European Respiratory Society
Interventional Pulmonology

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  • European Respiratory Society Monographs
  1. Page vii
  2. Page viii
  3. Page ix
  4. Page 1
    Abstract
    Correspondence: C.T. Bolliger, Division of Pulmonology, Dept of Medicine, University of Stellenbosch, P.O. Box 19063, Tygerberg 7505, Cape Town, South Africa. E-mail: ctb@sun.ac.za

    The two instruments available for investigation and therapy of the trachea and bronchial tree are the rigid and the flexible bronchoscope. Each instrument has its advantages and disadvantages and in many instances they can be used together in a complementary fashion. Bronchoscopy should preferably be performed in a dedicated theatre, but should also have the feature of mobility. Adequately trained staff is essential to ensure patient safety and avoid complications. Various tools are available for obtaining samples during bronchoscopy and will depend on the nature of the process to be sampled. Exciting recent developments in the field of bronchoscopy include the use of narrow band imaging, endobronchial ultrasound and electromagnetic navigation.

  5. Page 18
    Abstract
    Correspondence: A. Lorx, Dept of Anaesthesiology and Intensive Therapy, Semmelweis University, Kútvölgyi út 4, H-1125 Budapest, Hungary. E-mail: lorxa@kut.sote.hu

    The provision of anaesthesia for bronchoscopic procedures poses a number of challenges and requires that the anaesthetist be fully familiar with different airway management, ventilation and anaesthesia techniques.

    The pre-operative management includes a complete assessment of the patient and detailed planning of the possible course of the diagnostic or therapeutic procedure in close cooperation with the bronchologist. As with any anaesthesia, continuous monitoring of the vital signs is crucial, and the management of both cardiac and respiratory complications should be prepared for. The range of possible forms of anaesthesia is wide, depending on the difficulty and length of the procedure, and spans from topical anaesthesia and mild sedation to general anaesthesia with muscle relaxation. Sedation can be achieved with intravenous drugs and combinations, such as benzodiazepines, propofol and opiates, whereas general anaesthesia can be produced with intravenous or volatile anaesthetics or a combination of both. Adequate ventilation and an appropriate level of oxygenation must be ensured during bronchoscopic procedures, though it is often difficult; the course of the procedure determines the level of ventilatory assistance needed.

    Most bronchoscopies can be performed with spontaneous ventilation or bag and mask ventilation, but other situations may call for more invasive airway management procedures, such as the laryngeal mask airway or endotracheal intubation (with either an endotracheal tube or a rigid bronchoscope) and positive-pressure or jet ventilation. The latter can be executed with the use of different connectors, catheters and swivel attachments. The special characteristics of jet ventilation make it an ideal method for guaranteeing adequate oxygenation during bronchoscopy, whether the patient is breathing spontaneously or is under general anaesthesia, and its role in bronchoscopic anaesthesia is therefore pivotal.

    Post-operative monitoring until full recovery from the anaesthesia is an absolute necessity in order to avoid respiratory complications and rapidly emerging life-threatening complications, such as stent displacement.

    1. Page 35
      Abstract
      Correspondence: T.G. Sutedja, Dept of Pulmonary Medicine, Free University Academic Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. E-mail: tg.sutedja@vumc.nl

      Early detection of lung cancer implies that early interventional strategy improves the outcome of lung cancer patients. It should be realised that the entire chain of interventions (early detection, accurate staging, local treatment and close surveillance) should be practically feasible in the cohort at risk in our ageing population. This requires a comprehensive understanding for the optimal exploitation of the non- and minimally invasive technologies currently available in clinical practice.

      Catheter-based optical technologies, such as bronchoscopic techniques, are by virtue of their minimal invasiveness extremely valuable for individuals at highest risk, who frequently suffer from severe comorbidities, limiting the application of more conventional measures. Therefore, individuals at risk are candidates for early intervention using bronchoscopic techniques; this has an important advantage as many patients may be regarded surgically inoperable. Current videobronchoscopes have limited access beyond the segmental branches of the tracheobronchial tree, due to their size. Development of single optics and ultrathin applicators will definitely broaden bronchoscopic use towards the more peripheral field of the lung parenchyma.

