Clinical utility of flexible bronchoscopy and bronchoalveolar lavage in young children with recurrent wheezing

doi:10.1016/S0022-3476(98)70451-2

The Journal of Pediatrics

Volume 132, Issue 2, February 1998, Pages 312-318

Presented in part at the Annual Meeting of the Southern Society for Pediatric Research, Jan. 31-Feb. 2, 1996, and at the Annual Meeting of the American Thoracic Society, May 11-15, 1996.

https://doi.org/10.1016/S0022-3476(98)70451-2 Get rights and content

Abstract

Objective: The objective of this study was to determine in young children with recurrent wheezing poorly responsive to bronchodilator therapy whether flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) provide clinically useful information, whether age-specific differences are present in bronchoscopic and BAL fluid (BALF) findings, and whether differential cellular analysis of BALF is useful in suggesting an infectious or inflammatory process. Study design: This was a retrospective case series with descriptive and analytical components. The study population included children referred to a large tertiary care children's hospital subspecialty service for further evaluation of recurrent wheezing. Clinical and demographic data and findings of FB and BALF studies were collected from chart review. For purposes of data analysis patients were divided into 0- to 6-, 7- to 12-, and 13- to 18-month age groups. Results: Thirty otherwise healthy children, 0 to 18 months of age with recurrent wheezing, who had undergone FB were identified; and 28 were found to have positive diagnostic findings. Airway abnormalities were found in 17 (57%) and tended to be more common in the 0- to 6-month age group. In the 27 who also had BAL performed, 3 (11%) had a positive bacterial culture, 9 (33%) a positive viral culture, and 5 (19%) an elevated lipid-laden macrophage index suggesting aspiration. Differential cellular analysis was abnormal in 11 (41%), a finding that was significantly associated with a positive bacterial culture, a positive viral culture, or an elevated lipid-laden macrophage index. Conclusions: In this population of young children with recurrent wheezing poorly responsive to bronchodilator therapy, FB and BAL yielded useful diagnostic findings in most children studied. In addition, in the presence of an infectious or inflammatory process, differential cellular analysis of BALF revealed an increased percentage of neutrophils. (J Pediatr 1998;132:312-8)

Section snippets

Study Population

All children who underwent FB with or without BAL between July 1993 and August 1995 for the primary indication of recurrent wheezing were identified from local flexible airway endoscopy and bronchoalveolar lavage databases. Demo- graphic and clinical data were obtained from retrospective chart review. Patients were included for further analysis if they were 0 to 18 months of age and had recurrent episodes of wheezing that were clinically refractory or poorly responsive to inhaled albuterol.

Patient Demographic and Clinical Characteristics

A total of 48 children were identified who had undergone FB for the primary indication of recurrent wheezing between July 1993 and August 1995, and 30 of the 48 children met the inclusion criteria. All 30 patients had received inhaled albuterol, and all had a history of recurrent wheezing for greater than 1 month. Secondary indications for FB included poor response to inhaled cromolyn or nedocromil (n = 16), poor response to inhaled corticosteroids (n = 3), poor response to one or more courses

Discussion

Our results indicate that in a selected group of otherwise healthy children 0 to 18 months of age with recurrent wheezing that was poorly responsive to bronchodilator therapy, FB and BAL yielded clinically useful information that led to therapeutic changes in most of the patients. In agreement with previous reports, we found airway abnormalities in most of our patients.6, 7, 8 However, the inverse relationship of age to the occurrence of airway abnormalities in young children with recurrent

References (40)

