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Background: Flexible fibreoptic bronchoscopy (FFB) has the potential to enhance diagnostic capabilities and improve pulmonary function in children on extracorporeal membrane oxygenation (ECMO)., Objectives: The objective of this study was to evaluate the benefits (clinical, radiological, and microbiological) of FFB and assess associated complications in children on ECMO., Methods: We conducted a single-centre retrospective observational cohort study in a tertiary paediatric intensive care unit. All FFB episodes performed during the study period on children aged 0-18 years on ECMO were included., Results: Out of the 155 children who received ECMO, 36 (23%) underwent a total of 92 episodes of FFB. FFB provided anatomical and pathological information in 53% (19/36) of cases and proved beneficial in clearing the airways in 62% (54/87) of the episodes. Overall, patients exhibited transient increases in ECMO and mechanical ventilation support 1 h post FFB in 14% (13/92) and 9.7% (9/92) episodes, respectively. At 6 h, the mean fraction of inspired oxygen on the mechanical ventilator was lower (0.46 [±0.21] vs 0.53 [±0.21] p < 0.01), with no change in mean airway pressure. Similarly, compared to pre-FFB, the fraction of inspired oxygen on the mechanical ventilator on ECMO was lower at 6 h and 24 h (0.65 [±0.25] vs 0.71 [±0.23] p < 0.01 and 0.006, respectively), with no significant change in the sweep gas flow and ECMO flow. The radiological imaging indicated improved or stable findings in 91% (83/91) of FFB episodes. FFB contributed to the identification of new and previously unknown microbiological information in 75% (27/36) of the patients. The incidence of major complications was 7.6%. Minor self-resolving bleeding occurred in 25% (23/92) episodes, and major bleeding occurred in two episodes, with a total of 10 episodes needing blood product transfusion., Conclusions: FFB is a valuable adjunct in managing children with severe respiratory failure on ECMO, offering clinical benefits with a low rate of major complications. Further studies should aim to develop a consensus approach encompassing criteria and clinical management around FFB in patients on ECMO., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Introduction: Elective flexible bronchoscopy (FB) is now widely available and standard practice for a variety of indications in children with respiratory conditions. However, there is limited evidence regarding the utility of elective FB in children. This systematic review (SRs) aimed to determine the utility of FB on its impact in clinical decision making and quality of life (QoL)., Methods: We searched Pubmed, Cochrane central register of controlled trials, Embase, World Health Organization Clinical Trials Registry Platform and Cochrane database of SRs from inception to April 20, 2023. We included SRs and randomized controlled trials (RCTs) that used parallel group design (comparing use of elective FB vs. no FB, or a wait-list approach [early FB vs. usual wait FB]) in children aged ≤ 18 years. Our protocol was prospectively registered and used Cochrane methodology for systemic reviews of interventions., Results: Our search identified 859 articles; 102 duplicates were removed, and 753 articles were excluded by title and abstract. Four full text articles were reviewed and subsequently excluded, as none met the inclusion criteria outlined in our patient, intervention, comparator, outcome measures framework., Conclusions: There is a paucity of high-quality RCT evidence to support the routine use of elective FB in children with respiratory conditions. However, available retrospective and a single prospective study demonstrate the high utility of FB in the elective pediatric setting., Registration: PROSPERO CRD42021291305., (© 2024 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.)

