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Seattle, WA
Dr. Carter is Associate Professor of Pediatrics, University of Washington School of Medicine.
Correspondence to: Edward R. Carter, MD, FCCP, Mail Stop 3D-4, Children’s Hospital & Regional Medical Center, 4800 Sand Point Way NE, Seattle, WA 98105; e-mail: 5carter{at}msn.com
The Renaissance biographer Giorgio Vasari quotes Donatello saying to his good friend and fellow artist Paolo Uccello: "Eh, Paolo, this perspective of yours makes you leave what is certain for the uncertain...."1 While Donatello was referring to the art of painting, these words pertain just as well to the art of medicine. Indeed, our perspective affects how we manage patients, and this is definitely true when evaluating children with noisy breathing. Noisy breathing, especially in infants, is a common problem, and its evaluation is not always straightforward. The workup will depend on one’s perspective (eg, training, experience, and patient population). Primary care providers encounter many of these patients first, often make the diagnosis without using invasive diagnostic aids, and refer only a few to specialists. Patients referred to specialists are more likely to undergo fiberoptic nasopharyngoscopy (NP) and flexible fiberoptic bronchoscopy (FB). Otolaryngologists routinely perform NP in the clinic setting without proceeding to FB, while pulmonologists are more likely to look further down the airway via FB.
How much workup for noisy breathing is enough? The majority of infants with inspiratory stridor have laryngomalacia, which can often be diagnosed by history and physical examination.2345 However, infants and children with noisy breathing who are referred for specialty evaluation may be more likely to have lower airway lesions. Reports in the literature45678 consistently have demonstrated that children with noisy breathing can have concomitant upper and lower airway lesions (called synchronous lesions) with the prevalence ranging from 8 to 18%. Importantly, in those studies many of the patients with synchronous lesions had lower airway abnormalities that either did not require emergent treatment (eg, tracheomalacia) or could have been diagnosed by methods other than FB (eg, vascular ring).
The concern for missing lower airway abnormalities led one of the pioneers of pediatric FB, Dr. Robert Wood, as well as others5679 to recommend consideration of FB in addition to NP when evaluating children with stridor. The American Thoracic Society statement on pediatric airway endoscopy and the American College of Chest Physicians interventional pulmonary procedures guidelines both state that noisy breathing is a common indication for FB in children, but neither comments on when it is appropriate to perform NP without FB.1011 A European Respiratory Society task force on pediatric FB concluded that there was insufficient information on the frequency of concomitant upper and lower airway lesions.12 It recommended performing FB plus NP in infants with severe or persistent symptoms and hypoxemia, and, also in older children with unexplained noisy breathing. In a review of pediatric FB, Nicolai13 emphasized the importance of looking below the vocal cords. However, the performance of FB in children, unlike that of NP, requires deep sedation, cardiorespiratory monitoring, and a significant amount of scheduled time. Thus, when is it really necessary?
The study by O’Sullivan et al in this issue of CHEST (see page 1266) challenges the need to perform FB in most children presenting with noisy breathing, provided that the noisy breathing is primarily inspiratory. The authors retrospectively reviewed their 10-year experience with children presenting to their clinic for evaluation of noisy breathing. The same group of pulmonologists did all of the assessments, so while there was no preset decision tree for when to perform diagnostic tests, the evaluations were fairly consistent. Patients with inspiratory or biphasic noise were considered for FB early in the evaluation. Patients with primarily inspiratory noise were first assessed clinically. Those who were not in respiratory distress and had noise typical for laryngomalacia were observed, and those who did not meet these criteria underwent NP. Patients with findings on NP that reasonably explained their noisy breathing were observed, but if the results of the NP were normal or did not sufficiently explain the noisy breathing, then FB was performed. The authors performed 82 NP procedures on 81 of the 356 children referred for evaluation of noisy breathing. More than half of the 81 patients were < 6 months old. The majority of patients (76%) presented with inspiratory stridor, and laryngomalacia was diagnosed in 50% of them (31 of 62 patients). Another 35% (22 of 62 patients) had other abnormalities identified on NP that explained their noisy breathing. Only 6% of the patients with plausible explanations for their noisy breathing identified by NP had synchronous lower airway lesions, none of which went undiagnosed for long.
There are some problems with the study by O’Sullivan et al. The patients were assessed retrospectively, and the decision to perform NP and/or FB was not standardized. The sample size was rather small, and 22% of the 81 children underwent FB shortly after NP, suggesting that the threshold for performing FB was fairly low. Nevertheless, their findings reassure us that many children who undergo NP for assessment of inspiratory stridor do not need to undergo FB.
Based on the studies by O’Sullivan et al and other investigators, I propose the following plan for the use of NP and FB in assessing children with noisy breathing. First, infants and children with expiratory or biphasic noise without an obvious cause often require a lower airway evaluation with FB or rigid bronchoscopy, although airway fluoroscopy is another option.14 Second, infants with inspiratory stridor who have significant respiratory signs and symptoms should have their upper airway evaluated by someone experienced in NP. If a plausible reason for the noisy breathing is found with NP and one is not suspicious about the presence of other lesions, then it is reasonable to observe the patient without looking further down the airway. However, if a likely cause is not found with NP, then further evaluation with FB, rigid bronchoscopy, and/or perhaps fluoroscopy is indicated. Third, most children outside of infancy who have inspiratory stridor of unknown cause should be evaluated with NP. Finally, if a patient is already sedated for the procedure, then take the opportunity to look all the way down the airway from the nose to the bronchi.
Vasari tells us that Paolo Uccello would sit up nights exclaiming "Oh, what a sweet thing this perspective is!"1 but Donatello would have Paolo, and us, abandon perspective for fact. However, perspective and data interpretation are inseparable, and we must use both to guide our decisions and to make the uncertain more certain. Chevalier Jackson, a founding father of pediatric otolaryngology and inventor of the rigid bronchoscope, offered insightful advice on when to perform bronchoscopy: "The indications for diagnostic bronchoscopy in disease appear very clearly in most instances from a study of the particular case; but it is difficult to lay down hard and fast rules on the subject. In a general way it may be stated that diagnostic bronchoscopy is indicated whenever there is an unsettled diagnostic question, and yet to follow this course would often be unwise because of the complacent satisfaction in an erroneous diagnosis so often manifest in cases of pulmonary disease."15
References
This article has been cited by other articles:
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  Y. Sivan, J. Ben-Ari, R. Soferman, and A. DeRowe Diagnosis of Laryngomalacia by Fiberoptic Endoscopy: Awake Compared With Anesthesia-Aided Technique. Chest, November 1, 2006; 130(5): 1412 - 1418. [Abstract] [Full Text] [PDF]
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