DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.

PAEDIATRIC BRONCHOSCOPY AN OVERVIEW

* V. J. Vikram, **S. K. Jha, **D. Roy, **B. Chowdhury, **G. C. Sahoo

ABSTRACT
Bronchoscopy is frequently required procedure to
diagnose and treat various pathologies affecting the
airway like malignancies, foreign body, tumors etc.
This article aims to exemplify the proper technique and
handling of the bronchoscope in children, where it is
frequently performed to remove foreign bodies stuck in
the airway.
Key Words: Pediatic bronchoscopy.
Address for correspondence:
Dr. S. K. Jha
32, Upendra Kishore Path
City Centre, Durgapur
West Bengal-713216

INTRODUCTION
Bronchoscopy in children for removal of foreign
bodies (F.B.) in the hand of a skillful endoscopist is very
safe now due to advanced anesthetic techniques with
constant monitoring of cardio-pulmonary function unlike
some years ago when cardiac monitor or pulse oximeter
were not available, cyanosis and pallor were the only
signs of imminent cardiac arrest with impending danger
to the child. Bronchoscopy is perhaps the most common
endoscopic procedure usually done for the possibility of
airway foreign body in children but unfortunately, it is
still being regarded as a risky and unsafe procedure due to
concern about the possible anesthetic complications in
partially obstructed airway. However, contrary to this,
bronchoscopy in children can help in sucking out the

Phone: +91-8335055714

insipid secretions or mucous ping thereby removing the

Email: sandeep.kr.jha@gmail.com

block in the obstructed airway where it is not possible for

the child to cough it out to clear out the airway. Whenever

Vol.-9, Issue-I, Jan-June - 2015

there is a suspicion of trachea-bronchial F.B., the

otolaryngologist must prepare for an early endoscopic
intervention with adequate and careful preparation. As per
Holinger, If two hours are spent in preparations, the safe
endoscopic procedure may take two minutes but if only
two minutes are taken for preparation, the endoscopist
may find himself attempting ineffective procedure for the
1

next two hours . Bronchoscopy in children with airway

F.B. may

22

*Madras Medical college, Chennai, Tamil Nadu, **IQ City Medical College and Narayana Multispecialty Hospital, Durgapur, West Bengal

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1

cause hypoxia or anoxia at times. Hence, all the

and the thyrohyoid membrane is very short. This

equipments must be chosen & assembled carefully

unique relationship of high larynx in child makes its

before administration of anesthesia to avoid any

visualization and intubation difficult for the anesthetist.

catastrophic complications during the tenuous situation

The chances of respiratory failure in infants are also

for immediate and adequate control of the airway by

high due to low respiratory reserve, narrow airway and

the endoscopist.

high peripheral airway resistance. In infants and small

HISTORY:

children the functional residual capacity of lung is less,

the BMR and oxygen consumption per minute are

Pioneering work was done by Chevalier Jackson

in designing various useful instruments for safe &

more and hence the heat loss is considerable to cause

dehydration with rapid respiratory rate. All these

successful removal of foreign bodies . Other pioneers

anatomic & physiological peculiarities in the infants &

who developed the science of bronchoesophagology

children are challenging not only for the anesthetist but

subsequently are Jackson Jr., Holinger and Tucker.

also for the otolaryngologist to perform a risky

Broyles (1963) and Holinger (1965) demonstrated fiber

optic light and fiber optic carrier respectively for

procedure as both of them fight for the same space in

the airway which is already compromised.

illumination in endoscope without any impingement on

the narrow lumen3. Brubaker and Holinger in 1972
introduced the method of still and motion picture

INDIACATIONS8:

cough & ipsilateral diminished air entry.

photography through Storz Hopkins telescope . Wood

and Fink in 1977 demonstrated the use of fiber optic

Classical Diagnostic triad of unilateral wheezing,

High degree of suspicion of F.B aspiration by

flexible endoscope in children .

SURGICAL

ANATOMY

pediatrician or parents.
&

APPLIED

Shifting consolidation from one side to another.

