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\begin{document}

\title{A survey of Pediatric Flexible bronchoscopy in India}



\author[1]{Kana Jat}%
\author[1]{Sheetal Agarwal}%
\author[2]{RAKESH LODHA}%
\author[1]{Sushil Kabra}%
\affil[1]{All India Institute of Medical Sciences}%
\affil[2]{AIIMS}%


\vspace{-1em}



  
  \date{May 28, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: Pediatric bronchoscopy is an important tool in pediatric
pulmonology. However, the practices involved in the procedure are
variable. Objective: To evaluate prevalent practice and variations in
pediatric flexible bronchoscopy in India. Methods: An online survey
conducted between September 2018 to March 2019 via Google forms. The
survey was sent to members of the Respiratory Chapter of IAP, personal
contacts, and members of Indian Chest Society. Physicians performing
flexible bronchoscopy in children were asked to respond. Survey had 95
questions in seven domains including patient preparation, sedation,
procedural aspects, monitoring, bronchoscope cleaning, and
complications. Results: The survey received 24 (14 in private sector)
complete responses from 14 cities. Pediatric bronchoscopy was mainly
done for diagnostic purposes. Conscious sedation was used by most (19,
79\%). Midazolam plus fentanyl 9 (37.5\%) was the preferred sedation
regimen. Routine atropine was used by 4 (16\%). For topical anaesthesia-
nebulized only, both nebulized and spray as go, and spray as go
lignocaine only was used by 1 (4.2\%), 6 (25\%), and 17 (71\%) centres,
respectively. The methods of providing oxygen during bronchoscopy were
free flow (9,37.5\%), nasal prongs (8,33.3\%), mask (6,25\%), and LMA
(1,4.2\%). Therapeutic procedures included removal of mucus plugs (17,
71\%), bronchoscopic intubation (11, 45\%) and foreign body removal (10,
41\%). The suction for BAL included wall mounted suction in maximum (15,
62.5\%). The number of aliquots for BAL varied from 2-6 and volume for
each aliquot also varied (1-2 ml/kg or 5-10 ml). The complications rate
of less than 5 \% was reported by almost all. Conclusion: There is large
variation in pediatric flexible bronchoscopy practices across the
country highlighting the need to develop a uniform guideline.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Flexible bronchoscopy is an important procedure in pediatric pulmonology
and many centres across India have started performing this procedure.
However, the practices involved in the procedure are variable and
standard guidelines are not available. It is important to have a
standardized procedure for optimal output. The first step in this
direction is to assess the current practices. There are surveys
regarding bronchoscopy in adults from various countries like Canada (1),
UK (2), Japan (3), Australia and New Zealand (4), and India (5). There
is hardly any survey exclusively for pediatric bronchoscopy. Guidelines
for pediatric bronchoscopy are available (6) (7), but it is little
known, how much they are followed.

We conducted a survey to evaluate prevalent practice and variations in
pediatric flexible bronchoscopy practices in India. The survey also
aimed to compare current pediatric flexible bronchoscopy practices with
published guidelines.

\textbf{Methods}

The pediatric bronchoscopy survey was an online survey via an email
link. It was sent to members of the Respiratory Chapter of Indian
Academy of Pediatrics (IAP) and those performing pediatric flexible
bronchoscopy were asked to complete the survey. The same survey email
was also sent to members of Indian Chest Society of adult pulmonologists
to know if they were doing flexible bronchoscopy in children. Authors
also sent emails to their personal contacts doing pediatric flexible
bronchoscopy.

The survey had 95 questions in following seven domains: (A)
Demographics, (B) Patient preparation, (C) Sedation/Anesthesia, (D)
Bronchoscopy procedure, (E) Bronchoscope cleaning, (F) Monitoring during
and after procedures, and (G) Complications (Supplementary file S1). The
questions for survey were decided by bronchoscopy guidelines and
questions used in previous adult bronchoscopy surveys.

A ``Google form'' was created using Google interface for the online
survey. Questions were yes/no type, multiple option questions and space
for additional information was also provided. A trial run was done where
authors themselves completed the survey to identify any difficulty in
completing the survey. The survey link was sent within 2 weeks to all
and kept open for the next 3 months to collect the responses. A reminder
was sent after 1 month. The participation in the survey was voluntary
and no incentives were offered to the participants for responding. The
study was approved by Institute Ethics Committee.

\textbf{Statistics}

The categorical variables were presented as percentage and continuous
variables as mean (SD) if normally distributed or as median (IQR) if not
normally distributed. Chi-square test, Fisher exact test, t-test,
Mann-Whitney test, analysis of variance (ANOVA), and Kruskal-Wallis
tests were used as appropriate. We used the STATA version 12 software
for statistical analysis.

\textbf{Results}

We emailed the survey to 256 members of respiratory chapter of IAP
including personal contacts and 336 to members of Indian Chest Society.
There were 48 and 89 wrong emails for respiratory chapter of IAP and
members of Indian Chest Society respectively. Seven replied that they
were not doing pediatric flexible bronchoscopy. We received a total of
27 completed survey. Out of these, three were from outside India (two
from United Kingdom and one from Nepal) and were excluded. We included
24 responses from India for this study.

