Diagnostic and Interventional Bronchoscopy in Children

Preface
Contents
Contributors
Part I: History and Fundamentals of Flexible Bronchoscopy
1: Pediatric Bronchoscopy: A Personal Odyssey Through 5 Decades
References
2: Organizing and Maintaining a Flexible Bronchoscopy Program
The Team
The Venue
Preoperative and Patient Recovery Facilities
Equipment
Equipment Cleaning
Equipment Storage
Handling the Data Generated by the Procedures
Communication
Business Matters
References
3: Upper Airway Anatomy and Physiology
Nasal Cavity
Anatomy
Physiology
Nasal Cycle
Nasal Valve
Mucociliary Clearance
Oral Cavity
Anatomy
Physiology
Pharynx
Anatomy: Endoscopic Evaluation
Nasopharynx
Oropharynx
Tonsils
Glossoptosis
Hypopharynx
Drug-Induced Sleep Endoscopy
Pharyngeal Musculature
Pharyngeal Physiology
Airway Patency
Swallow
Larynx
Anatomy
Laryngeal Framework
Musculature
Innervation
Endoscopically Relevant Anatomy
Supraglottis
Glottis
Subglottis
Vocal Fold Histology
Physiology
Phonation
Airway Protection
Respiratory Control
References
4: Lower Airway Anatomy
Introduction
The Normal Trachea and Carina
The Bronchial Tree
Normal Variants
Bronchial Nomenclature
Bibliography
5: Physiology of the Airways
Introduction
Functional Aspects of the Airways
Airway Patency and Resistance
The Influence of Bronchoscopes upon Airway Function
Mucociliary Clearance
Pulmonary Vessels
Innervation of the Airways
Lymphatic System
Further Reading
6: Indications and Risks of Flexible Bronchoscopy in Children
Indications
General Considerations
Diagnostic Indications
Chronic/Recurrent Symptoms
Chronic/Recurrent Diagnoses
Airway Evaluation
Diagnostic Bronchoalveolar Lavage
Endobronchial Biopsy
Transbronchial Biopsy (TBB)
Transbronchial Needle Aspiration (TBNA) with Endobronchial Ultrasound (EBUS)
Therapeutic Indications
Risks/Complications
Risks Associated with Anesthesia
Risks and Complications
Infection
Risks in Critically Ill Children
Risk of Therapeutic and Interventional Bronchoscopy
Risks to Medical Team
Risk of Damage to Equipment
Conclusion
References
7: Bronchoalveolar Lavage: Sampling Methods
Techniques and Wedge
Site of Lavage
Type and Amount of Solution
Fluid Recovery
References
8: Bronchoalveolar Lavage: Cytology
Cell Types, Adequacy, and Specimen Handling
Flow Cytometry
Special Stains for Cytology
Prussian Blue
Oil-Red-O
Special Stains for Pulmonary Alveolar Proteinosis
Special Stains for Organisms
References
9: Bronchoalveolar Lavage: Microbial Evaluation
Introduction: Overall Diagnosis of Infection by Bronchoscopic Techniques
Bacteriology
Bacterial Etiologies and Sampling
Methods for Detecting Bacterial Infection in Bronchoscopic Samples
Culture
PCR/Nucleic Acids
Mycobacteriology
Tuberculosis
Nontuberculous Mycobacteria
Methods for Detecting Mycobacterial Infection in Bronchoscopic Samples
Culture
Molecular-Based Testing
Pathology/Cytology
Virology
Introduction
Respiratory Viruses
Herpesviruses
Cytomegalovirus
Herpes Simplex Virus
Varicella Zoster Virus
Other Herpesviruses
Human Papillomavirus (HPV)
Histopathology/Direct Microscopy
Culture
PCR/Nucleic Acid Testing
Antigen-Based Testing
Mycology
Introduction
Fungi That Cause Pulmonary Infections
Aspergillus
Pneumocystis jirovecii
Candida
Cryptococcus
Mucorales Species
Dimorphic Fungi
Methods to Diagnose Fungal Pulmonary Infections
Histopathology/Direct Microscopy
Culture
PCR/Nucleic Acid Testing
Antigen-Based Testing
Galactomannan
β-D-glucan
Parasitology
Introduction
Culture
PCR/Nucleic Acid Testing
Antigen-Based Testing
Pathology/Cytology
Airway Microbiome
References
10: Bronchoalveolar Lavage: Biomarkers
Biomarkers for Specific Conditions
Pulmonary Langerhans Cell Histiocytosis
Hypersensitivity Pneumonitis
Cystic Fibrosis
Chronic Lung Allograft Dysfunction and Acute Cellular Rejection
References
11: Anesthesia Consideration for Flexible Bronchoscopy
Goals of an Airway Anesthesia Team
Preoperative Assessment
Preoperative Preparation
Induction and Maintenance of Anesthesia
Perioperative Events
