Pediatric Bronchoscopy Research Articles

Exploración de la vía aérea en el paciente pediátrico

Introduction and objective: The management of the airways represents a constant challenge in pediatric practice. In the last years, bronchoscopy has become an essential technique in the diagnosis and treatment of various abnormalities of the child's respiratory system. The special characteristics of the pediatric airway and the differentiated pathology it presents give pediatric bronchoscopy its own entity. Pediatric bronchoscopy is a safe technique with many applications, both diagnostic and therapeutic. The use of both types of bronchoscopes (flexible and rigid) allows to take advantage of each one of them. Flexible bronchoscopy in pediatrics is a relatively simple and low-risk procedure that provides anatomical and dynamic information on the airways, as well as cytological and microbiological studies. The simplicity and low risk of this technique, in addition to not requiring general anesthesia, allows it to be performed even at the head of the patient, which has led to an increasingly extensive field of indications. The purpose of this article is to provide a review on the timeliness of the pediatric bronchoscopy procedure, especially about its indications. Method: Narrative review. Conclusion: The endoscopic examination of the airway is a cost-effective technique in pediatrics, with little complications and can offer very valuable diagnostic information, as well as perform certain therapeutic procedures. It is recommended that all professionals involved in the management of patients with airway pathology should know their indications, contraindications, complications, as well as their therapeutic applications.

The indications and role of paediatric bronchoscopy in a developing country, with high prevalence of pulmonary tuberculosis and HIV

ABSTRACTBackground: Bronchoscopy, an important investigation for the diagnosis and management of respiratory diseases, is widely used in high income countries. There is limited information on value of paediatric bronchoscopy in low and middle income countries (LMIC).Aims and Objectives: Aim was to describe the indications, findings and complications of bronchoscopy in a middle income country with a high prevalence of tuberculosis and HIV.Methodology: A retrospective analysis of a database over a 3.5 year period.Results: A total of 509 bronchoscopies were performed on neonates (2.3%) and children (median age = 18 months) of which 5.1% were HIV-infected. The main indications were: possible large airway compression 40%, complicated pneumonia (25%) and persistent stridor (15%). Pathology was observed in 64% of bronchoscopies. The most findings were lymph node compression of the airways (21%), and upper airway pathology (12%). Interventional procedures were performed in 112 cases (22%), the commonest being foreign bodies removal (30%), endobronchial lymph node enucleation (30%) and transbronchial needle aspiration (20%). No major complications.Conclusion: The diagnostic yield of paediatric bronchoscopy did not differ from high income countries emphasising the importance of paediatric bronchoscopy in the management of childhood lung disease in LMICs.

A Retrospective Analysis on Anesthetic Management during Rigid Bronchoscopy in Children with Foreign Body Aspiration: Propofol and Sevoflurane with Controlled Ventilation.

Background:Bronchoscopic removal of foreign body in the airway is one of the important life-saving procedure and demands skill and expertise on the part of the surgeon and anesthesiologist.Aim:To study the outcome of controlled ventilation during rigid bronchoscopy in children with foreign body aspiration.Materials and Methods:A review of fifty cases of foreign body in the bronchi, from January 2014 to December 2015 was undertaken in Vittal Institute of Child Care Hospital, Dharwad, through patient case records. Patients between 6 months and 14 years were included in the study. Cases of foreign body in the larynx and trachea were excluded. Patients were induced with propofol and maintained on sevoflurane. The parameters observed were bronchoscopy attempts, succinylcholine requirement, episodes of laryngospasm, cough, bronchospasm and spontaneous recovery. Statistical analysis was done by Chi-square test using software OpenEpi version 7.3.Results:Of 45 patients with organic foreign body, 42 (94%) patients required one attempt of bronchoscopy and 3 (6%) patients required two attempts. Five (100%) patients with inorganic foreign body required single attempt (P = 0.66). Forty-three (96%) patients with organic foreign body required two repeat doses of succinylcholine and 2 (4%) patients required three repeat doses. All 5 (100%) patients with inorganic foreign body required two repeat doses (P = 0.7461). Two (4%) patients aspirated with organic foreign body had laryngospasm, and there was no cough or bronchospasm with either patient. Two (4%) patients with organic foreign body required tracheostomy. Inorganic foreign body group of patients had lesser complications.Conclusion:In our study, patients on controlled ventilation had few intraoperative complication and smooth early recovery. Controlled ventilation with relaxation should be preferred for any pediatric bronchoscopies. Eliciting history of type of foreign body helps in planning and management of procedure.

