(Chest. 2001;120:614-616.)
© 2001
American College of Chest Physicians
Pediatric Fiberoptic Bronchoscopy With a Laryngeal Mask Airway*
Eliezer Nussbaum, MD, FCCP and
Michael Zagnoev, MD
*
From the Division of Pediatric Pulmonary Medicine and Cystic Fibrosis Center (Dr. Nussbaum), and Department of Anesthesiology (Dr. Zagnoev), Miller Children’s Hospital at Long Beach Memorial Medical Center, Long Beach, CA.
Correspondence to: Eliezer Nussbaum, MD, FCCP, Pediatric Pulmonology and Cystic Fibrosis Centers, Miller Children’s Hospital, 2801 Atlantic Ave, 3rd Floor, Long Beach, CA 90801-1428; e-mail: enussbaum{at}memorialcare.org
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Abstract
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Background and objectives: Bedside flexible fiberoptic
bronchoscopy (FFB) with sedation has been recognized as a diagnostic
modality in children. In certain circumstances, general anesthesia with
endotracheal intubation is advocated. This study evaluates the
usefulness of the laryngeal mask airway (LMA) as an alternative to
endotracheal intubation during pediatric FFB.
Design,
setting, and patients: Between July 1995 and June 2000, we
studied 92 children (51 girls; age range, 1 through 15 years) in the
operating theater of a major tertiary children’s hospital. The LMA was
used in children with atelectasis, diffuse infiltrates, and those who
required BAL under general anesthesia. The size of the LMA was chosen
to accommodate a bronchoscope appropriate for the child’s weight and
age.
Results: Procedures were well tolerated, no
complications were observed, and oxygen saturation exceeded 95% in all
patients. Major findings included mucoid impaction and purulent
bronchial secretions, and BAL was successfully accomplished in all
individuals.
Conclusions: Diagnostic BAL or extraction
of mucous plugs should be accomplished with optimal control of the
airway under general anesthesia. The use of the LMA during FFB is safe,
provides excellent patient comfort, and should be utilized as an
alternative to endotracheal intubation.
Key Words: BAL • laryngeal mask airway • pediatric fiberoptic bronchoscopy
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Introduction
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Flexible
fiberoptic bronchoscopy (FFB) in children and infants has been
recognized as a diagnostic modality within the past 2
decades.1
2
3
4
5
6
7
8
9
Although considered a bedside procedure that
requires sedation and topical anesthesia in the pediatric ICU, in
certain circumstances general anesthesia is preferable to
sedation. Our study confirms previous observations10
11
12
13
that the laryngeal mask airway (LMA) is a simple and useful tool when
general anesthesia is required in pediatric FFB. A major advantage of
this technique is that endotracheal intubation is not required for
passage of the bronchoscope.
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Materials and Methods
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Ninety-two children (51 girls; age range, 1 through 15
years) underwent FFB. Primary indications were persistent or recurrent
atelectasis, pneumonia, or diffuse infiltrates. Because of the extent
or chronicity of the pulmonary infiltrates or atelectasis, the general
anesthetic mode was chosen, as it was considered the safest modality
for diagnostic BAL. As shown in Table 1
, the size of the LMA was chosen to accommodate a flexible fiberoptic
bronchoscope appropriate for the size of the
patient.10
11
12
13
The bronchoscope was introduced through a bronchoscopy adapter
connected to the LMA after general anesthesia was established by the
pediatric anesthesiologist. A 1% or 2% lidocaine solution, usually
between 1 mL and 2 mL in volume, was selectively applied over the vocal
cords via the bronchoscope in order to prevent laryngospasm. BP, oxygen
saturation, ECG, heart rate, end-tidal carbon dioxide, tidal volume,
and minute ventilation were all monitored continuously in the operating
room. A BAL specimen was analyzed based on standard criteria as
previously described.4
5
6
8
9
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Results
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None of our subjects experienced any complications, such as
arrhythmia, hypotension, or gas exchange disturbance. Oxygen
saturations were always maintained between 95% and 100% as the
pediatric anesthesiologist adjusted ventilator parameters and oxygen
supplementation.
Our major diagnostic categories included the following: (1) excessive
purulent bronchial secretions in patients with cystic fibrosis; (2)
mucoid impaction or yellow bronchial casts in plastic bronchitis,
associated with sickle cell disease and the acute chest syndrome; and
(3) pneumonia and reactive airway disease complicated by segmental (or
lobar) atelectasis due to a mucous plug.
Therapeutic bronchial lavage was accomplished in the majority of
subjects in whom thick secretions or mucous plugs were identified.
Within 1 h, patients returned to their rooms for further
monitoring.
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Discussion
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Bedside FFB, with provision for sedation in the pediatric ICU and
preference for the nasopharyngeal approach, has been traditionally
accepted by pediatric pulmonologists conscious about cost savings and a
desire to avoid general anesthesia.1
2
3
4
5
6
7
8
9
14
15
16
Contrary to
the rigid open-tube bronchoscope, which provides for patient
ventilation in the operating room, the flexible bronchoscope represents
an introduction of a foreign body into the pediatric airways. This
promotes mechanical complications of airway dynamics, including
increased airway resistance and disturbances of ventilation-perfusion
relationships.17
18
Most seriously, it may subject the
child or adolescent to hypoxia, hypoxemia, and hemodynamic
complications, which may be life threatening.17
18
19
20
Heavy
sedation may result in hypoventilation, while inadequate sedation may
increase patient discomfort and interfere with the
procedure.21
22
23
24
25
26
Because pediatric bronchoscopy may be
unsafe in unintubated patients, the LMA provides a reasonable and safe
alternative to endotracheal intubation.9
21
24
25
In certain circumstances, which we described here, controlling the
airway under general anesthesia utilizing the LMA is recommended. None
of our patients suffered any complications. Patient comfort and
tolerance were excellent, and the diagnostic and therapeutic objectives
of bronchoscopy were fully accomplished. The clinical categories cited
in this article necessitate extraction of secretions and diagnostic
BAL. Such interventions may become extensive, time-consuming, and
risky.19
21
The bronchoscopist should be offered another
option. Utilization of the LMA provides such option.
It is believed that in an era of high technology in which pediatric
anesthesiology has progressively reached higher standards, no child
should be subjected to the unnecessary risks of hypoxia or hypoxemia,
particularly when bronchoscopy becomes more interventional and requires
total control of the airway and ventilation.
Diagnostic BAL or extraction of mucous plugs should be accomplished in
an optimal setting with maximal patient comfort, particularly when
anesthesia via LMA can be provided by skilled individuals.
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Footnotes
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Abbreviations: FFB = flexible fiberoptic
bronchoscopy; LMA = laryngeal mask airway
Received for publication August 23, 2000.
Accepted for publication November 30, 2000.
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Abstract
Introduction
