What are the pre-procedure and procedural guidelines for a 2-year-old undergoing bronchoscopy?

ENT Consultation Order for 2-Year-Old Bronchoscopy

A 2-year-old child undergoing bronchoscopy requires careful pre-procedure planning with appropriate sedation or general anesthesia, continuous monitoring, and post-procedure care to minimize risks of respiratory complications.

Pre-Procedure Guidelines

Patient Assessment

• Complete history and physical examination focusing on:
  • Respiratory status (baseline oxygen saturation, presence of stridor, respiratory distress)
  • Airway abnormalities that may complicate the procedure
  • Bleeding risk (check coagulation parameters if biopsy planned)
  • Current medications and allergies
  • Previous anesthesia experiences

Laboratory and Imaging

• Chest radiograph to establish baseline and identify abnormalities
• If biopsy is planned: complete blood count, platelet count, PT/PTT 1
• Consider electrolyte assessment

Admission Planning

• Determine if day case or inpatient admission based on:
  • Procedure complexity
  • Child's underlying condition
  • Need for additional investigations 1

Informed Consent

• Written informed consent must be obtained by a senior physician
• Family should receive full information about:
  • Procedure purpose and expected benefits
  • Risks specific to the bronchoscopist's experience
  • Anesthesia plan and IV access requirements
  • Potential need for post-procedure intensive care 1

Procedural Guidelines

Anesthesia/Sedation Options

1. General anesthesia (recommended for 2-year-olds)

   • Allows controlled airway management
   • May be spontaneously breathing or ventilated depending on procedure requirements 1

2. Deep sedation (if general anesthesia contraindicated)

   • Requires dedicated monitoring personnel separate from the bronchoscopist 2, 3
   • Medications may include:
     • Midazolam: 0.05-0.1 mg/kg IV (titrate slowly over at least 2 minutes) 2
     • Consider reduced doses if other CNS depressants are used

Monitoring Requirements

• Continuous multi-modal physiological monitoring:
  • Pulse oximetry
  • ECG
  • Blood pressure (preferably continuous)
  • End-tidal CO₂ 4

Equipment Preparation

• Age-appropriate bronchoscope selection (ultrathin instruments for small airways)
• Endotracheal tubes as small as 2.5 mm may be required 1
• Resuscitation equipment immediately available
• Established IV access before procedure 4

Topical Anesthesia

• If conscious sedation used:
  • Lidocaine 2-5% for nose and larynx
  • Lidocaine 0.5-1% below larynx
  • Total dose should not exceed 5-7 mg/kg 1

Post-Procedure Care

Immediate Recovery

• Continue 100% oxygen in immediate recovery period
• Monitor for:
  • Respiratory depression
  • Airway obstruction
  • Bleeding (especially if biopsy performed)
  • Pneumothorax (obtain chest radiograph 1-2 hours post-procedure if transbronchial biopsy performed) 4

Discharge Criteria

• Return to baseline respiratory status
• Adequate pain control
• Stable vital signs
• Ability to tolerate oral intake

Special Considerations

Contraindications

• Absolute: procedure will provide no useful information
• Relative:
  • Severe pulmonary hypertension
  • Baseline hypoxia
  • Uncorrected bleeding diathesis 1, 5

Potential Complications

• Hypoxemia
• Laryngospasm or bronchospasm
• Bleeding (especially with biopsy)
• Pneumothorax
• Cardiac arrhythmias 5

Risk Mitigation

• Ensure immediate availability of:
  • Resuscitation drugs
  • Age-appropriate equipment
  • Personnel trained in pediatric airway management 2, 3
• Consider pre-procedure DNase administration for persistent atelectasis 1

Documentation Requirements

• Clear indication for procedure
• Detailed consent process
• Sedation/anesthesia plan
• Findings and interventions
• Post-procedure monitoring plan