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Pediatric bronchography performed through the flexible bronchoscope
European Journal of Radiology, 16 (1993) 158-161 0 1993 Elsevier Scientific Publishers Ireland Ltd. All rights reserved. 0720-048X/93/$06.00
158
EURRAD 00338
Pediatric bronchography performed through the flexible bronchoscope Robert T. BramsonaYb, James M. Shermanb ‘Ditiion
and Johan G. Blickman”
of Pediatric Radiology, Massachusetts General Hospital Boston, MA. USA ana’b University of South Florida College of Medicine, Tampa, FL, USA (Received 11 August 1992; accepted after revision 25 September
Key words: Bronchography,
1992)
pediatric; Bronchoscope
Abstract Ten children, ranging in age from 2 months to 16 years, were evaluated by bronchograms performed during bronchoscopy. Nine of the ten children had signiticant pathology demonstrated by the bronchogram that elucidated findings unclear from other imaging procedures at the time of bronchoscopy. Despite the generally negative opinions about the utility of bronchograms in children, information obtained by bronchography can be quite useful. Bronchography during bronchoscopy proved to be quick, simple, and safe.
Introduction In recent years the indications for pediatric bronchograms have decreased [l-4]. The advent of the flexible bronchoscope has allowed examination of some airways not easily seen with rigid instruments. In some children pathologic findings may occur in airways too small or too distal to be adequately inspected directly by even the flexible bronchoscope. Sometimes pathology in the bronchi, such as mild bronchiectasis, may remain unclear even after bronchoscopy. We found in selected individuals that bronchograms performed as a part of the bronchoscopy evaluation often provide additional useful information not obtained by bronchoscopy or other imaging procedures. Methods Four hundred fifty children underwent bronchscopy at our institution during a five year period. Ten children from this group, ages 2 months old to 16 years old, were selected to have bronchograms because they either had
Correspondence to: R. Bramson, Division of Pediatric Radiology, Massachusetts General Hospital, Fruit Street, Boston, Massachusetts 02114, USA.
undergone previous bronchoscopy that had not clearly determined the cause of pathology or they had certain clinical features or unclear findings from other imaging tests. Bronchoscopy was performed on these ten children in the fluoroscopy suite in anticipation that a bronchogram might be needed. There was another small select group of children who underwent bronchoscopy in the fluoroscopy suite in anticipation of a possible bronchogram, but the findings at bronchoscopy were sufficiently diagnostic that no bronchogram needed to be performed. The technique for bronchoscopy/bronchography was as follows: children 3 months old to 10 years old were kept NPO for four hours, sedated intramuscularly one hour prior to bronchoscopy with meperidine (2 mg/kg), promethazine (1 mg/kg), and chlorpromazine (1 mg/kg), and given topical anesthesia with 1% lidocaine. Children younger than 3 months old or older than 10 years received only topical lidocaine. Children had their bronchoscopy in a fluoroscopic suite using an Olympus BF3C4 flexible pediatric bronchoscope. After visual inspection of the airways by bronchoscopy, contrast material (Dionsil) was injected through the suction channel under fluoroscopic guidance into the area of clinical interest. Appropriate radiographs were taken. All ten children tolerated the bronchoscopy and bronchograms without complications.
159 TABLE
1
Results of broncbograms
performed as a part of bronchography
Pt.
Age
Clinical features/prebronchoscopy imaging features
Findings at bronchoscopy
Findings at bronchography
1
3m
Bronchocpuhnonary dysplasia, recurrent atelectasis on chest radiographs
Granilation tissue right mainstem (RMSB)
Stenosis RMSB, saccular RUL bronchiectasis, non-filling bronchus intermedius
2
2Y
Tbc, recurrent RML atelectasis on chest radiographs
Narrow RML orifice
Stricture medial segment, distal bronchiectasis
3
2m
Persistent LUL infiltrate on chest radiograph
? anomalous bronchi
Congenital absence of LUL
4
8~
Normal
5
2m
Persistent LLL infiltrate chest radiographs Cough, fever, unusual chest radio-
No airway to area of infiltrate (surgery sequestration) Congenital absence of left lung
graph
15 Y 16 Y 7Y
Recurrent pneumonia on chest radiograph Recurrent pneumonia on chest radiographs LLL recurrent pneumonia on chest radiographs
obstructing bronchus
Distorted bronchi, inability to definitely see a left mainstem bronchus
RML
Purulent secretions
Mild RLL, LLL bronchiectasis
Purulent secretions friable mucosa
RLL bronchiectasis
Unusually wide bronchi
Tubular LLL bronchiectasis
Normal
9
8~
Chronic LLL atelectasis on repeated chest radiographs
Normal
10
2Y
? foreign body, recurrent LUL infiltrate on chest radiographs
LUL forein body, stenosis bronchus
Fig. 1. Case 5: This child had repeated episodes of cough and fever. The bronchoscopy showed distorted anatomy with a strong suggestion of an absent left bronchus, but because of the unusual distorted anatomy the bronchogram was done through the scope and confhmed the absent left mainstem bronchus.