Recovery and Postoperative Care
Conclusion
References
12: The Physiological Effects of Flexible Bronchoscopy: Lessons for the Skilled Bronchoscopist
Introduction
The Effects of Flexible Bronchoscopy on Pulmonary Function
Hemodynamic Effects
Gas Exchange Effects
Additional Effects of Bronchoalveolar Lavage
Body Temperature Effects
Intracranial Pressure Effects
Physiological Effects of Anesthetic Agents
Procedural Anxiety
Clinical Implications of the Physiological Effects of Flexible Bronchoscopy
References
13: Non-Bronchoscopic Assessment of the Airways
Overview
Current Clinical Medical Imaging
Radiography
Computed Tomography
Magnetic Resonance Imaging
Ultrasound
Fluoroscopy
Virtual Bronchoscopy
Emerging Techniques
Developments in Magnetic Resonance Imaging
Geometric Airway Measurements from Imaging
Calculating Airway Function: Computational Fluid Dynamics
Limitations of Image-Based Airway Assessment
Summary
References
14: Flexible Bronchoscopy Training
Introduction
Part 1. What to Teach?
Why Is the Procedure Done?
The Airways
The Bronchoscope
Access
Entering the Airways
Other Perioperative Issues
Consent
The Bronchoscopy Report
Part 2. How Should the Bronchoscopy Be Taught?
Duration of Training and Assessment of Competence
Summary
References
15: Forty-Nine Ways to Get the Wrong Answer from a Bronchoscopy
Part II: Role of Flexible Bronchoscopy in Evaluation of Pediatric Respiratory Tract Disorders
16: Approach to Common Chief Complaints
Introduction
Airway Dynamics: General Considerations
Airway Dynamics: Specific Considerations
History
Physical Examination
Conclusion
References
17: Evaluating Airway Dynamics
Evaluation of Upper Airway Dynamics
Nasopharyngolaryngoscopy (NPL)
Drug-Induced Sleep Endoscopy (DISE)
Cine MRI
Evaluation of Lower Airway Dynamics
Flexible Bronchoscopy
Rigid Bronchoscopy
Imaging
Fluoroscopy
Multi-detector Computed Tomography
Magnetic Resonance Imaging
Summary
References
18: Extrinsic Compression of Lower Airway
Introduction
Vascular Anomalies
Complete Vascular Rings
Pulmonary Artery Sling
Innominate Artery Compression Syndrome
Diagnosis, Treatment, and Prognosis
Cardiac Disease
Mediastinal Mass
Lymphoma
Teratoma
Thymoma
Vascular Tumor
Bronchogenic Cyst
Lymphadenopathy/Lymphadenitis
Tuberculosis
Histoplasmosis
References
19: Pneumonia: Immunocompetent Children
Introduction
Community-Associated Pneumonia
Common Community-Associated Pneumonia Pathogens
Host-Defense and Viral-Bacterial Co-Infection
Diagnosis of Community-Associated Pneumonia
Flexible Bronchoscopy in Community-Associated Pneumonia
Diagnostic Testing of Bronchoscopy Specimens
Ventilator-Associated Pneumonia
Unusual Pathogens
Fungal Pneumonia
Conclusions
References
20: Pulmonary Infections in the Immunocompromised Host
Introduction
Bacterial Infections
Epidemiology
Diagnostics
Acute Management
Fungal Infections
Epidemiology
Viral Infections
Epidemiology
Herpesviruses
Respiratory Viruses
Parasitic Infections
Summary
References
21: Bronchiectasis and Suppurative Bronchitis
Brief Overview of Endobronchial Suppuration Disorders in Children
Bronchiectasis and Chronic Suppurative Lung Disease (CSLD)
Protracted Bacterial Bronchitis (PBB)
Primary Ciliary Dyskinesia (PCD)
Cystic Fibrosis (CF)
Diffuse Panbronchiolitis (DPB)
Flexible Bronchoscopy Findings in Endobronchial Suppurative Disorders
Common Generic Bronchoscopic Findings in Endobronchial Suppuration
Macroscopic Findings of Bronchitis
Airway Secretions, Mucosal Appearance and Bronchitis Scores
Tracheobronchial Abnormalities – Airway Malacia
BAL Findings
Airway Cellularity and Inflammatory Biomarkers
Airway Microbiology
Biofilm
Disease-Specific Bronchoscopy Findings
Bronchiectasis and CSLD
Macroscopic Findings
BAL Findings
Protracted Bacterial Bronchitis
Macroscopic Findings
BAL Findings
Primary Ciliary Dyskinesia
Macroscopic Findings
BAL Findings
Cystic Fibrosis
Macroscopic Findings
BAL Findings
Diffuse Panbronchiolitis
Macroscopic Findings
BAL Findings
When Should Bronchoscopy Be Undertaken?
