Bronchoscopy ByHarry

During the First Month of Life

Lindahl, Risto Rintala, Lasse Malinen, Mauri Leijala, and Heikki Sairanen Helsinki, Finland

l During the g-year period from 1984 to 1989, 196 bronchoscopies were performed on 132 neonates. The indications were grouped into four categories: (1) difficulties in artificial ventilation or failure to wean the baby from the ventilator (52); (2) other respiratory difficulties (52); (3) audible stridor (IS); and (4) routine preoperative or postoperative examination of esophageal atresia patients (12). The most common finding was laryngomalacia or tracheomalacia (31). Other findings were: obstructing tracheal or bronchial granulation or stricture (23), obstructing mucous plug (22). grave tracheobronchitis (111, tracheoesophageal H-fistula (5). laryngeal

perforation (3), congenital laryngeal stenosis (2), and complete laryngotracheoesophageal cleft (1). Four patients had miscellaneous pathology. The findings were normal in 30 patients. A therapeutic procedure was included in 99 of the 196 bronchoscopies. Seven serious complications occurred during the operative bronchoscopies, two of them requiring immediate pulmonary surgery. All complications were successfully managed. In contrast, no complications occurred in the 97 purely diagnostic bronchoscopies. In experienced hands, bronchoscopy of the newborn is a safe and useful examination. Complications occur when therapeutic procedures are included. Therefore, operative bronchoscopy should only be performed in conditions in which immediate thoracotomy and pulmonary surgery can be performed. Copyright o 1992 by W.B. Saunders Company INDEX WORDS: diatric.

Bronchoscopy,

neonatal;

bronchoscopy,

pe-

M

ODERN RESPIRATORY care of the newborn has increased the survival of small premature infants. However, it has been accompanied by an increase in airway complications due to prolonged endotracheal intubation,‘s3 resulting in the frequent need for both diagnostic and therapeutic bronchoscopies during the neonatal period. Congenital laryngotracheobronchial malformations are another indication for bronchoscopy in the very young.4 In our unit, bronchoscopy is the second examination after chest x-ray in the diagnostic workup for neonatal respiratory difficulties and suspected tracheobronchial malformations. Bronchoscopy is also used, often as an emergency procedure, in treating neonatal tracheabronchial obstructions. We report our

From the Helsinki University Central Hospital, Children S Hospital, Helsinki, Finland. Date accepted: February 4, 1991. Address reprint requests to Hany Lindahl, MD, Helsinki University Central Hospital, Children’s Hospital, Stenbiickinkatu 11, SF-00290, Helsinki, Finland. Copyright o 1992 by W.B. Saunders Company 0022-3468l921270.50002$03.00l0 548

experience with neonatal bronchoscopy 6-year period 1984 to 1989.

during the

MATERIALS AND METHODS During the 6-year period 1984 to 1989, 132 neonates underwent a total of 196 bronchoscopies. The youngest infants had the examination on the day of birth and the oldest was 30 days old. Their weight ranged from 700 to 4,800 g. The age and weight of the patients at the time of the first bronchoscopy can be seen in Fig 1. One hundred twelve patients had a primary disease for which they were already receiving treatment. The main primary diagnoses were: respiratory distress syndrome (RDS) (53 patients), cardiovascular malformation (20), esophageal atresia (18), meconium aspiration (6), gastrointestinal malformation (S), and diaphragmatic hernia (3). Seven patients were treated for miscellaneous reasons. The indications for endoscopy are listed in Table 1. The category “other respiratory difficulties” includes ventilatoty difficulties in unintubated infants, pulmonary atelectases or emphysemas, and the suspicion of congenital tracheobronchial malformations. All examinations were performed under general anesthesia using the Storz neonatal bronchoscope (Karl Storz GMBH & Co, Tuttlingen, Germany) with 2.5 and 3.0-mm rigid tubes. No antifog tubes were used. In addition, Wolf 9.5 and 10 Charrier cystoscopes (Richard Wolf GMBH, Knittlingen, Germany) and the Storz 10 Charrier cystoresectoscope, with ventilation arranged through one of the “waterholes.” were used for some of the operative procedures. A therapeutic procedure was performed in 99 of the 196 bronchoscopies. On 67 occasions this consisted of selective lavation of thick obstructing mucus, and in 32 occasions of dilatations or endoscopic abrasions. The dilatations were performed with a Fogarty no. 3 or 4 balloon dilatator, using biopsy forceps or the bronchoscope itself. The endobronchial abrasions were done with biopsy forceps and in one case with a cystoresectoscope. The analysis consists only of those examinations performed at or under the age of 30 days. In many patients operative or follow-up bronchoscopies continued beyond this age. However, hospital mortality figures included all patients regardless of age (sometimes several months), until their discharge, either to their home or to an institution providing only basic infant care. RESULTS

Findings

In patients with difficulties in artificial ventilation (n = 52, Table 2) the most common finding was obstructing tracheal or bronchial granulation or stricture. All but one required either forceps resection, dilatation, or lavation under direct vision. The obstructing mucous plugs all needed lavation and suction. The seven cases of grave tracheobronchitis required bronchoscopic cleansing of the airways, either with biopsy forceps or by lavation and suction under direct vision. The three laryngeal perforations occurred during emergency endotracheal intubation. In all three cases the cricothyroid membrane was Journal of Pediatric Surgery,

Vol 27,

No 5

(May), 1992:

pp 548-550

NEONATAL

5.030

BRONCHOSCOPY

549

. . ..

