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Rigid bronchoscopy in the pediatric age group: Diagnostic effectiveness
Rigid Bronchoscopy in the Pediatric Diagnostic Effectiveness By Nathan E. Wiseman,
lgnacio
Age Group:
Sanchez, and Richard E. Powell
Winnipeg, Manitoba 0 Over a 15-year period, 277 diagnostic bronchoscopic procedures were carried out at the Winnipeg Children’s Hospital using rigid bronehoscopic instrumentation. The objective of the review is to examine contribution to final diagnosis made by the procedure. The patient population included 60% male and 40% female patients ranging from the first day of life to 18 years (mean age, 6 years). Indications for bronchoscopy fell into two large groups, including 60% of patients with evidence of lower airway disease and 30% of patients with evidence of upper airway obstruction, In patients with upper airway obstruction, half werefound to have a congenital underlying cause and half were due to an acquired lesion. In 85% of patients, a specific diagnosis was reached and this proved to correlate positively with the preoperative diagnosis in 80% of patients and negatively in 20%. Definitive treatment in patients with upper airway obstruction included surgical intervention in one third of patients. Patients with lower airway disease were diagnosed as having consolidation in 43%. atelectasis in 39%. and bronchiectasis in 18%. Disease localized most frequently to the left lower and right upper lobes and in only 10 of 168 patients was a congenital cause determined. Among 168 patients, 30 had surgical treatment as the definitive management with the majority of patients treated medically. Bronchoscopy was shown to contribute to diagnosis in 88% of patients examined. Bronchoscopy was carried out with a complication rate of 3% and no mortality. Copyright o 1992 by W.B. Saunders Company INDEX WORDS:
Bronchoscopy,
rigid, pediatric.
EDIATRIC bronchoscopy can be performed using either rigid or flexible instrumentation.i-4 In general, rigid bronchoscopy is used as both a diagnostic and therapeutic tool (extraction of foreign bodies, airway manipulation), whereas the flexible bronchoscope is primarily diagnostic and can be passed more peripherally into the airways.3-G The rigid bronchoscope remains an excellent diagnostic tool for both upper and lower airway disease. Its limitations include the need for general anesthesia in most patients and somewhat difficult access to several segmental bronchi.4Js7
P
It remains our practice to assess patients with upper and lower airway problems using the rigid instrument, and we have reviewed our experience in children, specifically examining the diagnostic effectiveness in this age group. MATERIALS
AND METHODS
Over a E-year period, 277 diagnostic bronchoscopic procedures were carried out at the Winnipeg Children’s Hospital using rigid bronchoscopic instrumentation. The patient population included 60% male and 40% female patients ranging from the first day of life to 18 years of age (mean age, 6 years). We excluded all patients with a diagnosis of foreign body aspiration, which was published in a previous communicati0n.a Under general anesthesia, rigid pediatric ventilating bronchoscopes (Karl Storz GmbH Co, Tuttlingen, Germany) of appropriate sizes were used together with their antifog housing and Hopkins fibreoptic telescopes. When indicated, Stortz optical biopsy or grasping forceps were used through the instrumentation channel or the open tube. A retrospective review of 277 patients was carried out, looking at the patient demographics and diagnostic information. Indications for bronchoscopy were reviewed and a comparison was made between pre and post bronchoscopy diagnosis in order to assess the correlation. Findings at bronchoscopy and procedures carried out during bronchoscopy were also reviewed. An assessment of complications and an assessment of the contribution to diagnosis that the procedure was felt to have made was also reviewed. RESULTS
