ORIGINAL ARTICLE. Use of Rigid and Flexible Bronchoscopy Among Pediatric Otolaryngologists. widely used in the diagnosis and treatment of disorders

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1 ORIGINAL ARTICLE Use of Rigid and Flexible Among Pediatric Otolaryngologists Seth Cohen, MPH, MD; Harold Pine, MD; Amelia Drake, MD Objective: To explore how rigid and flexible bronchoscopy are used in pediatric otolaryngologic practice. Design: Survey. Participants: Members of the American Society of Pediatric Otolaryngology who practice in the United States and Canada and were listed in the membership directory were eligible. Of the 206 members, 24 practicing outside the United States or Canada and 11 without an address or a fax machine were excluded. Hence, a questionnaire was ed or faxed to 171 pediatric otolaryngologists. Main Outcome Measures: Questions concerned the practice setting, type and number of bronchoscopies, indications, complications, and medicolegal cases. Results: Responses were received from 120 subjects (70.2%), with 3 retired and 2 practicing only otology, leaving 115 respondents who completed at least some of the questionnaire. Rigid and flexible bronchoscopy were performed by 72.7% (56/77) of those in academic settings and by 71.1% (27/38) of those in group or solo practices. In the last 12 months, approximately total bronchoscopies were performed, with 2052 flexible and 9117 rigid bronchoscopies. Stridor, suspected foreign body inhalation, and laryngomalacia were the most common indications for bronchoscopy. Of the 83 respondents practicing rigid and flexible bronchoscopy, 25 (30.1%) used both instruments to manage complex or repeated foreign bodies, 25 (30.1%) used both to manage patients with cystic fibrosis, and 15 (18.1%) used both to manage simple foreign bodies. Complications were reported by 15.7% of the respondents, the most common being arrhythmia. Familiarity with a case resulting in medicolegal action was reported by 32.2% of the respondents. Conclusions: Rigid and flexible bronchoscopy have multiple uses in pediatric otolaryngologic practice. Also, flexible bronchoscopy appears to be emerging as a more frequently used diagnostic and therapeutic tool. Arch Otolaryngol Head Neck Surg. 2001;127: From the Division of Otolaryngology, University of North Carolina School of Medicine, Chapel Hill. Dr Cohen is now with the Department of Otolaryngology, Vanderbilt School of Mediicine, Nashville, Tenn. BRONCHOSCOPY HAS become widely used in the diagnosis and treatment of disorders involving the aerodigestive tract. Although rigid bronchoscopy may provide better views of the pharynx, hypopharynx, and postcricoid regions and allow for ventilation of the airway, flexible bronchoscopy provides more versatility. 1 The flexible instruments have broad viewing fields, allow inspection of the peripheral airways, and may be manipulated through a tracheostomy or stoma. Yet, although nonsurgeons more commonly use flexible bronchoscopy, surgeons have traditionally relied on the rigid instrument. 2,3 Nevertheless, the flexible bronchoscope has numerous applications in pediatric otolaryngologic practice. Examination of the nasal cavity, nasopharynx, larynx, trachea, bronchi, and esophagus may be accomplished with the flexible bronchoscope. 4,5 The small size of flexible bronchoscopes has also led to its use in cases involving children and neonates. 6,7 Diagnosis and treatment of respiratory tract problems in premature infants may be accomplished with flexible bronchoscopy. In addition, use of the flexible bronchoscope has been proposed as a diagnostic strategy for questionable foreign body inhalation. 8 To investigate the bronchoscopic practices of pediatric otolaryngologists, a questionnaire survey was conducted. RESULTS Of the 171 questionnaires sent, responses were received from 120 pediatric otolaryngologists, producing a re- 505

2 SUBJECTS AND METHODS A questionnaire was either ed or faxed to members of the American Society of Pediatric Otolaryngology who practice in the United States and Canada and were listed in the membership directory. If the address listed in the directory was nonfunctioning, the member was faxed a questionnaire. Of the 206 members, 24 practicing outside the United States or Canada and 11 without an address or a fax machine were excluded. Hence, a questionnaire was ed or faxed to 171 pediatric otolaryngologists. Four months after receiving the last questionnaire, those who did not respond to the first contact were faxed a second questionnaire. The questions concerned the practice setting, the type and number of bronchoscopies, use of general and local anesthesia, indications, complications, familiarity with cases resulting in medicolegal action, and respondents view of future rigid and flexible bronchoscopy use. Questions concerning years of experience, type and number