A different fibre-optic device for double lumen tube position confirmation!

Sir, The review article ‘lung isolation, one-lung ventilation and hypoxaemia during lung isolation’ by Atul Purohit et al. in the September issue was an academic treat. We would like to report a novel and alternative device for confirming double lumen tube (DLT) position. The conventional method needs a paediatric fibre-optic bronchoscope (PFOB) which may not always be available.[1,2,3] We used a flexible fibre-optic uretero-renoscope (F-URS), which has an outer diameter (OD) similar to PFOB, to confirm the DLT position [Figure 1]. Figure 1 Double lumen tube loaded on fibre-optic uretero-renoscope A 24-old-year male patient was posted for the right upper lobectomy for aspergilloma in the right upper lobe cavity as a sequel to pulmonary tuberculosis. After induction of general anaesthesia, a 39 French left-sided DLT was inserted under direct laryngoscopic vision with capnographic confirmation. A “3-step” clinical method was followed to confirm position of left DLT: The tracheal cuff was inflated and air entry was confirmed bilaterally The bronchial cuff was inflated and the tracheal lumen was clamped proximally for the left lung isolation. Bronchial lumen of the DLT was ventilated and unilateral ventilation confirmed On releasing the clamp of the tracheal lumen, ventilation was resumed bilaterally. Hence, the DLT positioning was confirmed clinically.[3] The F-URS was then passed through the tracheal lumen of the DLT, which on exit showed the carina, the right main bronchus and absence of herniation of the bronchial cuff. The two left bronchi were seen on passing the F-URS through the bronchial lumen of the DLT.[1,2,3] The F-URS can confirm placement of right-sided DLT as the working length would be adequate to visualise the right upper lobe bronchus. The F-URS we used was the E Line Compact Flexible Uretero-renoscope®, manufactured by M/S Richard Wolf, Germany-8703.524; 8/9.8 Fr, with an OD of 2.67/3.27 mm and working length of 430 mm. It costs approximately Rs. 7.5–8 lakhs. The F-URS works on fibre-optic technology similar to a FOB and is used for urosurgery as a flexible fibre-optic scope. A 39 Fr DLT accepts a FOB with 3.9–4.2 mm OD, whereas a 37 Fr DLT accepts OD of 3.5–3.9 mm. The F-URS with OD of 2.67/3.27 mm easily accepts 37 and 39 Fr DLTs [Figure 2].[1,2] Figure 2 Comparing length of double lumen tube and fibre-optic uretero-renoscope Methods used for the confirmation of the DLT are clinical, FOB and recently ultrasonography (USG).[4] The clinical method as the sole confirmatory method is inaccurate in detecting malpositions of the DLT, and may present significant intra-operative problems during one-lung ventilation.[1,2] Using a FOB aids in confirming DLT position, repositioning if necessary during surgery, visualising the operated site before DLT removal and perioperative pulmonary toileting.[2,5] Its use may be limited by non-availability, also it does not confirm deflation of non-ventilated lung.[4,5] Confirmation of lung deflation can be done by lung USG by the lung sliding and lung pulse sign. USG is dependent on availability, cost of the machine and subjective assessment of the performer.[4] Hence, FOB remains the gold standard for confirming DLT position.[1,4,5,6] The presence of a super speciality urology facility in our institute ensured the presence of the F-URS. It has a smaller OD, larger working channel, active deflection and better fibre optics due to advanced technology. The indications for its use include diagnostic procedures, management of calculus disease and endoscopic management of upper tract tumours, endoureterotomy or endopyelotomy.[7] The sterilisation procedure for the F-URS is similar to other fibre-optic devices, and hence, it can be reused for urosurgery. We would like to emphasise that this was a one time use of the F-URS for confirmation of the position of DLT in the absence of PFOB, and we do not intend to use it on a regular basis. Hence, the warranty terms and conditions would not be affected. The limitation of this device would only be its non-availability in certain institutions. We would like to draw attention to the fact that application of fibre-optic technology to broader medical specialities can be used to the patients’ advantage. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Use of Airtraq(®) optical laryngoscope for the intubation in Pierre Robin sequence in a teenage child.

