PAEDIATRIC FLEXIBLE BRONCHOSCOPY: EXPERIENCE FROM PESHAWAR. Mohammad Yousaf Khan, Sajjad Ali, Muhammad Umar*

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1 ORIGINAL ARTICLE PAEDIATRIC FLEXIBLE BRONCHOSCOPY: EXPERIENCE FROM PESHAWAR Mohammad Yousaf Khan*, Sajjad Ali*, Muhammad Umar* * Department of Pulmonology, Post Graduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan Address for correspodence: Dr. M. Yousaf Khan, Department of Pulmonology, Post Graduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan ABSTRACT Background and Objective: Flexible bronchoscopy is an important procedure in respiratory medicine. There is no local data available summarizing the experience of flexible bronchoscopy in pediatric population. We, therefore, decided to documents and record all bronchoscopies performed on children in our unit. The aim was to find different indications for flexible bronchoscopy, explore the diagnostic yield for these indications and highlight the potential complications. Methodology: Seventy one () diagnostic and therapeutic bronchoscopies, performed in children during a years period, were analyzed. Results: There were male and 5 female. Age ranged from days to years, with a mean age of. years +. SD.Suspected foreign body inhalation ( cases), persistent lower zone opacity ( cases) and opaque hemithorax ( cases) were the most common indications. Fifty () % of bronchoscopies had a meaningful outcome. Diagnostic yield for individual indications ranged from 5 % to %. Recurrent infections, as a group, were the most rewarding indications (% diagnostic yield); followed by radiographic abnormalities as a group ( % diagnostic yield). Complications were recorded only in.8 % of the children. Oxygen de-saturation was the most common (. %) but easily reversible complication; rest of the complications was small in numbers and also easily reversible. Conclusions: Flexible bronchoscopy in children is a safe procedure and the overall meaningful outcome for most indications is high. Key Words: Bronchoscopy; Pediatric Bronchoscopy; Diagnostic/Therapeutic Bronchoscopy. This Article may be cited as: Khan MY, Ali S, Umar M. peshawar. Pak J Chest Med 5; (): - Paediatric flexible bronchoscopy: experience from INTRODUCTION recent decades, flexible bronchoscope has become an integral part of pulmonary practice. Its use has lexible bronchoscopy (FB) is one of the most progressively increased to help cover the visual important and commonly performed proce- diagnosis of the upper and lower airways lesions. It is, Fdures in adult pulmonary medicine. FB was also use for interventional, therapeutic and supportive initially performed in pediatric population in 8 and work such as obtaining bronchoalveolar lavage (BAL) since then its use in this population is constantly for cytological, virological, bacteriological and increasing. This is because of the availability of high immunological investigations. Other potential quality optics in appropriately sized flexible instru- indications include bronchoscopic intubation for -5 ments. anesthetists, catheterization of fistulae, intraoperative assistance for cardiac and airway surgery, Pediatric bronchoscopy has come into fashion mainly through the efforts of respiratory physicians removal of distal foreign bodies not reached by rigid originally trained in adult flexible bronchoscopy. In the instruments and limited selective segmental or lobar PJCM 5; ()

2 Continuous supplemental oxygen inhalation was carried out via a nasal cannula through the free nostril. Continuous pulse and oxygen saturation monitoring done via pulse oximetry. Two flexible bronchoscopes were used, Olympus BF type PE (outer diameter. to 5. mm) and Olympus BF type N (outer diameter.8 to. mm). Flexible bronchoscopy was performed via the nasal route in most cases. However oral route was used if nasal route was too narrow for the scope to pass and when foreign body removal was a possibility, as determined by pre procedure assess- ment. bronchographic procedures. The pediatric airway has many differences in anatomy and pathology as compared to adult airways. The small size of the children airways, differences in the anatomy of the larynx