Tracheo-bronchial obstruction

Atypical Asthma not responding to usual treatment.

prone for edema . The glottis of a new born infant has an

Persistent pneumonia or bronchitis

antero-posterior length of 7-8mm and posterior transverse

History of violent cough or choking

Presence of stridor or any evidence of airway

breadth of around 4-6 mm in which a mere 1 mm of

mucosal edema can reduce the glottis space by 35-50%

obstruction

and similarly the sub glottis region with a diameter of 56mm can reduce the space by more than 40% and

emphysema on one side, collapse of lower lobe on

bronchus by mere 11% which may compromise the

7

either side and consolidation or collapse of lung

airway dangerously . The epiglottis at birth is at the level

of first cervical vertebra and cricoids at third vertebra.
The infant hyoid bone is very close to the larynx

Presence of radiological findings like obstructive

Mediastinal shift to normal side in check valve

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and sensitive but also it is high up and the submucosa is

JanJune

The larynx in infant is not only relatively small, soft

- 2015

PHYSIOLOGY OF PAEDIATRIC AIRWAY:

obstruction

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Early atelectasis & collapse with mediastinal shift

towards the involved side ball valve obstruction.

& a tracheotomy set should be kept ready for any

eventuality on side. The photographic equipment with
light source should be kept ready on right side for

EQUIPMENTS & INSTRUMENTS:

documentation. All the emergency drugs & all sizes of

Storz ventilating bronchoscopes of various sizes
from 2.5 mm to 6.0 mm with distal fiber optic
illumination are usually used for pediatric bronchoscopy
and it is better to use one size smaller endoscope for
diagnostic purpose than optional. Fiber optic conventional
rigid endoscopes with Halogen light source (250 Watts
Halogen Lamp) & built in spare bulbs along with various
types of F.B. holding forceps, suction canulas, cup shaped
biopsy forceps, Y type of suction tube to collect
0

aspiration materials are basic requirements. 0 and 30

Hopkins Telescope are necessary for diagnostic and

photographic purposes with Xenon light source. Flexible

endotracheal tube must be kept ready including extra

full oxygen & gas cylinder. In most cases, experienced
& skilled anaesthetist is the key person for the success of
the procedure who takes full charge of the situation to
oxygenate the child adequately and give sufficient time to
the surgeon to perform the procedure. In the event of
slight evidence of bradycardia or falling of oxygen level,
the surgeon should move out to give all the space &
assistance to anaesthetist for avoiding cardiac arrest.
Induction should be done with thiopentone, relaxation
& apnoea with scoline & oxygenation is maintained with
jet ventilation after introduction of endoscope. Many

fiber optic pediatric bronchoscopes are though ideal for

diagnosis but are not useful for any endoscopic surgical
procedure in infants & children as it may sometimes
9

obstruct an airway already obstructed . It must be noted

that the numbers indicating the size of the endoscopes are
not on the outer diameter but the inner diameter. The table
given below is a guide to use the correct size of
11

bronchoscopes as per the age of the child .

Operation Theatre Layout & Anaesthesia:

There should be proper operation room set up

Vol.-9, Issue-I, Jan-June - 2015

before taking the child for endoscopy besides having

checked all the necessary instruments & equipments.
The surgeon usually sits at the head end & the
anaesthetist on the left side of the child for consistently
monitoring of heart & oxygen saturation by cardiac
monitor and pulse oximeter. The light source should be
kept behind the right hand side of the surgeon including
the instrument trolley & suction machine. The assistant
& the nurse should stand on the right side of the patient

24

Advantages & Disadvantages of Rigid Vs Flexible

Bronchoscopy:

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anaesthetists also prefer induction with inhalation

bronchus with slight angulation towards the left. Then it

anaesthesia

can be withdrawn slightly and angled towards the right

breathing.