Sir, We report a case of a 14-year-old girl with Pierre Robin sequence (PRS) with micrognathia, glossoptosis and high-arched palate for the dental treatment at our hospital. She was a case of isolated PRS without any other associated anomalies or syndromes. She weighed 30 kg and was having mild mental retardation. Her mouth opening was more than 2.5 cm, with Mallampati airway Grade 3 [Figure 1] and high-arched palate. She had very small receding mandible [Figure 1] and thyromental distance was <1.5 cm. Rest of the airway assessment as well as laboratory reports were normal. She was not co-operating for dental treatment under local anaesthesia. The duration of the procedure was close to 1 h requiring general anaesthesia with oral intubation. Figure 1 Anatomical features Equipment for direct laryngoscopy, size 2, 3 and 4 of Airtraq® optical laryngoscope and ultra-thin flexible fibreoptic bronchoscope (2.0 mm size) were kept ready. Intravenous line was secured in the ward and no sedation was administered. Inside the operation theatre, she was administered glycopyrrolate 0.2 mg plus midazolam 1 mg. As she became agitated, 30 mg propofol was given to induce sleep. Standard monitoring (electrocardiogram, non-invasive blood pressure, SpO2, respiration rate and EtCO2) was applied, and she was induced with sevoflurane with 100% oxygen. After achieving adequate depth of anaesthesia, mask ventilation was tried. Effective mask ventilation was verified by the presence of adequate chest rise and presence of end-tidal CO2 trace. She was given succinylcholine (60 mg) to achieve relaxation for endotracheal intubation. Effective mask ventilation with oxygen (6 L) and sevoflurane 3% was continued for 60s after succinylcholine injection. Direct laryngoscopy was tried, which showed Cormack–Lehane Grade 3 laryngoscopy view. Mask ventilation was restarted and Airtraq® laryngoscope size 3 with preloaded endotracheal tube size 5 with cuff was introduced [Figure 2]. Vision under Airtraq® optical laryngoscope was Cormack–Lehane Grade 1 and intubation was achieved successfully on the first attempt. Figure 2 Intubation with Airtraq® Intubation and/or ventilation can be difficult in children with PRS.[1] Various modalities of management can be used successfully depending on expertise and availability of equipment.[2] Though direct laryngoscopy can be successfully applied, flexible fibreoptic intubation can be a method of choice if direct laryngoscopy fails.[3] Alexander reported as high as 63% failure rate of direct laryngoscopy, requiring flexible fibreoptic intubation.[3] Though this was reported mainly in neonatal population, intubation can still be difficult in older children as patient characteristics, not the age, decide the difficulties.[4] Intubation with flexible fibreoptic bronchoscope under sedation is a difficult skill to acquire, especially in the paediatric population. It requires special paediatric flexible fibreoptic bronchoscope, which is not available in every anaesthesia department. Intubation of paediatric patients with adult fibreoptic bronchoscope requires special understanding and experience. Intubation of a paediatric patient with adult flexible fibreoptic bronchoscope has higher chances of failure. With the development of video laryngoscopy, many intubations, earlier considered difficult, can be done successfully even in the paediatric population.[5] Airtraq® is one of the very few video laryngoscopy devices available for the paediatric population. It is a disposable, cheap and easily available device. Airtraq® is an optical video laryngoscope with indirect vision, removing the necessities of aligning various angles required for direct laryngoscopy which improves Cormack-Lehane view when compared with conventional laryngoscope as evident in our patient also. As force or traction on the upper jaw is needed, it helps in management of the patients having large lip and palate defects. Dedicated channel for endotracheal tube in Airtraq® allows preloading of endotracheal tube which reduces the intubation time. Intubation time with Airtraq® is almost comparable to direct laryngoscopy. This is especially valuable in paediatric population where de-saturation occurs earlier. With fibreoptic bronchoscope-guided intubation not accessible, Airtraq® video laryngoscope can be an effective alternative in difficult airway cases such as PRS. Airtraq® use has been reported in few cases of PRS.[6] Though it requires validation from randomised controlled studies, Airtraq® laryngoscopy and intubation can be considered the first line of management in cases of PRS. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A 'Y'-shaped connector as an indispensable component of paediatric bronchoscopy mask: A novel innovation!