of bronchoscopies, and percentage of practice involved in airway management required respondents to state their answer. For all other questions, the respondents could choose one of the provided answers or give their own response. When a respondent did not answer a question, the response was denoted as no response. Nine of the respondents who performed only rigid bronchoscopy answered one or more questions concerning flexible bronchoscopy. To ensure that data about flexible bronchoscopy reflected those who truly use the flexible bronchoscope, answers to flexible bronchoscopy questions from these 9 respondents, except the question about the future use of flexible bronchoscopy, were ignored. The practice type academic included a physician practicing in an academic center exclusively or a physician practicing in either a group or a solo practice and partly in an academic center. The practice type nonacademic included physicians with no association with an academic center and practicing either in a group or solo practice or in a community hospital. To calculate the number of bronchoscopies performed in the last 12 months, the number, the lowest value if the answer was reported as a range, stated by each respondent was summed. Because of this method of calculation and because some respondents did not report the total number and type of bronchoscopy performed, the number of flexible and rigid bronchoscopies does not equal the total number of bronchoscopies. However, these values serve as estimates. If more than one respondent from a particular practice or academic center was aware of a similar case that resulted in medicolegal action, only one of the respondent s answers was recorded to reduce the likelihood of counting the same case more than once. The data are presented in numerical form and, when applicable, as a percentage. sponse rate of 70.2%. Three members retired and 2 practiced solely otology, leaving 115 questionnaires, 108 from US residents and 7 from Canadian residents, Table 1. Number of Bronchoscopies Performed in the Last 12 Months* No. of Bronchoscopies Total (n = 114) Rigid (n = 114) Flexible (n = 82) (8.8) 13 (11.4) 42 (51.2) (27.2) 34 (29.8) 23 (28.0) (25.4) 27 (23.7) 4 (4.9) (14.0) 13 (11.4) 1 (1.2) (8.8) 10 (8.8) (8.8) 7 (6.1) 1 (1.2) No response 8 (7.0) 10 (8.8) 11 (13.4) *Data are given as the number (percentage) of respondents performing each type of bronchoscopy in the last 12 months. Percentages may not total 100 because of rounding. One respondent did not practice clinically in the last 12 months, leaving 114 total respondents and 82 respondents using both instuments. that were at least partially completed. Hence, of the respondents, 95.8% were using the bronchoscope in some fashion. Most respondents did not practice in small population centers, with 110 (95.7%) practicing in a population area of at least people and 88 (76.5%) practicing in an area of at least people. Also, the respondents were experienced with bronchoscopy, with only 13 (11.3%) practicing bronchoscopy for less than 10 years and only 6 (5.2%) practicing bronchoscopy for only 5 to 7 years. Last, 76 (66.1%) had more than 20% of their practice involved in airway management and 77 (67.0%) were involved in academics. In the last 12 months, total bronchoscopies, with 2052 flexible and 9117 rigid bronchoscopies, were performed (Table 1). The mean number of total bronchoscopies performed in the last 12 months was 91.7 (range, 1-905). Because one respondent did not practice clinically in the last 12 months, the mean was calculated using data from the remaining 114 respondents. The distribution of those using both instruments is similar among the respondents in academic and nonacademic environments (72.7% [56/77] vs 71.1% [27/38]). Also, just as 26.0% (20/77) of respondents in academic settings used only the rigid bronchoscope, 28.9% (11/38) in nonacademic settings used only the rigid instrument. Furthermore, the percentage of respondents using rigid and flexible bronchoscopy was similar for respondents practicing more than 10 years compared with those practicing for 10 years or less (73.1% [68/93] vs 71.4% [15/21]), for those practicing in areas of more than people compared with those practicing in areas of people or less (73.9% [65/88] vs 69.2% [18/26]), and for those with at least 40% of their practice involved in airway management compared with those with 20% or less of their practice involved in airway management (66.7% [16/24] vs 63.9% [23/36]). Whereas all respondents who practice rigid bronchoscopy use general anesthesia for the procedure, of the 83 respondents who practice rigid and flexible bronchoscopy, 53 (63.9%) use general anesthesia for 506

