Flexible airway endoscopy (FAE) is well accepted and widely used to manage children with known or suspected airway and lung disorders. “FAE is a powerful diagnostic tool that allows for direct visualization of the airway,” says Albert Faro, MD. “Dynamic airway problems can be evaluated, as can various congenital anomalies in the anatomy of the airway.”, FAE is also ideal for obtaining cultures from the lower airways to identify organisms that may be playing a role in a child’s decompensation so that these issues can be specifically addressed.

For children with certain airway and lung disorders, FAE can be used to provide therapy. For example, the mainstay of therapy for children with alveolar proteinosis is often repeated bronchoalveolar lavage (BAL), explains Dr. Faro. “FAE can also be used to intubate children with difficult airways or to remove mucus plugs in those with atelectasis that is not improving and remains problematic or in plastic bronchitis,” he adds.

Questions on Pediatric Flexible Airway Endoscopy

Despite numerous uses (Table 1), nearly 2 decades have passed since technical standards were published on the performance of pediatric FAE. “The way FAE is performed and the instrumentation that’s available have changed over time,” Dr. Faro says. The American Thoracic Society convened an international, multidisciplinary committee to develop technical standards for the performance of pediatric FAE and develop its official statement on flexible endoscopy of the pediatric airway. The standards were published in the American Journal of Respiratory and Critical Care Medicine.

Pediatric Sedation During Flexible Airway Endoscopy

“One of the major goals of the standards was to address the use of sedation during FAE,” explains Dr. Faro, lead author of the document. “The level of sedation determines the quality of the FAE. When the last standards were published, pediatric pulmonologists provided their own sedation.”

Over the last 20 years, for the benefit of patients, anesthesiologists have become more involved with FAE, Dr. Faro says. “It has become fairly ubiquitous for anesthesiologists to use the laryngeal mask airway for FAEs, but this can distort the picture of the upper airway. Ideally, to see airway dynamics and assess the entire airway, FAE for airway evaluation should be performed on a spontaneously breathing patient through a natural airway. If FAE is used to sample the airway, perform BAL, or conduct a biopsy, the patient can then be provided with the airway that’s necessary to safely complete the procedure.”

Overall, the goals of sedation for FAE should provide patient comfort, maintain hemodynamic stability, maintain adequate gas exchange, and provide satisfactory conditions for therapeutic or diagnostic FAE, according to the standards. Collaboration between endoscopists and anesthesiologists is essential to optimizing anesthetic depth, airway management, and accurate diagnosis.

Airway Entry Techniques: Endotracheal Tube

The various airway entry techniques all have advantages and disadvantages, explains Dr. Faro (Table 2). “For example,” he says, “while a natural airway allows physicians to truly inspect the entire airway and assess airway dynamics, it is more difficult to monitor the patient’s gas exchange than with other approaches. An endotracheal tube allows for simple, fast access to the lower airway and provides a secure airway should the patient not tolerate the procedure. However, it doesn’t allow physicians to assess the upper airway, vocal cord motion, or airway dynamics.”

Bronchoscopic Training & Future Needs

The standards committee initiated a discussion regarding how to measure competency in bronchoscopic skills. “Traditionally, 50 procedures has been considered the minimum number of FAEs to perform in order to be considered able to perform the procedure alone,” explains Dr. Faro. “Clearly, that’s an inadequate way to assess competency.” The standards now recommend that a core set of demonstrable competencies be defined, including subsequent monitoring and documentation of trainee progress.

In developing the standards, Dr. Faro and colleagues performed a comprehensive literature search to better understand where gaps exist in knowledge and the types of studies that are needed to close these gaps. For example, the committee determined that further investigation is needed for optimizing the performance of BAL because few analyses have systematically studied it. The interpretation of certain markers found in BAL fluid also remains uncertain and requires future inquiry.

“The standards point out where there isn’t any evidence to support one approach over another,” says Dr. Faro. “It’s vital that we conduct more studies, specifically in children, so we can serve this patient population better.”

The technical standards are limited by a lack of controlled studies in the field. However, it is the hope of the writing committee that the current document provides a framework for how to perform pediatric FAE and stimulates further discussion, development, and research in the field.


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Midulla F, de Blic J, Barbato A, et al. Flexible endoscopy of paediatric airways. Eur Respir J. 2003;22:698-708.

Leong A, Green C, Kurland G, Wood R. A survey of training in pediatric flexible bronchoscopy. Pediatr Pulmonol. 2014;49:605-610.