Flexible Bronchoscopy Procedures Research Articles

Hypoxaemia risk in pediatric flexible bronchoscopy for foreign body removal: a retrospective study

BackgroundHypoxemia represents the most prevalent adverse event during flexible bronchoscopy procedures aimed at foreign body retrieval in pediatric patients; if not expeditiously managed, it carries the potential for cardiac or respiratory arrest. The specific risk factors contributing to the occurrence of hypoxemia during foreign body FB removal via bronchoscopy have yet to be definitively established.MethodsThis retrospective study included a cohort of 266 pediatric subjects from January 1, 2015, to December 31, 2022, who underwent flexible bronchoscopy for the purpose of FB extraction. In this cohort, the supraglottic airway was used to connect the anesthesia apparatus during the removal procedure.ResultsIn total, 45 of the pediatric patients (16.9%) experienced episodes of hypoxemia during the FB removal procedure. Multivariate analysis revealed that the following factors were significantly associated with the occurrence of hypoxemia: an operation time exceeding 60 min (odds ratio [OR] 8.55; 95% confidence interval [CI] 3.82–19.13), a maximum diameter exceeding 7 mm (OR 5.03; 95% CI, 2.24–11.29), and the presence of radiological evidence indicating pneumonia (OR 2.69; 95% CI, 1.27–5.69).ConclusionDuring flexible bronchoscopy procedures aimed at FB removal in pediatric patients, there is an increased susceptibility to hypoxemia. Factors including extended operation duration, larger FB dimensions, and radiographic evidence suggestive of pneumonia significantly contribute to a heightened risk of hypoxemia.

Experience of flexible bronchoscopy in the pediatric pulmonary diseases clinic.

Flexible bronchoscopy is a valuable method in the diagnosis and treatment of respiratory tract diseases in children. This study aimed to examine the indications for and results of flexible bronchoscopy in children. The study included patients aged 0-18 years who underwent flexible bronchoscopy between 1 January 2017 and 31 December 2022. The patients were evaluated for demographic characteristics, indications for bronchoscopy, comorbidities, bronchoscopy findings, and the results of bronchoalveolar lavage. During the defined study period, a total of 410 flexible bronchoscopy procedures were performed. 51.9% of the patient population were male, and 48.1% were female, with a mean age of 96.93 ± 63.45 months. The most common indication for flexible bronchoscopy was recurrent lower respiratory tract infection (26.8%), followed by chronic cough (19.1%). The bronchoalveolar lavage culture results showed that the most commonly isolated microorganisms were H. influenzae non-type b (7.8%) followed by M. catarrhalis (7.3%). Mucus obstruction and secretion (33.0%) constituted the most common bronchoscopic findings, while the flexible bronchoscopy examination was normal in 27% of patients. No serious complications occurred in any patient during or after the procedure. The results of this study demonstrated that the most common indication for flexible bronchoscopy was recurrent lower respiratory tract infection and the most common bronchoscopy finding was purulent secretion with mucus obstruction. Flexible bronchoscopy is an important diagnostic and treatment tool for patients with recurrent respiratory symptoms. It is a highly valuable method as it enables direct visualization of the airways and facilitates the collection of bronchoalveolar lavage samples.

Spray nozzle for topical anaesthesia during flexible bronchoscopy: a randomised controlled trial.

The effectiveness of using a spray nozzle to deliver lidocaine for superior topical airway anaesthesia during non-sedation flexible bronchoscopy (FB) remains a topic of uncertainty when compared with conventional methods. Patients referred for FB were randomly assigned to receive topical lidocaine anaesthesia via the bronchoscope's working channel (classical spray (CS) group) or through a washing pipe equipped with a spray nozzle (SN group). The primary outcome was cough rate, defined as the total number of coughs per minute. Secondary outcomes included subjective perceptions of both the patient and operator regarding the FB process. These perceptions were rated on a visual analogue scale, with numerical ratings ranging from 0 to 10. Our study enrolled a total of 126 (61 CS group; 65 SN group) patients. The SN group exhibited a significantly lower median cough rate compared with the CS group (4.5 versus 7.1 counts·min-1; p=0.021). Patients in the SN group also reported less oropharyngeal discomfort (4.5±2.7 versus 5.6±2.9; p=0.039), better tolerance of the procedure (6.8±2.2 versus 5.7±2.7; p=0.011) and a greater willingness to undergo a repeat FB procedure (7.2±2.7 versus 5.8±3.4; p=0.015) compared with those in the CS group. From the operator's perspective, patient discomfort (2.7±1.7 versus 3.4±2.3; p=0.040) and cough scores (2.3±1.5 versus 3.2±2.4; p=0.013) were lower in the SN group compared with the CS group, with less disruption due to coughing observed among those in the SN group (1.6±1.4 versus 2.3±2.3; p=0.029). This study illustrates that employing a spray nozzle for the delivery of lidocaine provides superior topical airway anaesthesia during non-sedation FB compared with the traditional method.

