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.