Rigid Bronchoscopy

Paediatric bronchoscopy entails two endoscopic techniques: flexible and rigid bronchoscopy. Flexible bronchoscopy is mainly performed by pulmonologists, whereas rigid bronchoscopy is a more invasive procedure usually carried out by otorhinolaryngologists. Each method has advantages and drawbacks. The selection of flexible or rigid bronchoscopy depends on the indication, the clinical context and the expertise of each medical centre. Flexible bronchoscopy has an essential role in the diagnosis of airway disease. On the other hand, rigid bronchoscopy is more efficient in the interventional management of airway lesions. Foreign-body removal is the most frequent indication for paediatric rigid bronchoscopy. Rigid tubes (laryngoscope and bronchoscope) are also used for the treatment of laryngeal and tracheal lesions thanks to the continuous evolution of various endoscopic techniques such as stenting, dilatation, debulking with laser or microdebrider, and intralesional injections. The rigid tube can secure the airway in case of obstruction, thus allowing for concomitant assisted ventilation. Rigid and flexible instruments complement each other in the evaluation of paediatric airways, and the close collaboration between otorhinolaryngologists and paediatric pulmonologists helps to ensure the selection of the most efficient and safe procedure. Copyright © 2010 S. Karger AG, Basel The respiratory tract can be explored using two endoscopic methods: flexible (fig. 1) and rigid (fig. 2) laryngoscopy and bronchoscopy. This chapter discusses the methods of and the indications for rigid (tube) airway exploration in the paediatric population as well as the differences between flexible and rigid laryngotracheobronchoscopy. Flexible bronchoscopy is carried out under light sedation or general anaesthesia usually by a pulmonologist whereas rigid bronchoscopy is invariably performed in the operating theatre under general anaesthesia, usually by an otorhinolaryngologist. Complications of either procedure are rare but paediatric rigid bronchoscopy in particular necessitates anaesthesia and careful monitoring, and good cooperation between the anaesthetist and otorhinolaryngologist. During rigid endoscopy, two surgical instruments are used for visualizing the respiratory tract: the rigid laryngoscope (assisted by rod lens telescope; fig. 3) and the rigid bronchoscope (also assisted by the rod lens telescope; fig. 4). The external diameter of the rigid bronchoscope is selected according to the weight of the child (table 1). There are several types of rigid telescopes, e.g. direct (0°) or angled vision (30° and 70°), and two main diameters, i.e. 2.7 and 4 mm. The main advantage of the rigid bronchoscope is that it secures the airway and allows for assisted ventilation during the procedure (fig. 4), whereas the rigid laryngoscope does not allow for simultaneous assisted ventilation. Thanks to recent technological advancements, the therapeutic use of rigid endoscopy has expanded in the last 10 years. Current treatment of upper respiratory tract diseases by means of rigid bronchoscopy may render the performance of tracheostomy unnecessary, a procedure which is associated with high mortality (0.5–4%) and morbidity (44– 70%) rates in neonates and children [1, 2]. Complete exploration of the airway with the rigid endoscope includes visualization of the larynx, the trachea and the proximal bronchi, i.e. the main and lobar bronchi, and the orifices of the segmental bronchi. The indications for laryngotracheoscopy will be detailed in the first part, and those of tracheobronchoscopy in the second part of this chapter.