1.

Table 2. Findings in Patients With Difficulties in Artificial Ventilation

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.

.

Granulation/stricture

.

.

.

.

.

.

.

.



.

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.*

t *.

0

0

f

5

.

)

10

- .

.

. . -

.*

.

*

:

. ’ .* .

.

. I *

*.

.

:

.

-

:-

.I

. 15

20

25

30

-

17

Obstructing mucous plug

*

*

.

.

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.

0..

.

.

.*.

I



-:

*..I

9

Tracheobronchitis

7

latrogenic laryngeal perforation

3

Tracheomalacia or bronchomalacia

2

Tracheal dislocation

1

Pulmonary hemorrhage

1

Normal

12

Total

52

AGE (DAYS)

Fig 1.

The ages and weights of the patients at the first bronchos-

COPY.

anteriorly perforated, resulting in ventilation to the subcutaneous tissues. The one tracheal displacement was caused by a central eventration of the diaphragm. The eventration was operatively corrected under the same anesthesia. The indication for the bronchoscopy of the patient with pulmonary hemorrhage was blood coming from the endotracheal tube after intubation. During brochoscopy, blood was seen to come from bronchial periphery. The cause of the hemorrhage was not found and the bleeding ceased spontaneously. In 12 patients no tracheobronchial explanation for the difficulties was found. Obstructing mucous plug was the most common finding in patients with other respiratory difficulties (n = 52, Table 3). All patients with a tracheoesophageal H-fistula underwent cervical closure of the fistula during the same anesthesia after the bronchoscopy. In one of two patients with bronchial displacement the cause was left upper lobar emphysema, and in the other, pulmonary adenomatous malformation. Both underwent lobectomy. The patient with complete tracheoesophageal cleft was operated on immediately after the bronchoscopy. He also had a complex inoperable congenital cardiac malformation and died of meningitis at the age of 28 days. In 18 patients no bronchoscopic pathology was found. Stridor (n = 16) was caused by laryngomalacia in 13 patients, by congenital laryngeal stenosis in 2, and by acquired tracheal stricture in 1. The patient with tracheal stricture had previously been endotracheally intubated. All 12 patients who were routinely examined because of esophageal atresia showed slight to moderTable 1. Indications

ate tracheomalacia. None had a proximal fistula or a refistula. Altogether, 102 of the 132 patients showed airway pathology. The findings in all indications groups are presented in Table 4. Complications There were no complications in the 97 purely diagnostic procedures. Seven major complications occurred in the 99 therapeutic endoscopies. These included pneumothorax in five patients, right lower lobe bronchial rupture in one, and rupture of the right pulmonary artery during the endobronchial removal of an obstructing granuloma in one. No mortality was associated with the complications. All five cases of pneumothorax were managed with pleural suction with a chest tube. The bronchial rupture required immediate right lower lobectomy. Emergency right pneumectomy was performed on the patient with ruptured pulmonary artery. Hospital mortality was 19 patients. The immediate cause of death in six patients was bronchial pathology: bronchial or tracheal obstruction (2), purulent or obstructing tracheobronchitis (3), and bronchopleural fistula (1). Three of these six patients also had severe cardiac anomalies. Five babies died of the complications of RDS, three of abdominal complications, three of serious cardiovascular malformations, and two of miscellaneous nonbronchologic complications. DlSCUSSlON

Bronchoscopy consists of the direct visualization of the larynx, trachea and bronchi. The examination of Table 3. Findings in Patients With Other Respiratory Difficulties Obstructing mucous plug Laryngomalacia or tracheomalacia