A 'Y'-shaped connector as an indispensable component of paediatric bronchoscopy mask: A novel innovation!

Flexible bronchoscopy in children: Utility and complications.

Background and objectivesThe flexible bronchoscope has become widely used by pediatric pulmonologists as a diagnostic and therapeutic tool. Nevertheless, there are several gaps in our knowledge to help refine its use and reduce its complications. In this study, we aimed to evaluate the utility and complications of pediatric bronchoscopy.Design and settingWe conducted a retrospective review of bronchoscopy cases between March 2006 and April 2015 at a tertiary care medical center (King Fahad Medical City). One-hundred forty nine patients were studied.Patients and methodsWe evaluated how bronchoscopy contributed to the patients' diagnosis, assessed the accuracy of bronchoalveolar lavage white blood cell count (BAL WBC) to differentiate between infectious and non-infectious conditions, assessed the ability of clinical factors to predict high risk of desaturation during bronchoscopy, and finally summarized the reported procedural complications.ResultsWe found pediatric bronchoscopy was a crucial diagnostic (confirming, ruling out, and discovering unexpected diagnosis) and therapeutic tool. The accuracy of BAL WBC counts is poor (AUC (95% CI) = 0.609 (0.497–0.712)); however, using two cutoff values (≤10 WBCs (sensitivity = 84.44% and specificity = 29.27%) to rule out, and ≥400 WBCs (sensitivity = 33.33% and specificity 81.49%) to rule in infection) helped in early differentiation between infectious and non-infectious conditions. From the factors that we test, none we found predictive of desaturation. The most common procedural complication was desaturation (pooled incidence (95% CI) = 13 (8–19)%) followed by cough, mild airway bleeding, and spasm.ConclusionsFlexible bronchoscopy is an important and relatively safe diagnostic and therapeutic tool in pediatric medicine, and utilization of this service should be encouraged after a careful consideration of which patient needs this procedure and a rigorous estimate of its pros and cons.

High Dose Rate (HDR) Dual Intraluminal Brachytherapy Catheter in Treatment of Bilateral Endobronchial Tumor Progression: A Case Report

SESSION TITLE: Lung Cancer Cases SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 12:00 PM INTRODUCTION: The use of brachytherapy is one method of delivering a higher radiation dose to endobronchial tumor while sparing the surrounding normal tissues. Although commonly done with a single catheter we report on the simultaneous use of dual HDR-intraluminal brachytherapy catheters. CASE PRESENTATION: We report of a 71-year-old man with left mainstem recurrence of squamous cell carcinoma who was treated with chemoradiation (63 Gy/ 35 tx) previously. Three months ago, bronchoscopy revealed extension of tumor involving carina and proximal 2 cm of both left and right mainstem bronchi. Biopsy confirmed squamous cell carcinoma. He underwent tumor debulking using Nd:YAG laser first and then referred for HDR-brachytherapy to treat any submucosal extension. Since both main stem bronchi were involved, a decision was made to place two catheters to radiate both sides simultaneously. A pediatric bronchoscope was inserted next to the catheter to verify positioning (Fig. 1). The position of the catheters was confirmed with digital orthogonal x-rays and conebeam CT. Eclipse software was used to plan the treatment of the proximal 5 cm of both the right and left mainstem bronchi and carina with 750cGy prescribed to 1 cm from the source at the carina. The target volume is shown above (Fig.2). 750 cGy was delivered over actual time of 466.2 seconds with the high activity (4.33 Ci) Ir-192 source (nominal treatment time = 201.6 seconds). Two additional weekly treatments of 750 cGy to the above area were planned. DISCUSSION: HDR-brachytherapy is effective in palliating dyspnea. In our patient, given the bilaterality of tumor progression, routine HDR-intraluminal brachytherapy would have required our patient to undergo unilateral treatment separately in multiple sessions and may have resulted in overlap of the brachytherapy isodoses. By planning the bilateral HDR-intraluminal brachytherapy catheters simultaneous, the risk of future overlap is avoided, and the overall treatment interval is reduced in half CONCLUSIONS: HDR-intraluminal brachytherapy has demonstrated improvement of overall quality of life with single luminal therapies. We demonstrate the concomitant use of two intraluminal brachytherapy catheters placed in separate bronchi decreased the overall treatment interval. Future studies need to be conducted to evaluate efficacy. Reference #1: Hennequin C, et al. Long-term results of endobronchial brachytherapy. Int J Radiat Oncol Biol Phys. 2007;67(2):425. DISCLOSURE: The following authors have nothing to disclose: Larry Ladi, John Grecula, Eric Allen, Shaheen Islam No Product/Research Disclosure Information

