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Use of Rigid and Flexible Bronchoscopy Among Pediatric Otolaryngologists
Seth Cohen, MPH, MD;
Harold Pine, MD;
Amelia Drake, MD
Arch Otolaryngol Head Neck Surg. 2001;127:505-509.
ABSTRACT
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Objective To explore how rigid and flexible bronchoscopy are used in pediatric
otolaryngologic practice.
Design Survey.
Participants Members of the American Society of Pediatric Otolaryngology who practice
in the United States and Canada and were listed in the membership directory
were eligible. Of the 206 members, 24 practicing outside the United States
or Canada and 11 without an e-mail address or a fax machine were excluded.
Hence, a questionnaire was e-mailed or faxed to 171 pediatric otolaryngologists.
Main Outcome Measures Questions concerned the practice setting, type and number of bronchoscopies,
indications, complications, and medicolegal cases.
Results Responses were received from 120 subjects (70.2%), with 3 retired and
2 practicing only otology, leaving 115 respondents who completed at least
some of the questionnaire. Rigid and flexible bronchoscopy were performed
by 72.7% (56/77) of those in academic settings and by 71.1% (27/38) of those
in group or solo practices. In the last 12 months, approximately 10 454
total bronchoscopies were performed, with 2052 flexible and 9117 rigid bronchoscopies.
Stridor, suspected foreign body inhalation, and laryngomalacia were the most
common indications for bronchoscopy. Of the 83 respondents practicing rigid
and flexible bronchoscopy, 25 (30.1%) used both instruments to manage complex
or repeated foreign bodies, 25 (30.1%) used both to manage patients with cystic
fibrosis, and 15 (18.1%) used both to manage simple foreign bodies. Complications
were reported by 15.7% of the respondents, the most common being arrhythmia.
Familiarity with a case resulting in medicolegal action was reported by 32.2%
of the respondents.
Conclusions Rigid and flexible bronchoscopy have multiple uses in pediatric otolaryngologic
practice. Also, flexible bronchoscopy appears to be emerging as a more frequently
used diagnostic and therapeutic tool.
INTRODUCTION
BRONCHOSCOPY HAS become widely used in the diagnosis and treatment of
disorders involving the aerodigestive tract. Although rigid bronchoscopy may
provide better views of the pharynx, hypopharynx, and postcricoid regions
and allow for ventilation of the airway, flexible bronchoscopy provides more
versatility.1 The flexible instruments have
broad viewing fields, allow inspection of the peripheral airways, and may
be manipulated through a tracheostomy or stoma. Yet, although nonsurgeons
more commonly use flexible bronchoscopy, surgeons have traditionally relied
on the rigid instrument.2, 3
Nevertheless, the flexible bronchoscope has numerous applications in
pediatric otolaryngologic practice. Examination of the nasal cavity, nasopharynx,
larynx, trachea, bronchi, and esophagus may be accomplished with the flexible
bronchoscope.4, 5 The small size
of flexible bronchoscopes has also led to its use in cases involving children
and neonates.6, 7 Diagnosis and
treatment of respiratory tract problems in premature infants may be accomplished
with flexible bronchoscopy. In addition, use of the flexible bronchoscope
has been proposed as a diagnostic strategy for questionable foreign body inhalation.8 To investigate the bronchoscopic practices of pediatric
otolaryngologists, a questionnaire survey was conducted.
SUBJECTS AND METHODS
A questionnaire was either e-mailed or faxed to members of the American
Society of Pediatric Otolaryngology who practice in the United States and
Canada and were listed in the membership directory. If the e-mail address
listed in the directory was nonfunctioning, the member was faxed a questionnaire.
