A procedure that allows a pediatric pulmonologist to see the inside of a child's larger airways and take a sample from lower in the lungs. The procedure is done under anesthesia in the hospital. Most children go home a few hours after the procedure.

For outpatient procedures (when your child is not hospitalized), they most often occur early in the mornings as your child cannot eat nor drink in the hours prior (exact timing varies and will be communicated to you prior to the procedure). Most procedures occur in the endoscopy unit (directions will be provided) of the hospital. 

After reviewing the anesthesia plan and the bronchoscopy procedure, consent forms to proceed will be signed.

Initial anesthesia medication (either gas breathed in or IV medication) is given and your child falls asleep.

The bronchoscope (see photo below) is then inserted either through a nostril or through the mouth (only if the patient has an endotracheal tube or laryngeal mask airway present). The vocal cords are identified and are usually numbed by spraying a small amount of lidocaine medication on them.

The bronchoscope is then passed between the vocal cords and into the trachea (windpipe). When the bronchoscope reaches where the trachea splits into the right and left sides (called the carina), more lidocaine is placed. Then the larger airways on both the left and right sides of the lungs are examined.

While the bronchoscope is being inserted into the lungs, the structures are being carefully observed for redness, swelling, abnormal movements, presence of secretions and any abnormal tissue. 

In most cases a bronchoalveolar lavage (BAL) is also performed. Sometimes we also call this a "wash." For this part of the procedure, a small amount of salt water (called normal saline) is pushed through the channel in the bronchoscope into a small section of the lung. That fluid sits there for a few seconds and is then suctioned back out and into a sterile container. The fluid collects cells in the lower part of the lungs (the patient's cells as well as any infectious cells or viruses). After the procedure this fluid is analyzed in the lab to tell us if an infection is present and about which of the natural cells in the lung are most abundant (which can give clues to what is causing issues for your child).

After the bronchoscopy is completed, the anesthesia medication needs to be stopped and cleared from the body. While this is happening, your child remains in a recovery room. Your child cannot eat or drink for 45-60 minutes after the numbing medication was placed on their vocal cords (which is early during the bronchoscopy procedure).

Infection: if the respiratory symptoms your child is experiencing could be due to infection and has not responded to other therapies, then doing a bronchoalveolar lavage (BAL) as described above can help obtain more details on the type of infection is present and which treatment(s) would be best moving forward

Noisy breathing or airway narrowing: visualizing the airway can help diagnose the exact cause of noisy breathing as we can see any malformations, growths, or abnormal airway movements

Persistent cough: while flexible bronchoscopy is not the first test in the evaluation of persistent cough, it is used if a child is not responding to treatment(s) as expected to look for infection, airway irritation or an airway abnormality

Abnormal chest x-ray or chest CT scan: visualizing an area from the inside can help obtain more information about what is going on in the lung causing the abnormality on imaging

Suspected aspiration: aspiration is when food or fluid that is being swallowed is leaking into the lungs which make the lungs inflamed causing persistent cough and sometimes infections; performing a bronchoalveolar lavage (BAL) as described above gathers cells from deep inside the lungs that can be a sign of aspiration

There are other more rare reasons to perform flexible bronchoscopy as well. 

The bronchoscope is a small, flexible tube that carries a fiber optic system that attaches to a video camera and light source. The image from the end of the scope transmitted through the fiber optic system to monitor so that the inside of the airways can be seen. Most bronchoscopes also have a open channel that allows for oxygen, suction, fluids or specialized tools to be passed to the end of the bronchoscope.

The risks and benefits of flexible bronchoscopy are individualized to each patient. These will be discussed with the parent(s)/guardian(s) prior to the procedure.

That being said, there are some general risks and possible complications for most patients as all medical tests carry some risks. Although the risks from a flexible bronchoscopy are very low, you should know about the possible complications.

Bleeding from the tissues of the nose or airways: this is from scraping by the bronchoscope and is usually very minimal and almost always stops by itself.

Infection: as the bronchoscope passes through the nose, it can carry bacteria above the vocal cords to the lungs. This risk is extremely small and is treated with antibiotics.

Perforation (hole) in the airway leading to a collapsed lung: the risk of this complication is less than 1 in 1000. In that event, the air around the lung would have to be removed with a chest tube. This would mean your child would have to stay longer at the hospital until the hole in the lung is healed, which usually takes 1 to 3 days.

More common but mild "side effects" from flexible bronchoscopy and bronchoalveolar lavage (BAL) include:

Cough: as having the bronchoscope in the lungs and having a small amount of fluid placed in the lungs can cause some irritation, a normal reaction is to cough; this will resolve usually within 24 hours; you can give you child albuterol if they have it prescribed

Fever: about one-third (1/3) to one-half (1/2) of children who undergo a bronchoalveolar lavage (BAL) will develop a low grade fever within 12 hours of the procedure; this is due to the body's normal immune response and is normally treated with an anti-fever medication like acetaminophen (brand name Tylenol®) or ibuprofen

Noisy breathing/wheezing: this is also due to the irritation of the bronchoscope and BAL and usually resolves within 24 hours; you can give you child albuterol if they have it prescribed

Blood in mucus: if there is some mild bleeding of the tissue in the nose, throat or lungs due to the irritation of caused by the bronchoscope or BAL, sometimes you will see small amounts of blood mixed with mucus or saliva

"Red flag" symptoms after the procedure include:

Trouble breathing: while mild cough is quite common, trouble breathing is not and would require seeking medical care in the pediatric emergency room or pediatric office

Coughing up large amounts of blood: very small streaks of blood mixed with mucus or saliva can happen and would not be dangerous/worrisome but having large amounts of blood that is coughed up or spat out is concerning and you should seek medical care in the pediatric emergency room

Fever that persists more than 24 hours: while having a mild fever in the first 12-24 hours after bronchoscopy is somewhat common, having fevers that persist past 24 hours should be evaluate or discussed with a pediatrician

University of Chicago:

https://www.uchicagomedicine.org/comer/conditions-services/pulmonary-medicine/patient-guides

Children's Hospital of Pittsburgh:

https://www.chp.edu/our-services/pulmonology/patient-procedures/flexible-bronchoscopy

Nationwide Children's (Columbus, Ohio):

https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/bronchoscopy-flexible-bronchoscopy-and-bronchoalveolar-lavage