The indications for bronchoscopic examination included two large patient categories. The first consisted of 168 patients with lower airway (parenchymal) disease including consolidation, lobar collapse, and bronchiectasis, and comprised 60% of the total. The second large group consisted of 87 patients with upper airway obstruction comprising 31% of the total. The remaining 22 patients included those with hemoptysis (5) congenital anomalies (12), and miscellaneous group (5). Upper Airway Obstruction
From the Sections of Pediatric Surgery and Respirology, Department of Pediatrics, University of Manitoba, Winnipeg Children S Hospital, Winnipeg, Manitoba. Presented at the 23rd Annual Meeting of the Canadian Association of Paediattic Surgeons, Quebec City, Quebec, September 19-22, 1991. Address reprint requests to Nathan E. Wiseman, MD, Pediatric General Surgery, Children’s Hospital, AE206-671 William Ave, Winnipeg, Manitoba R3E OZ2, Canada. Copyright o I992 by W.B. Saunders Company 0022-3468/92/2710-0009$03.00/O 1294
A total of 87 patients underwent bronchoscopic examination with clinical evidence of large airway obstruction. This group consisted of 34 females and 53 males with a mean age of 22 months. Forty-six patients (53%) were found to have a congenital etiology accounting for the airway obstruction and 41 (47%) had an acquired etiology. Acquired lesions included 21 patients with a cause related to a tracheobronchial infection, 17 with acquired tracheal stenoJournalofPediatric Surgery, Vol27, No 10 (October), 1992: pp 1294-1297
RIGID BRONCHOSCOPY
IN PEDIATRIC PATIENTS
1295
Table 1. Diagnosis and Age Distribution in Children With Upper Airway Obstruction No. of Patients Oiagnosis
1.3yr
-
Laryngomalacia Tracheomalacia
>3yr
4
Bronchomalacia
-
Vocal cord paralysis
-
3 -
Subglottic stenosis
8
Vascular ring
2
-
7
Papillomatosis
-
Hemangioma, cysts
13
1
Infection (tracheitis. epiglottitis)
5
4
4
Normal findings
4
1
1
55
20
18
Total
-
3
sis, and in 3 patients both were encountered. Frequency of specific diagnosis in the different age groups is shown in Table 1. At the time of bronchoscopy the abnormal findings were classified as endobronchial (9 patients: pus, mucous, purulent plugs), bronchial wall (70 patients: 48 with structural abnormalities, 15 with endothelial abnormalities, and 7 with both). Seven patients were noted to have extrinsic compression that was due either to an inflammatory lesion, tumor, or vascular ring. An additional procedure was carried out in 14 patients, consisting of aspiration of bronchial secretion in 9, bronchial lavage in 1, and biopsy in 4. In 11 patients a therapeutic intervention (dilatation of bronchial tree or biopsy of bronchial wall) occurred, leading into an increase in airway calibre. Following endoscopy, 29 patients (33%) came to ultimate surgical treatment, consisting of a variety of procedures such as division of vascular ring, resection of mediastinal cyst or tumor, and laser resection of endobronchial tumor such as papilloma. The duration of the procedure was 47 +- 20 minutes (mean + SD). Procedures were relatively uncomplicated with only 2 (0.5%) recorded episodes of postbronchoscopy stridor that required medical treatment. Among 87 patients who underwent rigid bronchoscopy for upper airway obstruction the procedure ied to a specific diagnosis in 74 (85%) and failed to yield a specific diagnosis in 13 patients (15%). In patients with a specific postbronchoscopy diagnosis there was a positive correlation in 60 (81%) with the prebronchoscopy diagnosis and a negative correlation in 14 (19%). LowerAirway Obstruction
A total of 168 patients underwent bronchoscopy with evidence of lower airway disease including: atelectasis (66), recurrent pneumonia (72), and bron-
