Chapter 8



Shailendra Das, DO, FAAP



Flexible bronchoscopy allows for examination of the nose, pharynx, larynx, and tracheobronchial tree.

Bronchoscopic developments, including smaller scope sizes and improvements in picture quality and video technology, have facilitated use in younger children and neonates.

Indications for Bronchoscopy

Stridor (especially in the setting of failure to thrive or apneic spells)

Persistent wheezing (especially if asthma therapies do not alleviate symptoms)

Monophonic wheezing (suspicion of foreign body)

Persistent wet cough

Recurrent and/or persistent pneumonia

Persistent abnormal chest radiographic and/or computed tomographic findings (atelectasis, infiltrate)

Recurrent aspiration

Foreign-body aspiration

Hemoptysis and/or pulmonary hemorrhage

Respiratory symptoms in an immunocompromised host

Interstitial lung disease

Tracheostomy evaluation

Lung transplant surveillance

Direct instillation of medications (deoxyribonuclease, hypertonic saline, N-acetylcysteine, sodium bicarbonate) to aid in thinning and removing mucus

Additional Tests

Bronchoalveolar lavage

Evaluation of alveolar cells via instillation of saline in a pulmonary lobe to obtain diagnostic information


Microbial cultures (bacterial, fungal, viral, and mycobacterial) and rapid diagnostic tests

Cytologic analysis and cell count


Aspiration or gastroesophageal reflux

Cytologic findings in bronchoalveolar lavage

Normal: >80% macrophages

Inflammation and/or infection: increased numbers of neutrophils

Asthma: increased percentage of eosinophils

Alveolar or airway hemorrhage: presence of hemosiderin-laden macrophages

Aspiration and/or gastroesophageal reflux: presence of lipid-laden macrophages (sensitive, not specific)

Interstitial lung disease: increased numbers of lymphocytes, eosinophils, neutrophils

Sarcoidosis: increased lymphocyte count (CD4+ cells)

Hypersensitivity pneumonitis: increased lymphocyte count (CD8+ cells)

Transbronchial biopsies: evaluation for acute cellular rejection in patients who underwent lung transplantation, sarcoidosis

Endobronchial biopsies: evaluation of airway inflammation, potential malignant lesions, granulation tissue

Endobronchial brush biopsies: evaluation of ciliary motility and cilia electron microscopy ultrastructure (primary ciliary dyskinesia)

Deciding Between Flexible and Rigid Bronchoscopy

Flexible bronchoscopy

Usually performed by pulmonologists

Can be performed at the bedside (eg, in the pediatric intensive care unit) or in an outpatient procedure suite

Can be performed with moderate sedation or general anesthesia

Rigid bronchoscopy

Usually performed by otolaryngologists or pediatric surgeons

Usually performed in an operating room

Requires general anesthesia

Table 8-1 shows indications for flexible and rigid bronchoscopy.

In general, flexible bronchoscopy

Allows for more maneuverability, giving a better view of the lower airways

Offers a more dynamic view of the airway

Provides the opportunity for sampling of the lower airways for microbial and cytologic testing

Direct laryngoscopy (without endotracheal tube)

Allows for better examination of the posterior glottis

Rigid bronchoscopy

Provides for controlled ventilation through the scope

Provides for a bigger working channel for removal of a foreign body (see Figure 8-1 for evaluation and/or management of a foreign body)

Essential for ruling out suspected H-type tracheoesophageal fistula

Table 8-1. Choosing Between Flexible and Rigid Bronchoscopy
Area of Interest or Evaluation Flexible Rigid
Vocal cord function and/or movement  
Diagnostic workup (microbial, cytologic analysis)  
Mainstem bronchi
Lobar, segmental, and subsegmental bronchi  
Endobronchial biopsy
Foreign-body removal  
Diagnosis of foreign body
Control of bleeding  

aIf a laryngeal cleft is suspected, direct laryngoscopy must be performed, with palpation of the interarytenoid space.


Upper-airway lesions

Vocal cord paralysis

Vocal cord dysfunction


Laryngeal web

Laryngeal cleft

Subglottic stenosis

Subglottic cysts

Lower-airway lesions


Tracheal stenosis and/or complete tracheal rings

External (vascular) compression of the airway

Tracheal bronchus

Tracheoesophageal fistula

Protracted bacterial bronchitis

Endobronchial foreign body

Endobronchial mass



Figure 8-1. Algorithm for assessment of foreign body.

Complications of Bronchoscopy

Common complications


Low-grade fever

Transient hypoxemia, due to either sedation or obstruction of the airway by the scope itself

Minor airway and/or nasal bleeding, due to local trauma

Local trauma during rigid endoscopy procedures

Abrasions of the lips or gingiva

Chipped teeth

Rare complications

Laryngospasm: avoided by using topical laryngeal anesthesia

Bacteremia: caused by spread of infection

Pneumothorax: incidence increased when transbronchial biopsy performed

Hemorrhage: incidence increased when transbronchial biopsy performed

Airway obstruction: can occur during removal of a foreign body

Resources for Families

Flexible Bronchoscopy (Airway Endoscopy) (American Thoracic Society).

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Aug 8, 2019 | Posted by in PEDIATRICS | Comments Off on Bronchoscopy
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