LUL
Stenosis of LUL bronchus distal bronchiectasis
with
Fig. 2. Case 10: This child had recurrent pneumonia and a questionable history of foreign body aspiration. At bronchoscopy the orifice was too narrow to allow the scope to be advanced. Contrast was injected through the scope and demonstrated focal narrowing of the LUL bronchus (arrow), but showed that the bronchi beyond this point, and leading toward the intiltrate in the LUL, had some mild bronchiectasis, but were otherwise not obstructed. Surgery confirmed a focal stricture secondary to a granulomatous reaction about an old foreign body.
160
Results Table 1 provides a summary of the clinical, bronchoscopic, and bronchographic findings on the ten patients. The ten patients reported here represent approximately 2% of the patients undergoing bronchoscopy during the selected period. The information obtained from the bronchogram had a definitve impact on either the diagnosis or the management of each patient studied.(Table 1, Figs 1 and 2). Discussion In recent years both pediatricians and radiologists have advocated decreasing the number of bronchograms performed on children [ 1,2]. This policy has resulted in fewer unnecessary examinations and fewer children exposed to the potential side effects of the study: atelectasis, chemical pneumonitis, and the complications of general anesthesia. Flexible bronchoscopy has been demonstrated to be a safe, useful procedure in children [3-81. It does not require general anesthesia and generally has a low rate of complications. Although airways not easily seen with a rigid bronchoscope may be inspected with flexible instruments, pathologic conditions can still be either too far distal to visualize well by direct inspection or remain unclear even after flexible bronchoscopy. A limited bronchogram, performed at the same time as the bronchoscopy, allows evaluation of bronchi distal to the end of the bronchoscope. Some investigators find general anesthesia more acceptable than local anesthesia for bronchoscopy. Although we did not utilize general anesthesia in this series, the use of local anesthesia requires considerable experience and patience to achieve optimum results in a child. If general anesthesia is utilized for whatever reason, this technique of injecting contrast through the bronchoscope into the local area of interest is still a useful way to evaluate those areas of concern that require brochgrams. Again the ability to suction out the contrast through the bronchscope at the end of the procedure is a useful advantage of this technique. There are frequently other ways of diagnosing some of the diseases discovered in our series. Multiple authors have debated the merits of thin-section CT images in bronchial diseases. All of these studies involved adults or older children.[9-121. High resolution CT can be of enormous value if a young patient can be induced to cooperate and hold his breath for a quality high resolution CT study. Unfortunately children .frequently can not or will not hold their breath and co-
operate for an optimum study unless sedated or under general anesthesia. Therefore, bronchoscopy becomes a viable option and frequently must be performed anyway. Bronchography in certain highly selected instances may help clarify findings seen on bronchoscopy. Seven of our patients would not have benefited from CT, or would have been diiIicult to image without sedation. Most of the cases in which bronchiectasis was discovered had some other feature which compelled bronchoscopy; suspicion of foreign body, persistent atelectasis, etc., and the bronchogram was simply done as an adjutant to the bronchoscopy. Others have suggested the utility of bronchography in selected patients.[ 131 Levy reported a high diagnostic yield in nine bronchograms performed through an endotracheal tube during general anesthesia [ 81. Wood briefly mentioned the flexible bronchoscope as being useful in performing pediatric bronchograms but gave no details regarding the frequency of the procedure or the diagnostic yield [ 51. A number of indications for bronchoscopy are given in pediatric textbooks and joumals.