Levels and predictors of patient satisfaction during flexible bronchoscopy procedures.

Flexible bronchoscopy (FB) is a safe and commonly performed procedure in pulmonary medicine. Bronchoscopy literature mainly focusing on technical aspects. However, data on patients satisfaction and bronchoscopy is rare. To evaluate levels and factors affecting patient satisfaction with flexible bronchoscopy (FB). This prospective study, conducted between June 2017 and May 2019 at King Abdulaziz University Hospital (Jeddah, Saudi Arabia), included all consecutive diagnostic bronchoscopies for adult patients. Patient willingness to return for another bronchoscopy (definitely not, probably not, unsure, probably would, or definitely would) was used as the indicator of satisfaction. Patients ranked their experiences with doctors, nurses, and process of care using a 5-choice scale (poor, fair, good, very good, or excellent). A total of 351 patients participated in this study. Overall, patients were highly satisfied with their doctors, nurses, and process of care. However, only 34.1% of patients indicated that they would return for another FB if necessary. Predictors of return for FB were younger age (<65 years), university education, use of midazolam and higher doses of fentanyl >100 mcg, and inpatient setting. Logistic regression demonstrated that younger age (P = 0.005) and inpatient setting (P = 0.02) were significantly linked to willingness to return for bronchoscopy. Patient satisfaction with bronchoscopy was lower in our study compared to other studies, despite high ratings of doctors' and nurses' skills. Elderly patients and patients with outpatient bronchoscopies were less likely to return and should therefore be approached with extra care. Physicians can improve FB-related patient experiences by decreasing discomfort during bronchoscope insertion and by improving topical anesthesia.

Flexible bronchoscopy indications and outcomes between indigenous and non-indigenous patients in the Northern Territory of Australia.

There is sparse evidence in the literature in relation to indications and outcomes among adult indigenous patients requiring a flexible bronchoscopy (FB). In this study, FB indications and outcomes between indigenous and non-indigenous patients were assessed. To assess the similarities and differences of FB indications and outcomes between indigenous and non-indigenous patients. Self-reported indigenous status, resident locality and the primary indication for FB were assessed. The FB procedures details, results of microbiology, cytology and histopathology were compared between indigenous and non-indigenous patients. Chest computed tomography (CT) was also analysed for its relationship to FB outcomes. Of the 403 patients, 111 (28%) were indigenous, and indigenous patients were younger (mean difference 11 years) and had a higher proportion of remote residence (70% vs 13%). Malignancy (40%) and infection (31%) were the most common indications for FB, although indigenous patients reported significantly more haemoptysis (15% vs 9%). No differences were noted in findings of the preceding chest CT scans. For positive microbiology, indigenous patients had a higher presence of Streptococcus pneumoniae (30% vs 9%), while non-indigenous patients had a higher presence of Pseudomonas aeruginosa (43% vs 11%) and mycobacteria (15% vs 4%). There was no significant difference between indigenous and non-indigenous patients for a positive histopathology, particularly for a diagnosis of lung malignancy (58% vs 54%). This study has demonstrated that adult indigenous patients requiring a FB are significantly younger, tend to reside in remote communities and demonstrate differing microbiology with no significant difference in the diagnostic outcomes for lung malignancy. Ethnic status or remoteness should not preclude indigenous patients to undergo a FB if clinically indicated.