chiectasis (30). Frequency of diagnosis of the different age groups is shown in Table 2. The group consisted of 76 female and 92 male patients with a mean age of 64 months. The anatomic lobar distribution of disease was known in 135 patients (Table 3). Patients examined had a mean duration of lower airway disease of 3.54 + 6.64 months. The etiology for lower airway disease was a congenital anomaly in 10 patients (6%) and an acquired lesion in 158 patients (94%). The most common acquired problem was infection (155 patients). In 3 patients the disease was a result of intubation or trauma. Bronchoscopic abnormal findings were classified as endobronchial, bronchial wall, or extrinsic. Endobronchial abnormalities occurred in 144 patients, and consisted of endobronchial plug (6), purulent secretions (124), mucoid secretions (12), and bloody secretions (6). Bronchial wall abnormalities occurred in 152 patients consisting of endothelial inflammatory changes (1261, structural abnormalities (13), and both endothelial and structural abnormalities (13). There were 6 patients with evidence of extrinsic compression as a result of either an inflammatory lesion or tumor. There were 141 patients who underwent a therapeutic intervention such as a bronchial aspiration alone (61), aspiration with lavage (69), and biopsy (11). In 132 patients the appearance of the airway was significantly improved after having been cleared by aspiration and lavage; this was considered a positive therapeutic intervention. In 99 patients, data were available with respect to bacteriology from materials obtained at the time of bronchoscopy. Culture results indicated that Huemophilus influenzae was the most common organism isolated (56%), followed by Streptococcus viridans (22%), Pneumococcus (8%), and others (Staphylococcus, Brahmanella catarrhalis ). Following bronchoscopic investigation of patients with lower airway disease, 30 patients subsequently came to definitive surgical treatment. In most instances, this consisted of pulmonary resection for bronchiectasis. In 6 patients (3.5%) complications Table 2. Diagnosis and Age Distribution in Children With Lower Airway Disease No. of Patients Diagnosis
1-3 yr
Recurrent pneumonia
10
23
39
Lobe collapse
17
14
35
Bronchiectasis
1
1
28
Hemoptysis
1
Malformations
6
1
5
Others
1
2
2
36
41
113
Total
>3yr
4
1296
WISEMAN,
Table 3. Anatomic Lobar Distribution of Lower Airway Disease
SANCHEZ, AND POWELL
7
scopy and postbronchoscopy diagnosis was positive in 81% of patients with upper airway disease and 74% of patients with lower airway disease. The diagnosis returned following the procedure led to specific surgical intervention in 33% of patients with upper airway obstruction and 18% of patients with lower airway disease. In previously reported pediatric series of diagnostic bronchoscopies the incidence of upper airway obstruction as an indication has varied. Godfrey et al4 in a series of 379 rigid bronchoscopies had only 8% of patients with upper airway disease, whereas Wood,2 using the flexible bronchoscopic technique, had 49% of patients with upper airway disease. The differences in indications appear to be more a reflection of pattern of practice rather than to true incidence. In the series reported herein and also in the series published by Wood2 upper airway obstruction was typically diagnosed with stridor as the most common prebronchoscopy symptom. Other symptoms leading to bronchoscopy included hoarseness, wheezing, and an irritative cough. In a group of patients with upper airway obstruction Holinger’ noted an 87% incidence of congenital anomalies compared with 50% of the patients in the series reported herein. In patients presenting with upper airway problems a high diagnostic yield has been the rule following bronchoscopy and is in agreement with our experience.2,4J The incidence of diagnoses leading to surgical intervention has been somewhat variable in reported series. Although there are some limitations in conducting a retrospective analysis of diagnosis; it appears quite definite that rigit bronchoscopy frequently yields a specific diagnosis when the prebronchoscopy indication includes atelectasis, lobar consolidation, and recurrent pneumonia. This is in essential agreement with other reported series.2*4 In the series reported herein there was a somewhat higher incidence of bronchiectasis leading to a more frequent need for subsequent surgical intervention. Lobectomy was thus carried out following bronchoscopy more often than in other reported series. It is noteworthy that the lobar distribution favoring the left lower lobe and the right upper lobe is in specific agreement with the usual expected distribution of bronchiectasis. The rigid bronchoscopic procedure was carried out with a low morbidity rate (3%) and in each instance complications were of a minor nature. This complication rate is similar to other reported series of broncho-