3 Table 2. General Indications for Indication No. (%) of Respondents (n = 115) Stridor 109 (94.8) Foreign body 105 (91.3) Laryngomalacia 66 (57.4) Chronic cough 57 (49.6) Congenital tracheal stenosis 47 (40.9) Gastroesophageal reflux 44 (38.3) Wheeze not responding to therapy 36 (31.3) Persistent atelectasis 35 (30.4) Persistent pneumonia 27 (23.5) Hemoptysis 12 (10.4) Subglottic stenosis 4 (3.5) Tracheostomy care 4 (3.5) Other* 13 (11.3) *Includes staging papillomas, tracheal brush biopsy, failed extubation, tuberculosis, vocal cord paresis, respiratory distress, aspiration, recurrent croup, mucous plug, and excised granuloma. flexible bronchoscopy. Local anesthesia use was less widespread, with 56 (48.7%) of the 115 respondents using some form of local anesthesia. Lidocaine was the most commonly used local anesthetic. If used, local anesthesia was used more commonly for flexible than for rigid bronchoscopy. The respondents used bronchoscopy for various indications (Table 2). Stridor was listed by all but 6 respondents as a frequent indication. A foreign body, laryngomalacia, chronic cough, and congenital tracheal stenosis were all mentioned by more than 40% of the respondents. All but one respondent specified treating foreign body inhalation as a specific indication for rigid bronchoscopy (Table 3). Diagnosing stridor in neonates and a biopsy of the airway were the next most common indications for rigid bronchoscopy. Diagnosing stridor in neonates also appeared as the most frequent indication for flexible bronchoscopy, followed by removing secretions and inspecting the airway for trauma (Table 4). The use of rigid vs flexible bronchoscopy in diagnosing foreign body inhalation was also explored. For a patient with either a good history or radiological evidence of foreign body inhalation, 110 (95.7%) of the respondents, including 78 (94.0%) of the 83 who use both instruments, would use the rigid bronchoscope to make the diagnosis, and 5 (6.0% of those who use both instruments) would use the rigid and flexible bronchoscope to make the diagnosis. On the other hand, for an equivocal history of foreign body inhalation, 100 (87.0%) of the respondents, including 68 (81.9%) of the 83 who use both instruments, would use the rigid bronchoscope to make the diagnosis, 12 (14.5% of those who use both instruments) would use both instruments to make the diagnosis, and 3 (3.6% of those who use both instruments) would use the flexible bronchoscope to make the diagnosis. Furthermore, of the 83 respondents using rigid and flexible bronchoscopy, 25 (30.1%) use both instruments to manage complex or repeated foreign bodies, 25 (30.1%) use both to manage patients with cystic fibrosis, and 15 (18.1%) use both to manage simple foreign bodies. Table 3. Specific Indications for Rigid Indication No. (%) of Respondents (n = 115) Foreign body 114 (99.1) Diagnose stridor in neonates 91 (79.1) Biopsy 91 (79.1) Laser bronchoscopy 90 (78.3) Dilate strictures 73 (63.5) Stent placement 52 (45.2) Hemoptysis 49 (42.6) Bronchoalveolar lavage 5 (4.3) Other* 5 (4.3) *Includes sizing endotracheal tube, reducing laryngeal fracture, treating papilloma and gastroesophageal reflux, and diagnosing subglottic lesions. Table 4. Specific Indications for Flexible Indication No. (%) of Respondents (n = 83)* Diagnose stridor in neonates 50 (60.2) Remove secretions 40 (48.2) Inspect airway for trauma 39 (47.0) Bronchoalveolar lavage 34 (41.0) Tracheostomy care 4 (4.8) Evaluate dynamic airway movement 3 (3.6) Treat foreign body inhalation 2 (2.4) Difficult intubations 2 (2.4) Other 4 (4.8) No response 5 (6.0) *These 83 respondents perform rigid and flexible bronchoscopy. Includes biopsy, vocal cord nodules, atelectasis, and intensive care unit endoscopy. Eighteen (15.7%) of the 115 respondents reported 37 complications, producing a complication rate of 0.4% (37/10454). The complications were as follows: Complication No. of Events Arrhythmia other than tachycardia or bradycardia 17 Laryngospasm 6 Pneumothorax requiring a chest tube 5 Hemorrhage 50 ml 4 Tooth injury 2 Inability to remove a foreign body from the right 1 upper lobe Pneumomediastinum 1 Bronchial perforation 1 The most common complication was arrhythmia other than tachycardia or bradycardia, and all but 2 respondents stated that the complications occurred with the rigid bronchoscope. Last, 37 (32.2%) of the respondents were aware of a case resulting in medicolegal action. The reasons for the case are as follows: Reason for the Case No. (%) of Respondents (n=115) Foreign body 23 (20.0) Laser 20 (17.4) Stent placement 4 (3.5) Stridor 2 (1.7) Tracheostomy 1 (0.9) Obstruction from a granuloma 1 (0.9) No response 7 (6.1) The 2 most common situations involved foreign body inhalation and laser bronchoscopy. Only 2 of the respon- 507

