Journal Information
Vol. 56. Issue 2.
Pages 119-121 (February 2020)
Vol. 56. Issue 2.
Pages 119-121 (February 2020)
Scientific Letter
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Bronchoscopies in neonatal intensive care units
Broncoscopias en unidades de cuidados intensivos neonatales
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María del Carmen López Castilloa,
Corresponding author
mcarmen.lopez123@gmail.com

Corresponding author.
, Estela Pérez Ruizb, Pilar Caro Aguilerab, Enrique Salguero Garcíaa,c, Javier Pérez Fríasb,d
a Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga, Málaga, Spain
b Sección de Neumología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain
c Servicio de Neonatología, Hospital Regional Universitario de Málaga, Málaga, Spain
d Facultad de Medicina de Málaga, Málaga, Spain
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Table 1. Patient characteristics.
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To the Editor:

The diagnostic and therapeutic utility of bronchoscopy, along with its minimal morbidity and mortality, have made it an increasingly useful technique in the neonatal intensive care unit (NICU). It permits direct dynamic inspection of the airway and facilitates the diagnosis and management of a wide variety of both supra- and infraglottic disorders.

We performed a retrospective descriptive study of 32 bronchoscopies performed in 23 NICU patients in a tertiary hospital over a 5-year period (2014–2018). We recorded patient characteristics, type of bronchoscope, anesthesia, reason for the examination, findings, and complications. A Pentax flexible 2.8mm bronchoscope was used in all cases.

The average gestational age of the patients was 36weeks (IQR 33–38) (50 % preterm infants), with a median weight of 2345g (1,900-2,800), 11 boys and 12 girls. Underlying diseases included 6 cases of esophageal atresia.

The procedure was performed by a pediatric pulmonologist in infants with an average age of 32 days (8–65) and an average weight of 2900g (2,570-3,290) admitted to the neonatal unit. Patient care was the responsibility of the neonatologist. All procedures were performed under sedation, primarily ketamine. Respiratory support was used during the procedure, as follows: high flow nasal prongs in 9 (28.1 %), mechanical ventilation in 9 (28.1 %), CPAP in 5 (15.6 %), standard nasal prongs in 2 (6.3 %), laryngeal mask in 1 (3.1 %), and no support in 6 (18.8 %).

The indications (Table 1) that led to the realization of the procedure were: tracheoesophageal fistula (8), stridor (7), respiratory difficulty (3), difficulty to intubate (4), failure to extubate (3), atelectasis (2), upper airway obstruction (2), hypoventilation (1), and selective intubation (1).

Table 1.

Patient characteristics.

Patient GA and sex  Postnatal age and weight  Underlying disease  Indication  Bronchoscopic findings  Complications  Number of procedures and days of monitoring  Reason for follow-up procedure. New findings 
40+5w, ♂  7 days3,120 g  None  Stridor, respiratory difficulty  Laryngomalacia  No  – 
29+4w, ♀  60 days3,600 g  Nemaline myopathy  Repeated atelectasis  Normal  No  – 
31+2w, ♀  67 days2,600 g  Cri du chat syndrome  Upper airway obstruction  Bilateral vocal cord paralysis  No  – 
33+1w, ♂  3 days1,850 g  Prematurity  Respiratory difficulty and difficulty in intubation  Subglottic stenosis and esophageal duplication  Mild desaturation  2283 days  Persistent respiratory difficulty Tracheal stenosis 
40 w, ♂  10 days3,380 g  None  Biphasic stridor  Subglottic stenosis  No  217 days  Persistent stridor Findings without changes 
36w, ♂  10 days2,570 g  Charge syndrome  Respiratory difficulty  Choanal stenosis  No  – 
31+3w, ♂  24 days1,600 g  Prematurity  Respiratory difficulty  Pharynogmalacia  Mild desaturation  – 
39w, ♀  7 days3,000 g  Apneas  Apneas and respiratory difficulty  Tracheomalacia  Severe desaturation  – 
41w, ♀  39 days3,200 g  None  Respiratory difficulty, extubation failure  Laryngeal stenosis  No  290 days  Follow-up oflaryngomalacia 
33w, ♂  16 days2,300 g  Prematurity  Choking, respiratory difficulty  Tracheomalacia  Severe desaturation  225 days  Follow-up No new findings 
40 w, ♀  8 days3,000 g  DiGeorge syndrome  Stridor and hoarseness  Laryngomalacia, choanal stenosis  No  – 
34w, ♂  8 days2,055 g  TEF  Stridor, complete study  TEF  No  248 days  Persistent stridor Bronchial stenosis 
33w, ♂  42 days2,600 g  TEF  Stridor, complete study  TEF  Severe desaturation  269 days  Follow-up. No new findings 
38 w, ♀  7 days2,600 g  TEF and Shone syndrome  Complete study  TEF and choanal stenosis  Severe desaturation  210 days  Selective intubation. Bronchial stenosis 
33w, ♀  75 days2,950 g  Prematurity  Hoarseness and stridor  Normal  No  – 
35+2w, ♀  1 day2,190 g  TEF  Stridor, complete study  TEF and tracheomalacia  No  – 
38+1w, ♂  48 days3,190 g  TEF  Extubation failure  TEF and tracheomalacia  No  389 and 97 days.  Follow-up. No new findings 
37+1w, ♂  2 days2,490 g  TEF  Complete study  TEF  No  – 
26+1w, ♀  240 days5,490 g  Prematurity, hyper-IgE syndrome  Stridor, respiratory difficulty  Subglottic stenosis, tracheomalacia  Mild desaturation  – 
37+1w, ♂  47 days2,760 g  Hypoxic-ischemic syndrome  Stridor  Laryngopharyngomalacia  No  – 
37+4w, ♀  41 days2,285 g  Corpus callosum agenesis, heart disease  Repeated atelectasis  Mucous plugs  Severe desaturation  – 
37+6w, ♀  23 days3,000 g  Myelomeningocele, unilateral coloboma  Upper airway obstruction  Pharyngolaryngomalacia  Mild desaturation  – 
35w, ♀  60 days2900Hypotonia  Hypoventilation  Tracheal bronchus and tracheomalacia  No  – 