Cystic fibrosis
2
scopies.4,5,7,9,10
Leukemia
5
In conclusion, rigid bronchoscopy in children remains an important diagnostic procedure with a high
No. (“lo)
Leftlower lobe
51 (30)
Right upper lobe
39 (23)
Right middle lobe
26 (16)
Right lower lobe
23 (13)
Left upper lobe
16
Complete right or left lung
11 (6)
Total
(9)
166 (97)
occurred consisting of postbronchoscopy stridor in 1, respiratory failure in 3, and others in 2 patients. There was no mortality. The mean duration of the procedure was 51 minutes. The associated diagnoses at the time of bronchoscopy are shown in Table 4. Among 168 patients with lower airway disease who underwent bronchoscopy the procedure was shown to contribute to diagnosis in 149 patients (88%). The contribution was positive in 127 patients (85%) in whom a specific diagnosis was reached, and was negative in 22 patients (15%) in whom specific diagnoses were ruled out. In 19 patients (12%) the procedure was considered to be noncontributory. The prebronchoscopy and postbronchoscopy diagnoses correlated in a positive fashion in 124 patients (74%) and a negative correlation was observed in 44 patients (26%) in whom a different diagnosis was made following the endoscopic examination. DISCUSSION
This review of rigid bronchoscopy was undertaken to evaluate the diagnostic yield and to examine the contribution to final diagnosis made by the technique in children. Indications for bronchoscopy fell into two large categories: upper airway obstruction (30% of patients) and lower airway disease (60% of patients). Bronchoscopy led to a specific diagnosis or contributed to the diagnosis in 85% of patients with upper airway obstruction and in 88% of patients with lower airway disease. The correlation between prebronchoTable 4. Associated Diagnoses at the Time of Bronchoscopy Diagnosis Down’s syndrome
No. of Patients
5
Prematurity
12
Associated congenital anomalies
15
Posttraumatic
8
Tuberculosis
8
Bronchopulmonary
dysplasia
Asthma
Gastroesophageal
reflux
11
5
RIGID BRONCHOSCOPY
IN PEDIATRIC PATIENTS
1297
yield of specific diagnoses in patients with both upper and lower airway disease. In addition, therapeutic intervention and airway manipulation is facilitated by the rigid bronchoscope. The procedure has been carried out with a low mobidity rate and without
ing diagnostic intervention.
mortality.
excellent secretarial assistance.
The procedure
remains
important
in supply-
information
preliminary
to surgical
ACKNOWLEDGMENT We are grateful to Doris Jensen and Kirsten Ryan for their
REFERENCES 1. Wood RE, Postma D: Endoscopy of the airway in infants and children. J Pediatr 112:1-6,1988 2. Wood RE: The diagnostic effectiveness of the flexible bronchoscope in children. Pediatr Pulmonol 1:188-192, 1985 3. Sherman JM: Rigid or flexible bronchoscopy in children. Pediatr Pulmonol3:141,1987 4. Godfrey S, Springer C, Maayan C, et al: Is there a place for rigid bronchoscopy in the management of pediatric lung disease? Pediatr Pulmonol3:179-184, 1987 5. Friedman EM, Williams M, Healy GB, et al: Pediatric endoscopy: A review of 616 cases. Ann Otol Rhino1 Laryngol 93:517-519. 1984
6. Wood RE: Pitfalls in the use of the flexible bronchoscope in pediatric patients. Chest 97:199-203,199O 7. Holinger LD: Etiology of stridor in the neonate, infant, and child. Ann Otol Rhino1 Laryngol89:397-400,198O 8. Wiseman NE: The diagnosis of foreign body aspiration in childhood. J Pediatr Surg 19:531-535, 1984 9. Nussbaum E: Flexible fiberoptic bronchoscopy and laryngoscopy in children under 2 years of age: Diagnostic and therapeutic applications of a new pediatric flexible fiberoptic bronchoscope. Crit Care Med 10:770-772,1982 10. Schnapf BM: Oxygen desaturation during fiberoptic bronchoscopy in pediatric patients. Chest 99:591-594, 1991