Patient-Controlled Sedation by Non-Anaesthesiologists During Flexible Bronchoscopy – A One-Year Experience Regarding Safety, Feasibility and Costs

Background: Patient-controlled sedation (PCS) is an efficient and cost-saving method for sedation during flexible bronchoscopy (FB) in the presence of anaesthetic staff, but no data is available for PCS in a non-anaesthesiologist environment. Methods: This descriptive study describes PCS with propofol in a non-anaesthesiologist setup during outpatient FB procedures, including transbronchial biopsy, transbronchial needle aspiration, cryotherapy/biopsy and/or multistation endobronchial ultrasound, and endoscopic ultrasound with bronchoscope. Results: 287 procedures were completed. The median (range) duration for the procedures were 45 (10–105) minutes. The median (range) total propofol dose administered was 201 (55–570) mg, and 61 procedures (21%) required bolus doses of alfentanil. Desaturation occurred during 21% of the procedures and was resolved spontaneously (59%) or by using a jaw thrust (41%). No evidence was found that alfentanil contributed to desaturation (p=0.081). Inconsistent results were shown regarding the impact of alfentanil on the reduction of cough. The post-procedural assessment revealed high score of satisfaction and feasibility. 3 (1%) procedures were cancelled due to insufficient sedation. No prolonged recovery with need of overnight stay was reported. The direct costs for sedation were 180 USD/procedure. Conclusion: PCS with propofol and the presence of trained non-anaesthesiologists during outpatient FB has shown to result in high procedure feasibility and satisfaction without compromising patient safety or increasing the risk for unhandled respiratory adverse events. The method reduces costs for sedation and offers the possibility to increase patient turn over due to no prolonged recovery

Patient-Controlled Sedation by Non-Anaesthesiologists during Flexible Bronchoscopy: A One-Year Experience Regarding Safety, Feasibility and Costs

Background: Patient-controlled sedation (PCS) is an efficient and costsaving method for sedation during flexible bronchoscopy (FB) in the presence of anaesthetic staff, but no data is available for PCS in a non-anaesthesiologist environment. Methods: This descriptive study describes PCS with propofol in a non-anaesthesiologist setup during outpatient FB procedures, including transbronchial biopsy, transbronchial needle aspiration, cryotherapy/biopsy and/or multistation endobronchial ultrasound, and endoscopic ultrasound with bronchoscope. Results: 287 procedures were completed. The median (range) duration for the procedures was 45 (10-105) minutes. The median (range) total propofol dose administered was 201 (55-570) mg, and 61 procedures (21%) required bolus doses of alfentanil. Desaturation occurred during 21% of the procedures and was resolved spontaneously (59%) or by using a jaw thrust (41%). No evidence was found that alfentanil contributed to desaturation (p=0.081). Inconsistent results were shown regarding the impact of alfentanil on the reduction of cough. The post-procedural assessment revealed high score of satisfaction and feasibility. 3 (1%) procedures were cancelled due to insufficient sedation. No prolonged recovery with need of overnight stay was reported. The direct costs for sedation were 180 USD/procedure. Conclusion: PCS with propofol and the presence of trained nonanaesthesiologists during outpatient FB has shown to result in high procedure feasibility and satisfaction without compromising patient safety or increasing the risk for unhandled respiratory adverse events. The method reduces costs for sedation and offers the possibility to increase patient turn over due to no prolonged recovery.

Benefits and risks of bronchoalveolar lavage in severe asthma in children.

BackgroundAlthough bronchoscopy can be part of the exploration of severe asthma in children, the benefit of bronchoalveolar lavage (BAL) is unknown. The present study aimed to decipher whether systematic BAL during a flexible bronchoscopy procedure could better specify the characteristics of severe asthma and improve asthma management.Material and methodsThe study took place in two departments of a university hospital in Paris. Children who underwent flexible bronchoscopy for the exploration of severe asthma between April 2017 and September 2019 were retrospectively included.ResultsIn total, 203 children were included, among whom 107 had a BAL. BAL cell count was normal in most cases, with an increasing number of eosinophils with age, independently from the atopic status of the patients. Compared with bronchial aspiration only, BAL increased the rate of identified bacterial infection by 1.5. Nonatopic patients had more bacterial infections (p<0.001). BAL induced a therapeutic modification only for azithromycin and omalizumab prescriptions. The practice of a BAL decreased bronchoscopy tolerance (p=0.037), especially in the presence of tracheobronchial malacia (p<0.01) and when performed in a symptomatic patient (p=0.019).Discussion and conclusionAlthough BAL may provide interesting information in characterising severe asthma, in most cases its impact on the patient's management remains limited. Moreover, BAL can be poorly tolerated and should be avoided in the case of tracheobronchial malacia or current asthma symptoms.

