Communications to the Editor |

Sedation for Pediatric Bronchoscopy FREE TO VIEW

Simon Stacey, MBBS; Elizabeth Hurley, BSc; Andrew Bush, MD
Author and Funding Information

London, United Kingdom

Correspondence to: Simon Stacey, MBBS, Anesthesia and Critical Care, Royal Brompton & Harefield, Sidney St, London SW3 6NP, UK

Chest. 2001;119(1):316-317. doi:10.1378/chest.119.1.316-a
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Published online

To the Editor:

We read with interest the experience of Slonim and Ognibene, published in CHEST (December 1999),1 regarding sedation for pediatric fiberoptic bronchoscopy, a technique that we have almost completely abandoned in our institution in favor of general anesthesia using inhalational agents. We now perform approximately 120 bronchoscopies under general anesthesia per year in children for a variety of indications (stridor, recurrent infection, asthma, cough, etc.). Many of these children have significant comorbidity, and an anesthetist dedicated to managing the airway and providing anesthesia allows the investigator to focus on the procedure itself. Diagnostic conditions are excellent, additional procedures can be performed painlessly, and recovery is swift, allowing early ambulation and discharge.

The use of a variety of anesthetic techniques (face mask, laryngeal mask airway [LMA], intubation) allows flexibility to the bronchoscopist. The choice depends on the question being addressed by the examination. For example, a lavage in an immunocompromised child with alveolar space disease and the assessment of a stridor in a baby should not be approached with the same technique if maximal safety and maximal information are to be guaranteed. Preprocedure discussion between the anesthetist and bronchoscopist facilitates selection of an appropriate technique.

During 1998, we anesthetized 118 children for flexible fiberoptic bronchoscopy in an anesthetic induction room, as opposed to the threatening surroundings of an ICU. The children ranged in age from 2 weeks to 17 years, with weights from 2.5 to 75 kg. To our knowledge, none of them were HIV positive. Data concerning indication, weight, anesthetic technique, and any adverse events (cough, laryngospasm, bronchospasm, apnea, desaturation [defined as a fall of > 10% from baseline], airway obstruction, bradycardia, hypotension) were documented.

Elective preprocedure intubation was planned in 29 patients and successfully performed in 28 patients (24%). One patient was a difficult intubation, tracheal intubation was abandoned, and the procedure continued using a face mask. Two patients (2%) already had tracheostomies through which the procedure was performed. A LMA was used in 40 patients (34%). In all other 48 patients (40%), a face mask was held and the scope passed via the mask and then through the nose. The larynx and trachea were anesthetized topically with 10% lidocaine spray in 25 patients (22%).

One or more adverse events were documented in 33 procedures (28%). Desaturation occurred in 18 patients (15%), and coughing severe enough to disrupt the operator occurred in 11 patients (9%). Apnea occurred in 10 patients (8.5%) and laryngospasm in 4 patients (3%). Significant upper-airway obstruction occurred in seven patients (6%), and four children required urgent intubation. Two patients could not be extubated due to complete airway obstruction, and they were transferred to the ICU to receive mechanical ventilation. Two patients were admitted to a high-dependency unit for postprocedure observation. There were no episodes of vomiting, nasal bleeding, or hypotension, and no deaths. In the majority of cases, complications were referable to the underlying pathologic condition.

Like Slonim and Ognibene, we have identified those patient groups at highest risk of adverse events. Upper-airway pathology, persistent radiographic changes, oxygen dependence, and weight < 10 kg were the highest risk factors for adverse events during the procedure.


Slonim, AD, Ognibene, FP (1999) Amnestic agents in pediatric bronchoscopy.Chest116,1802-1808




Slonim, AD, Ognibene, FP (1999) Amnestic agents in pediatric bronchoscopy.Chest116,1802-1808
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