Paediatric bronchoscopy

Physiological differences to consider

Large tongue

Higher larynx

Cricoid is narrowest part

Vt fixed in young infants so ventilation frequency must increase to increase minute ventilation

Ventilation in infants is mainly diaphragmatic, fewer type 1 fibres so fatigue early

Indications

Diagnostic

• Airway obstruction
• Persistent pneumonia
• TOF
• Bushings/biopsies for cytology
• Failure to wean from ventilator
• Haemoptysis

Therapeutic

• Removal FB
• Suctioning mucus plugs
• Facilitate endobronchial intubation for OLA
• Laser therapy
• Balloon dilatation
• Stent insertion

Bronchoscopes

Flexible

• Spontaneous ventilation around the scope
• Can be introduced orally or nasally with or without sedation

Rigid

• Ventilating
  • Storz bronchoscope
    • Used for therapeutics and diagnostics
    • Can attach breathing system used via SV or IPPV
    • Has a removable optical telescope inside a bronchoscope
    • Ventilation occurs via the space between the lumen of the bronchoscope and the inner telescope
    • Holes at 5cm to allow ventilation in contra lateral lung
    • Sized according to age
• Venturi
  • Open-ended metal tube
  • Gas exchange via jet insufflation using Sander's injector
  • Can not measure airway gases or deliver volatiles
  • Best reserved for pts over 40kg due to risks of barotrauma

Always assume bradycardia is due to hypoxia

Anaesthetic considerations

Review old charts

Previous bronchoscopies?

• Size used
• Difficulties
• Grade view
• Post-op stridor?

Specific Investigations

• Flow volume loops
• CXR
• CT

Premedication

• Oral midazolam in selected patients only
• Anticholinergic at induction
  • Reduce secretions
  • Avoid bradycardia
• Dexamethasone up to 0.6mg/kg

Preparation

• Variety of tubes, laryngoscopes and bronchoscopies
• Standard monitoring
• Requires GA in children
• SV is best preserved for FB

GA conduct - ventilating bronchoscope

• Spray cords with 4mg/kg max. Lignocaine
• Sevoflurane can be used for induction and attached to the bronchoscope. May take longer due to hypoventilation in FB
• Once the telescope is put through the bronchoscope, the work of breathing increases ++
• Hypercapnoea and resp acidosis is a problem
• Give rectal paracetamol for post-op pain
• Remain NBM for 2hrs post op

Complications

• Hypoxia
  • Bradycardia
• Trauma to lips, teeth, base of tongue
• Epiglottic and laryngeal trauma
• Atelectasis
• Air trapping
• Hypercarbia
• Bronchospasm
• Stridor
  • 0.5mg/kg Nebulised 1:1000 adrenaline
  • May require reintubation

CEACCP

Link: 41.full.pdf