The clinical safety and efficacy of flexible bronchoscopy in a neonatal intensive care unit

Flexible bronchoscopy (FB), developed in the 1960s, is widely used in the clinical practice of pediatrics and has demonstrated fundamental value in clinical diagnoses and treatment. However, as an invasive procedure, the use of FB is limited due to concerns regarding the tolerance of the procedure and the possible complications in neonatal units. Thus, the present study aimed to investigate the clinical safety and efficacy of flexible bronchoscopy (FB) in a neonatal intensive care unit (NICU). Neonates (n=54) who received FB in the NICU of Shanghai Children's Hospital between January 2012 and December 2016 were enrolled as the experimental group and another 54 neonates who required nebulization and tracheal secretion suction treatments were the control group. Indicators including blood gas, complete blood count, C-reactive protein (CRP), X-ray, patient breathing rate, temperature and blood pressure were monitored prior to and following the procedure. No significant differences in sex, gestational age, birth weight or postnatal age were observed between the experimental group and the control group (P>0.05). Among the 54 FB patients, several cases with side effect were identified, including 18 (33.3%) with respiratory tract stenosis, nine (16.7%) with malacia and stenosis and six (11.1%) with esophagotracheal fistula. Among the 54 members of the control group, 44 neonates (81.4%) were discharged with improved condition, five (9.3%) succumbed and five patients (9.3%) abandoned the treatment and left the hospital. Bronchoalveolar lavage demonstrated consistent results with respiratory secretion culture or tracheal tube culture. In comparison between the experimental and the control groups, no significant difference in pH, partial pressure of carbon dioxide (PCO2), partial pressure of oxygen (PO2) and HCO3 - was observed, while there were no statistical differences in the values of pH, PCO2 and HCO3 - (P>0.05). However, PO2 was significantly increased, and CRP was significantly reduced, following FB procedure compared with prior to FB (P<0.05). No pneumothorax, shock, other severe complications, fever or diffused pneumonia were observed during or after FB. The data from the present study demonstrated that FB is a safe and effective strategy for the diagnosis and differentiation of neonatal respiratory diseases in NICU.

Safety of diagnostic flexible bronchoscopy in patients with echocardiographic evidence of pulmonary hypertension.

The presence of pulmonary hypertension (PH) and treatment with anticoagulant agents could potentially increase the risk for bleeding/hemodynamic complications associated with bronchoscopic procedures. The aim of this study was to assess the safety of diagnostic flexible bronchoscopy (FB) in patients with PH. A retrospective review of clinical records of patients with echocardiographic evidence of PH (right ventricular systolic pressure [RVSP] > 40 mm Hg) who underwent diagnostic FB between 2004 and 2016 at a single facility in Japan was conducted. Patients with no clinical evidence suggestive of PH who underwent FB during the same period were enrolled as a pairwise-matched control group; factors used in matching included age, sex, and performed procedures. Overall, there were 45 patients in the PH group and 90 patients in the control group. Six (13%) patients in the PH group had severe PH (RVSP > 61 mm Hg). Forceps biopsies and transbronchial needle aspirations were performed in 62% and 13% of patients, respectively, in the PH group, and 58% and 13% of patients, respectively, in the control group. The total incidence of bleeding during FB was not significantly different between the two groups (18% versus 16%; p = 0.742). Vital signs recorded 2 h after FB were also not significantly different between the two groups. There were no episodes of cardiac arrhythmias or deaths associated with the FB procedures. The data suggest that diagnostic FB procedures can be performed safely in patients with echocardiographic evidence of PH.

The effect of audiovisual distraction on the tolerability of flexible bronchoscopy: a randomized trial.