Of the 206 members, 24 practicing outside the United States or Canada and
11 without an e-mail address or a fax machine were excluded. Hence, a questionnaire
was e-mailed or faxed to 171 pediatric otolaryngologists. Four months after
receiving the last questionnaire, those who did not respond to the first contact
were faxed a second questionnaire. The questions concerned the practice setting,
the type and number of bronchoscopies, use of general and local anesthesia,
indications, complications, familiarity with cases resulting in medicolegal
action, and respondents' view of future rigid and flexible bronchoscopy use.
Questions concerning years of experience, type and number of bronchoscopies,
and percentage of practice involved in airway management required respondents
to state their answer. For all other questions, the respondents could choose
one of the provided answers or give their own response.
When a respondent did not answer a question, the response was denoted
as no response. Nine of the respondents who performed only rigid bronchoscopy
answered one or more questions concerning flexible bronchoscopy. To ensure
that data about flexible bronchoscopy reflected those who truly use the flexible
bronchoscope, answers to flexible bronchoscopy questions from these 9 respondents,
except the question about the future use of flexible bronchoscopy, were ignored.
The practice type "academic" included a physician practicing in an academic
center exclusively or a physician practicing in either a group or a solo practice
and partly in an academic center. The practice type "nonacademic" included
physicians with no association with an academic center and practicing either
in a group or solo practice or in a community hospital. To calculate the number
of bronchoscopies performed in the last 12 months, the number, the lowest
value if the answer was reported as a range, stated by each respondent was
summed. Because of this method of calculation and because some respondents
did not report the total number and type of bronchoscopy performed, the number
of flexible and rigid bronchoscopies does not equal the total number of bronchoscopies.
However, these values serve as estimates. If more than one respondent from
a particular practice or academic center was aware of a similar case that
resulted in medicolegal action, only one of the respondent's answers was recorded
to reduce the likelihood of counting the same case more than once. The data
are presented in numerical form and, when applicable, as a percentage.
RESULTS
Of the 171 questionnaires sent, responses were received from 120 pediatric
otolaryngologists, producing a response rate of 70.2%. Three members retired
and 2 practiced solely otology, leaving 115 questionnaires, 108 from US residents
and 7 from Canadian residents, that were at least partially completed. Hence,
of the respondents, 95.8% were using the bronchoscope in some fashion. Most
respondents did not practice in small population centers, with 110 (95.7%)
practicing in a population area of at least 100 000 people and 88 (76.5%)
practicing in an area of at least 500 000 people. Also, the respondents
were experienced with bronchoscopy, with only 13 (11.3%) practicing bronchoscopy
for less than 10 years and only 6 (5.2%) practicing bronchoscopy for only
5 to 7 years. Last, 76 (66.1%) had more than 20% of their practice involved
in airway management and 77 (67.0%) were involved in academics.
In the last 12 months, 10 454 total bronchoscopies, with 2052 flexible
and 9117 rigid bronchoscopies, were performed (Table 1). The mean number of total bronchoscopies performed in the
last 12 months was 91.7 (range, 1-905). Because one respondent did not practice
clinically in the last 12 months, the mean was calculated using data from
the remaining 114 respondents.
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Table 1. Number of Bronchoscopies Performed in the Last 12 Months*
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The distribution of those using both instruments is similar among the
respondents in academic and nonacademic environments (72.7% [56/77] vs 71.1%
[27/38]). Also, just as 26.0% (20/77) of respondents in academic settings
used only the rigid bronchoscope, 28.9% (11/38) in nonacademic settings used
only the rigid instrument. Furthermore, the percentage of respondents using
rigid and flexible bronchoscopy was similar for respondents practicing more
than 10 years compared with those practicing for 10 years or less (73.1% [68/93]
vs 71.4% [15/21]), for those practicing in areas of more than 500 000
people compared with those practicing in areas of 500 000 people or less
(73.9% [65/88] vs 69.2% [18/26]), and for those with at least 40% of their
practice involved in airway management compared with those with 20% or less
of their practice involved in airway management (66.7% [16/24] vs 63.9% [23/36]).