[6,8,14] Bronchograms performed using a flexible bronchoscope are quick, and provide an easy method to obtain information unavailable by direct visual bronchoscopy. Since the bronchogram is performed in conjunction with bronchoscopy, no additional anesthesia is required. The ability to inject contrast only in the area of interest as well as remove some of the contrast material by suctioning at the end of the procedure, may decrease the incidence of post-bronchoscopy atelectasis and chemical pneumonitis which have previously been reported [ 81. Other methods of performing bronchograms in children are technically more difficult and rely on the patient’s ability to cough for removal of contrast material. Some physicians have suggested the use of non-ionic contrast material as a possible alternative to the usual oily contrast used in this study. We have on one occasion used non-ionic contrast on a patient, not included in this study, and found it to be unsatisfactory. Nonionic contrast makes a “cast” of the bronchus in question, and does not coat the mucosal lining of the bronchi. Non-ionic contrast, although quite safe, simply floods the bronchus. The contrast is then quickly dissipated throughout the bronchial branches and can not be controlled to stay in one location. Nevertheless, there are some invesigators who are trying to find ways to utilize the obvious safety advantages of water soluble non-ionic contrast material.[ 151 Some investigators are trying high speed tine type exposures to freeze the contrast on a single frame, but the success has been limited. Hopefully, someone will come up with a method
161
to utilize non-ionic contrast material in the tracheobronchial tree. In this small series of ten patients we found the procedure to be safe. Pediatric bronchscopy requires considerable skill and experience and should only be performed by experienced bronchoscopists who have knowledge of the techniques necessary to evaluate children. The presence of other ancillary personnel experienced in the care of children is vital to the success of a safe and high quality diagnostic procedure. We believe that bronchograms performed as a part of bronchoscopy are very useful in selected patients and that the flexible bronchoscope provides an ideal means for performing the bronchogram. References 1 Avery, ME. Bronchography. Outmoded Procedure? Pediatrics 1970; 46: 333-334. 2 American Tboracic Society. Bronchography. Am Rev Respr Dis 1970; 101: 815-16. 3 Wood R, Sherman J. Pediatric Flexible Bronchoscopy. Ann Otorhinol Laryngol 1980; 89: 414. 4 Wood R, Fii R. Applications of Flexible Fiberoptic Bronchoscopy in Infants and Children. Chest 1978; 73: 737.
5 Wood R. Spelunking in the Pediatric Airway: Exploration with the Flexible Fiberoptic Bronchoscope. Ped Clinics N Am 1984; 31: 785-799. 6 Fitzpatrick S, Marsh B, Stokes D, Wang K-P. Indications for Flexible Fiberoptic Bronchoscopy in Pediatric Patients, Am. J. Dis. Child 1983; 137: 595-597. 7 Wood R. The Diagnostic Effectivenesss of the Flexible Bronchoscope in Children., Pediatric Pulmon 1985; 1: 88-92. 8 Levy M, Glick B, Springer C, et al. Bronchoscopy in Children: Experience with 110 Investigations. Am J Dis Child 1983; 137: 14-16. 9 Young K, Aspestrsnd F, Kolbenstvedt A. Higb Resolution CT and Bronchography in the Assessment of Bronchiectasis. Acta Radiologica 1991; 32: 439-441. 10 Phillips M, Wiiams M, Flower C.How Useful is Computed Tomography in the Diagnosis and Assessment of Bronchiectasis? Clin Radio1 1986; 37: 321-325. 11 Grenier P, et al. Bronchiectasis. Assessment by thin-section CT. Radiology 1986; 161: 95-99. 12 Nadich, D., et al., Basilar segmental bronchi. Thin-section CT Evaluation Radiology 1988; 169: 11. 13 Wilson J, Peterson G, Fleshman K: A Technique for Bronchography in Children 7ndash; An Experience with 575 Patients Using Topical Anesthesia. Am Rev Respir Dis 1972; 105: 564571. 14 Gans S. Bronchoscopy. In: Gans S, Ed., Pediatric Endoscopy, New York: Grune & Stratton, 1983; 38-41. 15 Oral Communication, Annual Neuhauser Society Meeting, Philadelphia, Pa. Septmenber 1992.