as well as the differences in pathologies according to age group, are characteris- tics that make the endoscopic examination of the pediatric population quite unique and different from adults. Common indications for pediatric flexible bronchoscopy are stridor, voice disturbance, persis- tent productive cough, unusual cough, hemoptysis, persisting chest signs such as wheeze or crackles in a localized area, persistent radiographic infiltrates or atelectasis, recurrent infiltrates, recurrent pneumonia or interstitial disorders. The aim of the present study was to share personal experiences of performing bronchoscopy, as a diagnostic and therapeutic tool, in pediatric population referred to our department with certain indica- tions. MATERIAL & METHODS This was a prospective, diagnostic/therapeutic and descriptive study, conducted at Pulmonology department, Post Graduate Medical institute, Lady Reading Hospital Peshawar, from to. The study was conducted on a diverse group of patients received for bronchoscopy from all over Khyber Pakhtunkhwa, adjacent areas of Punjab and Afghanistan. The referring doctors also belonged to different specialties, including pediatricians, pulmonologists, thoracic and E.N.T surgeons, general physicians and general practitioners. Database recordings included demographic characteristics, indications, bronchoscopic?ndings, bronochoalveolar wash analysis and complications. The patients were booked for the procedure on the basis of preliminary examination, clinical symptoms and X- ray examination. All patients' clinical record was reviewed to determine and reconfirm the indication for bronchoscopy. Informed written consent was taken from the guardians of patients before performing the procedure. Flexible bronchoscopy was performed in a designated bronchoscopy suite. Patients were advised to come for the procedure nil by mouth for at least hours before bronchoscopy. A combination of premedication's including sedative agents (midazolam, to mg i/v), local anesthesia (%lignocain) and supplemental oxygen (minimum L/min) were administered. Midazolam was not used in children below two years of age. Lignocain jelly ( %) was applied to the bronchoscope and lignocain PJCM 5; () solution ( %) sprayed into the nostrils via a syringe and then applied to the larynx and trachea via the bronchoscope. Bronchial wash was obtained for microbiological examination when needed as per indication. When foreign body inhalation was con- firmed and localized but its removal was not feasible, the patient was referred for rigid bronchoscopy. Children with stridor were bronchoscoped when there was a suspicion for diagnosis other than laryngomalacia or when there was failure to thrive. Children with recurrent infection were bronchoscoped when they failed to respond to appropriate antimicrobial agent for an appropriate period of time. We looked into diagnostic yield for each indication as well as analyzed the positive bronchscopic?ndings. At least one consultant pulmonologist, independ- ent from the operator, and two bronchoscopy technicians would monitor the respiration, cyanosis, pulse rate and oxygen saturation during the procedure. Children becoming hypoxic or distressed during the procedure were observed in the recovery room or ward for atleast- hours. Supplemental Oxygen inhalation and sulbutamol + steroid nebulization carried out, as per need, till complete stability of the child. In early infants small bronchoscope, without suction channel, was used mainly for diagnostic purpose. The infant would be held by the mother sitting, on the couch, cross legged/indian style. The whole procedure was performed very quickly. The bronchoscope was removed from trachea within seconds as only diagnostic inspection of the airways was done. That was how the procedure would be performed without making the baby much fretful i.e. without expressing distress or irritation. Data were analyzed by using SPSS version 5..Frequencies / Percentages were calculated for qualitative variables, while Mean+ standard deviation was calculated for quantitative variables. We looked into diagnostic yield for each indication as well as analyzed the positive bronchoscopic findings.