It is important to minimize patient discomfort during invasive diagnostic and therapeutic procedures such as bronchoscopy. The aim of this study was to investigate the effect of audiovisual distraction on the tolerability of flexible bronchoscopy (FB). We conducted a prospective, randomized, controlled trial on patients undergoing FB at a hospital in Zahedan, Iran, in 2015. The patients were equally and randomly divided into a control group and an experimental group. Patients in the control group received standard care during FB While patients in the experimental group selected familiar folk music that was played during the procedure along with the screening of images of nature. The duration of the FB was recorded and cough, dyspnea, choking, nausea and pain were evaluated using a visual analogue scale before and after the procedure. Statistical analysis was carried out using paired and independent t-tests, χ2 -tests and analysis of covariance. Sixty patients met the inclusion criteria and were randomized. The duration of the FB procedure was significantly shorter in the experimental group compared with the control group (mean ± standard deviation 7.87 ± 2.12 min and 10.27 ± 1.72 min, respectively; P < 0.05). Dyspnea, cough and pain were significantly less severe in the experimental group compared with the control group (P < 0.05), but choking and nausea were not significantly different between the two groups (P > 0.1). Our findings showed that audiovisual distraction had a positive effect on the tolerability of FB. This method has important potential as a simple and practical approach in reducing discomfort during invasive diagnostic and treatment procedures.

An Autopsy Case of Asphyxia Caused by Uncontrolled Hemorrhage Following Transbronchial Lung Biopsy

Bronchoscopy is an important technique and flexible bronchoscopy procedures are considered comparatively safe. Notwithstanding, we here describe a woman who died of asphyxia caused uncontrolled hemorrhage following transbronchial lung biopsy. A medico-legal autopsy disclosed a small wound with clotted blood at the point of the transbronchial lung biopsy. The right lung was filled with a large volume of blood. Other organs showed no significant findings. Thus, this woman died from asphyxia associated with uncontrolled hemorrhage from the site of a transbronchial lung biopsy. We believe that our case is very instructive for safety bronchoscopy procedures.

Safety of Dexmedetomidine Use in Intubated Patients for Sedation in Flexible Bronchoscopy Procedures

Safety of Dexmedetomidine Use in Intubated Patients for Sedation in Flexible Bronchoscopy Procedures

Impact of Flexible Bronchoscopy Procedure on Diagnostic Yield of Peripheral Lung Lesions

Impact of Flexible Bronchoscopy Procedure on Diagnostic Yield of Peripheral Lung Lesions

Indications for performing flexible bronchoscopy: Trends over 34 years at a tertiary care hospital.

Background and Aim:Due to its easy maneuverability, patient comfort and documented safety as an outpatient procedure, flexible bronchoscopy (FB) has replaced rigid bronchoscopy for routine diagnostic use. Herein, we report our 34-year experience with outpatient performance of FB.Materials and Methods:This was a retrospective analysis of all FB procedures performed between September 1979 and November 2013 (period I: 1979-1990; period II: 1991-2000; period III: 2001-2013) in a tertiary care hospital. Demographic profile of patients, indications for performing FB, and annual and seasonal trends were noted from the records.Results:A total of 24,814 bronchoscopies were performed during the study period. The mean (SD) age of patients (71.6% males) was 48.4 (15.5) years. The number of procedures performed per decade showed an absolute increase by 322%. The most common indication for FB was suspected bronchogenic carcinoma (32.2%) followed by pulmonary infections (18.6%) and interstitial lung diseases (13%). The proportion of annual cases due to interstitial lung diseases (3.9% in period I to 16.2% in period III) increased over the years, whereas disorders such as hemoptysis and pleural effusion showed a declining trend as an indication for FB. A seasonal trend was observed for diseases such as sarcoidosis, bronchogenic carcinoma and pulmonary infections. Six deaths were encountered during the study period in patients undergoing FB.Conclusion:FB is increasingly being performed in the diagnosis of respiratory disorders and is a safe outpatient procedure. Although bronchogenic carcinoma remains a common indication for performing FB, benign conditions such as pulmonary infections and sarcoidosis constitute important indications in the Indian scenario.

A novel technique of non‐invasive ventilation: Pharyngeal oxygen with nose‐closure and abdominal‐compression—Aid for pediatric flexible bronchoscopy