lgnacio
Age Group:
Sanchez, and Richard E. Powell
Winnipeg, Manitoba 0 Over a 15-year period, 277 diagnostic bronchoscopic procedures were carried out at the Winnipeg Children’s Hospital using rigid bronehoscopic instrumentation. The objective of the review is to examine contribution to final diagnosis made by the procedure. The patient population included 60% male and 40% female patients ranging from the first day of life to 18 years (mean age, 6 years). Indications for bronchoscopy fell into two large groups, including 60% of patients with evidence of lower airway disease and 30% of patients with evidence of upper airway obstruction, In patients with upper airway obstruction, half werefound to have a congenital underlying cause and half were due to an acquired lesion. In 85% of patients, a specific diagnosis was reached and this proved to correlate positively with the preoperative diagnosis in 80% of patients and negatively in 20%. Definitive treatment in patients with upper airway obstruction included surgical intervention in one third of patients. Patients with lower airway disease were diagnosed as having consolidation in 43%. atelectasis in 39%. and bronchiectasis in 18%. Disease localized most frequently to the left lower and right upper lobes and in only 10 of 168 patients was a congenital cause determined. Among 168 patients, 30 had surgical treatment as the definitive management with the majority of patients treated medically. Bronchoscopy was shown to contribute to diagnosis in 88% of patients examined. Bronchoscopy was carried out with a complication rate of 3% and no mortality. Copyright o 1992 by W.B. Saunders Company INDEX WORDS:
Bronchoscopy,
rigid, pediatric.
EDIATRIC bronchoscopy can be performed using either rigid or flexible instrumentation.i-4 In general, rigid bronchoscopy is used as both a diagnostic and therapeutic tool (extraction of foreign bodies, airway manipulation), whereas the flexible bronchoscope is primarily diagnostic and can be passed more peripherally into the airways.3-G The rigid bronchoscope remains an excellent diagnostic tool for both upper and lower airway disease. Its limitations include the need for general anesthesia in most patients and somewhat difficult access to several segmental bronchi.4Js7
P
It remains our practice to assess patients with upper and lower airway problems using the rigid instrument, and we have reviewed our experience in children, specifically examining the diagnostic effectiveness in this age group. MATERIALS
AND METHODS
Over a E-year period, 277 diagnostic bronchoscopic procedures were carried out at the Winnipeg Children’s Hospital using rigid bronchoscopic instrumentation. The patient population included 60% male and 40% female patients ranging from the first day of life to 18 years of age (mean age, 6 years). We excluded all patients with a diagnosis of foreign body aspiration, which was published in a previous communicati0n.a Under general anesthesia, rigid pediatric ventilating bronchoscopes (Karl Storz GmbH Co, Tuttlingen, Germany) of appropriate sizes were used together with their antifog housing and Hopkins fibreoptic telescopes. When indicated, Stortz optical biopsy or grasping forceps were used through the instrumentation channel or the open tube. A retrospective review of 277 patients was carried out, looking at the patient demographics and diagnostic information. Indications for bronchoscopy were reviewed and a comparison was made between pre and post bronchoscopy diagnosis in order to assess the correlation. Findings at bronchoscopy and procedures carried out during bronchoscopy were also reviewed. An assessment of complications and an assessment of the contribution to diagnosis that the procedure was felt to have made was also reviewed. RESULTS
