Bronchoscopy

Chapter 8


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Bronchoscopy


Shailendra Das, DO, FAAP


 


Introduction


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


Indications


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


Cytologic analysis and cell count


Bleeding


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
Nasopharynx  
Larynxa
Vocal cord function and/or movement  
Subglottis  
Trachea
Laryngomalacia  
Tracheobronchomalacia
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.


Findings


Upper-airway lesions


Vocal cord paralysis


Vocal cord dysfunction


Laryngomalacia


Laryngeal web


Laryngeal cleft


Subglottic stenosis


Subglottic cysts


Lower-airway lesions


Tracheomalacia


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


Bronchomalacia


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


Complications of Bronchoscopy


Common complications


Cough


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). www.thoracic.org/patients/patient-resources/resources/flexible-bronchoscopy.pdf

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