Gaps for Future Research
References
22: Aspiration
Introduction
Swallowing
Development of Swallowing
Pathophysiology of Aspiration
Evaluation of Aspiration
Chest Imaging
Oral Motor Feeding Assessment
Videofluoroscopic Swallow Study
Functional Endoscopic Evaluation of Swallowing
Dye Testing
Rigid Bronchoscopy
Esophageal Impedance
Other Studies
Flexible Bronchoscopy
Upper Airway Evaluation
Evaluation for Laryngeal Cleft
Vocal Cord Paralysis
Lower Airway Abnormalities
Lower Airway Inflammation
Bronchoalveolar Lavage
The Aerodigestive Model
Conclusion
References
23: Plastic Bronchitis
Overview of Plastic Bronchitis
Causes of Plastic Bronchitis
Diagnosis of Plastic Bronchitis
Therapy for Plastic Bronchitis
Medical Management
Interventional Management
Bronchoscopy
Percutaneous Pulmonary Lymphatic Embolization
Conclusion
References
24: Flexible Bronchoscopy and Pediatric Asthma
Introduction
Safety of Flexible Bronchoscopy in Asthma
Flexible Bronchoscopy in the Differential Diagnosis of Asthma
Expiratory Wheezing as Indication for Flexible Bronchoscopy
Bronchodilator Response
Air Trapping in the Lungs
Recurrent and Persistent Wheezing in Infants, American Thoracic Society (ATS) Guidelines
Association of Asthma with Anatomical Airway Abnormalities
Flexible Bronchoscopy in Severe Uncontrolled Asthma
Eosinophilic Airway Inflammation
BAL Eosinophils
EBB Eosinophils
Neutrophilic Airway Inflammation
Assessment of Airway Remodeling
Bacterial Lower Airway Infection and Inflammation in Asthma
Allergic Bronchopulmonary Aspergillosis
Flexible Bronchoscopy in Defining SUA Phenotypes
Persistent Airway Eosinophilia Phenotype
Airway Remodeling Phenotype
SUA/Bacterial Bronchitis Overlap Phenotype
SUA/Esophagitis Phenotype
Suggestions on the Practical Approach to SUA Management Based on Bronchoscopy Findings
References
25: Foreign Body Aspiration: The Role of the Pediatric Pulmonologist
Introduction
Epidemiology
Presentation
Evaluation
Treatment: Foreign Body Retrieval
History of Foreign Body Retrieval
Modern Methods of Foreign Body Retrieval
Anesthetic Considerations for Retrieval with a Flexible Bronchoscope
Timing of Treatment
Flexible Bronchoscopy Techniques for Foreign Body Retrieval
Complications
Follow-Up
Conclusion
References
26: Laryngotracheal Stenosis
Anatomic Review
Embryology and Histology
Etiologies of Stenosis
Diagnosing Stenosis
Managing Stenosis
Future Directions
References
27: Airway Tumors
Introduction
Types of Airway Tumors
Malignant
Carcinoid Tumors
Mucoepidermoid Carcinomas
Fibrosarcoma
Benign
Inflammatory Myofibroblastic Tumor (aka Plasma Cell Granuloma)
Hamartomas
Mucus Gland Adenoma
Hemangioma
Pseudotumors of the Airway
Tuberculosis
Coccidioidomycosis
Actinomyces
The Role of Flexible Bronchoscopy in Diagnosis and Management of Pediatric Airway Tumors
References
28: Hemoptysis and Pulmonary Hemorrhage
Definition
Epidemiology and Outcome
Anatomy and Pathophysiology
Differential Diagnosis
Bronchoscopic Evaluation
Intervention
Conclusion
References
29: Flexible Bronchoscopy and Children’s Interstitial Lung Disease
What Is ChILD?
