Rigid bronchoscopy provides an excellent visualization of the airway. With the advancement in medical technology, the indications and uses continue to expand. This has resulted in a shift in paradigm in airway surgeries. The development of flexible bronchoscopy has come in timely to resolve some of the limitations with rigid bronchoscopy such as its ability to be used in children with unstable spine and its ability to be passed to the distal airway. However, each instrument has its own limitations and together they can be complementary.
44 Pediatric Bronchoscopy
The father of modern bronchoscopy is considered to be Gustav Killian, who in 1897 developed a direct ocular mechanism for extracting foreign bodies from a patient’s airway. 1 Chevalier Jackson is often considered the father of endoscopy and was central to the development of safe and effective techniques of bronchoscopy and esophagoscopy. Since then, numerous physician scientists have expanded the capabilities of this technology. 2 In 1966, Shigeto Ikeda revolutionized the field with the development of the flexible fiberoptic bronchoscope, paving the way for imaging and video bronchoscopy. 3 This was followed in the early 1980s by the development of transbronchial needle aspiration and the use of lasers to coagulate endobronchial lesions. 4 Today, bronchoscopy has become an integral part of numerous subspecialties for the diagnosis and treatment of airway pathologies.
For many decades, rigid endoscopy has been the main tool used in the evaluation of airway disease. However, in recent years, with the introduction of flexible fiberoptic endoscopy, the role of rigid endoscopy has become much more clearly defined and the two types of endoscopy have proven complementary. Traditionally, rigid bronchoscopy has been used in the evaluation of airway disease, operative airway procedures, and removal of foreign body. Recent technologic advances and the development of specialized endoscopic tools have resulted in a new era of endoscopic airway surgery. This chapter will discuss the equipment and techniques used in rigid and flexible bronchoscopy in the evaluation and management of pediatric airway conditions.
A list of commonly used laryngoscopes and bronchoscopes recommended for the pediatric endoscopic airway cart is presented in ▶ Table 44.1 and ▶ Fig. 44.1 and ▶ Fig. 44.2.
Micrognathia, anterior larynx
Foreign body forceps
The Parsons, Benjamin, Lindholm, Phillips, or Miller blades are the most common laryngoscopes used in pediatric laryngoscopy. Most pediatric airway cases can be managed with the aforementioned laryngoscopes. However, in certain patients with difficult exposure, such as patients with micrognathia or Pierre Robin sequence, the slotted anterior commissure scope or the anterior commissure C-Mac D blade scope may be useful. The McIntosh blades are not commonly used by otolaryngologist as the curved blades make passing a telescope or rigid bronchoscope more difficult.
The Parsons and Lindholm are suspension laryngoscopes. The Parsons is a slotted scope and is preferred by some surgeons who enjoy the additional room for a second instrument (▶ Fig. 44.3). When a suspension laryngoscope is employed, the larynx can be examined with a microscope or a rigid telescope, such as the Hopkins rod telescopes. A microscope with 400 mm lens is recommended when two hands are needed for manipulation and surgical intervention. For routine examination, a Hopkins rod telescope connected to a camera and video monitor system gives superior image and improved ability to inspect the subglottis and the distal trachea.
Rigid bronchoscopes come in a variety of diameters and lengths. A list of the common sizes and accessories is presented in ▶ Table 44.2. Regardless of the type of scopes used, it is important to remember the outer diameter of the scope is larger than the listed size of the scope. For example, a size 3.5 bronchoscope has an inner diameter (ID) of 5.0 mm and outer diameter (OD) of 5.7 mm (▶ Fig. 44.4). The shorter length 18.5 cm scope should be used for small neonates and premature infants, and the 30 cm should be used for an older child. A common and easy to remember cut-off is the age of 6 months. An appropriately sized bronchoscope is crucial to ensure safe passage and minimal trauma to the airway.
Age bronchoscopes sizes outer diameter (mm)
Premature 2.5 (4.0)
Full-term newborn 3.0 (5.0)
6 months–1 year 3.0–3.5 (5.0)
1 year–2 years 3.5 (5.7)
2 years–3 years 3.5–4.0 (5.7–6.7)
3 years–5 years 4.0 (6.7)
10 years 5.0 (7.8)
14 years 5.0 (7.8)
When performing a diagnostic rigid bronchoscopy in the operating room, it is important to have various sizes of bronchoscopes available. Specifically, a bronchoscope appropriate for patient’s age as well as two sizes down should be readily available.
44.2.3 Ancillary Tools
A list of ancillary tools such as suction devices, light cords, anti-fog solutions, topical lidocaine sprays, tooth guards, saline-soaked gauze sponges, endotracheal tubes (ETT), and microsurgical instruments should be present. Depending on the patient’s diagnosis, microdebriders, airway balloons, optical forceps, and laser setup may be necessary.