Role of flexible bronchoscopy in
diagnosis and treatment in children
Ernst Eber, MD
Respiratory and Allergic Disease Division, Paediatric Department, Medical University of Graz, Austria
Bronchoscopy
• 1897 – open tube, first removal of a foreign body
• Late 1960s – flexible fibreoptic bronchoscope
• 1970s – smaller instruments for paediatric applications
• 1978 – first report on flexible bronchoscopy in infants and children
Rigid vs. flexible bronchoscopy
• Complementary methods
• Each with specific advantages
in different situations
Rigid endoscopy
• Method of choice for
foreign body removal
and other therapeutic
procedures
• Ideal for examination
of posterior aspects of
larynx and trachea
Flexible endoscopy
• Potential preservation of spontaneous ventilation
(vocal cord movements!)
• Entire upper airway visible
• Ideal for assessment of dynamic airway lesions
• Low incidence of complications
Flexible endoscopes considered the instruments
of choice for most diagnostic endoscopies
De Blic J et al. Eur Respir J 2002
“When in doubt as to whether bronchoscopy
should be performed, bronchoscopy should
always be performed.”
Chevalier Jackson, 1915
Flexible bronchoscopy – indications
Wood RE. Pediatr Clin North Am 1984
De Blic J et al. Eur Respir J 2002
ERS Task Force. Eur Respir J 2003;22:698-708.
Wood Pediatr Clin North Am 1984;31:785
Stridor
• Often the most prominent symptom of UAO
• Heard predominantly during inspiration
• Indicative of substantial narrowing or obstruction
of the larynx or extrathoracic trachea
increased velocity and turbulence of airflow
vibration of aryepiglottic folds or vocal cords
• Patients with more than 50% obstruction may be
asymptomatic!
Persistent stridor
n = 124
Results
laryngomalacia (n=95)
membranous subglottic stenosis (n=11)
subglottic haemangioma (n=10)
vocal cord paralysis (n=10; 3 bilateral)
Persistent stridor
Results cont.
cartilaginous subglottic stenosis (n=3)
laryngeal cyst (n=3)
laryngeal web (n=3)
malacia of the extrathoracic trachea (n=1)
laryngeal papillomatosis (n=1)
epiglottis bifida (n=1)
In 14-26% of patients with persistent stridor,
significant additional lower airway
abnormalities, or two or more synchronous
airway lesions may be detected.
Wood Pediatr Clin North Am 1984;31:785
Gonzalez Ann Otol Rhinol Laryngol 1987;96:77
Eber Monatsschr Kinderheilkd 1996;144:43
Persistent stridor
Summary
• Stridor is visible
• Additional pathology in the lower airways is
relatively common complete examination
of the respiratory tract
Persistent stridor
• Most common congenital laryngeal anomaly and
most common cause of persistent stridor in infancy
• Specific disease state with ill-defined pathogenesis
(specific aetiology still obscure)
• Anatomical abnormality or delayed development
in neuromuscular control?
• Worsened by application of lidocaine
Nielson Am J Respir Crit Care Med 2000;161:147
Laryngomalacia
Laryngomalacia
Haemangioma
Eber Paediatr Respir Rev 2004;5:9
Cyst (base of tongue)
Vocal cord paralysis
Laryngeal cyst
Laryngeal web
Atypical croup
Age less than 6 months
Prolonged symptoms
No response to treatment
Vocal cord dysfunction
• Inappropriate vocal cord adduction during inspiration or during both inspiration and expiration
• Often misdiagnosed as asthma
• Often initiated by emotional / physical stress or URTI
• Gastro-oesophageal reflux may play a causative role
Upper airway obstruction
Airway protection may have priority
over diagnostic procedures.
(“Whatever else you do, maintain an
adequate airway”)
For many patients with UAO,
flexible endoscopy is by far the most
important diagnostic tool.
