Pulmonary alveolar proteinosis is a rare disease, characterized by excessive intra-alveolar accumulation of surfactant lipids and proteins, and occurs in three clinically distinct forms: congenital, secondary, and acquired (Trapnell et al. 2003). Whole lung lavage has been described as a therapeutic option in selected children with pulmonary alveolar proteinosis. Small children do not allow positioning a double-lumen ETT. In this situation, lung lavage can be performed by inserting a balloon catheter with a distal opening through an ETT, which is then wedged into one of the main stem bronchi. Endoscopic control of the exact position and tight fit of the balloon with a very thin endoscope enhance the safety of this intervention (Paschen et al. 2005; Nicolai 2001; Mahut et al. 1996; McKenzie et al. 1989). Therapeutic lavages are done with up to 20 mL/kg body weight aliquots of normal saline and continued until the recovered fluid is gradually clearing. Depending of the size of the lung, this may require as much as 1–2 L for small children and up to 8–10 L for adolescents (Ceruti et al. 2007; Paquet and Karsli 2009).

Percutaneous dilatational tracheostomy has become a routine intervention in adult intensive care units since its first description in 1985 by Ciaglia (Veenith et al. 2008; Kluge et al. 2008). The Ciaglia procedure uses a dilator over a guide wire technique and is usually done at the bedside in the intensive care unit under fiber-optic bronchoscopic guidance in the intubated patient. Inadequate training and lack of familiarity with the technique are associated with an increased complication rate. There are also anatomical and medical conditions in which a surgical tracheostomy may be safer. This applies to the pediatric age group, where percutaneous dilatational tracheostomy is rarely undertaken and also controversial (Principi et al. 2008; Scott et al. 1998). Children have a smaller and more compliant trachea than adults leading to a tendency to collapse when pressure is exerted with dilators. Hence, this could lead to a lower success rate, higher incidence of posterior wall injury, and the possibility of invaginated fractured cartilage if the dilatation occurs through and not between the tracheal rings (Bell 1998). Severe tracheal stenosis has been described as sequel of such procedures in children (Scott et al. 1998). None of the commercially available dilatational tracheostomy sets are registered for use in children. Nevertheless, its use in pediatric intensive care has been described in case series, especially in children older than 10 years of age and in adolescents (Toursarkissian et al. 1994). The use of a rigid bronchoscope instead of a fiber-optic scope (through the ETT) may secure ventilation and eliminate tracheal squashing during the procedure in younger children (Fantoni and Ripamonti 2002). It has been suggested that endoscopy should be performed routinely before decannulation in children to detect and treat granulation tissue and other complications of the procedure (Scott et al. 1998).

The translaryngeal approach described by Fantoni et al. may be a safer technique in children below 10 years of age and offers another option to surgical tracheostomy (Zawadzka-Glos et al. 2004; Fantoni and Ripamonti 1997). In this procedure an armored tracheal cannula is pulled outwards through the oral cavity, larynx, and trachea without exerting external pressure to the compliant trachea. The procedure is performed under direct endoscopy, via rigid or flexible bronchoscope. This approach offers a high level of intrinsic safety with regard to the compliant trachea of children. Other advantages are the complete absence of loss of blood, minimal local trauma, and a perfect adherence of the stoma to the cannula.

Further research to investigate the role of nonsurgical tracheostomy techniques in selected groups of ventilated children is indicated, especially since in a recent survey the vast majority (81 %) of pediatric intensivists do not agree that the risks associated with percutaneous dilatational tracheostomy outweigh the potential benefits (Principi et al. 2008). Nevertheless, formal trials using especially designed equipment and techniques adapted for young children are warranted before routine clinical use of nonsurgical tracheostomies can be safely recommend in this age group.

Foreign body aspiration is a very common indication for bronchoscopy in pediatric practice outside the intensive care environment. Nevertheless, it is not always immediately diagnosed and may be a rare cause for respiratory failure ending in the pediatric intensive care unit (Jhamb et al. 2004). The symptoms can be nonspecific, and the chest radiograph findings are frequently normal or display abnormalities uncharacteristic for foreign body aspiration. Children in respiratory failure with a history suspicious of foreign body aspiration should undergo prompt bronchoscopy regardless of the radiological findings. Foreign body extraction is commonly performed by rigid bronchoscopy.

Airway obstruction due to malignant disease is very rare in children and benign causes such as tracheobronchial malacia or postoperative tracheal stenosis are reluctantly treated with tracheal stents, because these hardly represent a permanent solution considering growth and long-term experience with such devices. Nevertheless, airway stents are used in the management of severe pediatric tracheal, carinal, and bronchial disease. Airway stenting can help to treat tracheomalacia, bronchomalacia, fixed tracheal obstruction, and postoperative tracheal stenosis after tracheal reconstruction. They also offer a therapeutic option in life-threatening inoperable obstruction of the trachea. At present, intraluminal stent therapy should be the last resort to restore airway patency in children, because complications are common. Fiber-optic bronchoscopy may be helpful in intensive care units taking care of ventilated children with tracheobronchial stents to assess complications such as stent migration or the formation of granulation tissue (Nicolai et al. 2001; Jacobs et al. 2000; Fayon et al. 2005; Anton-Pacheco et al. 2008).

Massive pulmonary hemorrhage is a rare but distressful event putting the patient at risk of asphyxiation, rather than shock from exsanguinations. The crucial and delicate issue is time. If there is no time for imaging or for transferring the patient to the interventional radiology suite for catheter embolization, rigid bronchoscopy should be first choice in smaller children. Rigid bronchoscopy permits efficient simultaneous ventilation, and large-bore suction catheters allow better clearing of the airways than the small aspiration channels of pediatric flexible bronchoscopes (Sidman et al. 2001). Blocking of the feeding main bronchus by means of a balloon catheter inserted via the rigid bronchoscope may establish sufficient gas exchange. As another temporary measure, the non-bleeding bronchus may be intubated selectively with a cuffed tube under fiber-optic guidance. In adolescents, a double-lumen ETT may be an option, but primary misplacement or secondary dislodging of these tubes is common, and, in addition, rough airway manipulation may be hazardous in the multi-traumatized patient (Klein et al. 1998; Dweik and Stoller 1999; Kabon et al. 2001). Selective tamponade of the bleeding bronchus with a (4Fr) Fogarty catheter inserted via a flexible bronchoscope requires a suction channel of ≥2 mm diameter (Jean-Baptiste 2000). With less life-threatening hemoptysis, a vasoconstrictive drug, e.g., 5 mL epinephrine 1:10,000 (Sidman et al. 2001) or ≤0.5 mg terlipressin (Tüller et al. 2004), may be applied locally with the flexible bronchoscope. Success has also been reported with systemic and local application of tranexamic acid (500 mg/5 mL), a synthetic antifibrinolytic agent (Solomonov et al. 2009; Graff 2001).

Bronchoscopy has become an important diagnostic instrument in pediatric intensive care. Even more vital, though, is its therapeutic role in emergency situations for managing difficult airways or extracting foreign body aspiration. It is in the intensive care specialist’s interest to become perfectly familiar with this technique to be able to apply it safely in ventilated patients and critical situations. It is in the patient’s interest that the competing institutional faculties performing bronchoscopies come to terms on how to provide sufficient training and maintain expertise required for an around the clock availability of this essential tool in their institution.