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©The Author(s) 2015.
World J Crit Care Med. Feb 4, 2015; 4(1): 77-88
Published online Feb 4, 2015. doi: 10.5492/wjccm.v4.i1.77
Published online Feb 4, 2015. doi: 10.5492/wjccm.v4.i1.77
Table 1 Indications, diagnostic, and therapeutic outcomes for flexible bronchoscopy in critically ill pediatric patients
| Ref. | Population | Indications | Diagnostic yield | Diagnostic BAL findings | Therapeutic outcomes |
| Abu-Kishk et al[25], 2012 | 9 PICU: hemoptysis (age 2 mo-17 yr) | Hemoptysis | 77.8% (7/9) | ||
| Atzori et al[14], 2006 | 62 NICU: esophageal atresia (mean age 37.5 WGA) | Airway evaluation | 24.2% (15/62): Change in surgical management 9.7% (6/62): Change in anatomic class 11.3% (7/62): Tracheomalacia | ||
| Bar-Zohar et al[24], 2004 | 100 PICU: medical, non-airway surgery, and airway surgery groups (age 2 d-17 yr) | Airway evaluation; BAL; extubation failure | 73% (65/89): Upper airway 56% (14/25): Lower airway 63.6% (28/44): Extubation failure 38.6% (44/114): Change in medical management 20% (11/31): Airway surgical re-exploration | 46.7% (14/30) identified organism 50% (15/30) change in antimicrobials 40% (12/30) clinical improvement after change in antimicrobials 36.4% (4/11) concordance between BAL and blind tracheal aspirate | 84.6% (11/13) extubated after lavage 74.3% (26/35) re-expanded collapsed lobe |
| Chapotte et al[18], 1998 | 72 PICU: CHD (age 1 d-14 yr) | Perioperative evaluation; respiratory symptoms; radiologic respiratory signs | 70.8% (51/72) 48.6% (35/72) identified extra-luminal compression | 33.3% (2/6) identified organisms in patients with mucosal inflammation | |
| Davidson et al[17], 2008 | 129 PICU: ECLS, CHD (age 2.9 mo-3 yr) | Airway evaluation; atelectasis; BAL; ETT position; respiratory distress | 68.4% (78/114): Overall 46.3% (37/80): ECLS 60.3% (41/68): CHD identified extra-luminal compression | 45.3% (53/117): Overall identified organism 53.8% (28/52): ECLS subgroup identified organism | 82.1% (32/39) successful procedures: removed blood and mucous plugs, or instilled surfactant, placed endovascular stents |
| de Blic et al[4], 1991 | 33 NICU: CHD, lung disease and/or congenital malformations (age 2 d-9 mo) | Anatomic evaluation; atelectasis/emphysema; respiratory distress | 62.2% (23/37): Overall 52.8% (19/36): Change in management 13.9% (5/36): Change in surgical management 50% (5/10): CHD | ||
| Efrati et al[16], 2009 | 319 PICU: CHD, oncology (age 1-22 yr) | Anatomic evaluation; BAL; trauma | 79.3% (253/319): Overall 90.2% (46/51): CHD 83.3% (50/60): Oncology 21.9% (70/319): Change in management 3.4% (11/319): Change in surgical management | 17.6% (56/319): Identified organism 12.2% (39/319): Change in antimicrobials 88% (22/25): Abnormal cytology consistent with infection | |
| Fan et al[26], 1988 | 87 PICU: (age 1 wk-18 yr) | Anatomic evaluation; decannulation; difficult intubation; respiratory symptoms; tracheostomy | 94.8% (91/96) | 87.5%(7/8) 100% (5/5): Difficult airways intubated 66.7% (2/3): Re-expanded collapsed lobe | |
| Hintz et al[22], 2002 | 8 NICU: CDH on ECLS | Atelectasis | 87.5% (7/8): Improved lung expansion after lavage | ||
| Kamat et al[19], 2011 | 79 PICU: ECLS (10 d-21 yr) | Atelectasis; BAL; anatomic evaluation; surfactant instillation | 21.3% (33/155): Identified organism | 76.1% (118/155): Atelectasis 15.4% (10/65): Improved CXR 2.6% (4/155): Surfactant | |
| Kohelet et al[27], 2011 | 19 NICU: (age 1 d-8 mo) | Anatomic evaluation; atelectasis; BAL; difficulty weaning MV; respiratory symptoms | 60% (15/25): Overall 100% (6/6): Wean from MV 52% (13/25): Abnormal anatomy | 60% (6/10): Identified organism 50% (5/10): Change in antimicrobials | 75% (6/8): Re-expanded collapsed lobe |
| Kolatat et al[28], 2002 | 45 NICU: (mean age 33 WGA) | Respiratory distress post-extubation | 93.3% (42/45) | ||