3 RESULTS site of pathology, cases (.%). Right lung was involved in patients (. %). In four cases the Out of total children, were male and 5 pathology was central (5.%) and in one child both were female. Male to female ratio was.8:. The age sides were involved. Fifteen (.%) patients had of patients ranged from days to years, with a normal bronchoscopy study. Right lung was the most mean age of. years and standard deviation of + common site of involment in children with recurrent. SD. chest infections (85.%), persistent mid-zone opacity Different indications for bronchoscopy and (. %) and foreign body inhalation (.%); while left their positive bronchoscopic findings/diagnostic lung was mostly involved in children with opaque yields are summarized in (table ). Persistent hemithorax (88.%) and persistent lower-zone radiological opacity was the commonest indication, opacity (.%). 5 (5. %) cases. This was followed by bronchos- Abnormal?ndings on bronchoscopy are summacopy for suspected foreign body inhalation, (. rized in table. The table shows that most patients, %) cases. (.%), had a normal study. Increased secretions, The overall diagnostic yield (success rate for (.%) and inflammation with or without increased finding a cause for the indicated pathology i.e. secretions, (.%), were the most common meaningful outcome) was %. Most indications had abnormal bronchoscopic findings. Foreign body a high diagnostic yield (between and %).The localization, (.%) cases, was also a common highest diagnostic yield (%) was found, when findings. Bronchial tumour was noted in two patients. bronchoscopy was performed for infection as an One patient had aberrant upper division and stenosed indication; a positive diagnostic yield for infection was lower division of left main bronchus. Another had defined as the presence of purulent secretions and agenesis of left lung. bronchial inflammation. Suspected foreign body Therapeutic bronchoscopy was limited to foreign inhalation and opaque hemithorax had a relatively body removal mainly. Among patients with a conlower diagnostic yield, out of cases (5 %) and 5 firmed foreign body aspiration % ( cases) were out of cases (55%), respectively, while children male, whereas girls accounted for % ( cases). The referred with hemoptysis had the lowest diagnostic mean age of the patients with a confirmed aspiration yield (5 %). was.5 years. In % ( cases) children, foreign Table summarizes the site of pathology in body was identified on right side. While % ( cases) different indications. Left lung was the most common the aspiration was on left side. In children foreign body was successfully removed without any compli- Table : Different indications for bronchoscopy and their diagnostic yield (n=) Indications Patients Pathology Identified Undiagnosed / Pathology not Identified Diagnostic Yield (%) Suspected FB inhalation 5 Persistent lower zone opacity 8 Opaque hemithorax 5 55 To look for endobronchial pathology 8 88 Recurrent infection Hemoptysis 5 Persistent midzone opacity Tracheobronchial injury Persistent upper zone opacity Collapse lung Stridor Evaluation of tracheostomy tube 5 PJCM 5; ()

4 Table : Site of pathology in different indications (n=) Indications Site Normal Right Lung Left Lung Central Bilateral Suspected FB identified. %.%.% Persistent lower zone opacity.%.% Opaque hemithorax 8.% 88.% To look for endobronchial pathology. %.%.%.% Recurrent infection 85.%.% Hemoptysis 5% 5.% Persistent midzone opacity.%.% Tracheobronchial injury. %.% Persistent upper zone opacity 5.% 5.% Collapse lung 5.% 5.% Stridor Evaluation of tracheostomy tube 5. %.%.% 5.%.%.% cations during the course of the procedure. Other cases were referred for rigid bronchoscopy. Therapeutic option of bronchoscopy, done primarily for some other indication, was also used to suck out copious bronchial secretions in (. %) cases. stopped spontaneously. Only one patient had severe bronchospasm immediately after the procedure which subsided with nebulized steroid and bronchodilator therapy. One child with suspected foreign body inhalation was too restless, despite conscious sedations with mg medazolam, to undergo bronchoscopy. He would pull the broncho- scope out, when an attempt would be made to get into his nose. He was excluded from the study. DISCUSSION The pediatric airway has many differences in anatomy and pathology as compared to adults and therefore diagnostic and therapeutic skills have to be Complications during and after bronchoscopy were minor and recorded only in.8% of the children. Oxygen de-saturation was the commonest (.%), though easily reversible by increasing the flow of oxygen inhalation without interrupting the procedure. Three children experienced oxygen de-saturation during the procedure that required removal of the bronchoscope. Two patients had minor bleeding that PJCM 5; ()

