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Respiratory - Bronchoscopy and Broncho-Alveolar Lavage referral guidelines

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These guidelines describe the Starship Respiratory service referral criteria and timing for flexible bronchoscopy and lavage in the paediatric population in New Zealand. This is not a substitute for individual case-based clinical discussions with a Starship Respiratory Consultant (who can be called directly on 09 375 4330)

Overview

The primary purpose of Flexible Bronchoscopy (FB) ± Bronchoalveolar Lavage (BAL) is to acquire clinical information that will influence treatment or other management choices, and which cannot be obtained by less invasive means.

Bronchoscopy allows the clinician to directly visualise the lower respiratory tract, determine aspects of the cellular or microbiological milieu (via BAL), and apply topical therapy.

Information obtained by FB ± BAL can aid in making a diagnosis, guide initiation of treatment, monitor treatment response, or permit use of topical therapy (airway toileting, or application of mucolytics).

The decision for FB is not always clear cut and should be made after discussion between the referring senior medical officer (SMO) and an experienced paediatric bronchoscopist. We encourage colleagues to discuss individual cases with a Starship Respiratory Consultant, and these discussions should take place when the child's symptoms become significant (see Clinical Scenarios).

The decision to perform FB & BAL is a balance between likely benefit from added information versus risks of FB under general anaesthetic (GA).

Clinical information and potential benefit from Flexible Bronchoscopy

 Purpose  Possible findings
 Airway inspection • Stenosis, malacia
• Extrinsic compression/ airway 'kinking'with aberrant course
• Mucosal oedema - infection, aspiration
• Lesions - endobronchial disease with AFB, papillomata etc
• Occlusion with secretions
• Post infectious- bronchial occlusion post infection
• Response to PEEP
• Airway assessment with removal of tracheostomy
• Confirmation of foreign body
• Airway fistula
• Post smoke inhalational injury
• Airway calibre change over time
 Airway sampling (BAL) • Clinical LRTI with no identified organism
• Atypical/ opportunistic infection with immunocompromised
• CF/Bx/ PCD/CSLD - where sputum/cough suction results do not fit with clinical  response to treatment
• Suspected TB in smear negative children
• Fat laden macrophages for suspected aspiration - GOR, unsafe swallow, fistula
• (BAL) WBC differential - CTD, sarcoid, Rx induced lung disease,
• Confirm pulmonary source of blood
• Biochemical markers - galactomannan, ? pepsin/bile acids
• Cytology for malignant disease, ILD DDx (eos, neuts etc)
• Diagnose and sample bronchial casts for analysis
• (Small airway biopsy post-transplant)
 Treatment • Topical dornase alpha - CF, atelectasis when ventilated
• Toileting airway secretions if extreme clinical circumstances i.e. not done routinely
• Therapeutic lavage - alveolar proteinosis, lipoid ingestion
• ? surfactant Rx for ALI/ARDS (children > adults)

Limitations of Flexible Bronchoscopy

Bronchoscopy is not usually clinically indicated where the anticipated findings can likely be obtained by non-GA means, for example when a trial of treatment before FB/BAL would be appropriate.

Flexible bronchoscopy cannot:

  • diagnose bronchiectasis
  • differentiate between gastro-oesophageal reflux (GOR), and an unsafe swallow. Specific BAL findings can support but not diagnose aspiration
  • predictably confer any advantage over regular physiotherapy for atelectasis. This is a request we commonly receive. We recommend an overall clinical case management discussion with the Starship Respiratory team
  • allow removal of a foreign body. It may help establish the presence of a foreign body if clinical doubt exists
  • adequately clear an airway when there is severe lower respiratory tract bleeding.

Complications

Under general anaesthesia (GA), a review of 95 patients1 showed desaturation as the only post GA event. The same study reported >1200 patients scoped with conscious sedation - for which coughing and desats both occurred in approximately 2%.

BAL has been associated with transitory wheeze and/or bleeding, radiological infiltrates post lavage, transient fever post-BAL in 10-30% (most often when BAL culture is positive), and bronchospasm in 1% of cases. Severe complications include bronchial perforation and cardiac arrest. These are rare, and reports are anecdotal. There are a small number of reports of fatality after bronchoscopy, although the causal role (if any) of the procedure is not known.

Routine bronchoscopy

Bronchoscopy and BAL should be undertaken when clinically indicated, and in accordance with the timing guidelines set out in this document. Routine bronchoscopy is performed by some members of the Department as part of ongoing research projects.

Bronchoscopy at the same time as HRCT GA

If a child requires a chest CT scan under GA - due to inability to control phase of breathing during the scan (usually children < 5 years or with developmental delay) it may be appropriate to do the CT scan and FB under a single GA. The different information obtained from the two tests may mean it is preferable to do them at different times in the child's clinical course e.g. a CT scan done before an acute illness has resolved may show acute changes that are mistaken for chronic ones, and result in unnecessary long term management. Specific indications for chest CT (high resolution, and spiral with contrast) can be found on the Starship Radiology Procedural Guidelines

Timing of Flexible Bronchoscopy (FB)

There are no published descriptions of optimal timing of FB & BAL. The time frames given below are suggested. In any individual patient's circumstances, necessary timing may be different depending on other clinical factors eg concomitant risks or contraindications.

