Pitfalls in the Use of the Flexible Bronchoscope in Pediatric Patients
Flexible bronchoscopy is an important diagnostic (and sometimes therapeutic) tool that is underutilized in infants and children in many centers today. It is a relatively simple technique, but the unwary or inexperienced bronchoscopist can readily get into trouble, as there are many potential pitfalls. This article will review some of these pitfalls from the perspective of my own experience with more than 2,500 pediatric procedures over the past 16 years.
Indications for Endoscopy
Flexible bronchoscopy should not be performed unless there are valid indications for the procedure and unless the information or potential therapeutic result to be gained outweighs the potential risk. Although the absolute magnitude of risk is low, consideration should always be given to alternative methods for obtaining the same information. If bronchoscopy is the best way to obtain the necessary diagnostic information or to accomplish the necessary therapeutic goal, however, bronchoscopy is always indicated.
There are many indications for flexible bronchoscopy in children. Marginal indications for flexible endoscopy include the examination of the larynx in cases of uncomplicated, clinically typical croup, and bronchoscopy in cases of simple, uncomplicated pneumonia (especially in patients capable of producing sputum). When the information to be gained will not likely alter the patient s management or be of substantial benefit to the patient or family, flexible endoscopy is probably not indicated. For example, patients known to have aspirated a foreign body will need to undergo rigid bronchoscopy, and evaluation with a flexible instrument prior to rigid bronchoscopy should not be routinely performed.
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On the other hand, the definitive diagnosis of a condition (eg, laryngomalacia) that, while benign, causes substantial anxiety on the part of the family, may be beneficial and reduce subsequent unnecessary utilization of medical services. Likewise, diagnostic flexible bronchoscopy may be of great utility in the evaluation of children suspected of harboring a foreign body but in whom there is either no history of aspiration or no physical or radiographic findings which lead to a very high index of suspicion. Many of the children in whom I have found a foreign body had undergone flexible diagnostic bronchoscopy because of unexplained atelectasis or persistent wheezing, with no history of aspiration.
