Utility of flexible fiberoptic bronchoscopy for critically ill pediatric patients: A systematic review

Table 1 Indications, diagnostic, and therapeutic outcomes for flexible bronchoscopy in critically ill pediatric patients

Ref.	Population	Indications	Diagnostic yield	Diagnostic BAL findings	Therapeutic outcomes
Abu-Kishk et al[25], 2012	9 PICU: hemoptysis (age 2 mo-17 yr)	Hemoptysis	77.8% (7/9)
Atzori et al[14], 2006	62 NICU: esophageal atresia (mean age 37.5 WGA)	Airway evaluation	24.2% (15/62): Change in surgical management 9.7% (6/62): Change in anatomic class 11.3% (7/62): Tracheomalacia
Bar-Zohar et al[24], 2004	100 PICU: medical, non-airway surgery, and airway surgery groups (age 2 d-17 yr)	Airway evaluation; BAL; extubation failure	73% (65/89): Upper airway 56% (14/25): Lower airway 63.6% (28/44): Extubation failure 38.6% (44/114): Change in medical management 20% (11/31): Airway surgical re-exploration	46.7% (14/30) identified organism 50% (15/30) change in antimicrobials 40% (12/30) clinical improvement after change in antimicrobials 36.4% (4/11) concordance between BAL and blind tracheal aspirate	84.6% (11/13) extubated after lavage 74.3% (26/35) re-expanded collapsed lobe
Chapotte et al[18], 1998	72 PICU: CHD (age 1 d-14 yr)	Perioperative evaluation; respiratory symptoms; radiologic respiratory signs	70.8% (51/72) 48.6% (35/72) identified extra-luminal compression	33.3% (2/6) identified organisms in patients with mucosal inflammation
Davidson et al[17], 2008	129 PICU: ECLS, CHD (age 2.9 mo-3 yr)	Airway evaluation; atelectasis; BAL; ETT position; respiratory distress	68.4% (78/114): Overall 46.3% (37/80): ECLS 60.3% (41/68): CHD identified extra-luminal compression	45.3% (53/117): Overall identified organism 53.8% (28/52): ECLS subgroup identified organism	82.1% (32/39) successful procedures: removed blood and mucous plugs, or instilled surfactant, placed endovascular stents
de Blic et al[4], 1991	33 NICU: CHD, lung disease and/or congenital malformations (age 2 d-9 mo)	Anatomic evaluation; atelectasis/emphysema; respiratory distress	62.2% (23/37): Overall 52.8% (19/36): Change in management 13.9% (5/36): Change in surgical management 50% (5/10): CHD
Efrati et al[16], 2009	319 PICU: CHD, oncology (age 1-22 yr)	Anatomic evaluation; BAL; trauma	79.3% (253/319): Overall 90.2% (46/51): CHD 83.3% (50/60): Oncology 21.9% (70/319): Change in management 3.4% (11/319): Change in surgical management	17.6% (56/319): Identified organism 12.2% (39/319): Change in antimicrobials 88% (22/25): Abnormal cytology consistent with infection
Fan et al[26], 1988	87 PICU: (age 1 wk-18 yr)	Anatomic evaluation; decannulation; difficult intubation; respiratory symptoms; tracheostomy	94.8% (91/96)		87.5%(7/8) 100% (5/5): Difficult airways intubated 66.7% (2/3): Re-expanded collapsed lobe
Hintz et al[22], 2002	8 NICU: CDH on ECLS	Atelectasis			87.5% (7/8): Improved lung expansion after lavage
Kamat et al[19], 2011	79 PICU: ECLS (10 d-21 yr)	Atelectasis; BAL; anatomic evaluation; surfactant instillation		21.3% (33/155): Identified organism	76.1% (118/155): Atelectasis 15.4% (10/65): Improved CXR 2.6% (4/155): Surfactant
Kohelet et al[27], 2011	19 NICU: (age 1 d-8 mo)	Anatomic evaluation; atelectasis; BAL; difficulty weaning MV; respiratory symptoms	60% (15/25): Overall 100% (6/6): Wean from MV 52% (13/25): Abnormal anatomy	60% (6/10): Identified organism 50% (5/10): Change in antimicrobials	75% (6/8): Re-expanded collapsed lobe
Kolatat et al[28], 2002	45 NICU: (mean age 33 WGA)	Respiratory distress post-extubation	93.3% (42/45)
Kotby et al[29], 2008	35 PICU: suspected pulmonary fungal infections (age 1-15 yr)	BAL		40% (14/35): Identified organism 77.1% (27/35): Diagnosed probable pulmonary fungal infection (+ BAL culture or + BAL fungal antigen)
Maggi et al[36], 2012	44 PICU: status asthmaticus requiring MV (age 6 mo-18 yr)	Atelectasis; lavage; respiratory distress;			100% (29/29): Improved A-a gradient, shunt fraction, decreased FiO2, improved compliance. 37.9% (11/29): Extubated within 6 h 69% (20/29): Extubated within 12 h Reduced PICU LOS (3.06 d vs 3.4 d in control (P < 0.05)) Reduced length of time on MV [10 h vs 20.5 h (P < 0.0005)]