Adult fiberoptic bronchoscope assisted tracheal intubation in a child with extremely limited mouth opening

Tracheal intubation under vision in a child with extremely limited mouth opening requires the aid of pediatric fiberoptic bronchoscope. Often there can be only adult size bronchoscope in a center leading to a difficult situation when compromised pediatric airway requires stabilization. Aim of this case report is to describe the technique and feasibility of use of an adult fiberoptic bronchoscope for tracheal intubation of in child with extremely inadequate mouth opening unsuitable for conventional intubation. A 9-year-old boy with temporo-mandibular joint ankylosis was admitted for exploration of mastoid abscess under general anesthesia. In the absence of a pediatric fiberoptic bronchoscope we performed nasotracheal intubation of the child with the aid of an adult bronchoscope while maintaining spontaneous breathing with inhalational anesthetics. In remote locations, in centers with inadequate/nonworking equipments and in emergency situation where appropriate equipments are not available, adult fiberoptic bronchoscope may be helpful for tracheal intubation of pediatric patient.Journal of Society of Anesthesiologists of Nepal 2015; 2(2): 80-83

Clinical feature, lung imaging and bronchoscope characteristics analysis of infant bronchial foreign body

Objective To investigate the advantages of pediatric electronic fiber bronchoscope (FBO)in the infant bronchial foreign body, discuss the clinical features of infant bronchial foreign body, lung imaging characteristics and the kinds of microscopically position, the change of airway mucosa after stimulation by foreign body under local anesthesia in 30 cases of infant bronchial foreign body. Methods Thirty cases, aged 0 to 3 years, were collected from September to December, 2014.All of them were with foreign bodies examined by FBO in pediatric bronchoscopy room in Shengjing Hospital of China Medical University. Results In all infants, 6 cases (20.0%) without history of inhaled foreign bodies and 24 cases (80.0%) with a record history of inhaled.In the aspects of signs: normal breath sounds with a history of no choking cough in children were 2 cases (6.7%) , wheezing sounds were 3 patients (10.0%) and weakened side breath sound was 1 case (3.3%); with a history of choking cough in children, 6 cases(20.0%) with normal breath sounds, 12 cases(40.0%) with wheezing, 6 cases(20.0%) with lateral breath sounds less.Lung imaging characteristics was lack of specific performance: only a case of all(n=30)show foreign body directly.Otherwise, other 29 cases had no specificity.Lung emphysema in 13 cases (43.3%) is the main characteristic, while normal imaging findings in 2 cases (6.7%). Foreign bodies in 19 cases were in the left lung (63.4%) and 21 cases(70.0%) of foreign body stimulated granulation inside airway, necrosis sputum bolt in distal obstruction of airway occured in 5 cases (16.7%). Inhalled time of foreign body in airway was 4.5 [2.8, 12.5] day and inhalled time of foreign body in airway correlation coefficient with granulation hyperplasia(r=0.688, P=0.000), there was a significant correlation.Main adverse reaction was low oxygen in 6 cases (16.7%). Conclusion The diagnostic accuracy of FBO under local anesthesia on children is higher than other methods, and the FBO bronchial foreign bodies under local anesthesia is a safe and effective method. Key words: Children; Fiber bronchoscope; Bronchial foreign body; Local anesthesia

Chemocauterization with trichloroacetic acid in congenital and recurrent tracheoesophageal fistula: a minimally invasive treatment