Persistent wheezing
Tracheobronchial stenosis – causes
• Infections Acute laryngotracheobronchitis, bacterial tracheitis
• Accidents/trauma Foreign body, postintubation injury, airway burn, external trauma
• Tumors Bronchogenic cyst, enlarged lymph node, mediastinal tumor
• Congenital Fixed stenosis (incl. webs, cysts), dynamic stenosis (malacia)
Tracheo-/bronchomalacia
• congenital - acquired
• localised - generalised
• primary - secondary
Wood RE. Pediatr Clin North Am 1984
61 children n %
• Normal 8 13 • Abnormalities of lower airways 48 79
– Tracheomalacia 12 20– Tracheal compression 7 11 – Compression of left main bronchus 9 15 – Bronchial compression 2 3 – Foreign body 7 11 – Miscellaneous 11 18
• Abnormalities of upper airways 5 8 – Subglottic oedema 2 3– Laryngomalacia 3 5
Persistent wheezing
Schellhase DE et al. J Pediatr 1998
30 children (0 - 18 months)
• FB for recurrent wheezing
• Abnormalities of the airways 17– Segmental tracheomalacia 12
with vascular compression 10
– Laryngomalacia 6
• Abnormalities more frequent in children 0 - 6 months old
Recurrent wheezing
F.B., male, 6.8 yrsPrimary tracheomalacia
Persistent wheezing
M.A., male, 7.8 yrsSecondary tracheomalacia due to double aortic arch
Persistent wheezing
L.K., female, 15.1 yrsSecondary tracheomalacia due to pulmonary vascular sling
Persistent wheezing
„always suspect foreign body“
Persistent wheezing
Wood Pediatr Clin North Am 1984;31:785
De Blic J et al. Eur Respir J 2002
96 consecutive children (43m, 53f; age 1.7 ± 4.6 years)
with recurrent or persistent atelectasis
• Middle lobe 29 patients
• Right upper lobe 26 patients
• Left upper lobe 3 patients
• Right / left lower lobe 11 patients
• Right / left lung 17 patients
• Segmental 10 patients
Atelectasis
Flexible bronchoscopy
96 consecutive children (43m, 53f; age 1.7 ± 4.6 years)
with recurrent or persistent atelectasis
• Bronchial stenosis / bronchomalacia 42 patients
• Inflammation / mucus plugging 24 patients
• Granulation tissue 10 patients
Endobronchial tuberculosis 5 patients
• Carcinoid 1 patient
• No bronchial pathology 6 patients
Atelectasis
Flexible bronchoscopy
Atelectasis
Flexible bronchoscopyFlexible bronchoscopy Bronchial lavageBronchial lavage
Tb – positive:Tb – positive:
- microscopymicroscopy
- PCRPCR
- cultureculture
- MTDMTD
2 weeks prior to admission at admission
Atelectasis
CT scan
Flexible bronchoscopy
Recurrent/persistent pneumonia
V.M., female, 2 monthsH-type tracheo-oesophageal
fistula
Wood Pediatr Clin North Am 1984;31:785
• Endoscopic evaluation every 6 – 12 months (more
frequently in infants, patients with cerebral palsy or spinal
deformity, patients with unstable/rapidly changing medical
condition or severe complications)
• In children with acute complications (bleeding, UAO)
• Prior to decannulation (removal of the tube during
endoscopy)
Paediatric tracheostomy
Flexible endoscopy
Wood Pediatr Pulmonol 1985Bagley Chest 1994
Eber Wien Klin Wochenschr 1995 American Thoracic Society Am J Respir Crit Care Med 2000
Midulla Eur Respir J 2003
Paediatric tracheostomy
Flexible endoscopy
Tracheal granuloma Suction trauma
ERS Task Force. Eur Respir J 2000;15:217-231.
Bronchoalveolar lavage
Indications
• Diagnostic
- immunocompetent child
- immunocompromised child
• Therapeutic
• Research
Bronchoalveolar lavage
• Microbiological studies
• Cellular components- - Total & differential cell
counts
- Lymphocyte subsets
- Specific inclusions
• Noncellular components
Eber E. Journal of Bronchology 1998
Different disease processes and pretreatment with
antibiotics and antifungals affect the yield from BAL
BAL early in the course of the disease, ideally
before starting treatment (may also help to decrease
morbidity from therapy)
BAL – microbiological studies
BAL – microbiological studies
Bacterial infection vs. contamination
• Quantitative cultures (≥ 105 CFU/ml)
• Bilateral BAL
• Protected BAL
BAL – microbiological studies
Results must be interpreted with care, with regard to the underlying disease, the history, and the whole clinical picture
Diagnostic: M. tuberculosis, L. pneumophila, M. pneumoniae, P. carinii, Nocardia, Histoplasma, Blastomyces, influenza virus, RSV
Not diagnostic: atypical mycobacteria, bacteria, Aspergillus, Candida, CMV, HSV
BAL – microbiological studies
Pseudoinfections relatively common
Stringent adherence to cleaning and disinfection guidelines
Routine microbiological checks of instruments
