Flexible bronchoscopy techniques: bronchoalveolar lavage, bronchial biopsy and transbronchial biopsy

This article completes previous recommendations of the Techniques Group of the Spanish Society of Pediatric Pulmonologists on the practice of flexible bronchoscopy in children. We review the most frequently performed diagnostic and therapeutic procedures applied through the flexible bronchoscope: bronchoalveolar lavage, bronchial biopsy and transbronchial biopsy. Recommendations are also provided on the practice of nonbronchoscopic bronchoalveolar lavage. We review the indications and contraindications of these techniques, the equipment required, and the preparation and monitoring of the patient before, during and after the procedure. The complications of these techniques are also discussed. These recommendations may be adopted, modified or rejected according to clinical needs and constraints.     

中国儿科可弯曲支气管镜术在严重急性呼吸综合征冠状病毒2(SARS-CoV-2)感染疫情期间诊疗建议(试行)

严重急性呼吸综合征冠状病毒2(SARS-CoV-2)感染所致肺炎(COVID-19)的疫情已经蔓延到儿童。其传染性强,人群普遍易感,包括儿童。传染源主要是SARS-CoV-2感染的患者,无症状感染者也可能成为传染源。支气管镜诊疗中患儿咳嗽、开放气道等将产生大量的飞沫和分泌物,污染诊室、设备和空气等,甚至感染与患儿近距离接触的医务人员、其他患儿及陪护人员,属于传染高危操作。为此特组织专家撰写儿科可弯曲支气管镜术在SARS-CoV-2感染疫情期间诊疗建议(试行),确立儿科在疫情特殊时期支气管镜诊疗适应证及防控方案,为从事儿科可弯曲支气管镜工作的医务人员提供依据。     

纤维支气管镜在儿童感染性肺不张治疗中的应用

目的　探讨纤维支气管镜 (简称纤支镜 )在儿童感染性肺不张治疗中的作用。方法　12 5例住院儿童经X光胸片或CT证实为肺不张 ,且经纤支镜除外异物、畸形、肿瘤、结核等 ,明确为感染所至 ,分为纤支镜组及临床组 ,纤支镜组 65例以纤支镜治疗为主 ,经纤支镜治疗 2～ 6次。临床组60例 ,以临床抗炎、对症治疗为主 ,两组均定期复查胸X线片 ,3 0～ 40d时比较疗效 ;此外还对纤支镜组中不同病程的疗效进行了观察。结果　纤支镜组治愈 3 9例 ,好转 2 0例 ,无效 6例 ,临床组治愈 17例 ,好转 2 5例 ,无效 18例 (P <0 .0 1) ;纤支镜组中病程 <3月、3～ 6月、>6月三组疗效比较差异有显著性 (P <0 .0 1)。结论　纤维支气管镜在儿童感染性肺不张的治疗中起着十分重要的作用 ,病程短时有利于肺不张的恢复 ,支气管冲洗克服了支气管肺泡灌洗的缺点 ,更适应于感染性肺不张的治疗     

纤维支气管镜在小儿气管支气管软化症诊断中的价值

目的探讨纤维支气管镜对小儿气管支气管软化症的诊断作用。方法对335例常规诊治无明显好转的持续喘息或慢性咳喘患儿行纤维支气管镜（纤支镜）检查,观察气管支气管内腔变化,并对有感染灶者行纤支镜局部治疗。结果335例中诊断气管支气管软化症62例（占18．5％）,气管软化17例,主支气管软化27例,叶支气管软化15例,段支气管软化3例;气管支气管软化合并喉软化7例;62例中原发性软化症59例,继发性软化症3例。62例中有52例（83．9％）在行纤支镜检查前被误诊。结论气管支气管软化症是引起小儿持续喘息或慢性咳喘的常见病因之一,临床容易误诊,纤维支气管镜是目前诊断气管支气管软化症的金指标。     

纤维支气管镜在儿童难治性肺部疾病中的应用

随着纤维支气管镜技术的提高,其临床应用的适应证亦不断增加,已成为儿科呼吸疾病诊断和治疗的有力武器.文章就纤维支气管镜术在儿童难治性肺部疾病(如难治性肺不张、难治性肺炎、咯血及反复喘息等)诊治中的应用作一概述.     