158
EURRAD 00338
Pediatric bronchography performed through the flexible bronchoscope Robert T. BramsonaYb, James M. Shermanb ‘Ditiion
and Johan G. Blickman”
of Pediatric Radiology, Massachusetts General Hospital Boston, MA. USA ana’b University of South Florida College of Medicine, Tampa, FL, USA (Received 11 August 1992; accepted after revision 25 September
Key words: Bronchography,
1992)
pediatric; Bronchoscope
Abstract Ten children, ranging in age from 2 months to 16 years, were evaluated by bronchograms performed during bronchoscopy. Nine of the ten children had signiticant pathology demonstrated by the bronchogram that elucidated findings unclear from other imaging procedures at the time of bronchoscopy. Despite the generally negative opinions about the utility of bronchograms in children, information obtained by bronchography can be quite useful. Bronchography during bronchoscopy proved to be quick, simple, and safe.
Introduction In recent years the indications for pediatric bronchograms have decreased [l-4]. The advent of the flexible bronchoscope has allowed examination of some airways not easily seen with rigid instruments. In some children pathologic findings may occur in airways too small or too distal to be adequately inspected directly by even the flexible bronchoscope. Sometimes pathology in the bronchi, such as mild bronchiectasis, may remain unclear even after bronchoscopy. We found in selected individuals that bronchograms performed as a part of the bronchoscopy evaluation often provide additional useful information not obtained by bronchoscopy or other imaging procedures. Methods Four hundred fifty children underwent bronchscopy at our institution during a five year period. Ten children from this group, ages 2 months old to 16 years old, were selected to have bronchograms because they either had
Correspondence to: R. Bramson, Division of Pediatric Radiology, Massachusetts General Hospital, Fruit Street, Boston, Massachusetts 02114, USA.
undergone previous bronchoscopy that had not clearly determined the cause of pathology or they had certain clinical features or unclear findings from other imaging tests. Bronchoscopy was performed on these ten children in the fluoroscopy suite in anticipation that a bronchogram might be needed. There was another small select group of children who underwent bronchoscopy in the fluoroscopy suite in anticipation of a possible bronchogram, but the findings at bronchoscopy were sufficiently diagnostic that no bronchogram needed to be performed. The technique for bronchoscopy/bronchography was as follows: children 3 months old to 10 years old were kept NPO for four hours, sedated intramuscularly one hour prior to bronchoscopy with meperidine (2 mg/kg), promethazine (1 mg/kg), and chlorpromazine (1 mg/kg), and given topical anesthesia with 1% lidocaine. Children younger than 3 months old or older than 10 years received only topical lidocaine. Children had their bronchoscopy in a fluoroscopic suite using an Olympus BF3C4 flexible pediatric bronchoscope. After visual inspection of the airways by bronchoscopy, contrast material (Dionsil) was injected through the suction channel under fluoroscopic guidance into the area of clinical interest. Appropriate radiographs were taken. All ten children tolerated the bronchoscopy and bronchograms without complications.
159 TABLE
1
Results of broncbograms
performed as a part of bronchography
Pt.
Age
Clinical features/prebronchoscopy imaging features
Findings at bronchoscopy
Findings at bronchography
1
3m
Bronchocpuhnonary dysplasia, recurrent atelectasis on chest radiographs
Granilation tissue right mainstem (RMSB)
Stenosis RMSB, saccular RUL bronchiectasis, non-filling bronchus intermedius
2
2Y
Tbc, recurrent RML atelectasis on chest radiographs
Narrow RML orifice
Stricture medial segment, distal bronchiectasis
3
2m
Persistent LUL infiltrate on chest radiograph
? anomalous bronchi
Congenital absence of LUL
4
8~
Normal
5
2m
Persistent LLL infiltrate chest radiographs Cough, fever, unusual chest radio-
No airway to area of infiltrate (surgery sequestration) Congenital absence of left lung
graph
15 Y 16 Y 7Y
Recurrent pneumonia on chest radiograph Recurrent pneumonia on chest radiographs LLL recurrent pneumonia on chest radiographs
obstructing bronchus
Distorted bronchi, inability to definitely see a left mainstem bronchus
RML
Purulent secretions
Mild RLL, LLL bronchiectasis
Purulent secretions friable mucosa
RLL bronchiectasis
Unusually wide bronchi
Tubular LLL bronchiectasis
Normal
9
8~
Chronic LLL atelectasis on repeated chest radiographs
Normal
10
2Y
? foreign body, recurrent LUL infiltrate on chest radiographs
LUL forein body, stenosis bronchus
Fig. 1. Case 5: This child had repeated episodes of cough and fever. The bronchoscopy showed distorted anatomy with a strong suggestion of an absent left bronchus, but because of the unusual distorted anatomy the bronchogram was done through the scope and confhmed the absent left mainstem bronchus.
