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

Pediatric Pulmonology 47:1180–1184 (2012) Pediatric Fiberoptic Bronchoscopy as Adjunctive Therapy in Acute Asthma With Respiratory Failure J. Carlos Maggi, MD , 1,2 Eliezer Nussbaum, MD , 1,2 Christopher Babbitt, MD , 1,2 Flavio E. Maggi, MD , 1,2 and Inderpal Randhawa, MD1,2 * Summary. 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 standard- ized guidelines for status asthmaticus with mechanical ventilation. Ventilator management pri- oritized spontaneous breathing with pressure support. Extubation criteria included spontaneous tidal volumes of 5–7 cm 3 /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 bron- choalveolar 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: Bronchos- copies 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 thera- py in pediatric asthmatics with respiratory failure resulting in reduced mechanical ventilation and intensive care length of stay. Restoring lung volume in certain asthmatics during respirato- ry 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. s 2012 Wiley Periodicals, Inc. Key words: status asthmaticus; respiratory failure; bronchoscopy; intubated asthma. Funding source: none reported. INTRODUCTION Asthma remains a prevalent pediatric condition with associated morbidity and mortality despite modern ther- apeutic modalities. 1,2 A subpopulation of severe asthma suffers respiratory failure with 2% mortality. 2,3 Severe air ﬂow limitation leads to ventilation/perfusion (V/Q) imbalance, progressive alveolar hypoxia, hypoxemia, CO 2 retention, respiratory failure, and subsequent death. 4–8 The presence of infection, atelectasis, or se- vere mucous plugging may contribute to mechanical air ﬂow obstruction, segmental lung collapse, lung consoli- dation, and increased inﬂammation. 9–14 Several reports in the adult population elucidated the role of bronchoscopy in patients with severe asthma. 15–18 The safety and efﬁcacy of ﬂexible ﬁberoptic bronchoscopy in children with asthma and respiratory failure have not been established. The purpose of our study was to evaluate the safety, efﬁcacy, and clinical s 2012 Wiley Periodicals, Inc. outcomes of ﬂexible ﬁberoptic bronchoscopy and bron- choaleolar lavage in pediatric asthmatic patients with respiratory failure. Miller Children’s Hospital, Long Beach, California. UC Irvine School of Medicine, Irvine, California. Conﬂict of interest: None. *Correspondence to: Inderpal Randhawa, MD, 2801 Atlantic Ave, Ground Floor, Department of Pediatric Pulmonary, Long Beach, CA 90806. E-mail: docrandhawa@yahoo.com Received 28 December 2011; Accepted 29 March 2012. DOI 10.1002/ppul.22591 Published online 15 May 2012 in Wiley Online Library (wileyonlinelibrary.com).