The indications for bronchoscopic examination included two large patient categories. The first consisted of 168 patients with lower airway (parenchymal) disease including consolidation, lobar collapse, and bronchiectasis, and comprised 60% of the total. The second large group consisted of 87 patients with upper airway obstruction comprising 31% of the total. The remaining 22 patients included those with hemoptysis (5) congenital anomalies (12), and miscellaneous group (5). Upper Airway Obstruction
From the Sections of Pediatric Surgery and Respirology, Department of Pediatrics, University of Manitoba, Winnipeg Children S Hospital, Winnipeg, Manitoba. Presented at the 23rd Annual Meeting of the Canadian Association of Paediattic Surgeons, Quebec City, Quebec, September 19-22, 1991. Address reprint requests to Nathan E. Wiseman, MD, Pediatric General Surgery, Children’s Hospital, AE206-671 William Ave, Winnipeg, Manitoba R3E OZ2, Canada. Copyright o I992 by W.B. Saunders Company 0022-3468/92/2710-0009$03.00/O 1294
A total of 87 patients underwent bronchoscopic examination with clinical evidence of large airway obstruction. This group consisted of 34 females and 53 males with a mean age of 22 months. Forty-six patients (53%) were found to have a congenital etiology accounting for the airway obstruction and 41 (47%) had an acquired etiology. Acquired lesions included 21 patients with a cause related to a tracheobronchial infection, 17 with acquired tracheal stenoJournalofPediatric Surgery, Vol27, No 10 (October), 1992: pp 1294-1297
RIGID BRONCHOSCOPY
IN PEDIATRIC PATIENTS
1295
Table 1. Diagnosis and Age Distribution in Children With Upper Airway Obstruction No. of Patients Oiagnosis
1.3yr
-
Laryngomalacia Tracheomalacia
>3yr
4
Bronchomalacia
-
Vocal cord paralysis
-
3 -
Subglottic stenosis
8
Vascular ring
2
-
7
Papillomatosis
-
Hemangioma, cysts
13
1
Infection (tracheitis. epiglottitis)
5
4
4
Normal findings
4
1
1
55
20
18
Total
-
3
sis, and in 3 patients both were encountered. Frequency of specific diagnosis in the different age groups is shown in Table 1. At the time of bronchoscopy the abnormal findings were classified as endobronchial (9 patients: pus, mucous, purulent plugs), bronchial wall (70 patients: 48 with structural abnormalities, 15 with endothelial abnormalities, and 7 with both). Seven patients were noted to have extrinsic compression that was due either to an inflammatory lesion, tumor, or vascular ring. An additional procedure was carried out in 14 patients, consisting of aspiration of bronchial secretion in 9, bronchial lavage in 1, and biopsy in 4. In 11 patients a therapeutic intervention (dilatation of bronchial tree or biopsy of bronchial wall) occurred, leading into an increase in airway calibre. Following endoscopy, 29 patients (33%) came to ultimate surgical treatment, consisting of a variety of procedures such as division of vascular ring, resection of mediastinal cyst or tumor, and laser resection of endobronchial tumor such as papilloma. The duration of the procedure was 47 +- 20 minutes (mean + SD). Procedures were relatively uncomplicated with only 2 (0.5%) recorded episodes of postbronchoscopy stridor that required medical treatment. Among 87 patients who underwent rigid bronchoscopy for upper airway obstruction the procedure ied to a specific diagnosis in 74 (85%) and failed to yield a specific diagnosis in 13 patients (15%). In patients with a specific postbronchoscopy diagnosis there was a positive correlation in 60 (81%) with the prebronchoscopy diagnosis and a negative correlation in 14 (19%). LowerAirway Obstruction
A total of 168 patients underwent bronchoscopy with evidence of lower airway disease including: atelectasis (66), recurrent pneumonia (72), and bron-