Introduction: Elective flexible bronchoscopy (FB) is now widely available and standard practice for a variety of indications in children with respiratory conditions. However, there are no randomised controlled trials (RCTs) that have examined its benefits (or otherwise).Our primary aim is to determine the impact of FB on the parent-proxy quality-of-life (QoL) scores. Our secondary aims are to determine if undertaking FB leads to (a) change in management and (b) improvement of other relevant patient-reported outcome measures (PROMs). We also quantified the benefits of elective FB (using 10-point Likert scale). We hypothesised that undertaking elective FB will contribute to accurate diagnosis and therefore appropriate treatment, which will in turn improve QoL and will be deemed to be beneficial from patient and doctor perspectives., Methods and Analysis: Our parallel single-centre, single-blind RCT (commenced in May 2020) has a planned sample size of 114 children (aged <18 years) recruited from respiratory clinics at Queensland Children's Hospital, Brisbane, Australia. Children are randomised (1:1 concealed allocation) within two strata: age (≤2 vs >2 years) and indication for FB (chronic cough vs other indications) to either (a) early arm (intervention where FB undertaken within 2 weeks) or (b) delayed (control, FB undertaken at usual wait time). Our primary outcome is the difference between groups in their change in QoL at the T2 timepoint when the intervention group has had the FB and the control group has not. Our secondary outcomes are change in management, change in PROMs, adverse events and the Likert scales., Ethics and Dissemination: The human research ethics committee of the Queensland Children's Hospital granted ethical clearance (HREC/20/QCHQ/62394). Our RCT is conducted in accordance with Good Clinical Practice and the Australian legislation. Results will be disseminated through conference presentations, teaching avenues, workshops, websites and publications., Registration: Australia New Zealand Clinical Trial Registry ACTRN12620000610932., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction/aim: A validated tool for scoring bronchitis during flexible bronchoscopy (FB) is potentially useful for clinical practice and research. We aimed to develop a bronchoscopically defined bronchitis scoring system in children (BScore) based on our pilot study., Methods: Children undergoing FB were prospectively enrolled. Their FB was digitally recorded and assessed (two clinicians blinded to each other and clinical history) for six features: secretion amount (six-point scale), secretion color (BronkoTest, 0-8), mucosal oedema (0-3), ridging (0-3), erythema (0-3), and pallor (0-3) based on pre-determined criteria. We correlated (Spearman's rho) each feature with bronchoalveolar lavage (BAL) neutrophil percentage (neutrophil%). BScore was then derived using models with combinations of the six features that best related to airway BAL neutrophil%. The various models of BScore were plotted against BAL neutrophil% using receiver operating characteristic (ROC) curves., Results: We analyzed 142 out of 150 children enrolled. Eight children were excluded for unavailability of BAL cytology or FB recordings. Chronic/recurrent cough was the commonest indication for FB (75%). The median age was 3 years (IQR, 1.5-5.3 years). Secretion amount (r = 0.42) and color (r = 0.46), mucosal oedema (r = 0.42), and erythema (r = 0.30) significantly correlated with BAL neutrophil%, P < .0001. The highest area under ROC (aROC) was obtained by the addition of the scores of all features excluding pallor (aROC = 0.84; 95% CI, 0.76-0.90) with airway neutrophilia (defined as BAL neutrophil% of >10%)., Conclusion: This prospective study has developed the first validated bronchitis scoring tool in children based on bronchoscopic visual inspection of airways. Further validation in other cohorts is however required., (© 2020 Wiley Periodicals LLC.)

Background: A valid bronchoscopic scoring tool for bronchitis would be useful for clinical and research purposes as currently there are none in children. From 100 digitally recorded flexible bronchoscopies (FB), we related the various macroscopic features to airway neutrophil % to develop a FB-derived bronchitis score (BScore exp ). We aimed to develop a FB-derived bronchitis tool., Methods: FB recordings for six visualised features: secretions (amount and color) and mucosal appearance (erythema, pallor, ridging, oedema) based on pre-determined criteria on a pictorial chart were assessed by two physicians independently, blinded to the clinical history. These features were used to obtain various models of BScore exp that were plotted against bronchoalveolar lavage (BAL) neutrophil % using a receiver operating characteristic (ROC) curve. Inter- and intra-rater agreement (weighted-kappa, K) were assessed from 30 FBs., Results: Using BAL neutrophilia of 20% to define inflammation, the highest area under ROC (aROC) of 0.71, 95%CI 0.61-0.82 was obtained by the giving three times weightage to secretion amount and color and adding it to erythema and oedema. Inter-rater K values for secretion amount (K = 0.87, 95%CI 0.73-1.0) and color (K = 0.86, 95%CI 0.69-1.0) were excellent. Respective intra-rater K were 0.95 (0.87-1.0) and 0.68 (0.47-0.89). Other inter-rater K ranged from 0.4 (erythema) to 0.64 (pallor)., Conclusion: A repeatable FB-defined bronchitis scoring tool can be derived. However, a prospective study needs to be performed with larger numbers to further evaluate and validate these results., (© 2018 Wiley Periodicals, Inc.)