Whereas all respondents who practice rigid bronchoscopy use general
anesthesia for the procedure, of the 83 respondents who practice rigid and
flexible bronchoscopy, 53 (63.9%) use general anesthesia for flexible bronchoscopy.
Local anesthesia use was less widespread, with 56 (48.7%) of the 115 respondents
using some form of local anesthesia. Lidocaine was the most commonly used
local anesthetic. If used, local anesthesia was used more commonly for flexible
than for rigid bronchoscopy.
The respondents used bronchoscopy for various indications (Table 2). Stridor was listed by all but
6 respondents as a frequent indication. A foreign body, laryngomalacia, chronic
cough, and congenital tracheal stenosis were all mentioned by more than 40%
of the respondents. All but one respondent specified treating foreign body
inhalation as a specific indication for rigid bronchoscopy (Table 3). Diagnosing stridor in neonates and a biopsy of the airway
were the next most common indications for rigid bronchoscopy. Diagnosing stridor
in neonates also appeared as the most frequent indication for flexible bronchoscopy,
followed by removing secretions and inspecting the airway for trauma (Table 4).
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Table 2. General Indications for Bronchoscopy
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Table 3. Specific Indications for Rigid Bronchoscopy
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Table 4. Specific Indications for Flexible Bronchoscopy
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The use of rigid vs flexible bronchoscopy in diagnosing foreign body
inhalation was also explored. For a patient with either a good history or
radiological evidence of foreign body inhalation, 110 (95.7%) of the respondents,
including 78 (94.0%) of the 83 who use both instruments, would use the rigid
bronchoscope to make the diagnosis, and 5 (6.0% of those who use both instruments)
would use the rigid and flexible bronchoscope to make the diagnosis. On the
other hand, for an equivocal history of foreign body inhalation, 100 (87.0%)
of the respondents, including 68 (81.9%) of the 83 who use both instruments,
would use the rigid bronchoscope to make the diagnosis, 12 (14.5% of those
who use both instruments) would use both instruments to make the diagnosis,
and 3 (3.6% of those who use both instruments) would use the flexible bronchoscope
to make the diagnosis. Furthermore, of the 83 respondents using rigid and
flexible bronchoscopy, 25 (30.1%) use both instruments to manage complex or
repeated foreign bodies, 25 (30.1%) use both to manage patients with cystic
fibrosis, and 15 (18.1%) use both to manage simple foreign bodies.
Eighteen (15.7%) of the 115 respondents reported 37 complications, producing
a complication rate of 0.4% (37/10 454). The complications were as follows:
The most common complication was arrhythmia other than tachycardia or
bradycardia, and all but 2 respondents stated that the complications occurred
with the rigid bronchoscope.
Last, 37 (32.2%) of the respondents were aware of a case resulting in
medicolegal action. The reasons for the case are as follows:
The 2 most common situations involved foreign body inhalation and laser
bronchoscopy. Only 2 of the respondents who knew of a medicolegal case worked
at the same hospital, but they reported different cases.
COMMENT
Our response rate is higher than the 51.2% response rate in the American
College of Chest Physicians' study2 and the
40.8% response rate in the European Respiratory Society study.9
With 83 (72.2%) of the respondents using both instruments, the flexible bronchoscope
appears to have infiltrated the pediatric otolaryngologist's practice. Similarly,
the European Respiratory Society study9 showed
that 56.9% of pediatric pulmonology centers use both instruments. Hence, physicians
involved in some form of pediatric airway management use rigid and flexible
bronchoscopy. In contrast, the American College of Chest Physicians' study2 demonstrated that 91.6% of mostly adult pulmonologists
did not use the rigid bronchoscope, and the British Thoracic Society study3 of chest physicians found that 81% of respondents
used only flexible bronchoscopy. Nevertheless, in the attempt to evaluate
and treat the pediatric airway, the rigid and flexible bronchoscopes may complement
each other and have uses in surgical and nonsurgical fields of medicine.