GA: gestational age; TEF: tracheoesophageal fistula.

Of the total bronchoscopies, 23/32 (69 %) were diagnostic; of these, 21/23 (91 %) revealed pathology and more than one abnormality was found during the examination in 10/23 (43 %). Nine bronchoscopies (9/32) were performed to monitor progress. In 4 of these, no new findings were revealed. It is interesting to note that in 1 of the control bronchoscopies, selective intubation could be performed in a patient with recurrent pneumothorax.

The most frequent bronchoscopic diagnoses were malacia and stenosis at different levels. Findings are summarized in Table 1.

During the procedure, 5 patients had transient hypoxemia that required the temporary withdrawal of the bronchoscope, although the examination of the airway could be completed in all patients. There were no significant differences in complications between preterm and term infants.

Fiberoptic bronchoscopy is a technique increasingly used in the NICU for its high diagnostic yield and safety record.1

Patients admitted to these units often have episodes of respiratory difficulty, repeated atelectasis, or intubation or extubation problems.1,2 In all these processes, bronchoscopy may be required, or at least advisable.3 Moreover, direct visualization of the airway is essential for the diagnosis of possible malformations. This technique is usually performed under sedation, permitting dynamic airway examination. The indications for the procedure tend to be: stridor, atelectasis, respiratory distress, or difficulty in intubation.4 The most common bronchoscopic findings are mucous plugs, stenosis, and malacia at different levels.1,5

A high percentage of procedures reveal multiple diagnoses, so a full exploration of the upper and lower airway in each procedure is essential. In the case of suspected pneumonia or unilateral lung disease, bronchoalveolar lavage can also be performed during the procedure,6 which can be useful both for designing antibiotic regimens and for diagnosing certain uncommon but not unknown diseases, such as altered surfactant synthesis.

The most common complications are bradycardias and mild hypoxia.1 However, some authors believe that these situations are inherent to the procedure itself and cannot be considered complications,7 since the vast majority are transitory and resolve after temporary withdrawal of the bronchoscope. The procedure is usually conducted in neonatal units with continuous monitoring and under the supervision of the neonatologist.

We can, then, conclude that bronchoscopy is a very useful technique in the NICU and one that offers a high safety profile in expert hands.

References
[1]
J.A. Matute, R. Romero, F.J. Berchi, et al.
Broncoscopia en Unidad de Cuidados Intensivos Neonatales.
Cir Pediatr., 15 (2002), pp. 52-56
[2]
A. Bush.
Bronchoscopy in paediatric intensive care.
Paediatr Respir Rev, 4 (2003), pp. 67-73
[3]
J. Pérez Frías, E. Pérez Ruiz, P. Caro Aguilera.
Broncoscopia pediátrica y técnicas asociadas.
Ergon, (2014),
[4]
A. Sony, S. Badatya, M. Modi, S. Saluja.
Neonatal bronchoscopy-a review.
Curr Med Res Pract., 6 (2016), pp. 192-201
[5]
D. Vijayasekaran, D. Vijayasekaran, S. Kalpana, et al.
Indications and outcome of flexible bronchoscopy in neonates.
Indian J Pediatri., 79 (2012), pp. 1181-1184
[6]
M. Harshavadan, N. Lerusha, R. Prithiksha, et al.
Neonatal bronchoscopy: role in respiratory disease of the newborn-a 7 year experience.
Pediatr Pulmonol, (2019), pp. 1-7
[7]
J. De Blic, C. Delacourt, P. Scheinmann.
Ultrathin flexible bronchoscopy in neonatal intensive care units.
Arch Dis Child, 66 (1991), pp. 1383-1385

Please cite this article as: Castillo MdCL, Ruiz EP, Aguilera PC, García ES, Frías JP. Broncoscopias en unidades de cuidados intensivos neonatales. Arch Bronconeumol. 2020;56:120–121.

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