Recurrent tracheoesophageal fistula (RTEF) is a serious complication after primary repair of esophageal atresia and tracheoesophageal fistula (EA/TEF). Treatment of RTEF involved an open surgery by thoracotomy. Technically it is a challenge with a high morbidity and mortality. Congenital tracheoesophageal fistula (CTEF) traditionally involved an open surgery by thoracotomy or cervicotomy. Many endoscopic techniques have been developed since the past decades: thoracoscopic or bronchoscopic approach for the treatment of RTEF and CTEF; nevertheless, optimal treatment is not still determined because of few numbers of patients, short-term follow-up, and different procedures. We report our experience and evaluated the efficacy in the chemocauterization of CTEF and RTEF, with the use of 50% trichloroacetic acid (TCA) as a technique minimally invasive. From 2010 to 2014, fourteen patients with TEF (twelve RTEF and two CTEF) were selected for endoscopic management in two centers. Twelve patients had RTEF after primary repair of EA/TEF by thoracotomy approach, and two patients had CTEF in the upper pouch, diagnosed after EA/TEF (Type B) long gap, treated by thoracotomy and thoracoscopy, respectively. In all cases the diagnosis was confirmed by esophagram, bronchoscopy, and clinical evaluation. Under general anesthesia, a rigid pediatric bronchoscope with a 0° rod lens telescope and tele-monitoring was used to localize the TEF. Cotton soaked with 50% TCA was applied on the TEF during 30 s, and the procedure was repeated 3 times. The endoscopic treatment was performed monthly until TEF closure was achieved. RTEF and CTEF were closed in all patients. The mean number of procedure in each patient was 1.8. Closure of TEF was confirmed by esophagram, bronchoscopy, and clinical evaluation. There were a bacterial pneumonia and bronchospasm as postoperative complications. Median follow-up was 41 months (8-72). All of these TEF remain completely obliterated, and all patients are asymptomatic. Endoscopic management of congenital and recurrent TEF with the use of 50% TCA is as a minimally invasive, effective, simple and safe technique in these patients and avoids the morbidity of open surgery.

Pitfalls in Pediatric Bronchoscopy

Bronchoscopy has traditionally been an integral part of pulmonary diagnostics and therapy. In pediatrics, bronchoscopy was originally mainly used for the extraction of aspirated foreign bodies or other interventions, less frequently for diagnostic procedures. Since the introduction of pediatric flexible instruments, bronchoscopy has become more available and has been used much more often in pediatric pulmonary medicine. With the current general availability of the method, it is essential to make sure that bronchoscopes are used according to accepted standards. This article reviews some of the potential pitfalls in performing and interpreting pediatric bronchoscopy.

Brochoscopy Intervention using Laryngeal Mask Airway in Infant for Severe Airway Stenosis

Fibreoptic bronchoscopy (FB) and laryngeal mask airway (LMA) have been used successfully in children since the early 1980s [11. Wood RE, Postma D (1988) Endoscopy of the airway in infants and young children. J Pediatr 112: 1-6.,22. Brain AI (1983) The laryngeal mask-a new concept in airway management. Br J Anaesth 55: 801-805.]. The paediatric fibreoptic bronchoscopy visa laryngeal mask airway (LMA) in general anesthesia was established in 1990s [33. Smyth AR, Bowhay AR, Heaf LJ, Smyth RL (1996) The laryngeal mask airway in fibreoptic bronchoscopy. Arch Dis Child 75: 344-345.,44. Wood RE (1996) Pediatric bronchoscopy. Chest Surg Clin N Am 6: 237-251.]. Although previous studies have shown some experience on FB in infant, conclusive effects on bronchoscopy intervention are unknown. We report the use of laryngeal mask airway (LMA) to guide electric bronchoscopy interventions (EBI) while maintaining an adequate depth of anesthesia and effective ventilation in small infant who was diagnosed of having severe airway stenosis from computed tomography (CT) scan.

Converting a nasoendotracheal tube to orotracheal, following fibreoptic intubation under general anaesthesia in a paediatric patient with complete cleft palate.

