or adherence that can be approached through the FB. It is used for removal of benign and malignant tumors, as well as relieve airway stenosis. In addition, bronchoscopic cryotherapy causes little trauma., An ice ball is generated by inserting the freezing probe into or just touch the lesion, and then, the crystallized lesion can be separated and removed from the airway. This procedure could be repeated several times for debulking. Due to the scanty experience reported, there are no well-established indications in children. It has been applied to release TB stenosis and atelectasis and remove foreign body, tuberculoma, and TB tumor. For endobronchial tuberculosis, performing FB cryotherapy at the proliferative phase of granulation tissue was often effective to reduce the formation of cicatricial stenosis.,,
For TB stenosis, local tissue reaction and swelling can cause transient lumen narrowing leading to dyspnea. Therefore, temporary tracheal intubation for 4–6 days may be indicated after cryotherapy (or LT). Contraindications include the external compression of airway and tracheobronchomalacia.
Both persistent and recurrent atelectasis are important indications for diagnostic FB., Depending on the findings, further targeted actions may be undertaken, such as suctioning, foreign body extraction, sampling materials, and other more specific procedures. An attempt to re-inflate the atelectatic lung parenchyma coupled with repeated saline lavages is considered standard practice. The inflation pressure should be closely monitoring to be <40 cmH2O. One-lung ventilation or endobronchial blocking is another technique, using an appropriate size balloon catheter to block the normal side bronchus and continue ventilating the atelectatic lung, with or without ETT, may to help re-open the atelectasis.
In refractory atelectasis, various drug applications have been tried through FB working channel. Surfactant administration was reported to improve ventilation by re-aeration of atelectatic regions and help wean victim from mechanical ventilation. Similarly, FB-administered recombinant human DNase was used in cystic fibrosis patients, noncystic fibrosis patients, and premature neonates, with variable success.
Balloon dilatation plasty (BDP)
The FB worked as a visual guide with an angioplasty balloon catheter of appropriate dimension. While using thin FB, the balloon catheter can placed in the TB working channel. The balloon catheter was prestiffed with a guidewire inside for easy manipulation. The method is as followed: a balloon catheter is inserted, covered the stenotic segment, and is gradually inflated with saline. High-pressure levels are delivered to the maximum balloon capacity, by a syringe-pump pressure inflator, and maintained for 10–30 s (pneumonic dilatation). Then, deflated the balloon and withdrawn the balloon catheter out of airway. In this intervention, the balloon diameter could be in increments from 4 to 10 mm (age dependent) gradually. Repeat doing these balloon inflation and deflation for several times in one session of BDP. Cicatricial process may occur with scar formation, relapse is frequently observed, and therefore, multiple interventions may be required.
In our published paper of an 11-year IFB in small infants of less than 5 kg, 38 BDP for corrected lumen narrowing which included 21 tracheal, 9 bronchial, 5 nasal tract, and 3 choanal atresia lesions. Twenty-four BDPs were used for simultaneous estimation and expansion of the dimension of target TB lumens, an essential step before stent placement. Ten BDPs were performed for the repair and re-expansion of distorted and loose stents. Five BDPs were done to compress the TB granulomas and restore adequate lumen patency. Three BDPs were for assisting the stent retrieval (see below).
Stent placement, plasty, and retrieval
Airway stenting in pediatric patients is relatively recent and follows the experience of the adult. Nevertheless, in contrast to adults, there are basic differences such as the benign nature of most lesions, the small size lumens, and the considerable luminal growth of the pediatric airway. Stent implantation for benign airway disease can be useful, either for temporary luminal stabilization after airway surgery or for relief of severe malacia or stenosis, when all other medical and surgical options have failed or are contraindicated. These specific features raise the issues of the precise role of TB stenting in children.
There are four main categories of stent currently being used: metallic, plastic, hybrid, and biodegradable. Each has its own advantages and drawbacks, so the ideal stent is not yet available.
