The Importance of Flexible Bronchoscopy in Difficult-to-treat Asthma from a Pediatric Pulmonology Perspective

Abstract

Objective Asthma is the most common chronic lung disease in childhood. Difficult-to-treat asthma is defined as the continuation of symptoms or attacks of patients despite step 4 or 5 of Global Initiative for Asthma therapy. In the differential diagnosis of these patients, flexible fiberoptic bronchoscopy is recommended to exclude other lung diseases. In this study, we aimed to examine the clinical and radiologic features and flexible fiberoptic bronchoscopy findings of patients referred to our pediatric pulmonology department due to difficult-to-treat asthma and determine the effects of flexible fiberoptic bronchoscopy on the differential diagnosis and treatment. Materials and Methods The demographic characteristics and flexible fiberoptic bronchoscopy results of 62 patients who were diagnosed as having difficult-to-treat asthma in our pediatric pulmonology department between January 2015 and June 2020 were evaluated retrospectively. The symptoms, history, medications, physical examination findings, pulmonary function tests, and radiologic findings of patients who underwent flexible fiberoptic bronchoscopy were evaluated. Results The median age of the patients was 69 (interquartile range: 42-108 months). The most common reasons for the referral of these patients were chronic cough, recurrent pulmonary infections, and persistent wheezing. All patients had chest radiography and 37 (59.7%) had chest computed tomography at their first admission; 14 (37.8%) patients had abnormal findings on chest computed tomography. There was no significant difference in terms of age, physical examination findings, pulmonary function test results, and radiologic examinations between patients with and without pathologic bronchoscopy findings. None of the patients had complications during and after flexible fiberoptic bronchoscopy. The most common diagnoses of patients based on flexible fiberoptic bronchoscopy were persistent bacterial bronchitis in 19 (30.6%) patients, tracheomalacia and/or bronchomalacia in 12 (19.4%), and anatomic anomalies in 3 (4.8%) patients (separation of lingula into 3, separation of right upper lobe bronchus into 4, and tracheal dyskinesia). Mycobacterium tuberculosis growth was observed in the tuberculosis culture of 1 patient. According to the flexible fiberoptic bronchoscopy and bronchoalveolar lavage results, antituberculosis treatment was initiated in 1 patient and polypoid mass excision was performed in 1 patient. A proton pump inhibitor was started in 9 (15.5%) patients, physiotherapy in 5 (8.0%), antibiotics in 14 (22.5%), and ipratropium bromide in 7 (11.2%) patients. All patients were followed up with the diagnosis of asthma except for 2 patients. Conclusion To date, there is no prospective study evaluating the importance of flexible fiberoptic bronchoscopy in difficult-to-treat asthma in childhood. In our small cohort, persistent bacterial bronchitis, airway tracheomalacia and/or bronchomalacia, ...

The utility of elective flexible bronchoscopy to improve quality of life and clinical outcomes for children: A systematic review

“…Several retrospective studies have found that FB is a useful tool in children with persistent wheezing 34–36 or in “difficult to treat asthma” 37 with a definitive diagnosis made in 57%−85% of cases 34,35 . FB has also proven to be a valuable tool in the evaluation of infants with stridor (33.9% patients diagnosed with laryngomalacia, 49.5% of patients diagnosed with secondary airway lesions—tracheomalacia, tracheal compression, bronchomalacia, subglottic stenosis, 4.6% with subglottic haemangioma, 1.8% with subglottic web) 38 …”

Plastic bronchitis during childhood: Diversity of presentation, etiology, treatment, and outcomes

“…2,22,23 Bronchoscopy is an essential and safe method to diagnose and treat airway diseases in children. 8,24,25 Bronchoscope interventions facilitate cast clearance and access of inhaled drugs into the distal airways. 2,10,11 Recently, Kallam et al 12 reported that cryotherapy was useful and safe in bronchial casts that were refractory to conservative treatment.…”

“…Treatment includes low‐dose oral macrolides, oral or ICS, aerosol tPA, and bronchoscopy to remove the casts 2,22,23 . Bronchoscopy is an essential and safe method to diagnose and treat airway diseases in children 8,24,25 . Bronchoscope interventions facilitate cast clearance and access of inhaled drugs into the distal airways 2,10,11 .…”

“…Microbiologic cultures and cytology were studied from BAL samples. Detection of bacteria above 10 4 CFU/mL in BAL was considered significant and defined as a clinically important lower airway infection 8 . Optical forceps (Storz®) and rigid suctions were used to remove casts by pediatric surgeons.…”

“…Detection of bacteria above 10 4 CFU/mL in BAL was considered significant and defined as a clinically important lower airway infection. 8 Optical forceps (Storz ® ) and rigid suctions were used to remove casts by pediatric surgeons. A macroscopic view of a cast during bronchoscopy is shown in Figure 1.…”