Introduction: Flexible bronchoscopy (FB) is the current gold standard for diagnosing tracheobronchomalacia. However, it is not always feasible and virtual bronchoscopy (VB), acquired from chest multi-detector CT (MDCT) scan is an alternative diagnostic tool. We determined the sensitivity, specificity, and positive and negative predictive values of VB compared to FB in diagnosing tracheobronchomalacia., Methods: Children aged <18-years scheduled for FB and MDCT were recruited. FB and MDCT were undertaken within 30-min to 7-days of each other. Tracheobronchomalacia (mild, moderate, severe, very severe) diagnosed on FB were independently scored by two pediatric pulmonologists; VB was independently scored by two pairs (each pair = pediatric pulmonologist and radiologist), in a blinded manner., Results: In 53 children (median age = 2.5 years, range 0.8-14.3) evaluated for airway abnormalities, tracheomalacia was detected in 37 (70%) children at FB. Of these, VB detected tracheomalacia in 20 children, with a sensitivity of 54.1% (95%CI 37.1-70.2), specificity = 87.5% (95%CI 60.4-97.8), and positive predictive value = 90.9% (95%CI 69.4-98.4). The agreement between pediatric pulmonologists for diagnosing tracheomalacia by FB was excellent, weighted κ = 0.8 (95%CI 0.64-0.97); but only fair between the pairs of pediatric pulmonologists/radiologists for VB, weighted κ = 0.47 (95%CI 0.23-0.71). There were 42 cases of bronchomalacia detected on FB. VB had a sensitivity = 45.2% (95%CI 30.2-61.2), specificity = 95.5% (95%CI 94.2-96.5), and positive predictive value = 23.2 (95%CI 14.9-34.0) compared to FB in detecting bronchomalacia., Conclusion: VB cannot replace FB as the gold standard for detecting tracheobronchomalacia in children. However, VB could be considered as an alternative diagnostic modality in children with symptoms suggestive of tracheobronchomalacia where FB is unavailable. Pediatr Pulmonol. 2017;52:480-486. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Disc battery ingestion in children is becoming increasingly common with the proliferation of small battery-powered electronic devices. In the case of esophageal impaction, the likelihood and severity of complications are proportionate to the time between ingestion and removal. Tracheo-esophageal fistulae (TOF) are a recognized complication and can be life-threatening. We describe an interesting case of disc battery ingestion with delayed recognition of a TOF. We document the tracheal mucosal healing process of a large airway defect and describe the role of bronchoscopy in guiding the timing of surgical intervention. This case highlights the important role of early bronchoscopic assessment in management of these patients., (© 2013 Wiley Periodicals, Inc.)