Sir, Cleft lip and palate are commonly associated with retrognathia, micrognathia and glossoptosis,[1] and can be part of syndromes such as Pierre Robin syndrome, Treacher-Collin's syndrome or Goldenhar syndrome. The anaesthesiologists frequently face difficulty with airway maintenance, mask ventilation, laryngoscopy, and endotracheal intubation.[2] Many of these infants may require fibreoptic intubation when they come for surgery.[3] We are reporting a case of Pierre Robin syndrome posted for palatoplasty. The patient, 9-month-old male infant, was delivered normally and had a history of snoring and nasal regurgitation while feeding. On examination, mandible was markedly receding along with a complete cleft palate involving both soft and hard palates. After keeping the child nil per oral for 6 h, general anaesthesia was induced with 8% sevoflurane in oxygen using a Jackson Rees circuit. Following induction a nasopharyngeal airway was introduced through one nostril with an endotracheal tube connector attached to the proximal end. Anaesthesia was maintained with 4% sevoflurane in oxygen with Jackson Rees circuit connected to the airway. Electrocardiogram, non-invasive blood pressure, SpO2 and end-tidal CO2 (EtCO2) were monitored. A 4.0 mm internal diameter oral Ring-Adair-Elwyn (RAE) tube was loaded on to the paediatric bronchoscope and the child was intubated nasally through the opposite nostril. As the surgeons insisted on an oral tube, the nasal tube was pushed in till the proximal end was at the nostril [Figure 1]. Then the mouth was opened and the most proximal part of the endotracheal tube visible through the cleft was caught with a paediatric Magill's forceps and pulled into the oral cavity [Figure 2]. At the same time, the part of the tube in the pharynx was stabilised by pushing it posteriorly to the pharyngeal wall with the index finger of the left hand to prevent accidental extubation. Once the proximal end of tube was brought out through the oral cavity, endotracheal tube connector was attached and position confirmed with EtCO2 and auscultation. The tube was then fixed in the midline and surgery commenced after giving fentanyl 2 μg/kg and atracurium 0.5 mg/kg intravenously. Maintenance of anaesthesia was with O2 :N2O (1:2) with sevoflurane (1.5–2%). The child was extubated at end of surgery uneventfully after reversing the neuromuscular blockade and when fully awake.Figure 1: Nasal endotracheal tube being pushed in till the proximal end is at the nostrilFigure 2: Proximal end of endotracheal tube being pulled out through the oral cavityThough infants can be intubated orally with fibreoptic bronchoscope, technical ease is more with the nasal route. Fibreoptic intubation succeeds less frequently by oral route because of the greater angle between oral cavity and the laryngeal inlet and also since keeping the bronchoscope in the midline is more difficult with oral route.[4] Though a nasotracheal tube can be changed to orotracheal using a guide wire, in the presence of a complete cleft palate, the technique described by us can be safely and easily accomplished.

Parental Satisfaction Assessment After Paediatric Procedural Sedation: There Are Still Issues to Address

As paediatric sedation practices are becoming safer and more feasible everyday, they have been widely used for diagnostic and therapeutic procedures. This study intended to determine the relation between parental satisfaction and the branches applying procedures and demographic data of the patients and their families, physicians, nurses, and the healthcare personnel in the room. In total, 223 successive patients under 18 years of age and ASA I-II undergoing diagnostic or therapeutic procedures in paediatric pulmonary disease, gastroenterology, cardiology, and invasive radiology units were included in the study. The satisfaction level of the patients' parents was determined through a questionnaire of 22 questions. Average satisfaction scores for paediatric bronchoscopy and endoscopic interventions varied between 8.06 and 9.30, while the satisfaction scores of the interventions for the cardiovascular system, hepatic system, and renal system, as well as the invasive radiologic interventions, varied between 7.5 and 9.6. There was a statistically significant negative correlation between the age of parents and children and the necessity for a playground in the waiting area (p<0.05). A significant correlation was found between the age of children and the adequacy of the anaesthetist's behaviors (p<0.05). Satisfaction levels of the parents were high at the units where paediatric sedation was applied. However, the expectations of young patients and their parents were higher. When the physical conditions and communication with patients and their relatives are improved and the process schedules are followed more precisely, the clinical results will increase in a positive way.

Endoscopic necrosectomy by using a transgastric fully covered esophageal metal stent

Endoscopic necrosectomy with PEG-jejunostomy placement was performed in a 34-year-old man with infected pancreatic necrosis (Video 1, available online at www.giejournal.org). A pediatric bronchoscope was advanced through a 24F PEG to prevent looping as it was advanced to the jejunum. Alternatively, the guidewire could have been grasped with a gastroscope and advanced to the jejunum. The gastroscope was exchanged for a 12F jejunal tube. The area of necrosis was located with an echoendoscope. The puncture was made with a 19-gauge needle.

