In many respects, the pediatric population represents the most difficult challenge for the bronchoscopist. Some advocate that all pediatric fiberoptic bronchoscopy be performed in the operating room with the help of the anesthesia department.5
In this issue of CHEST (see page 315), Fauroux et al report important information about the efficacy and tolerability of fiberoptic bronchoscopy in children using a mixture of 50% nitrous oxide and 50% oxygen. This study was placebo-controlled, and it showed that the use of nitrous oxide resulted in a more successful procedure. Because this was a pediatric group with many subjects who were < 6 years of age, the authors developed multiple methods to evaluate the successfulness of the analgesic agent. These methods included the use of a CHEOPS score (a score measuring crying, facial expression, verbal expression, torso posture, touch, and leg position) by the endoscopy team, a self-reported assessment by patients old enough to do so, and the use of behavioral responses as judged by blinded independent observers who reviewed video recordings of each bronchoscopy. Using these methods, the authors were able to show that the nitrous oxide increased efficacy and decreased patient-perceived pain, and its use resulted in better scores by the independent observers. Nitrous oxide also improved the CHEOPS score by the endoscopy team.