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ATS Technical Standards: Flexible Airway Endoscopy in Children AMERICAN THORACIC SOCIETY DOCUMENTS Official American Thoracic Society Technical Standards: Flexible Airway Endoscopy in Children Albert Faro, Robert E. Wood, Michael S. Schechter, Albin B. Leong, Eric Wittkugel, Kathy Abode, James F. Chmiel, Cori Daines, Stephanie Davis, Ernst Eber, Charles Huddleston, Todd Kilbaugh, Geoffrey Kurland, Fabio Midulla, David Molter, Gregory S. Montgomery, George Retsch-Bogart, Michael J. Rutter, Gary Visner, Stephen A. Walczak, Thomas W. Ferkol, and Peter H. Michelson; on behalf of the American Thoracic Society Ad Hoc Committee on Flexible Airway Endoscopy in Children THESE OFFICIAL TECHNICAL STANDARDS OF THE AMERICAN THORACIC SOCIETY (ATS) WERE APPROVED BY THE ATS BOARD OF DIRECTORS,JANUARY 2015 Background: Flexible airway endoscopy (FAE) is an accepted and Results: There is a paucity of randomized controlled trials in frequently performed procedure in the evaluation of children with pediatric FAE. The committee developed recommendations based known or suspected airway and lung parenchymal disorders. predominantly on the collective clinical experience of our committee However, published technical standards on how to perform FAE in members highlighting the importance of FAE-specific airway children are lacking. management techniques and anesthesia, establishing suggested competencies for the bronchoscopist in training, and defining areas Methods: The American Thoracic Society (ATS) approved the deserving further investigation. formation of a multidisciplinary committee to delineate technical standards for performing FAE in children. The committee completed Conclusions: These ATS-sponsored technical standards describe a pragmatic synthesis of the evidence and used the evidence synthesis the equipment, personnel, competencies, and special procedures to answer clinically relevant questions. associated with FAE in children. Contents Processing Endoscopy of the Pediatric Airway, the ATS Overview Diagnostic Utility of BAL sponsored the development of technical Conclusions Infection standards for the performance of pediatric Methods BAL in CF flexible airway endoscopy (FAE). To complete Equipment and Procedural Setting BAL in the Diagnosis of this effort, an international, multidisciplinary Infection Control Pulmonary Aspiration committee comprehensively reviewed the Training BAL in Other Disorders literature and developed this report, including Common Reasons for Specialized Procedures an online supplement in which we describe Performing Flexible Airway Atelectasis select topics in more detail. Endoscopy Documentation Conclusions and Future Directions Preprocedure Evaluation Conclusions Sedation and Monitoring Airway Management and d Equipment and setting Examination B The number and type of The Role of the Rigid Overview bronchoscopes required at any Bronchoscope individual institution is determined by BAL To update the American Thoracic Society each institution’s understanding of the Performance (ATS) Official Statement on Flexible anticipated number of procedures. These technical standards were endorsed by the American Academy of Pediatrics, February 2015. Correspondence and requests for reprints should be addressed to Albert Faro, M.D., Washington University in St. Louis, Campus Box 8116, St. Louis, MO 63110. E-mail: [email protected] This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org Am J Respir Crit Care Med Vol 191, Iss 9, pp 1066–1080, May 1, 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1164/rccm.201503-0474ST Internet address: www.atsjournals.org 1066 American Journal of Respiratory and Critical Care Medicine Volume 191 Number 9 | May 1 2015 AMERICAN THORACIC SOCIETY DOCUMENTS This is based on the characteristics of B All care providers involved in the d Specialized procedures its patient population and typical procedure should review and agree B Bronchoscopic intubation, biopsies, indications for FAE. In addition, this upon the procedural plan, the airway dilatation, airway stenting, number should reflect the facility’s equipment needed, and the and removal of plugs and clots can ability to clean and disinfect the appropriate infection control all be performed via FAE in equipment in a timely fashion. measures required before the children in the appropriate setting B The appropriate setting for FAE is procedure. This may be best and for the appropriate indication. determined by the patient’s clinical accomplished in a formalized “Time Flexible airway endoscopy (FAE) in young condition, facilitates patient safety, Out” process, where individual children was first described in 1978 (1), allows completion of necessary patient information is also reviewed. and the technique is now widely used procedures, and