Managing human factors in the assembly of the paediatric bronchoscope

Foreign body aspiration in children is a life threatening event and prompt bronchoscopy and extraction is essential for their survival. During a recent paediatric airway emergency at Torbay hospital, Devon, the theatre staff were unable to assemble the paediatric bronchoscope. We therefore investigated methods to improve the efficiency and timeliness of the assembly of the paediatric bronchoscope.To assess the current problem we asked ten theatre staff at random to assemble the paediatric bronchoscope. 70% of the staff were not able to assemble the paediatric bronchoscope. A prompt poster was developed as a visual aid to help demonstrate how to assemble the paediatric bronchoscope. Another ten theatre staff were asked to assemble the paediatric bronchoscope. Now all of the staff were able to assemble the paediatric bronchoscope.The prompt poster enabled all the theatre staff tested to correctly assemble the paediatric bronchoscope and the average time taken was reduced. To further develop the service mandatory training sessions have been arranged to help theatre staff remain confident and continue to develop their skills and knowledge.

Heart, tracheo-bronchial and thoracic spine trauma. Succesful multidisciplinary management: a challenging thoracic politrauma

We reported the case of a 36 years old woman involved in a car accident and admitted to the Emergency Room with critical conditions. A CT scan showed hemopericardium, pneumomediastinum and D2 unstable vertebral fracture; then a sternotomy was promptly performed. After admittance to Intensive Care Unit a bronchoscopy showed a tear of the posterior wall of the trachea and the complete disruption of the left main bronchus with a 2 cm gap beetwen two consecutive cartilage rings. D2 fracture would have required stabilization, but pronation of the patient was contraindicated by the bronchial rupture. On the nineth day the vertebral fracture was stabilized, thus allowing a lateral decubitus and a left thoracotomy. The bronchial laceration was wrapped all around with a pedicled pericardial flap and a bronchial stent was placed inside the gap with a pediatric bronchoscope. Postoperative course was uneventful and the patient was transferred to the Physical Rehabilitation Unit after 23 d. The successful outcome of this case is the result of multidisciplinary management where every decision was shared by each specialist. From the surgical point of view survival is uncommon in such severe association of lesions. The use of pericardium wrap together with a bronchial stent represents an innovative solution to treat a complicated bronchial disruption.

Comparison of Total Intravenous Anesthesia (TIVA) with Inhalation Anesthesia in Pediatric Bronchoscopy

Background: Because of airway stimulations during the bronchoscopy and lack of direct access to the airway, preferred method of anesthesia for rigid bronchoscopy is already controversial. In this study we compared inhalation anesthesia with total intravenous anesthesia (TIVA) for rigid bronchoscopy. Method and Materials: 30 patients aged 2-6 years were chosen divided on two same groups. Anesthesia in group I maintained with halothane and in group II maintained with remifentanil and propofol. Oxygenation, heart rate, respiratory rate, coughing, bucking, laryngospasm, bronchospasm were evaluated during and after surgery. Also Operation success and surgeon’s satisfaction were recorded as well.Results: Demographic findings were the same in both groups. Oxygenation and heart rate were more stable in group II (P=0.047 and P=0.026 respectively) but there was no significant difference in respiratory rate between two groups (P=1). Success rate was also similar in both groups but surgeon’s satisfaction was significantly higher in TIVA (P=0.003). There was not any significant different between complications in two groups. Conclusion: We suggest TIVA for rigid bronchoscopy because of better oxygenation, more homodynamic stability, surgeon’s satisfaction, lack of air pollution and less interference with surgeon’s visual field.

Combination of adult and pediatric fiberoptic bronchoscopy in bronchial cleaning in smoke inhalation-induced respiratory distress syndrome

n the practice of medicine, new technologies are developed and old models are improved upon. As new technologies are integrated into standard practices, further innovation occurs to meet situational demands when patients have critical needs; what follows illustrates such an adaptation using modern bronchoscopic instruments. Smoke inhalation-induced respiratory distress has been known to cause high mortality among victims of À re accidents, especially for those who have been trapped inside burning buildings. In the aftermath of a À re accident, several victims died as a result of smoke inhalation-induced respiratory distress. We have effectively saved À re victims by scrubbing their bronchial airways using a À beroptic bronchoscope to improve ventilation and oxygenation. However, with a standard-sized bronchoscope it is not possible to reach smaller bronchi, so we combined the use of a pediatric bronchoscopy to the procedure in order to better clean the debris and secretions.