Few articles have described the airway management of parenchymal lung hydatid cysts complicated by endobronchial or airway involvement, and none have described the use of flexible bronchoscopy (FB) therapeutically in children. We present a child with a ruptured pulmonary hydatid cyst who underwent repeated FB for removal of cystic material from an obstructed right upper lobe segmental bronchus. This child did not require thoracic surgery and made a full clinical recovery, demonstrating that in selected cases FB may offer curative treatment., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Flexible bronchoscopy (FB) is the gold standard method of diagnosing tracheomalacia but it is not always feasible in settings with limited resources. Fluoroscopy is sometimes performed as an alternative diagnostic tool but there are no prospective studies that have evaluated the diagnostic accuracy of airway fluoroscopy for tracheomalacia using a-priori definitions. We determined the sensitivity, specificity, and likelihood predictive ratio of airway fluoroscopy compared with FB in children suspected of having an airway abnormality., Methods: Airway fluoroscopic examination was undertaken within 2-weeks of a FB in children aged <18-years and reported by a pediatric radiologist blinded to FB data. Fluoroscopic and FB methods and diagnostic criteria were standardized and defined a-priori. Tracheomalacia diagnosed by FB were independently scored (mild, moderate, severe) by 2 pulmonologists in a blinded manner., Results: In 22 children (median age 33 months, range 1-187) evaluated for airway abnormality, tracheomalacia was found in 21 children at bronchoscopy. Of these, fluoroscopy detected tracheomalacia in five children. Airway fluoroscopy was poorly sensitive (23.8%) but highly specific (100%), positive likelihood ratio was 8.6. However, in moderate-severe tracheomalacia, the sensitivity improved to 57.1% but the specificity reduced (93.3%). The agreement between bronchoscopists for tracheomalacia severity was excellent, weighted kappa 0.74 (95% CI 0.77, 0.98)., Conclusion: Airway fluoroscopy cannot replace FB which remains the tool for definitively diagnosing airway malacia. However, in absence of other modalities for diagnosis fluoroscopy should be considered in the setting of persistent respiratory symptoms compatible with the clinical picture of tracheomalacia., (Copyright © 2011 Wiley Periodicals, Inc.)

Foreign matter aspiration occurs relatively commonly in drowning and near-drowning events. In most cases, stomach contents are aspirated. Sand aspiration rarely occurs and there are no reported cases in children with near drowning. Limited data are available on clinical presentation and management of sand aspiration with accidental burial. We report a 3-year-old boy who nearly drowned while swimming in brackish waters and was found face down in sand. Sand aspiration was suspected when the child continued to have persistent wheezing and high ventilatory requirement despite intensive bronchodilator and corticosteroids therapy with an inability to wean after 4 days post-near-drowning event. Radiology was non-specific in the absence of sand bronchogram. Presence of sand in the airways was confirmed when a bronchoscopy was undertaken and sand seen in the bronchoalveolar lavage fluid. Sequential lung washing followed by exogenous surfactant administration (3 ml/kg) was undertaken and lead to significant improvement such that within 12 hr post-therapeutic lavage, his ventilatory requirements reduced substantially. The child was extubated 4 days post-lavage and on review 2 months post-event, was clinically well with airway resistance within normal predicted values measured on forced oscillatory spirometry (IOS).

There is currently no validated scoring system for quantification of airway secretions in children. A user friendly, valid scoring system of airway secretions during flexible bronchoscopy (FB) would be useful for comparative purposes in clinical medicine and research. The objective of this study was to validate our bronchoscopic secretion (BS) scoring system by examining the relationship between the amount of secretions seen at bronchoscopy with airway cellularity and microbiology. In 106 children undergoing FB, the relationship of BS grades with bronchocalveolar lavage (BAL) cellularity and infective state (bacterial and viral infections) were examined using receptor operator curves (ROC). BAL was obtained according to European Respiratory Society guidelines; first lavage for microbiology and second lavage for cellularity. Area under the ROC was significant for total cell count (TCC) and neutrophil % but not for lymphocyte %. BS grade significantly related to infection positive state (chi(trend) (2) = 5.85, P = 0.016). The area under the ROC for infection positive state versus BS grade was 0.645, 95% CI 0.527-0.763. The BS scoring system is a valid method for quantifying airway secretions in children undergoing bronchoscopy. The system related well to airway cellularity and neutrophilia, as well as to an airway infective state. However, the system is only complementary to cell counts and cultures and cannot replace these laboratory quantification techniques.