      Optical advancements beyond the spectrum of visible light, improvements in noninvasive dynamic imaging and four-dimensional navigational assistance can provide new avenues towards encompassing dynamic monitoring and early intervention of thoracic diseases in vivo.

      In the present chapter, we focus on early detection by bronchoscopy and briefly describe the concept behind it, which, in combined use with other techniques, may generate a coherent cost-effective strategy for early intervention. Ensuing chapters by experts in the field will deal with various issues for complementary use of alternative bronchoscopic techniques that warrant a more practical application in daily clinical practice.

    2. Page 45
      Abstract
      Correspondence: F.J.F. Herth, Dept of Pneumology and Critical Care Medicine, Thoraxklinik at the University of Heidelberg, Amalienstraße 5, D-69126 Heidelberg, Germany. E-mail: Felix.Herth@thoraxklinik-heidelberg.de

      A tissue diagnosis of mediastinal nodes is frequently needed for accurate lung cancer staging as well as the assessment of mediastinal masses.

      Transbronchial needle aspiration (TBNA) is a safe procedure that is performed during routine bronchoscopy. Provided mediastinal metastases are confirmed, TBNA has a high impact on patient management. Unfortunately, TBNA remains underused in current daily practice, mainly due to the lack of real-time needle visualisation. The introduction of echo-endoscopes has overcome this problem.

      Endobronchial ultrasound-guided (EBUS)-TBNA allows real-time controlled tissue sampling of paratracheal, subcarinal and hilar lymph nodes. Mediastinal lymph nodes located adjacent to the oesophagus can be assessed by transoesophageal ultrasound-guided fine needle aspiration (EUS-FNA). Owing to the complementary reach of EBUS-TBNA and EUS-FNA in assessing different regions of the mediastinum, recent studies suggest that complete and accurate mediastinal staging can be achieved by the combination of both procedures.

      It is expected that implementation of minimally invasive endoscopic methods of EBUS-TBNA and EUS-FNA will reduce the need for surgical staging of lung cancer significantly.

    3. Page 59
      Abstract
      Correspondence: U. Costabel, Dept of Pneumology/Allergy, Ruhrlandklinik, University of Duisburg-Essen, Tueschener Weg 40, 45239 Essen, Germany. E-mail: ulrich.costabel@ruhrlandklinik.uk-essen.de

      Bronchoalveolar lavage (BAL) represents not only a safe diagnostic method, but also has remarkable research potential to investigate prognostic and pathogenetic markers. In the complex field of interstitial lung diseases, including those caused by infections, BAL has become a crucial diagnostic tool. There are several unambiguous findings, for example in alveolar proteinosis, Langerhans cell histiocytosis, diffuse alveolar haemorrhage, diffuse malignancies or dust exposure, where BAL can replace lung biopsy. In other diseases, BAL allows the range of the differential diagnosis to be narrowed or to exclude certain diseases.

    4. Page 73
      Abstract
      Correspondence: L. Thiberville, Clinique Pneumologique, Hôpital Charles Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen Cedex, France. E-mail: Luc.Thiberville@univ-rouen.fr

      In vivo endoscopic microscopy aims to provide the clinician with a tool to assess architecture and morphology of a living tissue in real time, with an optical resolution similar to standard histopathology. To date, available microendoscopic devices use the principle of fluorescence confocal microscopy, and thereby mainly analyse the spatial distribution of specific endogenous or exogenous fluorophores. Fluorescence microendoscopes devoted to respiratory system exploration use a bundle of optical fibres, introduced into the working channel of the bronchoscope. This miniprobe can be applied in vivo onto the bronchial inner surface or advanced into a distal bronchiole down to the acinus, to produce in situ, in vivo microscopic imaging of the respiratory tract in real time.