chiectasis (30). Frequency of diagnosis of the different age groups is shown in Table 2. The group consisted of 76 female and 92 male patients with a mean age of 64 months. The anatomic lobar distribution of disease was known in 135 patients (Table 3). Patients examined had a mean duration of lower airway disease of 3.54 + 6.64 months. The etiology for lower airway disease was a congenital anomaly in 10 patients (6%) and an acquired lesion in 158 patients (94%). The most common acquired problem was infection (155 patients). In 3 patients the disease was a result of intubation or trauma. Bronchoscopic abnormal findings were classified as endobronchial, bronchial wall, or extrinsic. Endobronchial abnormalities occurred in 144 patients, and consisted of endobronchial plug (6), purulent secretions (124), mucoid secretions (12), and bloody secretions (6). Bronchial wall abnormalities occurred in 152 patients consisting of endothelial inflammatory changes (1261, structural abnormalities (13), and both endothelial and structural abnormalities (13). There were 6 patients with evidence of extrinsic compression as a result of either an inflammatory lesion or tumor. There were 141 patients who underwent a therapeutic intervention such as a bronchial aspiration alone (61), aspiration with lavage (69), and biopsy (11). In 132 patients the appearance of the airway was significantly improved after having been cleared by aspiration and lavage; this was considered a positive therapeutic intervention. In 99 patients, data were available with respect to bacteriology from materials obtained at the time of bronchoscopy. Culture results indicated that Huemophilus influenzae was the most common organism isolated (56%), followed by Streptococcus viridans (22%), Pneumococcus (8%), and others (Staphylococcus, Brahmanella catarrhalis ). Following bronchoscopic investigation of patients with lower airway disease, 30 patients subsequently came to definitive surgical treatment. In most instances, this consisted of pulmonary resection for bronchiectasis. In 6 patients (3.5%) complications Table 2. Diagnosis and Age Distribution in Children With Lower Airway Disease No. of Patients Diagnosis
1-3 yr
Recurrent pneumonia
10
23
39
Lobe collapse
17
14
35
Bronchiectasis
1
1
28
Hemoptysis
1
Malformations
6
1
5
Others
1
2
2
36
41
113
Total
>3yr
4
1296
WISEMAN,
Table 3. Anatomic Lobar Distribution of Lower Airway Disease
SANCHEZ, AND POWELL
7
scopy and postbronchoscopy diagnosis was positive in 81% of patients with upper airway disease and 74% of patients with lower airway disease. The diagnosis returned following the procedure led to specific surgical intervention in 33% of patients with upper airway obstruction and 18% of patients with lower airway disease. In previously reported pediatric series of diagnostic bronchoscopies the incidence of upper airway obstruction as an indication has varied. Godfrey et al4 in a series of 379 rigid bronchoscopies had only 8% of patients with upper airway disease, whereas Wood,2 using the flexible bronchoscopic technique, had 49% of patients with upper airway disease. The differences in indications appear to be more a reflection of pattern of practice rather than to true incidence. In the series reported herein and also in the series published by Wood2 upper airway obstruction was typically diagnosed with stridor as the most common prebronchoscopy symptom. Other symptoms leading to bronchoscopy included hoarseness, wheezing, and an irritative cough. In a group of patients with upper airway obstruction Holinger’ noted an 87% incidence of congenital anomalies compared with 50% of the patients in the series reported herein. In patients presenting with upper airway problems a high diagnostic yield has been the rule following bronchoscopy and is in agreement with our experience.2,4J The incidence of diagnoses leading to surgical intervention has been somewhat variable in reported series. Although there are some limitations in conducting a retrospective analysis of diagnosis; it appears quite definite that rigit bronchoscopy frequently yields a specific diagnosis when the prebronchoscopy indication includes atelectasis, lobar consolidation, and recurrent pneumonia. This is in essential agreement with other reported series.2*4 In the series reported herein there was a somewhat higher incidence of bronchiectasis leading to a more frequent need for subsequent surgical intervention. Lobectomy was thus carried out following bronchoscopy more often than in other reported series. It is noteworthy that the lobar distribution favoring the left lower lobe and the right upper lobe is in specific agreement with the usual expected distribution of bronchiectasis. The rigid bronchoscopic procedure was carried out with a low morbidity rate (3%) and in each instance complications were of a minor nature. This complication rate is similar to other reported series of broncho-
