Pitfalls in the Use of the Flexible Bronchoscope in Pediatric Patients: AIRWAY DYNAMICS
Abnormal airway dynamics (laryngomalacia, tracheomalacia, bronchomalacia) are frequently seen during pediatric bronchoscopy. One must be careful not to overdiagnose dynamic changes in airway caliber as pathologic states. In general, one should be able to visualize change in the airway size sufficient to cause symptoms before making a diagnosis of tracheomalacia or bronchomalacia. In other words, one should see the opposite walls of the airways touch or nearly touch each other, at least during coughing. The presence of the flexible bronchoscope may increase airway resistance to the point that normal dynamics are exaggerated. Therefore, the diagnosis should also be consistent with the clinical history of the patient or radiographic findings. A patient suspected of having tracheomalacia or bronchomalacia must also be examined under conditions which will produce sufficient changes in intrathoracic pressure to demonstrate the abnormal airway dynamics. I have seen a number of children who had very significant airway collapse during flexible bronchoscopy but in whom rigid bronchoscopy under general anesthesia failed to demonstrate any abnormality. Likewise, children with stridor should usually be examined while they are stridulus—the vibrating structures should then always be visible.
Occasionally, dynamic changes occur so rapidly that it may be difficult to comprehend the nature of the event unless it occurs repeatedly. The use of an endoscopic video camera and a tape recorder will allow replay of the procedure in slow motion and facilitate the understanding of such events. Use of videotape may also prevent the unnecessary repetition of procedures. Videotape is a very useful tool for communicating findings to colleagues and families. viagra plus
