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.