Cystic fibrosis
2
scopies.4,5,7,9,10
Leukemia
5
In conclusion, rigid bronchoscopy in children remains an important diagnostic procedure with a high
No. (“lo)
Leftlower lobe
51 (30)
Right upper lobe
39 (23)
Right middle lobe
26 (16)
Right lower lobe
23 (13)
Left upper lobe
16
Complete right or left lung
11 (6)
Total
(9)
166 (97)
occurred consisting of postbronchoscopy stridor in 1, respiratory failure in 3, and others in 2 patients. There was no mortality. The mean duration of the procedure was 51 minutes. The associated diagnoses at the time of bronchoscopy are shown in Table 4. Among 168 patients with lower airway disease who underwent bronchoscopy the procedure was shown to contribute to diagnosis in 149 patients (88%). The contribution was positive in 127 patients (85%) in whom a specific diagnosis was reached, and was negative in 22 patients (15%) in whom specific diagnoses were ruled out. In 19 patients (12%) the procedure was considered to be noncontributory. The prebronchoscopy and postbronchoscopy diagnoses correlated in a positive fashion in 124 patients (74%) and a negative correlation was observed in 44 patients (26%) in whom a different diagnosis was made following the endoscopic examination. DISCUSSION
This review of rigid bronchoscopy was undertaken to evaluate the diagnostic yield and to examine the contribution to final diagnosis made by the technique in children. Indications for bronchoscopy fell into two large categories: upper airway obstruction (30% of patients) and lower airway disease (60% of patients). Bronchoscopy led to a specific diagnosis or contributed to the diagnosis in 85% of patients with upper airway obstruction and in 88% of patients with lower airway disease. The correlation between prebronchoTable 4. Associated Diagnoses at the Time of Bronchoscopy Diagnosis Down’s syndrome
No. of Patients
5
Prematurity
12
Associated congenital anomalies
15
Posttraumatic
8
Tuberculosis
8
Bronchopulmonary
dysplasia
Asthma
Gastroesophageal
reflux
11
5
RIGID BRONCHOSCOPY
IN PEDIATRIC PATIENTS
1297
yield of specific diagnoses in patients with both upper and lower airway disease. In addition, therapeutic intervention and airway manipulation is facilitated by the rigid bronchoscope. The procedure has been carried out with a low mobidity rate and without
ing diagnostic intervention.
mortality.
excellent secretarial assistance.
The procedure
remains
important
in supply-
information
preliminary
to surgical
ACKNOWLEDGMENT We are grateful to Doris Jensen and Kirsten Ryan for their
REFERENCES 1. Wood RE, Postma D: Endoscopy of the airway in infants and children. J Pediatr 112:1-6,1988 2. Wood RE: The diagnostic effectiveness of the flexible bronchoscope in children. Pediatr Pulmonol 1:188-192, 1985 3. Sherman JM: Rigid or flexible bronchoscopy in children. Pediatr Pulmonol3:141,1987 4. Godfrey S, Springer C, Maayan C, et al: Is there a place for rigid bronchoscopy in the management of pediatric lung disease? Pediatr Pulmonol3:179-184, 1987 5. Friedman EM, Williams M, Healy GB, et al: Pediatric endoscopy: A review of 616 cases. Ann Otol Rhino1 Laryngol 93:517-519. 1984
6. Wood RE: Pitfalls in the use of the flexible bronchoscope in pediatric patients. Chest 97:199-203,199O 7. Holinger LD: Etiology of stridor in the neonate, infant, and child. Ann Otol Rhino1 Laryngol89:397-400,198O 8. Wiseman NE: The diagnosis of foreign body aspiration in childhood. J Pediatr Surg 19:531-535, 1984 9. Nussbaum E: Flexible fiberoptic bronchoscopy and laryngoscopy in children under 2 years of age: Diagnostic and therapeutic applications of a new pediatric flexible fiberoptic bronchoscope. Crit Care Med 10:770-772,1982 10. Schnapf BM: Oxygen desaturation during fiberoptic bronchoscopy in pediatric patients. Chest 99:591-594, 1991