Author: Greta Di Mattia MD, The Maternal Childhood and Urological Sciences Department, Policlinico Umberto I, Sapienza University of Rome, Rome
Reviewer: Giuseppe Fabio Parisi, MD, PhD, Pediatric Bronchopneumology Unit, AOU Policlinico, Catania
Bronchoscopy is an essential examination in pediatric pulmonology, used to diagnose and treat a wide range of respiratory conditions in children. This procedure, although invasive, allows for direct visualization of the airways, collection of samples, and targeted therapeutic interventions. In the following paragraphs, we will clarify when and why it is necessary, how it is performed, and the main benefits and risks associated with it, providing parents with a complete guide on what to expect during this important exam.
What is Bronchoscopy, what are its main purposes, what is the bronchoscope and how does it work
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Bronchoscopy: what is its role and how is it performed?
Bronchoscopy is a very important examination for pediatric pulmonologists. It allows for the direct visualization of the airways, from the nose down to the bronchi. It is important because it enables the study of the anatomy and function of the respiratory airways (by observing their movement), the collection of samples, and the performance of some therapeutic procedures. It is considered an invasive examination because the introduction of an instrument, called a bronchoscope, into the airways is needed. It is a safe procedure when performed by experienced personnel.
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What is a bronchoscope?
To perform bronchoscopy, an instrument called a bronchoscope is used. There are two types of bronchoscopes: rigid and flexible. In pediatrics, the most commonly used is the flexible bronchoscope. The instrument consists of a small tube with a camera at the tip that transmits images to a screen. Inside the tube, there is also a channel to suction mucus, inject medications or saline solution, and pass other tools. There are bronchoscopes of various sizes depending on the child’s age: the smallest is 2.8 mm wide, and the largest is about 5 mm. The smallest possible instrument is always chosen to make the exam less uncomfortable.
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How is bronchoscopy performed? What type of anesthesia will be needed?
To perform bronchoscopy, your child will almost always need to be sedated. It is not a full anesthesia, but rather “deep sedation.” This means that medications will be administered to prevent your child from feeling discomfort, make him sleep, and prevent him from remembering the exam, while allowing him to breathe spontaneously. Full anesthesia is only performed if the child is in serious condition and needs to be intubated. During bronchoscopy, the child will be asked to lie on a bed, face up. If he is not intubated, drops of local anesthetic (lidocaine) will be placed in the nose, and the bronchoscope will be inserted through one nostril and slowly advanced down. The larynx is observed first, then the vocal cords, followed by the trachea and bronchi. In some cases, procedures like biopsies, brushing, or a bronchoalveolar lavage (where saline solution is injected and then suctioned to analyse the mucus in the bronchi) will be performed. During bronchoscopy, the child’s heart rate and oxygen saturation will always be monitored.
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How long does bronchoscopy take?
The duration of the exam is variable, ranging from 30 to 60 minutes.
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What are the main indications for bronchoscopy in children?
There are many reasons why your child may need bronchoscopy. Generally, less invasive diagnostic tests such as pulmonary function tests, chest X-rays, and sometimes chest CT scans are performed before this procedure. The most common indications are as follows:
- Airway obstruction: this results in noisy breathing if the obstruction is in the nose (e.g., stenosis or atresia of the choanae, craniofacial malformations, cysts); stridor if it is located in the larynx (e.g., laryngomalacia, laryngeal cleft, laryngeal membranes, supraglottic cysts, vocal cord paralysis, haemangioma, subglottic stenosis); persistent or severe wheezing if it is located in the trachea or bronchi (trachea-bronchomalacia, compression of airways by abnormal vessels, lymph nodes or tumors, bronchial obstruction from foreign bodies, mucus plugs, granulomas, tracheal or bronchial stenosis).
- Persistent radiographic anomalies: persistent or recurrent pneumonia in the same area of the lung; persistent atelectasis (collapse of part of the lung); localized emphysema (increased air); suspected tumor; bronchiectasis (dilated bronchi).
- Pulmonary infections: in this case, bronchoscopy is always combined with bronchoalveolar lavage to identify the organism causing the infection. It is performed in cases of severe pneumonia or pneumonia that does not respond to antibiotic therapy, in patients with cystic fibrosis, in immunocompromised patients, and in patients who have undergone a lung transplant.
- Chronic cough: if the cough lasts longer than 4 weeks and no cause is found through less invasive investigations.
- Suspected foreign body inhalation: if there is suspicion that the child may have inhaled food (most commonly peanuts, vegetable pieces) or other material, bronchoscopy is always essential. This is because other investigations (e.g., chest X-rays) may sometimes appear normal, and the foreign body needs to be removed as soon as possible.
- Bleeding: in cases of coughing up blood, bronchoscopy helps identify the source of the bleeding and, if it persists, can stop it.
- What are the risks of bronchoscopy?
During the exam, a temporary drop in oxygen levels in the blood may occur, which is generally resolved by giving the child oxygen. If this does not suffice, the exam will be paused until oxygen levels return to normal. Another fairly common complication is the temporary closure of the airways; if it occurs at the vocal cords, it is called laryngospasm, and if it occurs in the bronchi, it is called bronchospasm. The passage of the bronchoscope may also cause epistaxis (nosebleeds), haemoptysis (coughing up blood), or inflammation of the airway mucosa (edema). A more serious but very rare complication is pneumothorax (air loss around the lung) if a bronchus is damaged. Infections are very rare if the bronchoscope is properly cleaned. Finally, if your child has undergone bronchoalveolar lavage, he may experience a fever spike 8-12 hours after the bronchoscopy. Do not worry, this is a natu
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