      Fluorescence confocal microendoscopy has the capability to image the epithelial and subepithelial layers of the proximal bronchial tree, as well as the more distal parts of the lungs, from the terminal bronchioles down to the alveolar ducts and sacs. Potential applications include in vivo microscopic assessment of early bronchial cancers, bronchial wall remodelling evaluation and diffuse peripheral lung disease exploration, as well as in vivo diagnosis of peripheral lung nodules. The technique has also the potential to be coupled with fluorescence molecular imaging. This chapter describes the capabilities and possible limitations of confocal microendoscopy for proximal and distal lung exploration.

    5. Page 90
      Abstract
      Correspondence: S. Gasparini, Pulmonary Diseases Unit, Dept of Internal Medicine, Immunoallergic and Respiratory Diseases, Azienda Ospedali Riuniti, Via Conca, 71, 60020 Ancona, Italy. E-mail: s.gasparini@fastnet.it

      Diagnostic management of solitary pulmonary nodule (SPN) is a common problem for which universally accepted guidelines have not yet been defined. The definition of SPN should be reconsidered since small nodules (<0.8–1 cm in diameter) and non-solid nodules with a ground-glass appearance may need to be managed differently. For nodules >0.8 cm in diameter, in the case of high probability for malignancy and in good surgical candidates, the possibility of immediate surgery could be considered. Nevertheless, in most patients a bioptic assessment is necessary.

      An SPN, for bioptic purposes, may be approached both transbronchially and percutaneously. The bronchoscopic approach should always be performed by using a guidance system to verify the sampling site. Fluoroscopy is the traditional guidance system that is widely employed. Published results obtained with fluoroscopic guidance vary greatly (up to 83%) and this variability may be related to several factors, such as the size of the lesion, the sampling instrument used, the number of sampling instruments and the operator's experience.

      Among the sampling instruments, the transbronchial needle provides the best sensitivity. There is also evidence that the use of more than one sampling instrument provides better results. Washing and bronchoalveolar lavage have low diagnostic yield and should not be used alone. New technology (endobronchial ultrasound and electromagnetic navigation) have been recently proposed as guidance systems. It seems that these new systems may increase the diagnostic yield, especially for smaller nodules <2 cm in diameter (up to 92%), but no comparative studies to fully support this observation have been performed.

      Sensitivity of the transbronchial approach to SPN is lower than that obtained with the percutaneous approach (88–92%), but bronchoscopy has a lower incidence of complications and has the advantage of providing important information for staging (airways and lymph node involvement). The transbronchial approach to SPN should be the first step and percutaneous needle aspiration should be considered when bronchoscopy has failed. The set-up of teams able to utilise both approaches should be encouraged to optimise the bioptic management of SPNs.

    6. Page 109
      Abstract
      Correspondence: J. Strausz, “Korányi” National Institute for Tuberculosis and Pulmonology, Pihenő u. 1., Budapest, H-1121, Hungary. E-mail: strausz@koranyi.hu

      The development of diagnostic imaging and the widespread use of fine-needle biopsy have greatly improved the accuracy and safety of percutaneous transthoracic needle biopsy since its introduction >120 yrs ago. The indications of biopsy include intra-thoracic (chest wall, intra-pulmonary and mediastinal) lesions that cannot be adequately evaluated on bronchoscopy and require cytological and/or histological findings to determine prognosis and appropriate therapy.

      Most percutaneous transthoracic needle biopsies are carried out by radiologists working closely with pulmonologists and pathologists. In the majority of the cases, the collected samples are suitable for cytological examination; however, histological sampling techniques are being applied more frequently. The success of such sampling depends on the size and location of the lesion, the guiding technique and the biopsy method applied, the intra-procedural presence of the pathologists, and the experience of the biopsy-performing physician and the pathologist. Sensitivity should exceed 90% for tumours >2 cm in size. The most common complications include pneumothorax and bleeding, whereas fatal outcome and tumour cell dissemination are very rare occurrences. The majority of the complications occur within an hour of biopsy.