halothane
Some

and

maintain

anaesthetist

use

to visualise the left main bronchus. During the whole

intravenous Ketamine instead of Pentothal but it is not

procedure, suction should be done from time to time to

as safe in endoscopic procedure as it does not abolish

cleanse the secretions13. The bronchus, bronchoscope

the pharyngeal & laryngeal reflexes. Before starting

and the F.B. should lie in one straight line before it is

anaesthesia, a firm intravenous line should be

removed. The blades of F.B. forceps should be opened

12

established & infusion should be started.

after it crosses the tip of the endoscope and then the

TECHNIQUE OF BRONCHOSCOPY

F.B. should be caught firmly and brought near the tip of

After selecting an appropriate size bronchoscope

according to the age of the child, it should be checked for
proper illumination and cleaned thoroughly. A correct
size suction cannula should be checked and passed
through the bronchoscope. Out of various types of F.B.
forceps like toothed, non-toothed, cupped, serrated, flat,
crocodile, alligator etc. Selection should be done keeping
in mind the type of bronchial F.B. which can assure a firm
grip of the F.B. without damaging the bronchial mucosa.
After visualising the larynx after lifting the epiglottis by
the laryngoscope, the bronchoscope should be gently
introduced into the glottis with the tip upwards and under
the epiglottis. Bronchoscope should be held in the right
hand with pen hold grip and should be gently slid into

the bronchoscope. Then the bronchoscope along with

the F.B. forceps should be gently withdrawn
simultaneously till it reaches the glottis. After this, the
bronchoscope should be tilted slightly upwards with the
held F.B. to pass out through the posterior part of the
glottis which is wider. Loose F.B. in trachea are more
difficult which should not be caught directly when they
are in the trachea, rather it should be pushed down to
let them lodge in either main bronchus, usually the right
main bronchus, after which it is easy to catch and
remove. Otherwise, loose trachea F.B. may get stuck
in the subglottic region which is the narrowest one in
the airway, causing total airway obstruction until unless
removed as early as possible.

the trachea after visualising the vocal chords. The

After the removal of the F.B. the anaesthetist

anaesthetist should then start inflating the lungs with Jet

should oxygenate the child and allow the endoscopist to

ventilation by the side of the bronchoscope. Failure to

reintroduce the bronchoscope for inspection of

inflate the lungs with Jet ventilation and inability to

tracheobronchial tree for any remnant of F.B. or a

identify the tracheal rings should alert that the

second F.B. rarely . The tracheobronchial tree should

bronchoscope is not in the air passage but in the

be cleaned with suction and bronchoscope should be kept

oesophagus. After it is confirmed the endoscope is in

in trachea for proper oxygenation till the breathing is

trachea then it should be glided down over the left hand

spontaneous. Both the surgeon and anaesthetist should

fingers without undue force and always under vision. The

observe the child till the muscle tone returns to normal,

next step is the identification of carina and introduction of

cough reflex is present and child starts crying and air

the bronchoscope into the right main

entry is checked on either side. The child should be kept

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14

-2015

using

IssueI,
Jan-June

spontaneous

or

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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1

in left lateral position before shifting to ward and if

2.

Giddings CE, Rimmer J, Weir NJ Laryngol Otol.

there is any evidence of sub glottis oedema in the form

Chevalier Jackson: pioneer and protector of

of brassy cough or strider, then intravenous steroid

children. 2013 Jul;127(7):638-42. doi: 10.1017/

should be given including strict observation of child.

S0022215113001084. Epub 2013 May 24.

COMPLICATIONS:

Hypoxia,
respiratory

cardiac
acidosis

3.
arrhythmia,
&

optic

hypercarbia,

other

Laryngeal or subglottic edema due to oversize

endoscope & repeated instrumentation.

Sub glottis impaction of F.B while removal.

Post operative laryngeal spasm

Aspiration of secretion or vomiting

Inadequate ventilation leading to bradycardia,

cyanosis, pallor & cardiac arrest.

laryngoscopes,

bronchoscopes

and

esophagoscopes. Ann Otol Rhinol Laryngol. 1965

anaesthetic

Dec;74(4):1164-7.

complications.