Background: A quantitative understanding of airway sizes and proportions and a reference point for comparisons are important to a pediatric bronchoscopist. The aims of this study were to measure large airway areas, and define proportions and factors that influence airway size in children., Methods: A validated videobronchoscope technique was used to measure in-vivo airway cross-sectional areas (cricoid, right (RMS) and left (LMS) main stem and major lobar bronchi) of 125 children. Airway proportions were calculated as ratios of airways to cricoid areas and to endotracheal tube (ETT) areas. Mann Whitney U, T-tests, and one-way ANOVA were used for comparisons and standard univariate and backwards, stepwise multivariate regression analyses were used to define factors that influence airway size., Results: Airways size increased progressively with increasing age but proportions remained constant. The LMS was 21% smaller than the RMS. Gender differences in airways' size were not significant in any age group or airway site. Cricoid area related best to body length (BL): cricoid area (mm2) = 26.782 + 0.254* BL (cm) while the RMS and LMS area related best to weight: RMS area (mm2) = 23.938 + 0.394*Wt (kg) and LMS area (mm2) = 20.055 + 0.263*Wt (kg) respectively. Airways to cricoid ratios were larger than airway to ETT ratios (p = 0.0001)., Conclusion: The large airways progressively increase in cross sectional area size, maintain constant proportional relationships to the cricoid and are gender independent across childhood. Anthropometric factors (body length and weight) are significantly related to but only have weakly predictive influences on major airway size. The cricoid is the most suitable comparator for other airway site measurements. These data provide for quantitative comparisons of airway lesions.

Background: Accurate measurements of airway and lesion dimensions are important to the developmental progress of paediatric bronchoscopy. The malacia disorders are an important cause of respiratory morbidity in children, but no methods are currently available to measure these lesions or the airway lumen accurately. A new measurement technique is described here., Methods: The magnification power of a paediatric videobronchoscope was defined and a simple and user friendly computer based program (Image J) was used to develop an objective technique (colour histogram mode technique, CHMT) for measurement of the airway lumen., Results: In vivo intra-observer and inter-observer repeatability coefficients for repeated area measurements from 28 images using the Bland-Altman method were 0.9 mm2 and 1.6 mm2, respectively. The average intraclass correlation coefficient for repeated measurements of area was 0.93. In vitro validation measurements using a 2 mm diameter tube resolved radii measurements to within 0.1 mm (coefficient of variability 8%). An "acceptable result" was defined in 92% of 734 images completed with the CHMT alone and 8% with its modification. The success rate for two of three images being within 10% of each other's area was 100%. Measurements of cricoid cross sectional areas from 116 patients compared with expected airway areas for age derived from endotracheal tube sizes were comparable., Conclusions: The CHMT method of identifying and measuring airway dimensions is objective, accurate, and versatile and, as such, is important to the future development of flexible videobronchoscopy.

Background: Cough is the most common symptom presenting to doctors. The quality of cough (productive or wet vs dry) is used clinically as well as in epidemiology and clinical research. There is however no data on the validity of cough quality descriptors. The study aims were to compare (1) cough quality (wet/dry and brassy/non-brassy) to bronchoscopic findings of secretions and tracheomalacia respectively and, (2) parent's vs clinician's evaluation of the cough quality (wet/dry)., Methods: Cough quality of children (without a known underlying respiratory disease) undergoing elective bronchoscopy was independently evaluated by clinicians and parents. A 'blinded' clinician scored the secretions seen at bronchoscopy on pre-determined criteria and graded (1 to 6). Kappa (K) statistics was used for agreement, and inter-rater and intra-rater agreement examined on digitally recorded cough. A receiver operating characteristic (ROC) curve was used to determine if cough quality related to amount of airway secretions present at bronchoscopy., Results: Median age of the 106 children (62 boys, 44 girls) enrolled was 2.6 years (IQR 5.7). Parent's assessment of cough quality (wet/dry) agreed with clinicians' (K = 0.75, 95%CI 0.58-0.93). When compared to bronchoscopy (bronchoscopic secretion grade 4), clinicians' cough assessment had the highest sensitivity (0.75) and specificity (0.79) and were marginally better than parent(s). The area under the ROC curve was 0.85 (95%CI 0.77-0.92). Intra-observer (K = 1.0) and inter-clinician agreement for wet/dry cough (K = 0.88, 95%CI 0.82-0.94) was very good. Weighted K for inter-rater agreement for bronchoscopic secretion grades was 0.95 (95%CI 0.87-1). Sensitivity and specificity for brassy cough (for tracheomalacia) were 0.57 and 0.81 respectively. K for both intra and inter-observer clinician agreement for brassy cough was 0.79 (95%CI 0.73-0.86)., Conclusions: Dry and wet cough in children, as determined by clinicians and parents has good clinical validity. Clinicians should however be cognisant that children with dry cough may have minimal to mild airway secretions. Brassy cough determined by respiratory physicians is highly specific for tracheomalacia.