    7. Page 119
      Abstract
      Correspondence: M. Noppen, Interventional Endoscopy Clinic, University Hospital UZ Brussel, 101, Laarbeeklaan, B 1090 Brussels, Belgium. E-mail: marc.noppen@uzbrussel.be

      In about a quarter of patients presenting with a pleural exudate, the diagnosis remains unknown after noninvasive testing. Thoracoscopy is a relatively simple procedure that can be performed under local anaesthesia and that combines a high diagnostic accuracy (>90%) with the advantage of being therapeutic at the same time, when indicated (e.g. to perform pleurodesis).

      Its main indications are diagnostic (recurrent or persistent pleural exudates, pleural thickening or mass, diffuse interstitial lung disease, etc.) and therapeutic (pleurodesis in case of recurrent and/or persistent pleural fluid accumulation, recurrent or persistent pneumothorax, empyema, etc.). It is a very safe procedure with a very low complication rate.

    1. Page 135
      Abstract
      Correspondence: C-H. Marquette, Service de Pneumologie, Centre Hospitalier Universitaire de Nice, Hopital Pasteur, 30 de la Voie Romaine, Nice 06000, France. E-mail: marquette.ch@chu-nice.fr

      Tracheobronchial foreign body aspiration (FBA) is more commonly seen in children than adults. 80% of cases of FBA are seen in children aged <3 yrs and it is the most common cause of death due to unintentional injury in children aged <1 yr. Peanuts and food particles account for most cases of FBA.

      Clinical presentation varies from life-threatening respiratory distress to, more commonly, subtle signs and symptoms, especially in adults and older children. A high degree of clinical suspicion is needed in the diagnosis. The tracheobronchial tree should be examined in all cases of suspected FBA since a delay in the diagnosis can lead to complications.

      Fibreoptic bronchoscopy is the initial diagnostic and therapeutic procedure of choice in adults and children aged >12 yrs. Forceps, specially designed snares or a cryotherapy probe can be used to extract the foreign body (FB). Rigid bronchoscopy is preferred in children aged <12 yrs and in cases where the FB cannot be removed via flexible bronchoscopy. Rigid bronchoscopy allows better control and visualisation of the airway and easier manipulation of the FB with different types of forceps. Haemorrhage and FB displacement may complicate foreign body extraction.

      In most circumstances, FB extraction should be attempted by a trained physician in a setting where rigid bronchoscopy is readily feasible in case of failure or complications.

    2. Page 149
      Abstract
      Correspondence: H. Dutau, Thoracic Endoscopy Unit, Sainte Marguerite University Hospital, 270 Boulevard de Sainte Marguerite, 13009, Marseille, France. E-mail: hdutau@ap-hm.fr

      Despite the development of numerous other tools in interventional bronchoscopy, laser still maintains a central role in the management of benign and malignant central airway lesions. It is primarily used in conjunction with the rigid bronchoscope, a technique known as laser-assisted mechanical debulking. This improves the efficacy of the procedure and allows for a greater degree of safety.

      We will present the basic principles of laser, describe its mode of operation, its role in benign and malignant diseases and finally compare it with other available techniques with immediate onset of action.

      With adequate training and regulation, laser can be used safely with good effect and minimal complications in the central airways.