Manna et al[30], 2006	134 PICU: CHD (age 4 mo-6 yr)	Anatomic evaluation; atelectasis; BAL; extubation failure; hemorrhage	76.4% (113/148): Overall 84.4% (27/32): Upper airway 80% (56/70): Lower airway 18.6% (13/70): CHD identified extraluminal compression 90.5% (19/21): Extubation failure 44% (11/25): Pulmonary disease	35.3% (6/17): Identified organism	92.3% (24/26): Re-expanded collapsed lobe
Myer et al[30], 1988	10 NICU: (age 1 d-16 mo)	Atelectasis; hemorrhage; hypercarbia; hypoxia; hyperinflation; respiratory distress	50% (5/10): Overall 20% (2/10): Granuloma		60% (3/5): Re-expanded collapsed lobe 40% (2/5): Granuloma required rigid bronchoscopy
Nakano et al[5], 2004	16 NICU: esophageal atresia, Trisomy 21, CDH, hydrocephalus, Goldenhaar, and Kasabach-Merritt (age 3 d-8.5 mo)	Anatomic evaluation; extubation failure; hemorrhage; respiratory distress	66.7% (14/21)		23.8% (5/21): Removed obstruction (mucus plug, clot/local tissue) or altered suction practice
Nayak et al[21], 2012	30 PICU: CHD requiring mechanical ventilation prior to extubation (age 1 d-6 mo)	Anatomic evaluation; extubation failure	50% (15/30): Overall significant tracheobronchial narrowing 50% (4/8): Extubation failure		73.3% (22/30): Extubated
Nussbaum et al[31], 2002	2836 PICU: (age 1 d-15 yr)	Anatomic evaluation; atelectasis; BAL; hemorrhage; ETT position; intubation; tracheostomy evaluation; plastic bronchitis; respiratory distress	84.8% (2405/2836): Overall 95.2% (766/805): Upper airway 82.6% (1862/2254): Lower airway 47.9% (1358/2836): Inflammatory changes	24.1% (411/1705): Identified organism 41.7% (5/12): Transbronchial biopsy positive dyskinetic cilia syndrome 72.4% (21/29): Acute chest SCD plastic bronchitis
Peng et al[32], 2011	358 PICU and NICU: (age 1 d-17.5 yr)	Anatomic evaluation; BAL; intubation; respiratory distress	87.2% (312/358): Overall 47.8% (171/358): Airway malacia 39.4% (141/358): Inflammatory changes		56.1% (201/358): Interventional FFB 71.4% (518/725): of all FFB were interventional
Pietsch et al[37], 1985	19 NICU: necrotizing tracheobronchitis (mean age 6.53 d)	Therapeutic removal of obstruction			66.7% (10/15): Survived after removal of debris
Prentice et al[23], 2011	7 PICU: ECLS (age 8 d-27 yr)	Persistent atelectasis	100% (7/7) 57.1% (4/7): Bronchus compression/narrowing 71.4% (5/7): Mucus plugs	75% (3/4): Identified organism 75% (3/4): Change in antimicrobials	28.7% (2/7): Removed mucus plugs, ECLS subsequently weaned
Sachdev et al[35], 2010	30 PICU: clinical suspicion of VAP (age 1 mo-12 yr)	BAL		65% (26/40): Identified organism
Soong et al[43], 2011	8 PICU and NICU: obstructive fibrinous tracheal pseudomembrane (age 2 mo-13 yr)	Therapeutic ablation			100% (8/8): Ablation of obstructive membrane
Soong et al[33], 1995	207 NICU and PICU: (age 1 d-10 yr)	Respiratory symptoms; intractable pneumonia	81.1% (172/212)		35.4% (75/212): Resolution of atelectasis, improved secretions
Tang et al[3], 2009	47 PICU: (age 1 d-13 yr)	Anatomic evaluation, BAL; therapeutic (FB, clot removal, hemoptysis, intubation)	80.9% (38/47)	36.8% (7/19): Identified organism 57.9% (11/19): Change in antimicrobials	87.0% (20/23): Re-expanded collapsed lobe. 44.8% (13/29): Extubated < 24 h after mucus plug, blood clot, FB removed
Ward et al[15], 1987	25 PICU: CHD (n = 7), (age 1 d-11 yr)	Anatomic evaluation; atelectasis; confirm ETT/tracheostomy position; hyperinflation; respiratory distress	64% (16/25): Overall 62.5% (5/8): Tracheostomy - change in management 80% (4/5): Hemoptysis - change in management 85.7% (6/7): CHD

A-a gradient: Alveolar-arterial gradient; ARDS: Acute respiratory distress syndrome; BAL: Bronchoalveolar lavage; CDH: Congenital diaphragmatic hernia; CHD: Congenital heart disease; CXR: Chest X-ray; ECLS: Extracorporeal life support; ETT: Endotracheal tube; FB: Foreign body; FFB: Flexible fiberoptic bronchoscopy; F_iO2: Fractional of inspired oxygen; LOS: Length of stay; MV: Mechanical ventilation; NICU: Neonatal intensive care unit; PIC: Pediatric intensive care unit; SCD: Sickle cell disease; TEF: Tracheoesophageal fistula; VAP: Ventilator associated pneumonia; WGA: Weeks gestational age.