5 Table : Bronchoscopic findings (n=) Bronchoscopic Findings Number of Patients % Normal findings Increased Secretions Foreign Body localized Increased secretions and / or inflammation Narrowing / stenosis Narrowing due to external compression Inflammation with granulation tissue Bronchial tumour Tracheoesophageal fistula Agenesis of left lung Aberrant upper division and stenosed lower divison of left main bronchus TOTAL very different and unique. We therefore undertook foreign bodies were extracted in two children only and this prospective study in order to share personal the rest were referred for rigid bronchoscopy. experiences regarding different indications for Although there are studies that reported successful bronchoscopy in our pediatric population, explore extraction of aspirated foreign bodies by using diagnostic yield for these indications and highlight?exible bronchoscope, others strongly believe that potential complications. Similar study reports come Flexible Bronchoscope should not be used for foreign from different centers across the globe with variable 5, body removal. It is important to note that in our numbers of procedures performed on diverse study out of children did not have a foreign body 5,8 populations. These differences in local practice and and thus flexible bronchoscopy obviated the need expertise, as well as the difference in patient popula- for rigid bronchoscopy. We therefore suggest that in tions and ages, makes comparisons between cases where a diagnosis of foreign body aspiration is different centers problematic. not certain, flexible bronchoscopy should be the diagnostic modality of choice to avoid the risk of Regarding indications for bronchoscopy,, 8 general anesthesia for rigid bronchoscopy. radiological abnormalities such as persistent opacity Moreover, there is a need for high index of suspicion or atelectasis were the commonest ones (8 %). for FB aspiration because this entity can mimic Moreover in our study these radiological abnormali- various pathologies. ties also had a high diagnostic yield of %. Our team, originally trained in adult bronchoscopy, had to We bronchoscopied children with recurrent develop pediatric bronchoscopy skills because of infections to look for the cause of repeated infections. lack of specialist pediatric bronchoscopists. Despite Children with recurrent infection were bronchoscoped of this, overall % of pediatric bronchoscopies had a only when they failed to respond to an appropriate meaningful outcome. This outcome is similar to the antibiotic for an appropriate period of time. The most?gures published by Maffey et al recently and Wood et common?ndings included abundant secretions with, al reported years ago. Moreover Pérez- Godfrey or without in?ammed mucosa. This finding of otheret al and Ruiz et al reported an overall abnormality in wise normal bronchoscopy is similar to other study % and % of the children, respectively, that reports. Moreover, normal bronchoscopy can be very, underwent bronchoscopy over a ten years period. reassuring for parents of the children who suffer Kabra et at form India reported a lower diagnostic cough and fever for a long time. In these cases yield of 5 %. therapeutic suctioning was done and bronchial washings sent for microbiological examinations In our study foreign bodies were identi?ed in routinely. This has been reported to be of great help in out of patients who were bronchoscoped for patients with persistent or recurrent infection. suspected foreign body inhalation. Out of the children, with confirmed foreign body inhalation, In our study complications were in small numbers PJCM 5; () 5