To evaluate the safety, feasibility and efficacy of a novel non-invasive ventilation (NIV) technique--pharyngeal oxygen with nose-closure and abdominal-compression (PhO2 -NC-AC)--to aid pediatric flexible bronchoscopy (FB). A prospective 1 year study of patients who received FB. A basic PhO2 flow (0.5-1.0 L/kg/min, maximal 5.0 L/min) was routinely applied. Active NIV was initiated when the heart rate dropped <80 beats/min or desaturation was <80% for >10 sec. It was performed as follows: NC 1 sec for inspiration then released, followed by AC 1 sec for active expiration at a rate of 20-30 cycles/min until vital signs returned to acceptable levels for >10 sec. When the patients were stable, supplementary NIV was optionally given. Cardiopulmonary parameters were collected and analyzed. Three hundred thirty-seven FBs, including 188 therapeutic, were conducted in 286 patients with a mean age of 18.3 months (± 14.4, 10 min to 12 years) and a mean body weight of 13.5 kg (± 6.7, 0.5-35 kg). Three hundred thirty-three active NIVs were executed with a mean duration of 87.8 sec (± 40.4, 28-190 sec). A significantly longer FB duration (33.2 ± 16.7 min vs. 7.2 ± 2.8 min, P < 0.001) and a higher application rate of active NIV (1.44/FB vs. 0.42/FB) were noted in the therapeutic compared to the diagnostic group. Vital signs and blood gases (35 cases) improved rapidly and returned to baseline within 3 min. All FBs were safely and successfully completed without significant complications. PhO2 -NC-AC is a simple, safe and effective NIV technique for respiratory support and rescue during various pediatric FB procedures.

Pneumothorax following flexible fiberoptic bronchoscopy: A rare occurrence.

Sir, Pneumothorax following flexible fibreoptic bronhoscopy is rare. It occurs 1 in 450 bronchoscopy.[1] We report a case of such event in a trauma victim. A 34-year-old male patient with alleged history of road traffic accident admitted in our trauma center. On initial examination, his airway was patent, he was breathing at the rate of 22 breaths/min with air entry diminished over the right lung. Initial hemodynamics were stable with heart rate of 96 beats/min and blood pressure of 126/88 mmHg. Contrast-enhanced computed tomography scan chest revealed the fracture of 1st, 2nd, 3rd, and 7th ribs on the right side with hemopneumothorax and multifocal contusions in all lobes of the right lung. A right-sided intercostal tube drain (ICD) was placed. Pneumothorax and hemothorax resolved subsequently. He was shifted to the general ward. After 4 days of admission, patient developed acute respiratory distress with fall in oxygen saturation (90%) and was transferred to trauma intensive care unit (ICU). On initial evaluation, his chest X-ray showed [Figure 1] right lung collapsed with mediastinal shift toward the right side. A flexible bronchoscopy was contemplated in view of provisional diagnosis of mucus plug obstructing the major airways. A flexible bronchoscopy was carried out and a large mucus plug was aspirated from the right bronchus thereby clearing the airway. The patient was kept on positive pressure ventilation after the procedure. Immediately following the flexible bronchoscopy a large air leak became apparent in right-sided ICD. A follow-up chest X-ray showed a new large pneumothorax and collapse whole lung [Figure 2]. Ventilatory settings were adjusted to minimize the leak and the ICD was connected to negative pressure of 15 mmHg. A second ICD was inserted in order to control the leak and expand the lung. After 2 days, air leak controlled and lung got expanded. Patient was shifted to high dependency unit for further care. Figure 1 Chest X-ray showed collapsed right lung with mediastinal shift toward the right side Figure 2 Chest X-ray demonstrated a new large pneumothorax and collapse of whole the right lung Flexible fiberoptic bronchoscopy is a safe procedure carried out in patients admitted to ICUs. Its indication varies between diagnostic to therapeutic interventions including regular bronchoalveolar lavage for microbiological sampling, diagnosis of pulmonary hemorrhage, use in cases of difficult intubation, as a control in percutaneous tracheostomies, and aspirations of secretions.[2] Its use in clearing the airway because of mucus plug is considered as a standard practice particularly in patients where physiotherapy has failed to do so. However, its complications are infrequent. Most frequent complications cited in the literature are supraventricular tachycardia (3.8%), transient hypoxemia (6.7%), and slight bleeding of the bronchial mucosal membrane (2.4%).[2] Pneumothorax following flexible bronchoscopy has been reported infrequently in literature. Pue et al. have reported pneumothorax following flexible bronchoscopy in 0.16% of cases. Predominantly, it followed transbronchial biopsy procedure.[3] de Blic et al. analyzed prospectively in 1328 flexible bronchoscopy procedures in children and noted 0.1% incidence of pneumothorax.[4] In both the above analysis, none has reported pneumothorax following aspiration of secretion or mucus plug in case of chest injury following trauma. Moreover, flexible fiberoptic bronchoscopy was used here as a diagnostic modality to identify the cause of persistent pneumothorax and bronchial injuries. Mechanism that might have led to pneumothorax in our patient can be attributed to initial lung injury. Probably, the mucus plug had sealed the existent bronchial rent underlying lacerated lung and corrected the initial hemopneumothorax. As soon as the mucus plug got aspirated during flexible bronchoscopy the lung laceration got expose to high airway pressures and caused escaping of air into the pleural cavity. To conclude, although flexible bronchoscopy is a safe procedure, it mandates close monitoring during and after the procedure. It is important to have a high index of suspicion and a follow-up chest X-ray to identify a potentially dangerous complication.