    3. Page 161
      Abstract
      Correspondence: A. Ernst, Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Road, Deaconess Building 201, Boston, MA 02215, USA. E-mail: aernst@bidmc.harvard.edu

      Cryosurgery has a long history in airway interventions. The technique uses freezing cold energy delivered directly to the airway via specially designed probes and can be performed through either the rigid or flexible bronchoscope. It is a well-established adjunct in the removal of foreign bodies from the airway and can be very effective in the management of intraluminal obstruction and palliation of dyspnoea and haemoptysis associated with endobronchial malignancy. The outcomes for malignant airway obstruction are similar to those seen with more sophisticated and costly modalities such as laser and photodynamic therapy. The principal advantages of the technique over other therapeutic interventions are its low cost, ease of use and safety profile. The major disadvantages are that the results are typically delayed and repeated procedures are often necessary. Further indications for cryotherapy may be in the treatment of early-stage lung cancer and in the potentiation of radiation and systemic chemotherapy.

    4. Page 173
      Abstract
      Correspondence: R. Eberhardt, Dept of Pneumology and Critical Care Medicine, Thoraxklinik at Heidelberg University, Amalienstrasse 5, 69126 Heidelberg, Germany. E-mail: ralf.eberhardt@thoraxklinik-heidelberg.de

      High-dose-rate (HDR) brachytherapy has a well established role in palliative treatment of patients with endobronchial malignancies and advanced disease. It might have a curative potential in properly selected patients but it is in agreement with other options as a primary choice for radical treatment. Dosage and fractionation vary between centres and only consensus recommendations are available.

      However, it seems that larger fractions add to complications without a gain in palliation of symptoms, and caution is necessary when treating patients with HDR and external beam radiation therapy in combination. Contact of the applicator with the bronchial wall must be avoided and appropriate use of centring devices is necessary to protect the bronchial wall from being over dosed.

      A high percentage of patients, but not all, show evidence of recurrence or residual tumour before death. Treatment of a longer tumour length–volume, recurrence or more centrally located tumours covers a selection of patients with more advanced disease and seems to be responsible for an increased rate of complications, more than the treatment itself.

      Standardisation of doses and fractionation is an urgent priority as it will allow for a comparison between future studies. Image-guided HDR brachytherapy techniques, new combinations and application in nonmalignant cases warrant a long perspective for this modality.

    5. Page 190
      Abstract
      Correspondence: L. Freitag, Dept of Interventional Pulmonary Medicine, Ruhrlandklinik, University Hospital, Essen, Tueschener Weg 40, 45239 Essen, Germany. E-mail: lutz.freitag@ruhrlandklinik.uk-essen.de

      Airway stents are designed to palliate symptoms if central airways are compressed or if their walls are destroyed. They can be used to seal fistulas and bridge dehiscences. For the treatment of tracheobronchial malacias external stenting seems to be more efficient. Caution is required in cases of benign strictures. Stents should only be used if all other options are exhausted. Metallic stents are easier to place than polymeric stents but they can cause more problems that are difficult to deal with. State-of-the-art stents are completely covered, thin walled, self-expanding hybrid stents, cut or woven from nitinol or similar alloys. Straight cylindrically shaped stents are available in any length; branching stents are only obtainable in larger dimensions for the main bifurcation. Modern stents are easy to place and can provide immediate relief from dyspnoea. However, complications have to be considered. Typical side-effects after stent placement are mucostasis, migration and granulation tissue formation. Fractures and other mechanical failures are frequently found, sometimes requiring stent removal or replacement.

      Some stents can already be tailored to particular needs with individual lengths, diameters, recoil forces and angulations. Companies are working on bio-degradable stents and drug-eluting stents. Loading these airway prostheses with anti-inflammatory, anti-neoplastic and anti-microbial drugs should help to suppress unfavourable tissue growth and bacterial colonisation. Sophisticated surface treatment will be necessary to avoid retained secretions.

    6. Page 218
      Abstract
      Correspondence: T.P. Toma, Dept of Respiratory Medicine, University Hospital Lewisham, Lewisham High Street, London, SE13 6LH, UK. E-mail: ttoma@doctors.org.uk

      Emphysema is characterised by lung hyperinflation, which is the main contributor to the debilitating shortness of breath that cripples these patients. Endoscopic treatments for lung hyperinflation comprise a group of emerging endoscopic techniques, none of which is yet in routine clinical practice. Bronchoscopic lung volume reduction with valves is one of the most extensively studied. Patient selection and a practical business model for these treatments remain the main problems to be solved before these procedures can become really cost effective in routine clinical practice. This chapter reviews the rationale, technology and limited evidence available for each type of endoscopic lung volume reduction procedure for patients with emphysema.