RE Wood
Spelunking in the pediatric airways: explorations with the flexible fiberoptic bronchoscope
Pediatr Clin North Am
(1984)
LL Fan et al.
Appli- cations of an ultrathin flexible bronchoscope for neonatal and pediatric airway problems
Chest
(1986)
J Grigg et al.
Bilateral fiberoptic bronchoalveolar lavage in acute unilateral lobar pneumonia
J Pediatr
(1993)
DC Stokes et al.
Role of flexible bronchoscopy in the diagnosis of pulmonary infiltrates in pediatric patients with cancer
J Pediatr
(1989)
AC Ferguson et al.
Bronchial hyperresponsiveness in asthmatic children: correlation with macrophages and eosinophils in broncholavage fluid
Chest
(1989)
FD Martinez et al.
Asthma and wheezing in the first six years of life
N Engl J Med
(1995)
S Halken et al.
Recurrent wheezing in relation to environmental risk factors in infancy
Allergy
(1991)
AL Boner et al.
Clinical diagnosis of infant asthma
Pediatr Pulmonol
(1995)
FD Martinez et al.
Diminished lung function as a predisposing factor for wheezing respiratory illness in infants
N Engl J Med
(1988)
IB Tager et al.
Lung function, pre- and post-natal smoke exposure, and wheezing in the first year of life
Am Rev Respir Dis
(1993)

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Citation Excerpt :
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Flexible endoscopy (FE) for the pediatric aerodigestive tract is an invasive and complicated procedure; therefore, it is usually performed under an inpatient setting. We investigated whether FE could be a safe procedure for outpatient young children (< 5 years old) and analyzed the findings.
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A total of 728 children (479 boys, 249 girls) who underwent 834 FE procedures were collected. Of those without previously known airway anomalies, stridor was the most common symptom in group A (60.2%), and snoring in group B (34.1%) and group C (74.2%). Laryngomalacia was the most common FE finding in group A (60.2%) and group B (34.1%), and nasal adenoid hypertrophy in group C (69.6%). After FE, there were 57 admissions (6.8%), and higher in those aged less than 1 year or in those with major airway anomalies. Seven (0.7%) were complication-associated admissions.
From this study, we conclude that FE is a safe, effective and tolerable outpatient procedure in the majority of young children, and serious complications were uncommon.
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Three hundred nineteen children who underwent 335 FOB procedures. The indications for bronchoscopy included infectious agent identification in immune-competent patients with new pulmonary infiltrates seen on chest radiograph (46%) and in patients with fever and neutropenia with respiratory symptoms (18%), airway anatomy evaluation in patients with upper airway obstruction (16%), CHD (15%), and airway trauma (5%). Data were obtained by reviewing the patients’ charts, bronchoscopy reports, and laboratory results.
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^☆: From the Departments of Pediatrics and Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

^☆☆: Reprint requests: Dennis E. Schellhase, MD, Arkansas Children's Hospital, Department of Pediatrics, Pulmonary Medicine Section, 800 Marshall St., Little Rock, AR 72202-3591.

^★: 9/21/83687

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Clinical utility of flexible bronchoscopy and bronchoalveolar lavage in young children with recurrent wheezing☆,☆☆,★

Abstract

Section snippets

Study Population

Patient Demographic and Clinical Characteristics

Discussion

Pediatr Clin North Am

Chest

J Pediatr

J Pediatr

Chest

Asthma and wheezing in the first six years of life

N Engl J Med

Recurrent wheezing in relation to environmental risk factors in infancy

Allergy

Clinical diagnosis of infant asthma

Pediatr Pulmonol

Diminished lung function as a predisposing factor for wheezing respiratory illness in infants

N Engl J Med

Lung function, pre- and post-natal smoke exposure, and wheezing in the first year of life

Am Rev Respir Dis

The diagnostic effectiveness of the flexible bronchoscope in children

Pediatr Pulmonol

Flexible endoscopy in the diagnosis and management of neonatal and pediatric airway and pulmonary disorders

Respir Care

Recurrent aspiration in children: lipid-laden alveolar macro- phage quantitation

Pediatr Pulmonol

The diagnostic utility of bronchoalveolar lavage in immunocompetent children with unexplained infiltrates on chest radiograph

Pediatrics

Use of bronchoalveolar lavage in immunocompromised children with pneumonia

Pediatr Pulmonol

Bronchoalveolar lavage

Am Rev Respir Dis

Cells in bronchoalveolar lavage fluid

Am Rev Respir Dis

Bronchoalveolar lavage cellularity in healthy children

Am J Respir Crit Care Med

Lymphocyte subsets in bronchoalveolar lavage fluid of children without bronchopulmonary disease

Am J Respir Crit Care Med

Bronchoalveolar lavage studies in children without parenchymal lung disease: cellular constituents and protein levels

Pediatr Pulmonol