LUL
Stenosis of LUL bronchus distal bronchiectasis
with
Fig. 2. Case 10: This child had recurrent pneumonia and a questionable history of foreign body aspiration. At bronchoscopy the orifice was too narrow to allow the scope to be advanced. Contrast was injected through the scope and demonstrated focal narrowing of the LUL bronchus (arrow), but showed that the bronchi beyond this point, and leading toward the intiltrate in the LUL, had some mild bronchiectasis, but were otherwise not obstructed. Surgery confirmed a focal stricture secondary to a granulomatous reaction about an old foreign body.
160
Results Table 1 provides a summary of the clinical, bronchoscopic, and bronchographic findings on the ten patients. The ten patients reported here represent approximately 2% of the patients undergoing bronchoscopy during the selected period. The information obtained from the bronchogram had a definitve impact on either the diagnosis or the management of each patient studied.(Table 1, Figs 1 and 2). Discussion In recent years both pediatricians and radiologists have advocated decreasing the number of bronchograms performed on children [ 1,2]. This policy has resulted in fewer unnecessary examinations and fewer children exposed to the potential side effects of the study: atelectasis, chemical pneumonitis, and the complications of general anesthesia. Flexible bronchoscopy has been demonstrated to be a safe, useful procedure in children [3-81. It does not require general anesthesia and generally has a low rate of complications. Although airways not easily seen with a rigid bronchoscope may be inspected with flexible instruments, pathologic conditions can still be either too far distal to visualize well by direct inspection or remain unclear even after flexible bronchoscopy. A limited bronchogram, performed at the same time as the bronchoscopy, allows evaluation of bronchi distal to the end of the bronchoscope. Some investigators find general anesthesia more acceptable than local anesthesia for bronchoscopy. Although we did not utilize general anesthesia in this series, the use of local anesthesia requires considerable experience and patience to achieve optimum results in a child. If general anesthesia is utilized for whatever reason, this technique of injecting contrast through the bronchoscope into the local area of interest is still a useful way to evaluate those areas of concern that require brochgrams. Again the ability to suction out the contrast through the bronchscope at the end of the procedure is a useful advantage of this technique. There are frequently other ways of diagnosing some of the diseases discovered in our series. Multiple authors have debated the merits of thin-section CT images in bronchial diseases. All of these studies involved adults or older children.[9-121. High resolution CT can be of enormous value if a young patient can be induced to cooperate and hold his breath for a quality high resolution CT study. Unfortunately children .frequently can not or will not hold their breath and co-
operate for an optimum study unless sedated or under general anesthesia. Therefore, bronchoscopy becomes a viable option and frequently must be performed anyway. Bronchography in certain highly selected instances may help clarify findings seen on bronchoscopy. Seven of our patients would not have benefited from CT, or would have been diiIicult to image without sedation. Most of the cases in which bronchiectasis was discovered had some other feature which compelled bronchoscopy; suspicion of foreign body, persistent atelectasis, etc., and the bronchogram was simply done as an adjutant to the bronchoscopy. Others have suggested the utility of bronchography in selected patients.[ 131 Levy reported a high diagnostic yield in nine bronchograms performed through an endotracheal tube during general anesthesia [ 81. Wood briefly mentioned the flexible bronchoscope as being useful in performing pediatric bronchograms but gave no details regarding the frequency of the procedure or the diagnostic yield [ 51. A number of indications for bronchoscopy are given in pediatric textbooks and joumals.