ChILD and Airway Anatomical Evaluation
ChILD and BAL Results
Endobronchial Biopsy
CHILD and Timing of Flexible Bronchoscopy
Repeated Flexible Bronchoscopies in the Management of the Patient with chILD
References
Part III: Advanced Diagnostic and Interventional Bronchoscopy
30: Tracheobronchography
Introduction
Technique
Discussion
Tracheobronchoscopy and Radioprotection
References
31: Functional Endoscopic Evaluation of Swallowing (FEES)
Introduction
Patient Selection
Instrumentation
Technique
Evaluation
Scoring Systems
Evidence
References
32: Bronchoscopy in Pediatric and Neonatal ICU
Technical Aspects and Physiologic Considerations
Physiology
Systemic Review of Flexible Bronchoscopy in Critically Ill Pediatric Patients
Diagnostic Bronchoscopy
Therapeutic Bronchoscopy
Atelectasis
Hemoptysis and Pulmonary Hemorrhage
Bronchoscopy in Patients Receiving ECLS
Adverse Events During Bronchoscopy in the ICU
Summary
References
33: Endobronchial Biopsy (in Children with Severe Uncontrolled Asthma)
Safety of Endobronchial Biopsy in Pediatrics
Instruments
Endobronchial Biopsy Techniques
Traditional Technique
“Parallel” Technique
Sample Processing and Anatomic Pathology Report
Predominant Inflammatory Cells
Assessment of Eosinophils in Biopsy Sample
Reticular Basement Membrane Thickness
References
34: Transbronchial Biopsy
Introduction
Indications
Lung Transplantation
Lung Infections
Diffuse Lung Diseases
Neoplastic Pulmonary Disorders
Contraindications
Preparation
Biopsy Technique
Specimen Handling
Limitations
Complications
Cryobiopsy
Conclusion and Future Directions
References
35: Endobronchial Ultrasound
Introduction
Ultra-Miniature Radial Probe EBUS
Radial Balloon Probe EBUS
Convex Probe EBUS-TBNA
Future Directions
Conclusion
References
36: Electromagnetic Navigational Bronchoscopy
Introduction
Virtual Bronchoscopy
Electromagnetic Navigational Bronchoscopy
Robotic Bronchoscopy
Anesthesia
Fluoroscopy
Radial Probe Endobronchial Ultrasound
Rapid On-Site Evaluation
Diagnostic Yield
Complications
Limitations
Therapeutic Uses of ENB
Future Directions
Conclusion
References
37: Endobronchial Valves
Background
Alveolopleural Fistula
Incidence and Risk Factors for Prolonged Air Leak
Management of Prolonged Air Leak
Endobronchial Valve Management of Prolonged Air Leak
Summary
References
38: Whole-Lung Lavage
Introduction
Pulmonary Alveolar Proteinosis
Timing of Whole-Lung Lavage
General Considerations
Preparation
Double-Lumen Endotracheal Tube Technique
Alternative Techniques
Fluid Analysis
Conclusion
References
39: Treatment of Tracheobronchial Stenosis
Flexible Bronchoscopy as a Diagnostic Tool in Tracheobronchial Stenosis
Flexible Bronchoscopy as a Therapeutic Tool for Tracheobronchial Stenosis
Laser Dilatation
Balloon Dilatation
Electrosurgery
Electrocautery
Argon Plasma Coagulation (APC)
Cryotherapy
Probe Cryotherapy
Spray Cryotherapy
Bibliography
40: Excision of Airway Lesions
Epidemiology of Pediatric Endobronchial Lesions
General Considerations: Airway Management and Endoscopic Equipment
Laser Therapy
Cryotherapy
Microdebrider
Argon Plasma Coagulation
Mechanical Tumor Excision
Conclusion
References
41: Cryotherapy
Introduction
General Principles
Applications and Techniques
Summary
References
Bibliography
42: Bronchial Thermoplasty
Introduction
Updates in Asthma Therapy
Rationale for Using Bronchial Thermoplasty
Clinical Safety and Efficacy of BTP
Long-Term Effectiveness of BTP in Adults
Considerations for BTP in Children
Potential Modifications to the BTP Procedure in Children
References
43: Endoscopic Repair of Tracheoesophageal Fistula
Background
Approaches to Endoscopic Repair
Tracheal Diverticula
Success with Endoscopic Repair
Summary
References
Index