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??Objective??To evaluate the diagnostic and therapeutic value of flexible bronchoscopy in children with necrotizing pneumonia. Methods??Clinical data of children diagnosed with necrotizing pneumonia in the Department of Pediatrics of the First Hospital of Jilin University from December 2016 to December 2017 were collected. The general clinical manifestations??laboratory examination results??chest X-ray or lung CT??flexible bronchoscope and other examinations of all the children were analyzed retrospectively. Based on the characteristics??diagnosis??treatment and prognosis??the advantages of flexible bronchoscopy in this disease were analyzed. Results??All the 32 cases were diagnosed as necrotizing pneumonia by imaging examination??with an average diagnosis time of 14.1 d. All 32 cases of children with necrotizing pneumonia received flexible bronchoscopy and alveolar lavage. The alveolar lavage in 32 cases presented turbidity mitota-like changes??which had high sensitivity in the diagnosis of necrotizing pneumonia. The average time for mitota-like changes in alveolar lavage was 6.7 days. Conclusion??Flexible bronchoscopy is an important method in the diagnosis and treatment of necrotizing pneumonia??and the change of alveolar lavage fluid is a sensitive index for early prediction of necrotizing pneumonia.     

纤维支气管镜术在小儿非异物性肺不张中的应用

目的 探讨纤维支气管镜(纤支镜)术在儿科非异物性肺不张(肺不张)诊断和治疗中的应用价值.方法 总结2004-2006年收治的387例行纤支镜术的肺不张患儿诊治结果.采用Olympus公司生产的BFXP40、BF3C30、BFP40三种型号的纤支镜,根据患儿年龄、体重选用不同型号的纤支镜.结果 本组病例共进行425例次纤支镜术,纤支镜下发现病变352例,其中炎症214例(55.3%),其次为气道狭窄、软化及分支开口异常;未见明显异常35例.年龄不同,肺不张的病因不同,<1岁组气道软化、狭窄所占比例较大.全部病例均进行灌洗治疗.356例灌洗治疗后复查胸片或胸部CT显示,4周内完全复张253例(71.1%),部分复张74例(20.8%),未复张29例;3个月内完全复张305例(85.7%),部分复张42例(11.8%),未复张9例(2.5%).结论 肺不张的病因因年龄而异,<1岁患儿气道软化、狭窄所占比例较大.早期给予纤支镜下支气管肺泡灌洗可促使其尽早复张.     

支气管肺泡灌洗术在儿童迁延性肺炎诊治中的作用

目的探讨纤维支气管镜及支气管肺泡灌洗术在儿童迁延性肺炎诊治中的作用。方法收集2009年1月—12月入院的迁延性肺炎患儿,对其中105例行纤维支气管镜检查及支气管肺泡灌洗,与40例未行此术的患儿进行对照分析。结果 105例行纤维支气管镜检查的患儿均显示不同程度的支气管内膜炎症,其中单纯性气管支气管内膜炎43例,62例同时存在呼吸道基础疾病,呼吸中心中气管支气管软化32例、气管支气管狭窄19例、支气管开口异常6例。支气管肺泡灌洗组治愈85例,治愈率80.95%;对照组治愈22例,治愈率55.00%。两组差异有统计学意义(P<0.005)。结论纤维支气管镜术及支气管肺泡灌洗术对儿童迁延性肺炎有重要的病因诊断和治疗价值,且安全性好。     

纤维支气管镜术在104例儿童肺不张诊断及治疗中的应用

目的 探讨纤维支气管镜(简称纤支镜)术在肺不张患儿诊断和治疗中的作用.方法 对2006年1月至2010年5月入住我科的104例行纤支镜检查的肺不张患儿临床资料进行回顾性分析.结果 经支气管镜检查,104例中,痰液堵塞引起肺不张76例(73%),支气管肺发育异常13例(13%),其中1岁以内的婴幼儿占9例;支气管异物12例(12%),其中3岁以内婴幼儿占8例.经纤支镜治疗后104例中有100例肺叶复张.痰液堵塞导致肺不张的76例中,65例接受1次纤支镜术后肺叶复张,8例接受2次后复张,2例接受3次后复张;肺不张病程在3周以内的患儿1次纤支镜术后的肺叶复张率明显高于病程在3周或3周以上的患儿.结论 不同年龄儿童肺不张的病因构成不同,支气管肺发育异常在1岁以内患儿多见;1到3岁患儿异物吸入占比例较大,3岁以上患儿中痰液堵塞是常见原因.大多数痰堵导致肺不张患儿经一次纤支镜治疗就能够复张,肺不张病程越短,一次复张率越高.纤支镜术在肺不张患儿的病因诊断及治疗中发挥了重要作用.     

