Pediatric fiberoptic bronchoscopy as adjunctive therapy in acute asthma with respiratory failure

Abstract

Background Status asthmaticus respiratory failure is associated with thickened mucus secretions necessitating aggressive pulmonary clearance. The role of bronchoscopy in pediatric mechanically ventilated asthmatic patients has not been published. Methods A chart review was performed on all pediatric intensive care unit (PICU) asthmatics with respiratory failure over 13 years. Forty‐four patients were identified. Patients were managed per standardized guidelines for status asthmaticus with mechanical ventilation. Ventilator management prioritized spontaneous breathing with pressure support. Extubation criteria included spontaneous tidal volumes of 5–7 cm3/kg on low‐pressure support. Standard endotracheal tube pulmonary toilet were implemented. Twenty‐nine patients underwent bronchoscopy as an adjunctive therapy. Indications for bronchoscopy included: Pathogen identification via bronchoalveolar ravage, atelectasis, mucus obstruction resulting in severe air trapping, suspected aspiration, and poor response to standard therapy. Clinical outcomes of this intervention were compared to the fifteen patient cohort who did not undergo bronchoscopy. Results Bronchoscopies revealed thick mucus plugs, secretions, and bronchial casts. The large airways were lavaged for clearance of obstructive secretions with normal saline. All patients tolerated the procedure without any complications. Demonstrable improvement in pulmonary compliance was noted. The median time of intubation for the bronchoscopy group was 10 hr compared to 20.5 hr for the control group (P < 0.0005). The mean intensive care unit length of stay was 3.06 days for the bronchoscopy group versus 3.4 days for the non‐bronchoscopy group (P < 0.05). Conclusion Flexible bronchoscopy with bronchial lavage is a safe adjunctive therapy in pediatric asthmatics with respiratory failure resulting in reduced mechanical ventilation and intensive care length of stay. Restoring lung volume in certain asthmatics during respiratory failure may be deemed beneficial. Further validated studies are necessary to recommend bronchoscopy to the present, accepted treatment regimen in pediatric asthmatic respiratory failure. Pediatr Pulmonol. 2012; 47:1180–1184. © 2012 Wiley Periodicals, Inc.

Mechanical Ventilation for Severe Asthma

“…65 , 66 A study of children with asthma who were mechanically ventilated compared the outcomes of 29 patients who underwent bronchoscopy with 15 patients who did not. 67 Bronchoscopy was associated with a signifi cantly shorter duration of mechanical ventilation and was without complications, but given the retrospective nature of the study it is uncertain if the two groups were comparable. 67 Although probably safe in most instances, there is a potential for worsening bronchospasm.…”

“…67 Bronchoscopy was associated with a signifi cantly shorter duration of mechanical ventilation and was without complications, but given the retrospective nature of the study it is uncertain if the two groups were comparable. 67 Although probably safe in most instances, there is a potential for worsening bronchospasm. Of note, excellent outcomes without use of bronchoscopy have been reported.…”

Utility of flexible fiberoptic bronchoscopy for critically ill pediatric patients: A systematic review

“…[15] , [3,19,20,22,24,26,27,30,33] . In one study of 44 intubated children with status asthmaticus, FFB, compared to no FFB, was associated with decreased length of time on mechanical ventilation (20.5 h vs 10 h) and decreased PICU length of stay (3.4 d vs 3.1 d), but no change in total hospital length of stay [36] .…”

“…In pediatric studies, several specific populations appeared to derive the most benefit from therapeutic FFB. In a single study of patients with respiratory failure from asthma who underwent FFB, mucus plug removal was associated with improved oxygenation and lung expansion on chest X-ray, reduced ventilator support, and shorter PICU length of stay [36] . In patients receiving ECLS, FFB was associated with reduced need for ECLS support, particularly when bronchoscopy was performed multiple times.…”

Bronchoscopy as a rescue therapy in patients with status asthmaticus: Two case reports and review of literature

“…A recent report of 41 pediatric patients with status asthmaticus showed improvement in ventilator weaning, reduced time of ventilation, and decreased length of ICU stay after performing therapeutic bronchoscopy. [12]…”