\textbf{Demographic profile} : It is shown in Table 1. All except one
had right had as dominant hand. Maximum {[}9, (37.5\%){]} were from
Delhi, three (12.5\%) from Jodhpur (Rajasthan) and remaining 12 were one
each from 12 different cities of India including Pune (Maharashtra),
Mumbai (Maharashtra), Lucknow (Uttar Pradesh), Kanpur (Uttar Pradesh),
Coimbatore (Tamilnadu), Srinagar (Jammu and Kashmir), Bangalore
(Karnataka), Eluru (Andhra Pradesh), Vijayawada (Andhra Pradesh), Mandi
(Himachal Pradesh), and Thiruvalla (Kerala). Name of city was missing in
one response.

The median (IQR) number of years for which bronchoscopist were
performing pediatric bronchoscopy was 3.5 (2,8) years with a range of
one year to 28 years. Fourteen (58.3\%) had experience of less than 5
years, 3 (12.5\%) each had an experience of 5-10 years and more than 10
years. The median (IQR) number of total bronchoscopy and bronchoscopy in
last one year was 75 (25, 428) and 25 (15,45) respectively with range of
10 to 1000 and 5 to 230 respectively. Six (25\%) were also doing
bronchoscopy in adults and four (16.7\%) were also doing rigid
bronchoscopy. Three (12.5\%) were performing endobronchial Ultrasound
(EBUS).

\textbf{Patient preparation and monitoring:} The patient preparation and
monitoring details are summarized in Table 2. All the respondents took
written informed consent and filled checklist for bronchoscopy. There is
high variability in use of drugs for patient preparation (Table 2).

\textbf{Sedation/anesthesia (Table 2):} Pre-procedure institution of
xylocaine was universal but the site of instillation differed. Mostly
used conscious sedation, but choice of sedative agents and person
administering the sedation varied markedly (Table 2).

\textbf{Procedural aspects (Table 3):} Mostly held the bronchoscope in
left hand and stood behind the patient while performing the
bronchoscopy. Oxygen was routinely supplemented by most but the method
of delivering oxygen was variable (Table 3). The quantity of saline used
for BAL was also variable ranging from fixed 5 ml or 1 ml to 2 ml/kg and
number of aliquots also varied from 2 to 6 aliquots (Table 3). Type of
assistant varied from trained pediatric pulmonologist or trained nurse
or pediatric resident or a fellow or lab technician or anesthetist.

\textbf{Bronchoscope cleaning and disinfection (Table 4):} Again, there
was wide variation in doing cleaning of bronchoscope, frequency of leak
test, duration of disinfection and storage of the bronchoscope (Table
4).

Post procedure monitoring was done till child regains full consciousness
by 18 (75\%) respondents. The approximate rate of overall complication
was reported to be \textless{}5\%. Most common complications observed
were transient desaturations, bleeding from nose, tachycardia and
tachypnea.

\textbf{Discussion}

We reported one of the first pediatric flexible bronchoscopy survey from
India and found that there is highly variation in the bronchoscopy
practices. There is no uniform protocol for sedation, amount, and number
of aliquots for BAL etc. The therapeutic procedures using flexible
bronchoscope are being done very rarely in children.

Pediatric pulmonology is an emerging subspecialty in pediatrics. To our
knowledge there would be around 40 physicians who are performing
pediatric flexible bronchoscopy all over the country. The results of
this survey showed that most of the respondents were based in major
cities of the country and majority of them were young with an experience
of less than 5 years. This reflects the paucity of pediatric
bronchoscopy services, but gradually the services are expanding.

The common indications for which bronchoscopy was performed were
evaluation of airways, obtaining bronchoalveolar lavage and removal of
mucus plugs. Very few respondents were removing foreign body and none
were putting stents. Congenital anomalies and airway malformations still
remains the major indication of bronchoscopy in children as against
adults in whom diagnostic and therapeutic bronchoscopy (airway
examination, lavage, washings, TBNA, or biopsies) are the major
indications (5). Therapeutic and interventional bronchoscopy is less
frequently practiced in pediatrics probably due to several factors such
as the risks involved in small child, need for general anesthesia, size
of airway and the expertise of the bronchoscopist limiting the
interventions. Pre procedure nebulization with bronchodilator,
prophylactic antibiotics and routine atropine use was also observed in
few. Pre medication with atropine is not recommended now as there isn't
enough evidence to support its use (8). Similarly, nebulization with
bronchodilator and prophylactic antibiotics are not recommended as a
routine.