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??Objective To investigate the application of bronchoalveolar lavage of flexible bronchoscopy in diagnosis and treatment of children with Mycoplasma pneumoniae pneumonia??MPP??. Methods Clinical data of 155 pneumonia patients ??57 cases of MPP and 98 cases of non-MPP????who had examination in flexible bronchoscopy, MP-DNA of bronchoalveolar larlavage fluid(BALF),and the traditional blood serological test of Mycoplasma pneumoniae??were retrospectively analyzed from Aug.2011 to Apr.2012 in Anhui Provincial Children’s Hospital. Results Mycoplasma pneumoniae pneumonia often occur red in children over the age of 5 or with lobar pneumonia or atelectasis in the left lung. The accuracy of MP-DNA in BALF was higher than that of the blood serological test. After alveolar wash and administration of medicines, 95.7?? of the atelectasis cases were cured. Conclusions Flexible bronchoscopy and bronchoalveolar lavage should be applied to MPP and atelectasis cases as soon as possible to promote lung recruitment and improve the outcome.     

Safety and ethics of bronchoscopy and endobronchial biopsy in difficult asthma.

AIM: To investigate the safety of bronchoscopy and endobronchial biopsy in children with difficult asthma, and discuss the ethical issues associated with the procedure. METHODS: A three year prospective observational study was performed in two tertiary paediatric respiratory centres specialising in the management of children with difficult asthma. A total of 48 children with difficult asthma and 35 non-asthmatic children were studied. RESULTS: Flexible bronchoscopy was performed under general anaesthesia in 38 children with difficult asthma, and rigid bronchoscopy was performed in 10, following a two week course of prednisolone. Endobronchial biopsy was performed in 47 patients. Perioperative complications occurred in one asthmatic undergoing flexible bronchoscopy (desaturation) and in two undergoing rigid bronchoscopy (desaturation in one, and bronchospasm and desaturation in one). There were no cases of significant bleeding or pneumothorax among the asthmatics. Flexible bronchoscopy was performed in 35 non-asthmatic patients with a variety of clinical indications. The total number of perioperative complications was greater in the non-asthmatics undergoing flexible bronchoscopy than in the asthmatics (17 complications in 35 children versus one in 38). Fever requiring hospital admission was documented in two asthmatics following bronchoscopy. Four asthmatics reported an increase in symptoms in the week following bronchoscopy. CONCLUSIONS: Bronchoscopy and endobronchial biopsy under general anaesthesia can be performed safely in children with difficult asthma, when the bronchoscopist and anaesthetist are suitably trained. The procedure is acceptable to the families involved.     

无痛性纤维支气管镜术在儿科难治性肺部疾病中的应用

目的 探讨无痛性纤维支气管镜(纤支镜)术在儿童难治性肺部疾病诊治中的应用.方法 回顾分析221例行纤维支气管镜术患儿的临床资料,全部病例均采用异丙酚静脉复合麻醉.结果 221例患儿共行241例次纤支镜术.75例反复或持续喘息的患儿中气管支气管软化、狭窄30例(40.O%),炎性渗出、黏液栓子堵塞26例(34.7%),气道发育畸形9例(12.0%).72例肺不张患儿中炎症49例(68.1%),气道异常23例(31.9%).经局部灌洗及用药,68例术后复查,1个月内部分或完全复张57例(83.8%),3个月内复张63例(92.7%).17例气道异物中经纤支镜取出11例,仅6例有明确异物吸入史(35.3%).结论 无痛性纤维支气管镜术在儿童难治性肺部疾病的诊断和治疗中发挥重要作用,值得临床推广.     

Safety and ethics of bronchoscopy and endobronchial biopsy in difficult asthma

AIM—To investigate the safety of bronchoscopy and endobronchial biopsy in children with difficult asthma, and discuss the ethical issues associated with the procedure.METHODS—A three year prospective observational study was performed in two tertiary paediatric respiratory centres specialising in the management of children with difficult asthma. A total of 48children with difficult asthma and 35 non-asthmatic children were studied.RESULTS—Flexible bronchoscopy was performed under general anaesthesia in 38 children with difficult asthma, and rigid bronchoscopy was performed in 10, following a two week course of prednisolone. Endobronchial biopsy was performed in 47 patients. Perioperative complications occurred in one asthmatic undergoing flexible bronchoscopy (desaturation) and in two undergoing rigid bronchoscopy (desaturation in one, and bronchospasm and desaturation in one). There were no cases of significant bleeding or pneumothorax among the asthmatics. Flexible bronchoscopy was performed in 35 non-asthmatic patients with a variety of clinical indications. The total number of perioperative complications was greater in the non-asthmatics undergoing flexible bronchoscopy than in the asthmatics (17 complications in 35 children versus one in 38). Fever requiring hospital admission was documented in two asthmatics following bronchoscopy. Four asthmatics reported an increase in symptoms in the week following bronchoscopy.CONCLUSIONS—Bronchoscopy and endobronchial biopsy under general anaesthesia can be performed safely in children with difficult asthma, when the bronchoscopist and anaesthetist are suitably trained. The procedure is acceptable to the families involved.     