Bronchoscopic Evaluation in Childhood Pulmonary Tuberculosis

We aimed to describe the risk factors of airway involvement and to investigate the contribution of bronchoscopy in the bacteriologic diagnosis of tuberculosis. Airway involvement was more often present in patients with resistance to tuberculosis therapy than in the patients having bronchoscopy performed at initial presentation. Addition of bronchoalveolar lavage to the diagnostic workup increased the mycobacteriologic yield statistically.

Trainee Impact on Procedural Complications: An Analysis of 967 Consecutive Flexible Bronchoscopy Procedures in an Interventional Pulmonology Practice

Background: Increased complications have been demonstrated in patients undergoing some medical procedures performed by trainees. Flexible bronchoscopy is generally considered a safe procedure; however, complications can include pneumothorax, bleeding and even death. Objectives: This study aimed to determine the impact of trainees during interventional pulmonology procedures on procedure time, sedation use and complications. Methods: A retrospective review of a quality improvement database from all consecutive medical procedures performed by an interventional pulmonologist (D.R.S.) at the University of Calgary, from July 1, 2007, to April 1, 2011. Results: Of 1,100 consecutive procedures during the study period, 967 were flexible bronchoscopies. A trainee participated in 82.2% of the procedures. Complications occurred in 38 patients (3.9%). No death occurred. Significant differences were seen when a trainee participated in the procedure versus when no trainee participated for procedure length [50.81 vs. 32.49 min, difference 18.32 min (95% CI 16.04-20.60), p = 0.001], dose of midazolam used [6.34 vs. 5.73 mg, difference 0.61 mg (95% CI 0.15-1.08), p = 0.01], dose of propofol used [153.08 vs. 111.60 mg, difference 41.48 mg (95% CI 21.81-61.15), p = 0.001], as well as the number of complications [4.5 vs. 1.2%, difference 3.3%, p = 0.048]. Conclusions: In an academic interventional pulmonology practice utilizing the apprenticeship model for procedural education, trainee participation in procedures can increase procedure time and the amount of sedation required, and result in increased complications. Medical procedural training methods that do not involve practicing on patients warrant further investigation in order to reduce the burden of procedural learning for patients.

Bronchoscopic evaluation of unexplained recurrent and persistent pneumonia in children

Persistent or recurrent pneumonia in children can pose a significant challenge to paediatricians and respiratory physicians. The aim of this study is to determine the role of flexible bronchoscopy (FB) in evaluation of recurrent or persistent pneumonia that remain otherwise unexplained by non-invasive diagnostic tests in children. Retrospective evaluation of patients who underwent FB with an indication of recurrent or persistent pneumonia from 1997 to 2011. Among 2600 FB procedures, 434 (17%) were performed with the indication of recurrent or persistent pneumonia. There were 237 (54%) boys. Median age at presentation was 84 months, and median duration of symptoms was 9 months. FB led to specific diagnosis in 33% of the cases. The most common diseases diagnosed by FB were malacia disorders (n: 32, 7%), aspirated foreign body (n: 30, 7%), endobronchial tuberculosis (n: 20, 5%), congenital airway anomalies (n: 14, 3%), mucus plugs (n: 14, 3%), pulmonary haemosiderosis (n: 12, 3%) and middle lobe syndrome (n: 11, 3%). During FB, only 6% of the patients had minor complications such as transient hypoxia, stridor and tachycardia. In our study, FB proved to be a safe and effective tool in evaluation of children with persistent or recurrent pneumonia. FB is indicated for children with recurrent or persistent pneumonia where the underlying diagnosis remains unclear even after non-invasive diagnostic tests.