The majority of respondents were doing bronchoscopy under conscious
sedation; however, the choice of sedation was quite variable. Similar
observations were made in adult bronchoscopy surveys as well. In adults
a large number of respondents performed bronchoscopy without sedation in
our country as well as other countries. In Indian survey of bronchoscopy
practices in adults, bronchoscopy was performed only under topical
anesthesia and without any conscious sedation in 59\% of patients
whereas in our study almost all performed bronchoscopy under some form
of intravenous sedation (5). The reason for this is obvious as children
are not cooperative as adults and also that sedation facilitates the
performance of bronchoscopy and improves tolerance to the procedure
providing a comfortable environment for both patient and bronchoscopist.
There are no guidelines regarding use of sedation in pediatric
bronchoscopy and there is controversy regarding
proceduralist-administered versus anaesthetist-administered sedation.
Even though proceduralist administered sedation has been found to be
safe and cost effective, the risks of sedation should be considered and
appropriate facility to handle the adverse reactions should be available
(9,10,11). With regards to topical anesthesia spray as you go was the
most referred choice which is a well-established modality of topical
anesthesia. The evidence regarding nebulized lignocaine is not well
established (12). As against the literature in adult bronchoscopy
surveys, where transtracheal lignocaine is commonly used, administration
of transtracheal lignocaine in pediatric patients was not observed in
this survey (1,5). A recent survey from China about pediatric flexible
bronchoscopy also revealed the variation in the procedure and less
therapeutic procedures in children (13).

Providing oxygen during procedure was universal but the methods used
were variable. All of them monitored heart rate and oxygen saturation
but blood pressure was monitored only by 5 (21\%).

The strengths of the study are that large number of questions (95)
covering almost all domains of bronchoscopy procedure were included.
Also, this the first of its kind survey done in pediatrics. However, the
study also had few limitations such as the number of respondents were
quite less. This could be because of the electronic platform used or as
such the number of physicians performing pediatric bronchoscopy in the
country are very few. As per our estimate there would be approximately
40 physicians performing pediatric bronchoscopy in India. Of these we
got 24 responses i.e 60\% response rate which was fair and comparable to
the other bronchoscopy surveys (1-5).

To conclude, this survey documents the practices in pediatric
bronchoscopy in our country and reflects the wide variation in
practices. This documentation would further help in formulation of
appropriate guidelines. It also highlights that there is tremendous
scope for improving the overall procedure and need to develop standard
operating procedures (SOP) for various interventions such as foreign
body removal and putting stents. There is also need to develop
guidelines regarding use of pre procedure bronchodilator, prophylactic
antibiotics and use of atropine which is not indicated in all. There is
also a need to define safe sedation, method for providing oxygen during
procedure: nasal cannula or nasopharyngeal cannula and need for
monitoring including blood pressure, electrocardiogram and saturation.
For negative suction, wall mounted suction is found to be better but
there is need for more studies.

\textbf{References}

1. Pierce CW, Gjevre JA, Taylor-Gjevre RM. A survey of current
bronchoscopy practices in Canada: a dearth of evidence or evidence-based
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2. Honeybourne D, Neumann CS. An audit of bronchoscopy practice in the
United Kingdom: a survey of adherence to national guidelines. Thorax.
1997 Aug;52(8):709--13.

3. Niwa H, Tanahashi M, Kondo T, Ohsaki Y, Okada Y, Sato S, et al.
Bronchoscopy in Japan: a survey by the Japan Society for Respiratory
Endoscopy in 2006. Respirol Carlton Vic. 2009 Mar;14(2):282--9.

4. Barnett AM, Jones R, Simpson G. A Survey of Bronchoscopy Practice in
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5. Madan K, Mohan A, Agarwal R, Hadda V, Khilnani GC, Guleria R. A
survey of flexible bronchoscopy practices in India: The Indian
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6. Faro A, Wood RE, Schechter MS, Leong AB, Wittkugel E, Abode K, et al.
Official American Thoracic Society technical standards: flexible airway
endoscopy in children. Am J Respir Crit Care Med. 2015 May
1;191(9):1066--80.

7. P\selectlanguage{ngerman}érez-Frías J, Moreno Galdó A, Pérez Ruiz E, Agüero BGD, Isabel M,
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8. Malik JA, Gupta D, Agarwal AN, Jindal SK. Anticholinergic
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9. Dang D, Robinson PC, Winnicki S, et al. The safety of flexible
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10.Grendelmeier P, Kurer G, Pflimlin E, et al. Feasibility and safety of
propofol sedation in flexible bronchoscopy. Swiss Med Wkly 2011; 141:
w13248.

11.Hassan C, Rex DK, Cooper GS, et al. Endoscopist-directed propofol
administration versus anesthesiologist assistance for colorectal cancer
screening: a cost-effectiveness analysis. Endoscopy 2012; 44: 456--464.

12. Stolz D, Chhajed PN, Leuppi J, Pflimlin E, Tamm M. Nebulized
lidocaine for flexible bronchoscopy: A randomized, double\selectlanguage{english}-blind,
placebo-controlled trial. Chest 2005;128:1756-60

13. Lin J, Tao X, Xia W, Liu J, Zhong L, Sun X et al. A multicenter
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Pediatr. 2021 Jan;10(1):83-9

\textbf{Hosted file}

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