| Kotby et al[29], 2008 | 35 PICU: suspected pulmonary fungal infections (age 1-15 yr) | BAL | 40% (14/35): Identified organism 77.1% (27/35): Diagnosed probable pulmonary fungal infection (+ BAL culture or + BAL fungal antigen) | ||
| Maggi et al[36], 2012 | 44 PICU: status asthmaticus requiring MV (age 6 mo-18 yr) | Atelectasis; lavage; respiratory distress; | 100% (29/29): Improved A-a gradient, shunt fraction, decreased FiO2, improved compliance. 37.9% (11/29): Extubated within 6 h 69% (20/29): Extubated within 12 h Reduced PICU LOS (3.06 d vs 3.4 d in control (P < 0.05)) Reduced length of time on MV [10 h vs 20.5 h (P < 0.0005)] | ||
| Manna et al[30], 2006 | 134 PICU: CHD (age 4 mo-6 yr) | Anatomic evaluation; atelectasis; BAL; extubation failure; hemorrhage | 76.4% (113/148): Overall 84.4% (27/32): Upper airway 80% (56/70): Lower airway 18.6% (13/70): CHD identified extraluminal compression 90.5% (19/21): Extubation failure 44% (11/25): Pulmonary disease | 35.3% (6/17): Identified organism | 92.3% (24/26): Re-expanded collapsed lobe |
| Myer et al[30], 1988 | 10 NICU: (age 1 d-16 mo) | Atelectasis; hemorrhage; hypercarbia; hypoxia; hyperinflation; respiratory distress | 50% (5/10): Overall 20% (2/10): Granuloma | 60% (3/5): Re-expanded collapsed lobe 40% (2/5): Granuloma required rigid bronchoscopy | |
| Nakano et al[5], 2004 | 16 NICU: esophageal atresia, Trisomy 21, CDH, hydrocephalus, Goldenhaar, and Kasabach-Merritt (age 3 d-8.5 mo) | Anatomic evaluation; extubation failure; hemorrhage; respiratory distress | 66.7% (14/21) | 23.8% (5/21): Removed obstruction (mucus plug, clot/local tissue) or altered suction practice | |
| Nayak et al[21], 2012 | 30 PICU: CHD requiring mechanical ventilation prior to extubation (age 1 d-6 mo) | Anatomic evaluation; extubation failure | 50% (15/30): Overall significant tracheobronchial narrowing 50% (4/8): Extubation failure | 73.3% (22/30): Extubated | |
| Nussbaum et al[31], 2002 | 2836 PICU: (age 1 d-15 yr) | Anatomic evaluation; atelectasis; BAL; hemorrhage; ETT position; intubation; tracheostomy evaluation; plastic bronchitis; respiratory distress | 84.8% (2405/2836): Overall 95.2% (766/805): Upper airway 82.6% (1862/2254): Lower airway 47.9% (1358/2836): Inflammatory changes | 24.1% (411/1705): Identified organism 41.7% (5/12): Transbronchial biopsy positive dyskinetic cilia syndrome 72.4% (21/29): Acute chest SCD plastic bronchitis | |
| Peng et al[32], 2011 | 358 PICU and NICU: (age 1 d-17.5 yr) | Anatomic evaluation; BAL; intubation; respiratory distress | 87.2% (312/358): Overall 47.8% (171/358): Airway malacia 39.4% (141/358): Inflammatory changes | 56.1% (201/358): Interventional FFB 71.4% (518/725): of all FFB were interventional | |
| Pietsch et al[37], 1985 | 19 NICU: necrotizing tracheobronchitis (mean age 6.53 d) | Therapeutic removal of obstruction | 66.7% (10/15): Survived after removal of debris | ||
| Prentice et al[23], 2011 | 7 PICU: ECLS (age 8 d-27 yr) | Persistent atelectasis | 100% (7/7) 57.1% (4/7): Bronchus compression/narrowing 71.4% (5/7): Mucus plugs | 75% (3/4): Identified organism 75% (3/4): Change in antimicrobials | 28.7% (2/7): Removed mucus plugs, ECLS subsequently weaned |
| Sachdev et al[35], 2010 | 30 PICU: clinical suspicion of VAP (age 1 mo-12 yr) | BAL | 65% (26/40): Identified organism | ||
| Soong et al[43], 2011 | 8 PICU and NICU: obstructive fibrinous tracheal pseudomembrane (age 2 mo-13 yr) | Therapeutic ablation | 100% (8/8): Ablation of obstructive membrane | ||
| Soong et al[33], 1995 | 207 NICU and PICU: (age 1 d-10 yr) | Respiratory symptoms; intractable pneumonia | 81.1% (172/212) | 35.4% (75/212): Resolution of atelectasis, improved secretions | |
| Tang et al[3], 2009 | 47 PICU: (age 1 d-13 yr) | Anatomic evaluation, BAL; therapeutic (FB, clot removal, hemoptysis, intubation) | 80.9% (38/47) | 36.8% (7/19): Identified organism 57.9% (11/19): Change in antimicrobials | 87.0% (20/23): Re-expanded collapsed lobe. 44.8% (13/29): Extubated < 24 h after mucus plug, blood clot, FB removed |