 ACUTE (within 72 hours)
Acute LRTI due to unknown organisms and child has one or more "co-factor" such as:
   - intubated for acute respiratory support i.e. not just for a procedure
   - immunocompromise: post chemo/ BMTx, primary/ secondary immunodeficiency
   - significant clinical decline in a child with acute LRTI despite optimal anti infective therapy, as suggested by the working diagnosis
   - where identification of LRTI organisms will influence community infection control
Topical pulmozyme administration in ventilated child with atelectasis
Acute atelectasis of the whole lung
Aspiration of lipid based liquids eg mineral oil causing need for IPPV
Lavage of proteinaceous material causing significant respiratory compromise eg. in pulmonary alveolar proteinosis
Post lung transplant with possible infective exacerbation. NB: liaise with adult lung transplant team
SEMI ELECTIVE (within 6-8 weeks)
Lobar or segmental volume loss, despite 6 weeks of regular, age appropriate airway clearance therapy / chest physiotherapy.
   On discussion, further local inpatient treatment may be preferred prior to subjecting child to a bronchoscopy. 
• CF with significant atelectasis (1 or more lobes collapsed) - consider after aggressive physiotherapy for 6 weeks,
   with hypertonic saline and dornase. Topical dornase may be given via the bronchoscope.
• BAL for possible Mycobacterial infection where no significant clinical compromise, and timing of diagnosis
   has no implication for public health.
• Known primary diagnosis but with inexplicable failure to make clinical progress, despite adequate treatment for working diagnosis.
ROUTINE (can wait up to up to 4 months from referral)
Bronchoscopy for any indication, where child is not severely clinically unwell, nor in an above category where earlier treatment is suggested.

The above time frames are a guide only. Optimised timing for an individual patient is best discussed with the on call Starship Respiratory Consultant.

Clinical scenarios (examples)

Wheeze / Airway obstruction

FB should be considered if a child has:

  • persistent or frequent wheeze despite optimised therapy (including confirmation of adherence to medication)
  • focal wheeze
  • biphasic wheeze
  • onset of wheeze in first 3 months of life
  • episodes of severe illness requiring IPPV or CPAP (? not HFNO)
  • episodes of prolonged recovery from illness that is atypical for the existing Dx (e.g asthma or pre school wheeze)
  • a strongly suggestive history/ clinical exam for foreign body but insp/exp radiology not conclusive


Cough

FB should be considered in a child with:

  • cough present from first 3 months of life
  • moist cough > 6 weeks duration despite adequate empirical therapy - consider bronchoscopy:
    - if clinical course does not follow expected on basis of cough suction and/or sputum samples. o to visualise airways for coincidental comorbidity
    - if SCH chronic cough investigation schedule does not identify a cause.
  • hypoxia/ desaturation with cough (if not due to pertussis/ para-pertussis), and not confined to acute intercurrent infection
  • dry, sudden onset cough - consider:
    - foreign body. FB can confirm presence of foreign body; but cannot allow removal
    - bronchial casts - paroxysmal cough ± wheeze
    - BAL - WBC differential if DDx includes drug-induced lung disease
  • recurrent croup / barking cough - consider:
    - ENT referral for possible large airway malacia, laryngeal irritation (e/g GOR), recurrent laryngeal nerve palsy
    - BAL for evidence of aspiration
  • immunocompetence, but with severe LRTI requiring IPPV, but for which causal organism is not known
  • possible opportunistic infection with immunocompromise (1ry immunodeficiency, 2ry immunodeficiency [AIDS, Rx, malnutrition, burns]) with evidence of acute LRTI, but LRT microbiology unhelpful
  • Possible TB infection - but other tests (smear, Mantoux, gastric washings, yIFN) equivocal
  • history of haemoptysis, or if pulmonary source of bleeding is not established
  • history of lipoid aspiration eg. laxatives, essential oils/aromatherapy
  • known diagnosis with increased sputum volumes or difficulty in clearing sputum
    - Topical dornase therapy in CF or atelectasis with IPPV
    - Airway toileting with poor cough strength in clinical indication? Efficacy is not guaranteed.

Abnormal radiology

FB for assessment should be considered in a child with:

  • persistent focal chest xray changes despite regular ACT/ chest physiotherapy (6 weeks bd)
  • recurrent focal abnormality on chest radiograph, even if repeatedly recovers with antibiotics ? and regular ACT / chest physiotherapy
  • possible foreign body. Where a high index of suspicion for foreign body exists, child should be referred directly to ENT
  • possible TB where other tests (v.s.) are equivocal or unhelpful
  • diffuse CXR abnormalities and DDx includes aspiration, chronic pneumonitis, interstitial lung disease, PCP, Rx-induced lung disease, opportunistic infection, post transplant (BMTx/ lung) diffuse disease
  • pneumomediastinum after severe trauma eg RTC - to assess for large airway injury
  • HRCT "crazypaving" appearances consistent with alveolar proteinosis
  • diffuse lung disease where BAL may preclude need for lung biopsy
  • acute CXR changes in an immunocompromised child with no response to empirical antibiotics after 72 hours


Co-Factors

Previous or current co-morbidities which may influence consideration of FB:

  • previous trachea-oesophageal fistula, congenital diaphragmatic hernia
  • previous surgery: lobar excision, aortopexy, oesophageal atresia repair
  • enlarged great vessels / cardiac chambers that impinge on the airways
  • mediastinal lymphadenopathy
  • severe viral LRTI as herald event - to assess for evidence of viral shedding
  • known aspiration, increased aspiration risk (developmental delay, neuromuscular disease)
  • house fire smoke exposure
  • failure of respiratory clinical status to improve with somatic growth
  • chronic lung disease of prematurity
  • presence of a syndrome associated with airway calibre compromise: Down syndrome, mucopolysaccharidosis, VACTERL, overgrowth syndrome (e.g. Beckwith-Wiedemann syndrome, Simpson-Golabi-Behmel syndrome) etc.

References

  1. De Blic. Eur Respir J. 2002;20:1271

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Document Control

  • Date last published: 23 February 2018
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Respiratory
  • Editor: Greg Williams
  • Review frequency: 2 years

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