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Dr. Slonim is affiliated with the Departments of Critical Care Medicine and Performance Improvement, Children’s National Medical Center, and he is Assistant Professor of Internal Medicine and Pediatrics, The George Washington University School of Medicine. Dr. Ognibene is affiliated with the Critical Care Medicine Department, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, and he is an Associate Professor of Internal Medicine, The George Washington University School of Medicine.
Correspondence to: Anthony D. Slonim, MD, MPH, Department of Critical Care Medicine, Children’s National Medical Center, 111 Michigan Ave NW, Washington, DC 20010; e-mail: aslonim{at}cnmc.org
Conscious sedation enhances the safety, technical ease, and comfort of many pediatric procedures.1 2 3 Monitored conscious sedation is now standard practice for children in many different settings for a variety of procedures and with a number of different agents.1 2 3 Sedation and anesthesia strategies for flexible fiberoptic bronchoscopy (FFB) in pediatric patients also have been reported.4 5 6
Bronchoscopy is unique compared to other pediatric procedures, because a foreign body is introduced directly into the airway, thereby altering airway resistance and ventilation-perfusion relationships.4 In addition, the sedative selection may adversely affect the spontaneously breathing patient who has abnormal pulmonary physiology.4 5 6 Despite these differences, bronchoscopy still can be performed safely as a bedside procedure under many circumstances. In the properly selected patient, sedation is well tolerated and has a low, but definite, risk of minor complications.4 5 6 When the patient’s underlying disease, current physical status, or comorbidity suggests a potential clinical difficulty as a result of either the procedure or the sedation, the services of an anesthesiology department, including the operating room as the preferred site of the procedure, should be considered.4
In this issue of CHEST, Nussbaum and Zagnoev (see page 614) report their results using the laryngeal mask airway (LMA) as an alternative to endotracheal intubation for pediatric bronchoscopy procedures in 92 children at their referral center. The clinical condition of these patients and the interventions to be performed warranted a more controlled technique than could be accomplished with conscious sedation at the bedside. The authors report a successful completion of the procedure, a timely return of the patient to clinical baseline, and no complications.
This is the largest case series to date reporting the use of the LMA for FFB in children. However, it is not the first time the LMA has been evaluated as an airway adjunct in FFB procedures in children. The current series complements a number of smaller case series.7 8 9 10 In those series, the LMA was determined to be successful in assisting with FFB procedures. The major complications associated with its use have included airway obstruction and failure to place the LMA in the appropriate position.9 In addition, laryngospasm, bronchospasm, and oxygen desaturations have been reported.8
Why use the LMA? Nussbaum and Zagnoev have highlighted some of the factors that may relate to this decision in their patient population. The removal of secretions is sometimes difficult to perform, is time consuming, and increases the risk of the procedure. Other patients may require diagnostic bronchoscopy. In those patients, hypoxia or excessive work of breathing secondary to abnormal pulmonary physiology may increase the complexity of the procedure. In addition, the potential effect of the sedative agent on the patient’s condition should be assessed to determine whether the patient can tolerate the procedure.4
There are several advantages to the use of an LMA during FFB procedures in children. First, the airway is secured so that deep sedation and anesthesia can be provided, if needed, to facilitate the procedure. The ability to select from alternative drug regimens and techniques enhances the performance of a safe procedure that is free from pain and adverse memory for the patient.4 Second, because of its size, the LMA can accommodate a larger bronchoscope than the endotracheal tube, thereby allowing a bronchoscope with a suction channel to be used, thus improving the ease of suctioning.10 The resistance to gas flow utilizing a conventional endotracheal tube is twice that of an LMA.11 This also has implications for the size of the bronchoscope and ventilatory settings used for the procedure.11 In addition, with a larger bronchoscope, transbronchial biopsies can be performed in younger children, which, depending on the patient population being treated, may be a significant advantage.10 Finally, the LMA provides greater visibility of the glottis and supraglottic structures than does the endotracheal tube and allows the operator to assess airway dynamics in the spontaneously breathing patient.10
There are also disadvantages in comparing the LMA to an endotracheal tube for FFB procedures in children. An LMA is associated with an increased work of breathing when compared to endotracheal intubation.12 However, these effects may be lessened once the bronchoscope is inserted into the artificial airway. The LMA is also relatively contraindicated in those patients with severe respiratory distress in whom endotracheal intubation may provide a safer alternative10
The major task for the bronchoscopist is to identify those patients or procedures in which FFB performed under conscious sedation at the bedside may be difficult or may be more safely performed elsewhere with the support of an anesthesiologist. The LMA provides the anesthesiologist with a reasonable alternative to endotracheal intubation for FFB procedures in children. With appropriate skill and expertise, these results demonstrate that an LMA can be used safely and can allow bronchoscopy to be performed easily and with good results.
References
This article has been cited by other articles:
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  S. Roberts and R. E Thornington Paediatric bronchoscopy CEACCP, April 1, 2005; 5(2): 41 - 44. [Abstract] [Full Text] [PDF]
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