In the small child, the most common indications for bronchoscopy are recurrent croup, chronic stridor, and suspicion of foreign body aspiration.
Bronchoscopy is often done in combination with direct laryngoscopy or microlaryngoscopy, which allows for exposure and examination of the larynx prior to performing bronchoscopy.
Distal tracheal airway obstruction requires special preparation as complete obstruction can occur beyond the ventilation bronchoscope and lead to rapid respiratory compromise.
One of the most challenging clinical situations is the removal of a foreign body from the pediatric airway.
When a foreign body is aspirated, chest radiograph might show a radiopaque FB, air trapping, or post-obstructive atelectasis.
The airway assessment should be recorded in video format and reviewed with the family.
Bronchoscopy, flexible and rigid, should part of the armamentarium of the pediatric general surgeon. Even if otorhinolarygologists do most of the primary airway surgery and foreign body removal at one’s institution, it is a skill that can be invaluable in certain situations in the ICU, OR or even the ED. In general pediatric surgery, probably the most common indication for rigid bronchoscopy is as an adjunct prior to repairing esophageal atresia with TEF. These are usually straightforward procedures but they are important for confirming the diagnosis prior to thoracotomy and for ruling out the presence of a second more proximal fistula. It is a procedure with which one should be facile and effective. The infant should oriented transversely on the OR table and positioned properly with the neck slightly extended and bumps placed under the shoulder and, if necessary, the occiput. The surgeon should personally inspect and put together the equipment and make sure there is proper suctioning equipment readily available. Some prefer to use a ventilating scope, although using just the telescope for a brief assessment makes things less complicated and avoids insufflation of air through the fistula into the stomach. Some also prefer to have the patient breathing spontaneously so as to be able to identify moving vocal cords and assess the degree of tracheomalacia, although this information is rarely useful in the actual care of the patient. The surgeon should mask ventilate the child and then place a mouth guard or moistened gauze sponge against the upper gums. After visualization of the cords with a standard laryngoscope, the scope should be passed gently, without forcing or torquing, so that it enters the trachea without traumatizing the delicate structures of the airway. The surgeon should immediately be able to orient the view properly by identifying the membranous (posterior) portion of the trachea. The scope can be passed directly to the carina and then more slowly withdrawn to look for the primary fistula (sometimes located in one of the mainstem bronchi) and the rare second fistula. The scope should be withdrawn gracefully and the child should be immediately intubated in preparation for the operation. The entire procedure should take no more than 5 min.
Extraction of a foreign body from the airway is an art that is honed with experience. Most foreign bodies can be easily removed with rigid bronchoscopy and specialized graspers suited to the particular object. While extracting a foreign body from the bronchus, the object can become lodged in the trachea, converting a partial airway obstruction to a complete airway obstruction. If the object cannot be calmly and easily removed with a brief second attempt, it should be pushed back into the right mainstem bronchus temporarily while the patient is oxygenated, the staff take a deep breath, and a plan is formulated. It is important to not panic and to have a back-up strategy. Another significant problem is the long-standing foreign body that is now embedded in the wall of the trachea or bronchus and cannot be dislodged. Endobronchial surgical techniques can be attempted (debridement of granulation tissue, balloon catheters), but bleeding is a significant concern. Although exceedingly rare, tracheotomy (or thoracotomy) is a last resort.
Flexible bronchoscopy is most useful in intubated patients who have severe lobar collapse and concern for mucous plugging of the distal airway. Again, the surgeon should be familiar with the equipment and be able to perform such a procedure at the bedside with confidence, competence, and skill. If opportunities for practice are rarely encountered, one should take the opportunity participate in airway courses or simulation labs at least once a year, or spend an afternoon with an ENT colleague observing and assisting in several airway cases. Regardless of one’s experience, when preparing to do a detailed evaluation of the distal airways for hemoptysis, foreign body, or suspected tumor, it is a good idea to review the normal bronchial anatomy in a good surgical atlas and, if possible, to have a large diagrammatic illustration posted visibly in the OR during the procedure.