Diagnostic BAL
Immunocompetent child
• Pulmonary infection
• Tuberculosis
• Cystic fibrosis
• Non-infectious lung diseases
BAL – immunocompetent child
Pulmonary infection
• Less clear role than in the immunocompromised
child (retrospective study: diagnostic yield 30%)
• Empiric antibiotic therapy still the standard
treatment for pneumonia
• BAL should not be performed routinely, but in
patients unresponsive to empiric therapy or in a
severe clinical condition
BAL – immunocompetent child
Tuberculosis
• Chest radiographs frequently underestimate bronchial involvement in children
• Bronchoscopy valuable in management (assessment of bronchial involvement, need for steroids)
• Role in diagnosis of pulmonary tuberculosis not clear (BAL vs. gastric aspirate)
Gastric aspirates vs. BAL fluid in infants with endobronchial tuberculosis
Patient, gender, agePatient, gender, age gastric aspiratesgastric aspirates bronchial lavage fluidbronchial lavage fluid
MJ, f, 7 months culture&PCR 1x positive all positive*
HK, f, 9 months negative all positive*
KJ, f, 9 months negative all positive*
FE, m, 9 months culture 1x positive all positive*
MC, f, 11 months PCR 1x positive all positive*
MM, f, 15 months negative all positive*
HN, f, 18 months culture 1x positive ZN, culture, PCR positive
*: microscopy (ZN), cultures (liquid, solid), PCR, MTD
Thalhammer GH et al. Eur Respir J 2000
BAL – immunocompetent child
Cystic fibrosis
• Valuable in identifying the need for antibiotics in young children (before such a need is clinically apparent)
• Research tool
• Therapeutic role?
Bronchoalveolar lavage or oropharyngeal cultures to identify lower respiratory
pathogens in infants with cystic fibrosis
Armstrong DS et al. Pediatr Pulmonol 1996
Oropharyngeal cultures:
• Sensitivity 82%• Specificity 83%• Positive predictive value 41%• Negative predictive value 97%
Diagnostic accuracy of oropharyngeal cultures in infants and young children with
cystic fibrosis
Rosenfeld M et al. Pediatr Pulmonol 1999
Oropharyngeal cultures(P. aeruginosa, children 18
months):
• Sensitivity 44%• Specificity 95%• Positive predictive value 44%• Negative predictive value 95%
Foamy macrophagesNeutrophilic alveolitis
BAL – immunocompetent child
Non-infectious lung diseases
Disease Cytology CD4/CD8
Pulmonary haemorrhage Haemosiderin laden AM
Pulmonary alveolar proteinosis
Milky fluid, foamy AM
Langerhans cell histiocytosis
Langerhans cells CD1a>5%
Sarcoidosis Lymphocytosis
Hypersensivity pneumonitis
Lymphocytosis or normal
Collagen vascular disorders
Lymphocytosis/Neutrophilia
or
Bowel diseases Lymphocytosis
Pulmonary fibrosis Neutrophilia
ERS Task Force. Eur Respir J ERS Task Force. Eur Respir J 20042004
Non-infectious lung diseases
BAL – immunocompetent child
• In a few diseases diagnostic
• In several diseases useful (at least in eliminating a number of causes of ILD)
• Research tool (e.g. evaluation of disease activity)
Non-infectious lung diseases
BAL – immunocompetent child
BAL – immunocompromised child
HIV infection
• Microbiologic yield 55-84% (P. carinii and
other fungi, viruses, and bacteria)
• Sensitivity of BAL for P. carinii greater than
90% (superior to TBB)
BAL – immunocompromised child
Immunodeficiencies, haematologic diseases,
post bone marrow / solid organ transplantation
• Diagnostic yield 27-86% (P. carinii, CMV, other microorganisms)
• Differences in the diagnostic yield due to differences in the underlying disease, pretreatment, techniques for detection of organisms etc.
BAL – immunocompromised child
Bronchoscopy and BAL safe and effective
First line investigation in the exploration
of acute pneumonia and acute/chronic
interstitial pneumonitis
Diagnostic BAL
Summary
• Well-established role in the diagnosis of pulmonary infections, especially in immunocompromised children. Molecular methods allow identification of pathogens from small samples.
• Role in children with non-infectious interstitial lung diseases still to be defined.
Therapeutic BAL
• Alveolar proteinosis
• Cystic fibrosis ?
Flexible bronchoscopy
Contraindications
• Absolute: Investigation will yield no information
of value
The same diagnostic information can
be obtained by a less invasive method
• Relative: Severe pulmonary hypertension
Severe hypoxaemia
Severe airway stenosis / bronchospasm
Uncorrected bleeding diathesis
Massive haemoptysis
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