- Self-expanding metal stents: They are made of nitinol, a titanium-based alloy with shape memory. They are packaged as coils enclosed into a dedicated introducer sheath. While introducing into target TB lumen, stents are released by pulling back the external sheath
- Balloon-expandable metal stents: They are made of stainless steel tubular meshes. They are prethreaded over balloon catheters and can be expanded to a desired diameter by inflating the balloon. These stents can be repaired and further expanded in the follow-up periods, once indicated,
- Covered metal stents: They are made of nitinol coils covered with thin polymer sheaths. They are deployed the same way as with uncovered metal stents, either by balloon catheters or by introducer sheaths.
In experienced hands, the placement of TB metallic stents is technically feasible, with little directly procedure-related morbidity or mortality., However, subsequent stent-related complications may be encountered frequently and their management requires considerable expertise, which must be available at special centers. Although the usefulness of stents appears to be well established in children,, available data do not allow a firm conclusion in defined clinical circumstances. Hence, the US Food and Drug Administration had issued a black box warning against the implantation of metal stents in benign conditions due to the difficulty of removal and serious complications.,,
Despite increasing experience with stenting, definite clinical criteria for pediatric use are yet to be established. Even so, there seems to be a basic general agreement that stents may play a role in particular clinical settings where there are no other therapeutic options. The pediatric literature on airway stents is still limited. If stents are used, comprehensive information must be given to parents/patients about their possible benefits and risks to allow informed consent.
In our published data about the balloon-expandable metal stents in pediatric patients, which was so far the largest case series of 146 stents in 87 children and longest surveillance period of 20 years. The stent indication was severe TB narrowing (stenosis or malacia) resulting in prolonged ETT intubation and ventilator dependence. Both BDP and/or LT of IFB did not improve condition, and the patients still suffered from frequent life-threatening episodes. Stent placement was considered as the last option before more invasive surgical interventions. Four stents were placed after sliding tracheoplasty due to persistent lumen collapse (as mentioned above). All implanted stents were of metallic mesh type (IntraTherapeutics Inc., MN 55112, USA; or Boston Scientific Corporation, Marlborough, MA 01752, USA) which could be further expanded by technique of BDP to accommodate the growing lumens. These stent-associated IFB were all performed with a short-length FB of out diameter 3.2 mm to 5.0 mm. The smallest body weight was 2.3 kg and the youngest was 10 days old infant. Three carinal stents were placed in three growing extremes.
Metallic stent can be retrieved. This required inserting a deflated balloon catheter underneath the target stent, then inflating the balloon to well separate and detach the stent from the underlying airway mucosa. Finally, the detached stent was grasped and retrieved with the aid of RB and a powerful forceps.
| Benefit of Pediatric Interventional Flexible Bronchoscopy|| |
As described above, IFB can safely be performed immediately after the FB diagnosis. The combined diagnostic and therapeutic IFB in the same session actually decreased waiting time, medical expense, avoided more invasive interventions, and their associated iatrogenic damages. These benefits have been demonstrated and reported in many our previous reports.,,,,,,,,,,,,
Short-term efficacy of weaning respiratory supports
In our previous 11-year report in body weight less than 5 kg infants, IFB resulted in early weaning of respiratory support. In this report, original, there were 67 ETT with PPV supports, which immediately decreased to 22 (45 extubation) after IFB and further down to 11 in 7 days. In 121 infants who initially required nasal prongs PPV support, 62 infants weaned off within 7 days after IFB management. In a total of 188 PPV before IFB, 118 (62.8%) were successfully weaned within 7 days after IFB. The success of weaning PPV was mostly attributed to the three IFB procedures of LT (69.8%), BDP (47.5%), and stent implantation (75.0%). Finally, all survivors were able to be weaned to spontaneous breathing in room air.
| Conclusion|| |
In the last decade, IFB exhibits promise in pediatric airway practice. Our IFB modality of using short-length FB coupled with Soong's ventilation done in ICU settings may be safe, feasible, timely, and effective. In children, IFB facilitates weaning of respiratory support and avoidance of more invasive procedures such as RB or open surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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