4 dents who knew of a medicolegal case worked at the same hospital, but they reported different cases. COMMENT Our response rate is higher than the 51.2% response rate in the American College of Chest Physicians study 2 and the 40.8% response rate in the European Respiratory Society study. 9 With 83 (72.2%) of the respondents using both instruments, the flexible bronchoscope appears to have infiltrated the pediatric otolaryngologist s practice. Similarly, the European Respiratory Society study 9 showed that 56.9% of pediatric pulmonology centers use both instruments. Hence, physicians involved in some form of pediatric airway management use rigid and flexible bronchoscopy. In contrast, the American College of Chest Physicians study 2 demonstrated that 91.6% of mostly adult pulmonologists did not use the rigid bronchoscope, and the British Thoracic Society study 3 of chest physicians found that 81% of respondents used only flexible bronchoscopy. Nevertheless, in the attempt to evaluate and treat the pediatric airway, the rigid and flexible bronchoscopes may complement each other and have uses in surgical and nonsurgical fields of medicine. Furthermore, the use of rigid and flexible bronchoscopy appears widespread. Practice setting, population center, years of experience, and percentage of practice involved in airway management were not associated with type of bronchoscopy used. In addition, of those involved in resident teaching, half of the respondents teach rigid and flexible bronchoscopy. Thus, a foundation for the future use of both instruments is being laid. Yet, because the respondents were experienced with bronchoscopy and airway management and practiced in large population centers, this study may not represent the practice patterns of pediatric otolaryngologists in smaller towns and those with less experience. General anesthesia was frequently part of the bronchoscopic procedure. Just as the European Respiratory Society study 9 found that 91.2% of centers practicing rigid bronchoscopy used general anesthesia for the procedure, the respondents always used general anesthesia for rigid bronchoscopy. Yet, while only 16.5% of physicians in the American College of Chest Physicians study 2 and 12% of physicians in the British Thoracic Society study 3 used general anesthesia for flexible bronchoscopy, the respondents commonly used general anesthesia for flexible bronchoscopy. Although adults may tolerate flexible bronchoscopy with sedation and local anesthetics, children might be too anxious to cooperate. Furthermore, the respondents may have wanted the option to convert to the rigid technique, possibly explaining the higher frequency of general anesthesia use. has broad applications in various diagnostic and therapeutic situations. Just as in the studies by Hoeve and Rombout 10 and Wood, 11 stridor was among the most frequent indications (Table 2). Yet, pneumonia and atelectasis were less common than found in other investigations. 2,10,11 Although the frequency of indications depends on the patient population and referral patterns, the documented indications are vast, demonstrating multiple uses for bronchoscopy. As in the European Respiratory Society study, 9 treating foreign body inhalation and diagnosing stridor in neonates were the most common specific indications for rigid bronchoscopy (Table 3). Also, the respondents used the flexible bronchoscope to diagnose stridor in neonates (Table 4). Comparing diagnostic success rates and complication rates of the rigid and flexible technique of bronchoscopy for neonatal stridor might be an interesting area of future study. Furthermore, as mentioned in the study by Wei et al, 5 the flexible bronchoscope has therapeutic uses, such as in resolving sputum retention and chest infection. Likewise, the respondents found therapeutic functions for flexible bronchoscopy, such as removing secretions, tracheostomy care, and difficult intubations (Table 4). Nussbaum 12 and Wood and Sherman 13 also noted the flexible bronchoscope s therapeutic utility for airway toilet and resolving atelectasis. In addition, Wei et al noted that foreign body inhalation was a therapeutic use for flexible bronchoscopy. Wood and Gauderer 14 also commented on combining the flexible and rigid bronchoscope to diagnosis and treat, respectively, patients with questionable histories of foreign body inhalation. Some of our respondents also mentioned using flexible bronchoscopy to treat foreign body inhalation and used the combination of rigid and flexible bronchoscopy in the management of foreign bodies (Table 4). Perhaps there are certain features of the history and physical examination that influence the choice of bronchoscopy. Exploring these aspects, the rates of successful treatment, and the complication rates of using the rigid, the flexible, or both bronchoscopes in foreign body situations may help elucidate the safest and most efficient manner of handling this difficult problem. Last, some respondents were using the rigid and flexible bronchoscopes in treating patients with cystic fibrosis. There may be some clinical situations in which the rigid and flexible bronchoscopes complement each other. Overall, the flexible bronchoscope may be developing a growing niche in the pediatric otolaryngologic practice. Few complications were reported by the respondents. A study of flexible bronchoscopies found a complication rate of 0.3%, and complication rates of 1.9% and 1.7% have also been reported in a series of 1332 and 908 flexible bronchoscopies, respectively. 