Bronchoscopic procedures and lung biopsies in pediatric lung transplant recipients

Abstract

Bronchoscopy remains a pivotal diagnostic and therapeutic intervention in pediatric patients undergoing lung transplantation (LTx). Whether performed as part of a surveillance protocol or if clinically indicated, fibre-optic bronchoscopy allows direct visualization of the transplanted allograft, and in particular, an assessment of the patency of the bronchial anastomosis (or tracheal anastomosis following heart-lung transplantation). Additionally, bronchoscopy facilitates differentiation of infective processes from rejection episodes through collection and subsequent assessment of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) samples. Indeed, the diagnostic criteria for the grading of acute cellular rejection is dependent upon the histopathological assessment of biopsy samples collected at the time of bronchoscopy. Typically, performed in an out-patient setting, bronchoscopy is generally a safe procedure, although complications related to hemorrhage and pneumothorax are occasionally seen. Airway complications, including stenosis, malacia, and dehiscence are diagnosed at bronchoscopy, and subsequent management including balloon dilatation, laser therapy and stent insertion can also be performed bronchoscopically. Finally, bronchoscopy has been and continues to be an important research tool allowing a better understanding of the immuno-biology of the lung allograft through the collection and analysis of collected BAL and TBBx samples. Whilst new investigational tools continue to evolve, the simple visualization and collection of samples within the lung allograft by bronchoscopy remains the gold standard in the evaluation of the lung allograft. This review describes the use and experience of bronchoscopy following lung transplantation in the pediatric setting.

International Society for Heart and Lung Transplantation consensus statement for the standardization of bronchoalveolar lavage in lung transplantation

“…Previous research determined manual suctioning during bronchoscopy was associated with a higher percentage of BAL volume return and increased odds of performing technically acceptable procedures in children. 122 Consistent with this research and other reports, 119 the survey identified that pediatric LTx centers performing bronchoscopy with BAL in children after LTx use manual suctioning with a syringe (5 of 8 centers).…”

“…With evidence that children often have silent allograft rejection or subclinical infection, especially during the first year after LTx, 11 routine surveillance bronchoscopy is widely used according to published reports in pediatric LTx recipients. 119 Of the 8 pediatric LTx centers surveyed, 100% of centers reported performing surveillance bronchoscopies with BAL. In addition, diagnostic bronchoscopy is universally performed when clinical evidence suggests a deterioration in allograft health from infection, AR, AMR, or CLAD.…”

“…In addition, diagnostic bronchoscopy is universally performed when clinical evidence suggests a deterioration in allograft health from infection, AR, AMR, or CLAD. At a few select transplant programs where infants undergo LTx, surveillance and diagnostic bronchoscopy are performed even in the youngest post-LTx patient population, 119 , 120 so there are no age or size limitations.…”

ERS statement: interventional bronchoscopy in children

“…[38,39]. The technique has been described previously [4,39]. One study reported that 25% of TBBs performed in lung transplant recipients were undertaken for surveillance, 38% for follow-up of acute rejection and 37% for respiratory symptoms [40].…”

Pediatric pulmonology year in review 2015: Part 3

“…Wong et al described the utility of bronchoscopic procedures in pediatric lung transplant recipients, stating that the simple visualization and collection of samples remains the gold standard in post‐transplant evaluation of the allograft. This paper reviewed many practical aspects of the different procedures (including anesthesia, pre‐bronchoscopy preparation, BAL, transbronchial biopsy, balloon dilatation, and stent placement), as well as possible complications.…”