Holinger PH. Presentation of instruments. Fiber-

4.

Holinger PH, Brubaker JD. Still and motion picture

photography of the tracheobronchial tree and
esophagus through endoscopic telescopes. Ann Otol
Rhinol Laryngol. 1972 Dec; 81(6):809-11.

5.

Wood RE, Fink RJ. Applications of flexible

fiberoptic bronchoscopes in infants and children.

CONCLUSION:

Chest. 1978 May;73(5 Suppl):737-40.

6.

Pierre

Fayoux,

Bruno

Marciniak,

Louise

Devisme, and Laurent Storme. Prenatal and early

Paediatric Bronchoscopy is very safe and the most

postnatal morphogenesis and growth of human

common indication is suspicion of F.B in airway. The

laryngotracheal structures. J Anat. 2008 Aug;

anesthetist, endoscopist and assistants should work in

213(2): 8692.

tandem for a successful & safe procedure. The

bronchoscope must never be pushed with undue force

7.

Ohad Ronen, MD, Atul Malhotra, MD, and Giora

Pillar, MD, PhD Influence of Gender and Age on

against resistance & should be always under vision. A

Upper-Airway

meticulous planning & assessment is must by the

Length

During

Development.

Pediatrics. 2007 Oct; 120(4): e1028e1034. doi:

surgeon & anesthetist before bronchoscopy.

10.1542/peds.2006-3433.

DISCLOSURES

Vol.-9, Issue-I, Jan-June - 2015

8.
(a) Competing interests/Interests of Conflict- None

Karan Madan, Ritesh Agarwal, Ashutosh N.

Aggarwal, and Dheeraj Gupta.Therapeutic rigid
bronchoscopy at a tertiary care center in North

(b) Sponsorships - None

India: Initial experience and systematic review of

(c) Funding - None

Indian literature. Lung India. 2014 Jan-Mar;

REFERENCES:
1.

Holinger PH, Johnston KC. Bronchoscopic

problems in the newborn. Ill Med J. 1952
Feb;101(2):68-77.

26

31(1): 915. doi: 10.4103/0970-2113.125887.

9.

Wojciech Korlacki, Klaudia Korecka, and Jzef

Dzielicki.Foreign body aspiration in children:

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1

diagnostic and therapeutic role of bronchoscopy.

Pediatr Surg Int. 2011 Aug; 27(8): 833837.
10.

Amith. I. Naragund, R. S. Mudhol, A. S.

Harugop, P. H. Patil, P. S. Hajare, and V. V.
Metgudmath Tracheo-Bronchial Foreign Body
Aspiration in Children: A One Year Descriptive
Study. Indian J Otolaryngol Head Neck Surg.
2014 Jan; 66(Suppl 1): 180185. Published online
2011 Dec 7. doi: 10.1007/s12070-011-0416-2.
,

Rigid Bronchoscopy: Indications and Techniques.

Techniques

in

Thoracic

and

Cardiovascular Surgery. Volume 17, Issue 1,

Spring 2012, Pages 4451.
12. Patrick T. Farrell. Rigid bronchoscopy for foreign
body

removal:

anaesthesia

and

Pediatric Anesthesia 2004 14: 8489.

Donghi S, Galetta D, Gasparri R, Guarize J,

Pardolesi A, Solli P, Tessitore A, Venturino M,
Veronesi

G,

Spaggiari

L.

Operative

rigid

bronchoscopy: indications, basic techniques and

results. Multimed Man Cardiothorac Surg. 2014
May 27;2014. pii: mmu006. doi: 10.1093/mmcts/
mmu006.
14. Daniel G. Nicastri, Todd S. Weiser. Rigid

11. Daniel G. Nicastri, MD Todd S. Weiser, MD.

Operative

13. Petrella F, Borri A, Casiraghi M, Cavaliere S,

ventilation.

Bronchoscopy:
Operative

Indications

techniques

in

and

techniques.

Thoracic

and

Cardiovascular Surgery. Spring 2012, Volume 17,

Issue 1, pg 44-51.