Fibreoptic bronchoscopy without general anaesthetic.

We have used flexible fibreoptic bronchoscopy using sedation and local anaesthesia in 50 children aged 2-19 years (median 10) using an Olympus BFP20 instrument. Indications were opportunistic pneumonias (n = 11), persistent atelectasis (n = 11), recurrent pneumonia (n = 7), miscellaneous lower airway disease (n = 7), recurrent wheezing (n = 3), haemoptysis (3), to diagnose infection or rejection of heart-lung transplants (n = 3), stridor (n = 2), suspected airway compression (n = 1), evaluation of tracheostomy (n = 1), and suspected foreign body (n = 1). In 43 cases (86%) the diagnosis was related to the primary indication. In five (10%) unrelated abnormalities were found, and five (10%) were normal. In 13 (26%) treatment was altered as a result of flexible fibreoptic bronchoscopy. Complications were transient respiratory arrest (n = 2), hypoxia (n = 2), pneumonia (n = 2), and laryngospasm (n = 1). All complications were followed by complete recovery. Our results suggest that flexible fibreoptic bronchoscopy is safe. Advantages over rigid bronchoscopy include greater visual range, fewer complications, and the avoidance of a general anaesthetic. Though invasive it can yield important diagnostic and therapeutic information.     

Bronchoscopy precautions and recommendations in the COVID-19 pandemic

As the airways of SARS-CoV-2 infected patients contain a high viral load, bronchoscopy is associated with increased risk of patient to health care worker transmission due to aerosolised viral particles and contamination of surfaces during bronchoscopy. Bronchoscopy is not appropriate for diagnosing SARS-CoV-2 infection and, as an aerosol generating procedure involving a significant risk of transmission, has a very limited role in the management of SARS-CoV-2 infected patients including children. During the SARS-CoV-2 pandemic rigid bronchoscopy should be avoided due to the increased risk of droplet spread. Flexible bronchoscopy should be performed first in SARS-CoV-2 positive individuals or in unknown cases, to determine if rigid bronchoscopy is indicated. When available single-use flexible bronchoscopes may be considered for use; devices are available with a range of diameters, and improved image quality and degrees of angulation. When rigid bronchoscopy is necessary, jet ventilation must be avoided and conventional ventilation be used to reduce the risk of aerosolisation. Adequate personal protection equipment is key, as is training of health care workers in correct donning and doffing. Modified full face masks are a practical and safe alternative to filtering facepieces for use in bronchoscopy. When anaesthetic and infection prevention control protocols are strictly adhered to, bronchoscopy can be performed in SARS-CoV-2 positive children.     

纤维支气管镜在小儿难治性肺炎诊断与治疗中的应用

目的：探讨纤维支气管镜（简称纤支镜）在小儿难治性肺炎诊治中的作用。方法：60例确诊为难治性肺炎的住院患儿,随机分为灌洗组和对照组,每组30例。灌洗组在给予常规治疗基础上行纤支镜治疗,对照组给予常规治疗。观察并分析两组疗效及灌洗组病原学检查结果。结果：肺泡灌洗液（BALF）培养与痰培养比较符合率为63.3%,两者阳性检出率差异无统计学意义。BALF支原体PCR检测与血清支原体抗体检测阳性率比较符合率为73.3%,BALF支原体PCR检测阳性率高于血清支原体抗体检测,差异有统计学意义（P<0.05）。灌洗组有效率为97%,疗效显著高于对照组（73%）。结论：纤支镜在小儿难治性肺炎的诊断与治疗方面具有很大优势。     