[6,8,14] Bronchograms performed using a flexible bronchoscope are quick, and provide an easy method to obtain information unavailable by direct visual bronchoscopy. Since the bronchogram is performed in conjunction with bronchoscopy, no additional anesthesia is required. The ability to inject contrast only in the area of interest as well as remove some of the contrast material by suctioning at the end of the procedure, may decrease the incidence of post-bronchoscopy atelectasis and chemical pneumonitis which have previously been reported [ 81. Other methods of performing bronchograms in children are technically more difficult and rely on the patient’s ability to cough for removal of contrast material. Some physicians have suggested the use of non-ionic contrast material as a possible alternative to the usual oily contrast used in this study. We have on one occasion used non-ionic contrast on a patient, not included in this study, and found it to be unsatisfactory. Nonionic contrast makes a “cast” of the bronchus in question, and does not coat the mucosal lining of the bronchi. Non-ionic contrast, although quite safe, simply floods the bronchus. The contrast is then quickly dissipated throughout the bronchial branches and can not be controlled to stay in one location. Nevertheless, there are some invesigators who are trying to find ways to utilize the obvious safety advantages of water soluble non-ionic contrast material.[ 151 Some investigators are trying high speed tine type exposures to freeze the contrast on a single frame, but the success has been limited. Hopefully, someone will come up with a method
161
to utilize non-ionic contrast material in the tracheobronchial tree. In this small series of ten patients we found the procedure to be safe. Pediatric bronchscopy requires considerable skill and experience and should only be performed by experienced bronchoscopists who have knowledge of the techniques necessary to evaluate children. The presence of other ancillary personnel experienced in the care of children is vital to the success of a safe and high quality diagnostic procedure. We believe that bronchograms performed as a part of bronchoscopy are very useful in selected patients and that the flexible bronchoscope provides an ideal means for performing the bronchogram. References 1 Avery, ME. Bronchography. Outmoded Procedure? Pediatrics 1970; 46: 333-334. 2 American Tboracic Society. Bronchography. Am Rev Respr Dis 1970; 101: 815-16. 3 Wood R, Sherman J. Pediatric Flexible Bronchoscopy. Ann Otorhinol Laryngol 1980; 89: 414. 4 Wood R, Fii R. Applications of Flexible Fiberoptic Bronchoscopy in Infants and Children. Chest 1978; 73: 737.
5 Wood R. Spelunking in the Pediatric Airway: Exploration with the Flexible Fiberoptic Bronchoscope. Ped Clinics N Am 1984; 31: 785-799. 6 Fitzpatrick S, Marsh B, Stokes D, Wang K-P. Indications for Flexible Fiberoptic Bronchoscopy in Pediatric Patients, Am. J. Dis. Child 1983; 137: 595-597. 7 Wood R. The Diagnostic Effectivenesss of the Flexible Bronchoscope in Children., Pediatric Pulmon 1985; 1: 88-92. 8 Levy M, Glick B, Springer C, et al. Bronchoscopy in Children: Experience with 110 Investigations. Am J Dis Child 1983; 137: 14-16. 9 Young K, Aspestrsnd F, Kolbenstvedt A. Higb Resolution CT and Bronchography in the Assessment of Bronchiectasis. Acta Radiologica 1991; 32: 439-441. 10 Phillips M, Wiiams M, Flower C.How Useful is Computed Tomography in the Diagnosis and Assessment of Bronchiectasis? Clin Radio1 1986; 37: 321-325. 11 Grenier P, et al. Bronchiectasis. Assessment by thin-section CT. Radiology 1986; 161: 95-99. 12 Nadich, D., et al., Basilar segmental bronchi. Thin-section CT Evaluation Radiology 1988; 169: 11. 13 Wilson J, Peterson G, Fleshman K: A Technique for Bronchography in Children 7ndash; An Experience with 575 Patients Using Topical Anesthesia. Am Rev Respir Dis 1972; 105: 564571. 14 Gans S. Bronchoscopy. In: Gans S, Ed., Pediatric Endoscopy, New York: Grune & Stratton, 1983; 38-41. 15 Oral Communication, Annual Neuhauser Society Meeting, Philadelphia, Pa. Septmenber 1992.