    7. Page 228
      Abstract
      Correspondence: G. Cox, Room T2123 – Firestone Institute for Respiratory Health, St Joseph's Healthcare, 50 Charlton Ave E, Hamilton, ON L8N 4A6, Canada. E-mail: coxp@mcmaster.ca

      Despite substantial progress in developing anti-inflammatory treatments for asthma, there are needs among our patients that are not met. These arise from a variety of sources that include disease that is resistant to current therapies or that requires such high doses of effective medications that side-effects are troublesome. Bronchoconstriction resulting from airway wall smooth muscle contraction is a defining element of asthma and undoubtedly contributes to symptoms of the disease. Our current treatments do not affect the accumulation of excess muscle that characterises airway remodelling in asthma. Hence the proposition that bronchial thermoplasty, which is a procedure performed at bronchoscopy that delivers controlled heat to the airway to reduce the mass of smooth muscle there, is inherently attractive. If effective, bronchial thermoplasty would address the muscle component of airway remodelling and result in less potential for bronchoconstriction. This proposition has been tested in a series of four clinical trials (one observational, three randomised and controlled) involving patients with asthma ranging from mild to severe. While patients in all four studies who received bronchial thermoplasty reported benefit in control of their asthma, it is likely that in the future, this treatment will be directed at those patients who have severe asthma that is not well controlled by regular use of standard combinations of currently available therapies.

    1. Page 239
      Abstract
      Correspondence: W. De Wever, Dept of Radiology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. E-mail: walter.dewever@uzleuven.be

      Imaging techniques used for guidance of interventional pulmonology include fluoroscopy, cross-sectional imaging, ultrasonography and angiography. Advantages of fluoroscopy are familiarity to most operators, real-time control of the procedure, and its wide availability in radiological departments. It can be used for guidance of percutaneous transthoracic needle biopsy and for accessing and drainage of large free-flowing or loculated pleural collections. Computed tomography (CT) is particularly useful for guiding puncture of intrapulmonary, pleural and mediastinal lesions. CT fluoroscopy provides real-time guidance of the biopsy needle, decreases procedure time and requires fewer needle passes than CT-guided procedures without fluoroscopic guidance. Percutaneous catheter-based, minimally invasive angiographic techniques to treat various abnormalities of the pulmonary arteries can obviate open surgery.

      Virtual bronchoscopy (VB) is a CT-based imaging technique that allows a noninvasive intraluminal evaluation of the tracheobronchial tree. VB can be helpful in pre-operative staging, but it can also be used as a follow-up imaging tool in the post-operative assessment of patients with treatment of the bronchial tree in the evaluation of stenoses. VB can also be used for evaluation of the position and permeability of stents, evaluation of the surgical suture after lung transplantation, lobectomy and pneumectomy.

    2. Page 256
      Abstract
      Correspondence: H.D. Becker, Dept. of Interdisciplinary Endoscopy, Thoraxklinik at Heidelberg University, Amalienstrasse 5, D-69126, Heidelberg, Germany. E-mail: hdb@bronchology.org

      Lung cancer still is the leading cause of cancer-related deaths. However, the number of peripheral lesions is increasing and benign peripheral lesions are also frequent.

      As diagnostic confirmation by conventional methods is insufficient for avoiding unnecessary surgery, new navigation methods are in demand.

      By electromagnetic navigation, a sensor inside a catheter can be guided along an electronic track towards the lesion and, after retraction, instruments for bioptic confirmation can be introduced. The system can also be applied for guiding needle aspiration of mediastinal lymph nodes. Electromagnetic navigation application, in connection with endobronchial ultrasound, has proved to be highly successful and opened the way for bronchoscopic treatment of peripheral lesions.

