Role of flexible bronchoscopy in diagnosis and treatment in children

Transcription

1 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

2 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

3 Rigid vs. flexible bronchoscopy Complementary methods Each with specific advantages in different situations

4 Rigid endoscopy Method of choice for foreign body removal and other therapeutic procedures Ideal for examination of posterior aspects of larynx and trachea

5 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

6 De Blic J et al. Eur Respir J 2002

7 Flexible bronchoscopy indications When in doubt as to whether bronchoscopy should be performed, bronchoscopy should always be performed. Chevalier Jackson, 1915

8 Wood RE. Pediatr Clin North Am 1984

9 De Blic J et al. Eur Respir J 2002

10 ERS Task Force. Eur Respir J 2003;22:

11 Wood Pediatr Clin North Am 1984;31:785

12 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!

13 Persistent stridor n = 124 Results laryngomalacia (n=95) membranous subglottic stenosis (n=11) subglottic haemangioma (n=10) vocal cord paralysis (n=10; 3 bilateral)

14 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)

15 Persistent stridor 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

16 Persistent stridor Summary Stridor is visible Additional pathology in the lower airways is relatively common complete examination of the respiratory tract

17 Laryngomalacia 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

18 Laryngomalacia

19 Haemangioma Eber Paediatr Respir Rev 2004;5:9

20 Cyst (base of tongue)

21 Vocal cord paralysis

22 Laryngeal cyst

23 Laryngeal web

24 Atypical croup Age less than 6 months Prolonged symptoms No response to treatment

25 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

26 Upper airway obstruction For many patients with UAO, flexible endoscopy is by far the most important diagnostic tool. Airway protection may have priority over diagnostic procedures. ( Whatever else you do, maintain an adequate airway )

27 Persistent wheezing Tracheobronchial stenosis causes Infections Acute laryngotracheobronchitis, bacterial tracheitis Accidents/trauma Foreign body, postintubation injury, airway burn, external trauma Tumors Congenital Bronchogenic cyst, enlarged lymph node, mediastinal tumor Fixed stenosis (incl. webs, cysts), dynamic stenosis (malacia)

28 Tracheo-/bronchomalacia congenital - acquired localised - generalised primary - secondary

29 Persistent wheezing 61 children n % Normal 8 13 Abnormalities of lower airways Tracheomalacia Tracheal compression 7 11 Compression of left main bronchus 9 15 Bronchial compression 2 3 Foreign body 7 11 Miscellaneous Abnormalities of upper airways 5 8 Subglottic oedema 2 3 Laryngomalacia 3 5 Wood RE. Pediatr Clin North Am 1984

30 Recurrent wheezing 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 Schellhase DE et al. J Pediatr 1998

31 Persistent wheezing F.B., male, 6.8 yrs Primary tracheomalacia

32 Persistent wheezing M.A., male, 7.8 yrs Secondary tracheomalacia due to double aortic arch

33 Persistent wheezing L.K., female, 15.1 yrs Secondary tracheomalacia due to pulmonary vascular sling

34 Persistent wheezing always suspect foreign body

35 Wood Pediatr Clin North Am 1984;31:785

36 De Blic J et al. Eur Respir J 2002

37 Atelectasis Flexible bronchoscopy 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

38 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

39 Atelectasis

40 Flexible bronchoscopy Bronchial lavage Tb positive: - microscopy - PCR - culture - MTD

41 Atelectasis 2 weeks prior to admission at admission

42 CT scan

43 Flexible bronchoscopy

44 Recurrent/persistent pneumonia V.M., female, 2 months H-type tracheo-oesophageal fistula

45 Wood Pediatr Clin North Am 1984;31:785

46 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 1985 Bagley Chest 1994 Eber Wien Klin Wochenschr 1995 American Thoracic Society Am J Respir Crit Care Med 2000 Midulla Eur Respir J 2003

47 Paediatric tracheostomy Flexible endoscopy Tracheal granuloma Suction trauma

48 ERS Task Force. Eur Respir J 2000;15:

49 Bronchoalveolar lavage Indications Diagnostic - immunocompetent child - immunocompromised child Therapeutic Research

50 Bronchoalveolar lavage Microbiological studies Cellular components - Total & differential cell counts - Lymphocyte subsets - Specific inclusions Noncellular components

51 Eber E. Journal of Bronchology 1998

52 BAL microbiological studies 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)

53 BAL microbiological studies Bacterial infection vs. contamination Quantitative cultures ( 10 5 CFU/ml) Bilateral BAL Protected BAL

54 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

55 BAL microbiological studies Pseudoinfections relatively common Stringent adherence to cleaning and disinfection guidelines Routine microbiological checks of instruments

56 Diagnostic BAL Immunocompetent child Pulmonary infection Tuberculosis Cystic fibrosis Non-infectious lung diseases

57 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

58 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)

59 Gastric aspirates vs. BAL fluid in infants with endobronchial tuberculosis Patient, gender, age gastric aspirates bronchial 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

60 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?

61 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%

62 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%

63 BAL immunocompetent child Non-infectious lung diseases Neutrophilic alveolitis Foamy macrophages

64 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 2004

65 BAL immunocompetent child Non-infectious lung diseases 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)

66 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)

67 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.

68 BAL immunocompromised child Bronchoscopy and BAL safe and effective First line investigation in the exploration of acute pneumonia and acute/chronic interstitial pneumonitis

69 Summary Diagnostic BAL 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.

70 Therapeutic BAL Alveolar proteinosis Cystic fibrosis?

71 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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