纤维支气管镜术在儿童肺炎支原体肺炎诊治中的应用

目的探讨纤维支气管镜术(纤支镜)在儿童肺炎支原体肺炎(MPP)中的应用价值。方法回顾性分析204例行纤支镜术的MPP患儿的临床资料。结果 204例患儿中共进行了286例次纤支镜术。血清MP-IgM抗体阳性患儿121例(59.3%)支气管肺泡灌洗液(BALF)中FQ-MP-DNA阳性,BALF细菌培养阳性菌株25株(12.3%)。纤支镜镜下所见病变部位黏膜充血水肿,支气管开口痰堵54例(26.5%),形成痰栓29例(14.2%),炎性狭窄21例(10.3%),小结节样突起13例(6.4%);20例支气管黏膜组织电镜检查纤毛超微结构均有不同程度的纤毛柱状上皮损害。全部病例均进行肺泡灌洗治疗,合并肺不张的109例患儿经1～4次灌洗治疗,1个月后复查106例(97.2%)完全或部分复张。结论对于难治性MPP、合并肺不张者,早期应用纤支镜进行支气管肺泡灌洗治疗,能促进肺复张,改善预后,减少后遗症的发生。     

异丙酚静脉复合麻醉在小儿支气管镜检查术中的应用

目的　探讨异丙酚静脉复合麻醉在儿童支气管镜检查术中的应用。方法　在以异丙酚为主的静脉复合麻醉下对 5 6例患儿进行了 62例次支气管镜检查 ,其中硬质支气管镜检查5 0例次 ,纤维支气管镜检查 1 2例次 ;6例同时行局部冲洗或肺泡灌洗。结果　 62例次支气管镜检查过程中 ,1例并发双侧气胸及纵隔气肿 ;1例出现喉痉挛 ;1例因缺氧发作终止操作。全部患儿无呼吸抑制、低血压、心律失常、出血及死亡。术前怀疑异物吸入 44例中 ,经硬质支气管镜检查 ,发现异物 32例 ,分泌物阻塞 (痰栓 ) 1 0例 ,肉芽肿 2例。反复或持续肺炎 1 1例经纤维支气管镜检查及局部冲洗或肺泡灌洗检查 ,7例治愈 ,2例好转 ;1例确诊为特发性肺含铁血黄素沉着症 ,1例右上肺实变仍诊断不明。 1例不明原因咯血 ,经检查发现右主支气管黏膜 3处糜烂。结论　异丙酚静脉复合麻醉安全、副作用少 ,是儿童支气管镜检查的一种理想的麻醉方式。     

Airway foreign body removal by flexible bronchoscopy: experience with 1027 children during 2000–2008

Background  Foreign body aspiration (FBA) into the tracheobronchial tree is a common problem in children necessitating prompt recognition and management. This study aimed to report our experience in airway foreign body removal by flexible bronchoscopy in children. Methods  A total of 1027 patients with FBA were reviewed retrospectively. They were 626 boys and 401 girls aged from 5 months to 14 years with a median age of 17 months. The clinical manifestations, radiological findings, bronchoscopic findings and complications of the procedure were analyzed. Results  Among the patients, only 53.4% had a definite history of FBA. The most frequent symptom was paroxysmal cough (84.3%), followed by stridor or wheezing, fever and dyspnea. Chest X-ray showed emphysema in 68.8% of the patients, atelectasis in 13.3% and bronchopneumonia in 56.3%. A bronchoscope was inserted intranasally in most children, but through mouth and endotracheal tube in 17 and 3 children, respectively. Foreign bodies were removed successfully by flexible bronchoscopy with disposable grasping forceps or biopsy forceps in 938 (91.3%) of the patients. The other 89 patients turned to rigid bronchoscopy. During the procedures, 132 (12.9%) of the patients showed transient hypoxia, which was alleviated by oxygen supplement and/or temporary cessation of the procedure. A small amount of bleeding was found in 17 patients and bradycardia in 3. Air leak and laryngeal edema were noted in 2 patients and relieved within 24 hours. Conclusions  Flexible bronchoscopy is useful and safe in retrieving airway foreign bodies in children. With skilled personnel and perfect equipments, flexible bronchoscopy could be considered as the first choice for the removal of airway foreign body.     

Flexible fiberoptic bronchoscopy

The value of flexible fiberoptic bronchoscopy in children are increasing day by day, but still underutilized even in many advanced institutions. 630 Fiberoptic bronchoscopy procedures under local anaesthesia were performed for various clinical conditions for diagnosis and therapy. Nasal route is preferred than oral route. Therapeutic indications, are more in children than adults. Nearly one third of children with collapse, consolidation have shown radiological clearance after repeated bronchoscopy.