6 and easily reversible. The proportion of complications Flexible bronchoscopy in a pediatric, were in accordance with other studies. Literature pulmonology service. Arch Argent Pediatr. review shows that in proper designated sittings and in 8;:-5. experienced hands flexible bronchoscopy is a safe procedure. However, fatalities have been reported. Wood RE. The diagnostic effectiveness of the with the procedure. Therefore adherence to standard?exible bronchoscope in children. Pediatr protocols, by carrying out the procedure in a designated Pulmonol. 85;:88-. bronchoscopy suite in a hospital sitting and. Godfrey S, Avita l, Maayan C, Rotschild M, careful monitoring, is recommended to avoid morbidi- Springer C. Yield from?exible bronchoscopy in,, ties and mortalities during the procedure. children. Pediatric Pulmonology. ;:-. CONCLUSION. Pérez-Ruiza E, Pérez-Fríasa J, Martínez- Flexible bronchoscopy in children has a high Gonzálezb B, Martínez-Arána T, Milano-Mansoc diagnostic yield, overall %. Suspected foreign G, Martínez-Valverdea A. Fibrobroncoscopia inhalation and persistent radiological opacity are the pediátrica. Análisis de una década. An Esp most common indications for flexible bronchoscopy. Pediatr. ;55:-8. The therapeutic indications are practically limited to. Kabra SK, Lodha R, Ramesh P, Sarthi M. foreign body. Therapeutic suction of copious bron- Fiberoptic Bronchoscopy in Children: An Audit chial secretions constitutes a secondary therapeutic from a Tertiary Care Center. Indian Pediatrics. indication. The procedure is safe and complications 8;5:-. are rare and easily manageable. REFERENCES. Midulla F, de Blic J, Barbato A, Bush A, Eber E, Kotecha S, et al. Flexible endoscopy of paediatric airways. Eur Respir J. ; : Ramirez-Figueroa JL, Gochicoa-Rangel LG, Ramirez-San Juan DH, Vargas MH. Foreign Body Removal by Flexible Fiberoptic Bronchoscopy in Infants and Children. Pediatric Pulmonology. 5;:-.. Nicolai T. Pediatric bronchoscopy. Pediatric. Swanson KL, Prakash UBS, Midthun DE, Edell ES, Pulmonology. ; :5-. Utz JP, McDougall JC, et al. Flexible Bronchoscopic Management of Airway Foreign. Brownlee KG, Crabbe DCG. Paediatric bronchos- Bodies in Children. Chest. ; :5-. copy. Arch Dis Child. ; :-5.. Martinot A, Closset M, Marquette CH, Hue V,. Schellhase DE. Pediatric?exible airway endos- Deschildre A, Ramon P, et al. Indications for copy. Curr Opin Pediatr. ;:-.?exible versus rigid bronchoscopy in children 5. with suspected foreign-body aspiration. Am J Barbato A, Magarotto M, Crivellaro M, Novello A, Respir Crit Care Med. ;55:-. Jr., Cracco A, de Blic J, et al. Use of the paediatric bronchoscope,?exible and rigid, in 5 European 8. Cohen S, Avital A, Godfrey S, Gross M, Kerem E, centres. Eur Respir J. ;:-. Springer C. Suspected Foreign Body Inhalation in Children: What Are the Indications for. Wood RE. Spelunking in the pediatric airways: Bronchoscopy? The Journal of pediatrics. ; explorations with the flexible bronchoscope. 55:-8. Pediatr Clin North Am. 8;:85-.. Hilliard T, Sim R, Saunders M, Hewer SL,. Wood RE, Prakash UBS. Chapter : Pediatric Henderson J. Delayed diagnosis of foreign body Flexible Bronchoscopy. In Bronchoscope. Editor: aspiration in children. Emerg Med J. ;:- Prakash UBS. Raven Press ; Kabra SK, Lodha R, Ramesh P, Sarthi M. Fiberoptic Bronchoscopy in Children: An Audit from a Tertiary Care Center. Indian Pediatrics. 8;5:-.. Godfrey S, Avita l, Maayan C, Rotschild M, Springer C. Yield from?exible bronchoscopy in children. Pediatric Pulmonology. ;:-.. Maffey AF, Berlinski A, Schkair JC, Teper AM.. Barbato A, Magarotto M, Crivellaro M, Novello A, Jr., Cracco A, de Blic J, et al. Use of the paediatric bronchoscope,?exible and rigid, in 5 European centres. Eur Respir J. ;:-.. Gidaris D, Kanakoudi - Tsakalidou F, Papakosta D, Tzimouli V, Taparkou A, Ventouri M, et al. Bronchoalveolar lavage in children with in?ammatory and non in?ammatory lung disease. Hippokratia. ;:-. PJCM 5; ()

7 . De Blic J, Marchac V, Scheinmann P.? e x i b l e b r o n c h o s c o p y i n a n Complications of?exible bronchoscopy in immunocompromised infant. Pediatric children: prospective study of,8 proce- Pulmonology. 8;5:-. dures. Eur Respir J. ;:-.. Wagener JS. Fatality following?beroptic. Picard E, Schlesinger Y, Goldberg S, Schwartz S, bronchoscopy in a two-year-old child. Pediatric Kerem E. Fatal pneumococcal sepsis following Pulmonology. 8;:-. PJCM 5; ()

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