provides adequate B Informed consent procedures in the assessment and treatment of space to accommodate equipment should be followed and infants and children with a variety of and all necessary personnel. appropriately documented in the pediatric respiratory disease. The flexible d Infection control medical record in accordance with bronchoscope allows for functional and B The minimal acceptable standard for local and/or national guidelines. anatomical examination of the upper and reprocessing a flexible bronchoscope is d Sedation and airway management lower airways. FAE and specialized meticulous manual cleaning followed B The goals of sedation for FAE depend procedures, including bronchoalveolar by high-level disinfection. on clinical considerations and should lavage (BAL), are particularly important in B Established guidelines and (1) provide patient comfort, (2) the diagnosis and treatment of specific manufacturer’s recommendations for maintain hemodynamic stability, (3) respiratory problems, including congenital inspection, maintenance, storage, maintain adequate gas exchange, and or acquired airway anomalies, persistent cleaning, and manual or automated (4) provide satisfactory conditions for or recurrent pulmonary infiltrates, reprocessing of flexible bronchoscopes therapeutic or diagnostic FAE. community-acquired or ventilator- should be strictly followed. B Collaboration between the endoscopist associated pneumonia, pulmonary B Personnel responsible for reprocessing and the anesthesia or sedation infections in immunocompromised hosts, the flexible bronchoscope should provider is essential to optimize the and pulmonary hemorrhage. receive appropriate training, including interplay between anesthetic depth, The current American Thoracic Society initial and annual competency testing. airway management, and accurate (ATS) guidelines for FAE in children were B Personal protective equipment diagnosis by FAE. published over 20 years ago (2), and should be used during the d Airway examination advances in care have rendered these procedure, when handling used B Proximal airway anatomy and airway guidelines insufficient. The field has flexible bronchoscopes, and dynamics cannot always be witnessed expansion in the number and types throughout the cleaning and accurately evaluated when FAE is of procedures performed, and technological disinfection process. performed via a laryngeal mask evolution in available instruments, increased B Institutional protocols should airway or via an endotracheal use of general anesthesia with concomitant include the maintenance of a tube. Nasal passage of the flexible changes in airway management, and growth procedure log as well as a means endoscope is preferred when in associated applications of FAE have for identifying appropriately upper airway dynamics are to be enhanced the diagnostic and therapeutic disinfected bronchoscopes. evaluated. capability of the procedure. d Training B Rigid bronchoscopy serves B Definition of a core set of a complementary role with FAE and, demonstrable competencies is depending on the indication, may also Methods recommended including need to be performed to adequately subsequent monitoring and assess the pediatric airway. The ATS Pediatric Planning Committee documentation of trainee progress. d Bronchoalveolar lavage appointed a chair and formed a committee d Situations where FAE is commonly B Bronchoalveolar lavage (BAL) of international experts comprising multiple performed is an essential technique to disciplines to write technical standards. B The primary reason for performing identify microbiologic or cellular Potential conflicts of interest of our FAEiswhen,basedontheavailable abnormalities of the airway that committee members were disclosed, vetted, clinical data, the need for information may establish a diagnosis and guide and strictly managed according to the from or intervention within the lungs appropriate therapies. policies of the ATS. The committee was or airways is most safely, effectively, B The optimal manner of performing charged with reviewing the existing and easily achieved by FAE. BAL has not been systematically literature on pediatric FAE and presenting d Preprocedure evaluation studied and requires further recommendations for technology B A standardized preprocedural investigation. standardization or elucidating areas in need evaluation should include B The interpretation of certain of further study. An ATS Technical recognition of preexisting markers found in BAL fluid Standards is a document that describes how conditions that may affect the remains uncertain and is an area to perform a procedure. It is not intended to outcome of FAE. for future inquiry. be a systematic review of the literature. American Thoracic Society Documents
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