    3. Page 272
      Abstract
      Correspondence: J. Tímár, 2nd Dept of Pathology, Semmelweis University, Üllöi 93., Budapest, H-1091 Hungary. E-mail: jtimar@korb2.sote.hu

      Lung pathology experiences a paradigm shift moving from previously oversimplified two-part classification of nonsmall cell lung cancer and small cell lung cancer variants to a highly complex description of the biological variety of this tumour type. Although this heterogeneity had no clinical relevance before, this is rapidly changing due to our rapid increase of genetic and biological knowledge of the individual lung cancer sub-entities, which can be exploited clinically. However, the emerging great histological (and genomic) heterogeneity of lung cancer cannot be recognised, or even identified, in cytological smears or small biopsy specimens. This limitation of the small sample sizes or cell collections provides an exceptional challenge for surgical, immuno- and molecular pathology. It is our job to use all the available techniques at the bedside to collect as much information as possible from the specimens of the patients, providing not only diagnostic but prognostic, and more importantly, predictive (therapy-orienting) data. This chapter is aimed at clinicians, demonstrating that pathology (classic, immuno- or molecular pathology) is serving the patient and helping the oncopulmonologist.

    4. Page 297
      Abstract
      Correspondence: J. Chastre, Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié–Salpêtrière, 47, boulevard de l'Hôpital, 75651 Paris Cedex 13, France. E-mail: jean.chastre@psl.aphp.fr

      Fibreoptic bronchoscopy (FOB) not only enables direct visualisation of the endobronchial tree but also affords an opportunity to obtain distal respiratory secretions for culture and histology by various techniques, directly from the site of inflammation in the lung.

      Parodoxically, the risk of FOB is more important in nonventilated patients than in patients receiving mechanical ventilation (MV). When patients are receiving MV, FOB using bronchoalveolar lavage and/or protected specimen brush should be performed before the introduction of new antibiotics whenever it is possible, since it could improve identification of patients with bacterial pneumonia and permits safe determination of the responsible organisms.

      Although the true impact of a decision tree based on FOB on patient outcome has not yet been established, available data clearly suggest that being able to withhold antimicrobial treatment in some patients without infection may constitute a distinct advantage by minimising the emergence of resistant microorganisms in the hospital. In patients with community-acquired pneumonia, the risk of performing FOB may outweigh the benefit of determining the responsible pathogen(s) in most cases, except in deeply immunosuppressed patients.

      In no case should diagnostic testing lead to delays in the initiation of appropriate antimicrobial therapy.

    5. Page 307
      Abstract
      Correspondence: J. de Blic, Paediatric Respiratory and Allergology Unit, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France. E-mail: j.deblic@nck.aphp.fr

      Bronchoscopy has become indispensable for evaluating children with respiratory diseases. Most procedures can be performed with a flexible bronchoscope and classic fibreoptic bronchoscopes have been progressively replaced by videobronchoscopes.

      Bronchoscopy may be carried out under either conscious sedation or general anaesthesia and there are no unique protocols. Improvements in gas- and/or drug-induced anaesthesia may result in shorter bouts of deep sedation, with a quick recovery following the procedure. Desaturation represents the most frequent complications and may be related to partial or total airway obstruction by the bronchoscope and depression of respiratory drive by sedation.

      The main indication for the use of bronchoscopy is airway obstruction, even in children in paediatric or neonatal intensive care units. Except for extraction of inhaled foreign bodies, interventional bronchoscopy is less developed in children than in adults. Due to the potential risk of acute airway obstruction by granulation tissue and stent migration, selection for airway stenting should be restricted to critically ill children, in whom other options have failed or cannot be proposed. Therapeutic lung lavage is mainly used for children with pulmonary alveolar proteinosis.