Furthermore, the use of rigid and flexible bronchoscopy appears widespread.
Practice setting, population center, years of experience, and percentage of
practice involved in airway management were not associated with type of bronchoscopy
used. In addition, of those involved in resident teaching, half of the respondents
teach rigid and flexible bronchoscopy. Thus, a foundation for the future use
of both instruments is being laid. Yet, because the respondents were experienced
with bronchoscopy and airway management and practiced in large population
centers, this study may not represent the practice patterns of pediatric otolaryngologists
in smaller towns and those with less experience.
General anesthesia was frequently part of the bronchoscopic procedure.
Just as the European Respiratory Society study9
found that 91.2% of centers practicing rigid bronchoscopy used general anesthesia
for the procedure, the respondents always used general anesthesia for rigid
bronchoscopy. Yet, while only 16.5% of physicians in the American College
of Chest Physicians' study2 and 12% of physicians
in the British Thoracic Society study3 used
general anesthesia for flexible bronchoscopy, the respondents commonly used
general anesthesia for flexible bronchoscopy. Although adults may tolerate
flexible bronchoscopy with sedation and local anesthetics, children might
be too anxious to cooperate. Furthermore, the respondents may have wanted
the option to convert to the rigid technique, possibly explaining the higher
frequency of general anesthesia use.
Bronchoscopy has broad applications in various diagnostic and therapeutic
situations. Just as in the studies by Hoeve and Rombout10
and Wood,11 stridor was among the most frequent
indications (Table 2). Yet, pneumonia
and atelectasis were less common than found in other investigations.2, 10, 11 Although the frequency
of indications depends on the patient population and referral patterns, the
documented indications are vast, demonstrating multiple uses for bronchoscopy.
As in the European Respiratory Society study,9
treating foreign body inhalation and diagnosing stridor in neonates were the
most common specific indications for rigid bronchoscopy (Table 3). Also, the respondents used the flexible bronchoscope to
diagnose stridor in neonates (Table 4).
Comparing diagnostic success rates and complication rates of the rigid and
flexible technique of bronchoscopy for neonatal stridor might be an interesting
area of future study.
Furthermore, as mentioned in the study by Wei et al,5
the flexible bronchoscope has therapeutic uses, such as in resolving sputum
retention and chest infection. Likewise, the respondents found therapeutic
functions for flexible bronchoscopy, such as removing secretions, tracheostomy
care, and difficult intubations (Table 4). Nussbaum12 and Wood and Sherman13 also noted the flexible bronchoscope's therapeutic
utility for airway toilet and resolving atelectasis. In addition, Wei et al
noted that foreign body inhalation was a therapeutic use for flexible bronchoscopy.
Wood and Gauderer14 also commented on combining
the flexible and rigid bronchoscope to diagnosis and treat, respectively,
patients with questionable histories of foreign body inhalation. Some of our
respondents also mentioned using flexible bronchoscopy to treat foreign body
inhalation and used the combination of rigid and flexible bronchoscopy in
the management of foreign bodies (Table
4). Perhaps there are certain features of the history and physical
examination that influence the choice of bronchoscopy. Exploring these aspects,
the rates of successful treatment, and the complication rates of using the
rigid, the flexible, or both bronchoscopes in foreign body situations may
help elucidate the safest and most efficient manner of handling this difficult
problem. Last, some respondents were using the rigid and flexible bronchoscopes
in treating patients with cystic fibrosis. There may be some clinical situations
in which the rigid and flexible bronchoscopes complement each other. Overall,
the flexible bronchoscope may be developing a growing niche in the pediatric
otolaryngologic practice.
Few complications were reported by the respondents. A study of 48 000
flexible bronchoscopies found a complication rate of 0.3%, and complication
rates of 1.9% and 1.7% have also been reported in a series of 1332 and 908
flexible bronchoscopies, respectively.15, 16
However, our complication rate is based on both rigid and flexible bronchoscopies.