Background: CO2 monitoring is recommended for thoracic telescopic procedures and for spontaneous breathing general anesthesia in children. During flexible bronchoscopy (FB) in children, the various currently available methods of CO2 measurements are limited. The CO2 falls and increases have been reported in FB but it is unknown whether airway lesions predispose to CO2 change. The aim of this study was to describe and validate endoscopic intratracheal CO2 measurements in children undergoing FB under spontaneously breathing GA., Methods: Endtidal CO2 (P(E)CO2) measurements at the start (Start-CO2) and end (End-CO2) of FB on 100 consecutive children were performed using a newly designed endoscopic intratracheal method. To validate the method blood gas sampling was simultaneously performed in 28 children and results analyzed using the Bland and Altman method, intraclass correlation and 95% range for repeatability., Results: End-CO2 and CO2-change (End-CO2 minus Start-CO2) were significantly different in children with airway lesions (CO2 change: no lesion = 3 mmHg, extrathoracic airway lesion = 4.5, intrathoracic airway lesion = 8, P = 0.038). There was no significant difference in Start-CO2 values among the groups. CO2-change in those aged < or =12 months was similar to those >12 months. Intratracheal CO2 measurements were comparable with arterial blood values in the Bland and Altman plots. The intraclass correlation was 0.69 and 95% range for repeatability was 3.7-4.17 mmHg., Conclusions: Midtracheal P(E)CO2 provides a useful estimate of P(a)CO2 for monitoring the respiratory status of children undergoing FB. The presence of airway lesions rather than age is associated with significant increased PCO2 rise.

Flexible bronchoscopy is an emerging diagnostic, therapeutic and supportive procedure used in paediatric respiratory medicine. Despite the improvements in instruments and anaesthetic support for this procedure, supervised training, strict quality-control measures and ongoing research are essential to ensure standards of safe practice and judicial use of the procedure.

Background: Published data on the frequency and types of flexible bronchoscopic airway appearances in children with non-cystic fibrosis bronchiectasis and chronic suppurative lung disease are unavailable. The aims of this study were to describe airway appearances and frequency of airway abnormalities and to relate these airway abnormalities to chest high resolution computed tomography (cHRCT) findings in a cohort of children with non-cystic fibrosis chronic suppurative lung disease (CSLD)., Methods: Indigenous children with non-cystic fibrosis CSLD (>4 months moist and/or productive cough) were prospectively identified and collected over a 2.5 year period at two paediatric centres. Their medical charts and bronchoscopic notes were retrospectively reviewed., Results: In all but one child the aetiology of the bronchiectasis was presumed to be following a respiratory infection. Thirty three of the 65 children with CSLD underwent bronchoscopy and five major types of airway findings were identified (mucosal abnormality/inflammation only, bronchomalacia, obliterative-like lesion, malacia/obliterative-like combination, and no macroscopic abnormality). The obliterative-like lesion, previously undescribed, was present in 16.7% of bronchiectatic lobes. Structural airway lesions (bronchomalacia and/or obliterative-like lesion) were present in 39.7% of children. These lesions, when present, corresponded to the site of abnormality on the cHRCT scan., Conclusions: Structural airway abnormality is commonly found in children with post-infectious bronchiectasis and a new bronchoscopic finding has been described. Airway abnormalities, when present, related to the same lobe abnormality on the cHRCT scan. How these airway abnormalities relate to aetiology, management strategy, and prognosis is unknown.