| Ward et al[15], 1987 | 25 PICU: CHD (n = 7), (age 1 d-11 yr) | Anatomic evaluation; atelectasis; confirm ETT/tracheostomy position; hyperinflation; respiratory distress | 64% (16/25): Overall 62.5% (5/8): Tracheostomy - change in management 80% (4/5): Hemoptysis - change in management 85.7% (6/7): CHD |
Table 2 Adverse events reported with flexible bronchoscopy in critically ill pediatric patients
| Ref. | Hypoxia | Bradycardia/Hypoxia | Hypotension | Hemorrhage | Other |
| Bar-Zohar et al[24], 2004 | 0% (0/155) | 0% (0/155) | 19.3% (30/155) 12.9% (20/155) NS bolus | 0% (0/155) | 1.3% (2/155) intubated for mucus plug |
| Davidson et al[17], 2008 | 0% (0/200) | 0.5% (1/200) patient “instability” | |||
| de Blic et al[4], 1991 | 70.3% (26/37) transient moderate hypoxia (SaO2 > 80) | 0% (0/37) | |||
| Efrati et al[16], 2009 | 6.6% (21/319), resolved - O2 0.3% (1/319) - BMV 0.3% (1/319) required intubation | 3.4% (11/319), resolved - O2 and atropine | 1.6% (5/319), resolved-saline lavage | 1.6% (5/319) stridor resolved -steroids or epinephrine 0.9% (3/319) fever | |
| Fan et al[26], 1988 | 2.3% (2/87), resolved - removal of scope or O2 | 0% (0/87) | |||
| Hintz et al[22], 2002 | 37.5% (3/8) | ||||
| Kamat et al[19], 2011 | 34.2% (53/155) mild to moderate blood tinged secretions 2% (3/155) placed on HFOV for increased bloody secretions | ||||
| Kohelet et al[27], 2011 | Transient (number not reported) | 0% (0/25) | 0% (0/25) | 4% (1/25) pneumothorax | |
| Kotby et al[29], 2008 | 42.9% (15/35), transient | 5.7% (2/35), transient | 22.9% (8/35) | Decreased PaO2 | |
| Manna et al[20], 2006 | 10.8% (16/148) transient; 16.7% (3/18) of ARDS patients | 17.6% (26/148), NS bolus | 0.6% (1/148) rigid chest after fentanyl | ||
| Nussbaum et al[31], 2002 | 0.7% (21/2836), of those 76.2% (16/21) resolved - removal of scope or O2; 23.8% (5/21) emergency intubation; 2/5 apneic prior to FFB | Transient (number not reported) | 0% (0/2836) | 4% (113/2836) mild nasopharyngeal bleeding 0.4% (12/2836) bleeding after biopsy, resolved - epinephrine lavage | Transient stridor (number not reported) 0.6% (17/2836) laryngo/bronchospasm, resolved - albuterol and O2, BMV 9.5% (2/21) rigid chest after fentanyl |
| Peng et al[32], 2011 | Transient (number not reported) | Transient (number not reported) | 0.8% (6/725) laryngospasm, resolved - lidocaine spray and NIPPV 0.3% (2/725) pneumothorax 29.5% (214/725) fever | ||
| Pietsch et al[37], 1985 | 13.3% (2/15) death secondary to mainstem bronchus perforation 6.7% (1/15) pneumothorax - chest tube | ||||
| Prentice et al[23], 2011 | 5.9% (1/17), resolved - epinephrine lavage | ||||
| Soong et al[33], 1995 | 4% (10/247) transient, resolved - removal of scope or O2 1.2% (3/247) required BMV | Self-limited nasal bleeding (number not reported) | 2% (5/247) stridor | ||
| Tang et al[3], 2009 | 20.8% (11/53), mild | 3.8% (2/53), mild | 1.9% (1/53) SVT 1.9% (1/53) pneumothorax 1.9% (1/53) bronchospasm |
Table 3 Recommended indications for flexible bronchoscopy in critically Ill children
| Recommend | Consider |
| Upper airway symptoms (e.g., stridor) | CHD with persistent atelectasis |
| BAL in immunocompromised + respiratory distress | ECLS with persistent atelectasis |
| BAL in immunocompetent + respiratory distress AND + new/persistent fever AND infiltrate on chest X-ray on existing therapy | Prolonged mechanical ventilation |
| Esophageal atresia Asthma intubated + persistent atelectasis |
- Citation: Field-Ridley A, Sethi V, Murthi S, Nandalike K, Li STT. Utility of flexible fiberoptic bronchoscopy for critically ill pediatric patients: A systematic review. World J Crit Care Med 2015; 4(1): 77-88
- URL: https://www.wjgnet.com/2220-3141/full/v4/i1/77.htm
- DOI: https://dx.doi.org/10.5492/wjccm.v4.i1.77