One study17 from the Soviet Union found a 0.3%
complication rate of 1146 flexible bronchoscopies and a 1.1% complication
rate of 4595 rigid bronchoscopies. Thus, our complication rate is similarly
low. Of the 37 respondents reporting a complication, all but 1 had performed
more than 20 total bronchoscopies in the last 12 months, and 10 had performed
more than 100 total bronchoscopies in the last 12 months. In addition, only
4 respondents had less than 10 years of experience with bronchoscopy, and
only 2 had less than 20% of his or her practice involved in airway management.
Hence, although rare, some complications do occur, even among experienced
pediatric otolaryngologists. As in the study by Hoeve and Rombout,10 arrhythmia was the most commonly reported complication.
Moreover, one third of the respondents were aware of a case involving medicolegal
action. Despite only recording a case once in situations in which more than
one physician from the same practice or institution noted a particular medicolegal
case on the questionnaire, some overlap could still exist. Through personal
contact or peer review, physicians in the same city or even other locations
could be aware of a particular case, thereby elevating the number of respondents
who knew of a case requiring medicolegal action. Nevertheless, because diagnoses
may be missed and complications may occur, parents may pursue medicolegal
action. Hence, to sustain a high level of confidence in the various applications
of bronchoscopy, appropriate training in rigid and flexible bronchoscopy must
be maintained.
Some inherent weaknesses exist in retrospective survey studies. Pediatric
otolaryngologists who have not had positive results with bronchoscopy may
not have responded, leading to possible underestimation of the complication
rate and the number of cases resulting in medicolegal action. Also, those
who use bronchoscopy infrequently may not have answered the questionnaire,
causing an overestimation of the average number of bronchoscopies performed
in the last 12 months. Furthermore, certain questions may be misinterpreted
or left unanswered. In addition, the answer choices provided on the questionnaire
may influence the respondent's reply, and some important questions may not
have been considered by the questionnaire. Last, various questions, such as
those about complications, number of bronchoscopies, and familiarity with
cases resulting in medicolegal action, rely on the respondent's memory and
may be underestimated because of poor recall or reluctance to report the answer.
Nevertheless, this questionnaire provides some insight into how bronchoscopy
is used in the practice of pediatric otolaryngology across the country and
may lead to the critical evaluation of such use.
CONCLUSIONS
Rigid and flexible bronchoscopy have an established role in the practice
of pediatric otolaryngology. As technological advances occur in the flexible
bronchoscope, such as smaller instruments and improved forceps, the diagnostic
and therapeutic role may increase. In fact, whereas 25.2% of all respondents
thought flexible bronchoscopy use would become more prevalent in the future,
only 7.0% thought future rigid bronchoscopy use would increase. Having both
instruments available may facilitate patient care. Otolaryngology residents
should be familiar with the rigid and the flexible bronchoscope. Future areas
of research may compare diagnostic and therapeutic success rates, costs, complication
rates, length of the procedure, and physician preference in specific clinical
situations.
AUTHOR INFORMATION
Accepted for publication November 14, 2000.
Presented at the 15th Annual Meeting of the American Society of Pediatric
Otolaryngology, Orlando, Fla, May 16, 2000.
From the Division of Otolaryngology, University of North Carolina School
of Medicine, Chapel Hill. Dr Cohen is now with the Department of Otolaryngology,
Vanderbilt School of Mediicine, Nashville, Tenn.
Corresponding author: Seth Cohen, MPH, MD, 5025 Hillsboro Rd, Apt
7D, Nashville, TN 37215 (e-mail: seth.cohen{at}mcmail.vanderbilt.edu).
Reprints: Amelia Drake, MD, Division of Otolaryngology, University of North
Carolina School of Medicine, 610 Burnette-Womack, Campus Box 7070, Chapel
Hill, NC 27599-7070 (e-mail: drakeaf{at}med.unc.edu).
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