4

Tracheoesophageal

5

H-fistula

Granulation/stricture

5 4

Difficulties in artificial ventilation

52

Tracheobronchitis

Other respiratory difficulties

52

Bronchial displacement

Audible stridor

16

Complete tracheoesophageal

Esophageal atresia Total

12 132

13

2 cleft

Normal

1%

Total

52

-

550

LINDAHL ET AL

Table 4. Findings in All Patients Laryngomalacia, tracheomalacia,

or bronchomalacia

31

Granulation/stricture

23

Obstructing mucous plug

22

Tracheobronchitis

11

Tracheoesophageal

5

H-fistula

latrogenic laryngeal perforation

3

Congenital laryngeal stenosis

2

Complete tracheoesophageal Miscellaneous Normal Total

cleft

1 4 30 132

neonatal airways requires atraumatic technique and small sophisticated instruments.5 During the last 10 years small bronchoscopes equipped with the Hopkins rod telescope, suitable for neonatal use, have become available. This has made accurate and safe examinations possible even in premature infants.5 In the present study group, no deaths related to the procedures occurred and, in fact, no complications occurred in diagnostic bronchoscopies. In our experience, diagnostic bronchoscopy is safe even in premature babies weighing only 700 g. However, operative bronchoscopy is not without complications. Two of our patients with complications caused by therapeutic bronchoscopy were only saved by immediate surgery. Therefore, the operating room rather than the intensive care unit should be the preferred site when performing operative bronchoscopy. In our preliminary report,6 the most common indication for neonatal bronchoscopy was difficulty with artificial ventilation. This study of a larger series is in agreement with our earlier results. The suspicion of intubation trauma to the airways was the most common single indication. The complications of endotracheal intubation were also the most frequent single cause of symptoms. At least 26 patients had lesions that could be directly associated with endotracheal intubation. In addition, grave tracheobronchitis was

found in seven and obstructing mucous plugs in nine endotracheally intubated babies. Intubation and mechanical ventilation can be considered at least an additional cause of these complications. Pietsch et al3 reported the bronchoscopic treatment of necrotizing tracheobronchitis in mechanically ventilated neonates. The seven cases of grave tracheobronchitis in the present series each needed bronchoscopic removal of occluding debris in order to make ventilation possible. No histological specimens were obtained, but the macroscopic findings resembled those reported by Pietsch and coworkers. The simplest and most accurate way of diagnosing congenital laryngotracheobronchial anomalies is bronchoscopy.417,8Five H-fistulae were diagnosed in the present material during the 6-year period. This is in accordance with our previous estimate of 5% to 6% of all tracheoesophageal anomalies.9 In addition, one complete laryngotracheoesophageal cleft was diagnosed with bronchoscopy. The diagnosis of laryngomalacia, tracheomalacia, or bronchomalacia can only be confirmed by bronchoscopy.“’ In 19 of our patients it was the cause of neonatal respiratory symptoms. Tracheomalacia was also present in 12 esophageal atresia patients who were routinely examined. In these patients, however, it caused no significant difficulties. In accordance with a previous report from Holinger,” the most common cause of neonatal audible stridor was laryngomalacia. In conclusion, bronchoscopy is an accurate way of diagnosing congenital and acquired lesions of the neonatal airway. In experienced hands it is a safe procedure even in very small premature infants. The examination should be performed without unnecessary delay in cases in which there is suspicion of airway pathology. Operative bronchoscopy can be life-saving, but is not without complications. It should only be practiced in conditions in which immediate thoracotomy and pulmonary surgery can be performed if so needed.

REFERENCES 1. Grylack LJ, Anderson KD: Diagnosis and treatment of traumatic granuloma in tracheobronchial tree of newborn with history of chronic intubation. J Pediatr Surg 19:200-201,1984 2. Louhimo I, Leijala M: The treatment of low retrosternal trachea1 stenosis in the neonate and small children. Thorac Cardiovasc Surg 33:98-102,1985 3. Pietsch JB, Nagraj HS, Groff DB, et al: Necrotizing tracheobronchitis: A new indication for emergency bronchoscopy in the neonate. J Pediatr Surg 20:391-394, 1985 4. Benjamin B: Endoscopy in congenital tracheal anomalies. J Pediatr Surg 15:164-171, 1980 5. Gans SL: Bronchoscopy, in Gans SL (ed): Pediatric Endoscopy. Philadelphia, PA, Grune and Stratton, 1983, pp 37-54 6. Lindahl H, Rintala R, Leijala M, et al: Neonatal bronchoscopy. Z Kinderchir 43:12-13,1988 (suppl I)

7. Gans SL, Johnson RO: Diagnosis and surgical management of “H-type” tracheoesophageal fistula in infants and children. J Pediatr Surg 12:233-236, 1977 8. Lindahl H, Nyman R: Congenital bronchobiliary fistula successfully treated at the age of three days. J Pediatr Surg 21:734-735, I986 9. Louhimo I, Lindahl H: Esophageal atresia: Primary results of 500 consecutively treated patients. J Pediatr Surg 18:217-229,1983 10. Benjamin B, Cohen D, Glasson M: Tracheomalacia in association with congenital tracheoesophageal fistula. Surgery 79:504-508,1976 11. Holinger LD: Etiology of stridor in the neonate, infant and child. Ann Otol89:397-400,198O

Bronchoscopy during the first month of life.

During the 6-year period from 1984 to 1989, 196 bronchoscopies were performed on 132 neonates. The indications were grouped into four categories: (1) ...
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