Is neonatal (newborn) bronchoscopy feasible in a neonatal intensive care unit (NICU) setting?

Neonatal Bronchoscopy is Feasible and Safe in the NICU Setting

Yes, neonatal bronchoscopy can and should be performed in the NICU when clinically indicated, using flexible bronchoscopes as small as 2.2 mm outer diameter, with diagnostic procedures being remarkably safe and therapeutic interventions requiring heightened precautions. 1

Equipment and Technical Feasibility

• Modern flexible bronchoscopes with outer diameters as small as 2.2 mm make direct visual assessment of even extremely preterm neonatal airways technically possible 1
• These ultrathin instruments can be passed through endotracheal tubes as small as 2.5 mm and allow procedures in neonates weighing as little as 530 grams 1, 2
• The improved suction channels in newer bronchoscopes enable therapeutic maneuvers including mucous plug aspiration, drug instillation, and bronchoalveolar lavage 1

Common Clinical Indications

The most frequent indications for neonatal bronchoscopy based on large case series include:

• Persistent atelectasis (38% of cases) 1
• Unexplained episodes of cyanosis (11% of cases) 1
• Unexplained respiratory distress (10% of cases) 1
• Stridor (7% of cases) 1
• Difficulty weaning from mechanical ventilation 3
• Evaluation of artificial airways (endotracheal tube or tracheostomy position and patency) 1

Diagnostic Yield and Clinical Impact

• Abnormal findings are detected in 81% of neonates with chest radiograph abnormalities undergoing bronchoscopy 1
• The most common pathologies identified include tracheal or bronchial stenosis (28%), tracheomalacia/bronchomalacia (45-48% in chronic lung disease patients), vascular compression (13%), and granulomas (9%) 1, 4
• Bronchoscopy results in revision of diagnosis in 57% of cases and changes clinical management in 63% of patients 4, 5
• Bronchoalveolar lavage yields positive microbiology in 54-70% of cases, directly guiding antibiotic therapy 4, 5, 6

Safety Profile: Critical Distinction Between Diagnostic and Therapeutic Procedures

The safety profile differs dramatically based on procedure type:

• Purely diagnostic bronchoscopy has an excellent safety record with no complications reported in large series 3
• Flexible bronchoscopy is safer than rigid bronchoscopy, particularly in infants under 1500 grams 2
• Therapeutic procedures carry higher risk, with serious complications occurring in approximately 3.6% of operative bronchoscopies 3
• The most common minor complication is transient hypoxemia, occurring in less than 3% of cases and typically self-resolving 5

Procedural Technique for Mechanically Ventilated Neonates

For critically ill, ventilated neonates in the NICU, specific technical modifications are essential:

• Use rapid insertion-withdrawal technique (10-45 seconds) with video recording to minimize airway compromise, as the bronchoscope nearly completely occludes the endotracheal tube 1
• Review the video recording afterward for detailed assessment rather than prolonged direct visualization 1
• Maintain strict temperature control as these infants are highly prone to hypothermia 1
• Provide analgesia with opiates (diamorphine or fentanyl); sedation with benzodiazepines like midazolam is rarely used 1
• Monitor continuously: heart rate, oxygen saturation, blood pressure, and temperature 1, 7

Anesthesia and Monitoring Requirements

• Always perform with local anesthesia of the larynx (2% lidocaine spray to vocal cords) plus either sedation or general anesthesia 1
• General anesthesia with experienced anesthesiologist monitoring has advantages over sedation alone for constant airway surveillance 1
• Total lidocaine dose should not exceed 5-7 mg/kg 1
• The bronchoscope can be inserted pernasally, through a laryngeal mask, or through the tracheostomy port 1

Post-Procedure Management

Critical post-procedure monitoring is mandatory:

• Watch closely for apnea, hypoxia, and bradycardia, which are common complications 1
• Obtain blood gases in mechanically ventilated infants and adjust ventilator parameters accordingly 1
• Consider short course of corticosteroids if laryngeal edema is exacerbated by the procedure 1, 7
• Continue monitoring for at least several hours as complications can develop after the procedure 1

Critical Pitfalls to Avoid

• Never perform operative/therapeutic bronchoscopy unless immediate thoracotomy and pulmonary surgery capabilities are available, as serious complications requiring emergency surgery can occur 3
• Avoid prolonged procedure times in ventilated preterm infants; use the rapid video-recording technique instead 1
• Do not use flexible bronchoscopy for foreign body extraction—rigid bronchoscopy is required for removal 8, 9
• Infants under 1500 grams require extra caution with more frequent desaturations and higher FiO2 requirements 2

When to Choose Rigid vs. Flexible Bronchoscopy

• Flexible bronchoscopy is the preferred modality for diagnostic evaluation and assessment of airway dynamics in neonates 9, 2
• Rigid bronchoscopy is reserved for foreign body extraction, large resistant mucus plugs that cannot be cleared with flexible scope, and certain therapeutic interventions 1, 8
• Flexible bronchoscopy is significantly safer than rigid bronchoscopy in neonates, especially those under 1500 grams 2