15,16 However, our complication rate is based on both rigid and flexible bronchoscopies. One study 17 from the Soviet Union found a 0.3% complication rate of 1146 flexible bronchoscopies and a 1.1% complication rate of 4595 rigid bronchoscopies. Thus, our complication rate is similarly low. Of the 37 respondents reporting a complication, all but 1 had performed more than 20 total bronchoscopies in the last 12 months, and 10 had performed more than 100 total bronchoscopies in the last 12 months. In addition, only 4 respondents had less than 10 years of experience with bronchoscopy, and only 2 had less than 20% of his or her practice involved in airway management. Hence, although rare, some complications do occur, even among experienced pediatric otolaryngologists. As in the study by Hoeve and Rombout, 10 arrhythmia was the most commonly reported complication. Moreover, one third of the respondents were aware of a case 508

5 involving medicolegal action. Despite only recording a case once in situations in which more than one physician from the same practice or institution noted a particular medicolegal case on the questionnaire, some overlap could still exist. Through personal contact or peer review, physicians in the same city or even other locations could be aware of a particular case, thereby elevating the number of respondents who knew of a case requiring medicolegal action. Nevertheless, because diagnoses may be missed and complications may occur, parents may pursue medicolegal action. Hence, to sustain a high level of confidence in the various applications of bronchoscopy, appropriate training in rigid and flexible bronchoscopy must be maintained. Some inherent weaknesses exist in retrospective survey studies. Pediatric otolaryngologists who have not had positive results with bronchoscopy may not have responded, leading to possible underestimation of the complication rate and the number of cases resulting in medicolegal action. Also, those who use bronchoscopy infrequently may not have answered the questionnaire, causing an overestimation of the average number of bronchoscopies performed in the last 12 months. Furthermore, certain questions may be misinterpreted or left unanswered. In addition, the answer choices provided on the questionnaire may influence the respondent s reply, and some important questions may not have been considered by the questionnaire. Last, various questions, such as those about complications, number of bronchoscopies, and familiarity with cases resulting in medicolegal action, rely on the respondent s memory and may be underestimated because of poor recall or reluctance to report the answer. Nevertheless, this questionnaire provides some insight into how bronchoscopy is used in the practice of pediatric otolaryngology across the country and may lead to the critical evaluation of such use. CONCLUSIONS Rigid and flexible bronchoscopy have an established role in the practice of pediatric otolaryngology. As technological advances occur in the flexible bronchoscope, such as smaller instruments and improved forceps, the diagnostic and therapeutic role may increase. In fact, whereas 25.2% of all respondents thought flexible bronchoscopy use would become more prevalent in the future, only 7.0% thought future rigid bronchoscopy use would increase. Having both instruments available may facilitate patient care. Otolaryngology residents should be familiar with the rigid and the flexible bronchoscope. Future areas of research may compare diagnostic and therapeutic success rates, costs, complication rates, length of the procedure, and physician preference in specific clinical situations. Accepted for publication November 14, Presented at the 15th Annual Meeting of the American Society of Pediatric Otolaryngology, Orlando, Fla, May 16, Corresponding author: Seth Cohen, MPH, MD, 5025 Hillsboro Rd, Apt 7D, Nashville, TN ( seth.cohen@mcmail.vanderbilt.edu). Reprints: Amelia Drake, MD, Division of Otolaryngology, University of North Carolina School of Medicine, 610 Burnette-Womack, Campus Box 7070, Chapel Hill, NC ( drakeaf@med.unc.edu). REFERENCES 1. Birchall MA, Croft CB. Examination and endoscopy of the upper aerodigestive tract. In: Kerr AG, ed. Otolaryngology: Laryngology and Head and Neck Surgery. 6th ed. Woburn, Mass: Butterworth-Heinemann; 1997: Prakash UB, Offord KP, Stubbs SE. in North America: the ACCP survey. 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