The medical records of neonates who underwent FFB in the NICU of a tertiary care multispecialty hospital from January 2011 to June 2017 were reviewed. The data extracted from records included age, gender, gestation, birth weight, feeding problems, size and type of endotracheal tube, duration of mechanical ventilation and comorbid conditions like congenital heart disease, and post-operative status. Also data related to the indications of bronchoscopy, radiological findings, bronchoscopic findings, bronchoalveolar lavage (BAL) yield, and complications during the procedure were noted. We also noted the results of interventions (medical or surgical) done by the neonatologists post-bronchoscopy.

Bronchovideoscope (Olympus BF-XP160F) of size 2.8 mm with 1.2 mm working channel and ultrathin bronchoscope (Olympus BF-N20) of 2.2 mm outer diameter with no working channel were used. An informed consent was taken from the guardians prior to the procedure. The bronchoscopy team included pediatric pulmonologist, a fellow trained in assisting broncho-scopy and resuscitation, experienced nurse and a technician. Oxymetazoline (0.025%) nasal drop was instilled in both nostrils before the procedure. Bronchoscopy was done transnasally or through endotracheal tube or laryngeal mask airway. Oxygen by simple mask was delivered continuously during transnasal bronchoscopy. All subjects were monitored using multi-parameter monitor for oxygen saturation and arrhythmia.

The anatomy and dynamics of laryngeal structures including arytenoids, epiglottis and vocal cords were studied. During the procedure, 1% lidocaine was instilled by "Spray and proceed technique" through the working channel. After negotiating the vocal cord, the subglottis and trachea and bronchi were evaluated anatomically and functionally. All along the lower airways, the bronchial mucosa and the airway pattern were studied. All procedures were recorded and stored electronically. The need for FFB was at the discretion of treating neonatologist.

During the study period, 83 neonates underwent bronchoscopy. The characteristics of the study subjects are described in Table I. Congenital heart disease was present in 18 cases. The indications of FFB included unresolved atelectasis (25), consolidation or persistent pulmonary infiltrates (21) and hyperinflation (6) on chest X-ray. Three of the children had persistent oxygen dependency and one child had stridor.

TABLE I	Characteristics of the Neonates (N=83) who Underwent Fiberoptic Flexible Bronchoscopy

There were 88 bronchoscopic procedures in the 83 participants. In 77 of the procedures, an abnormality was detected. The abnormalities detected included tracheobronchitis (23), tracheobranchomalacia (18), laryngomalacia (17), laryngeal cleft (4) and subglottic stenosis (7). Tracheoesophageal fistula (2), abnormal tracheal rings (2) and extrinsic compression of airway (1). Eight children had multiple findings.

Bronchoalveolar lavage (BAL) was taken during 52 procedures. Indications for taking BAL were lung collapse (21), extubation failure (4), consolidation or pulmonary infiltrates (21), suspected aspiration (5), and airway bleed (1). Microbiological yield was obtained in 16 (30.7%) BAL cultures. Multiple organisms were grown in three specimens. Organisms isolated were Acinetobacter baumannii (7), Pseudomonas aeroginosa (5), E. coli (3), Klebsiella pneumoniae (2) and Enterocccus spp. (1). Candida species were isolated in four BAL samples.

There was complete or partial resolution in 20 out of 25 cases of atelectasis within 24 hours of FFB. Table II lists the other medical and surgical interventions consequent to FFB. Radiological improvement was seen in 38 (43.1%) neonates after bronchoscopy or after interventions guided by bronchoscopic findings.

TABLE II	Treatment Interventions After Fiberoptic Flexible Bronchoscopy Procedure

This study reports our experience of using flexible fibreoptic bronchoscopy in neonates over the past 7 years. The indications for FFB procedure in our series were comparable to other studies [3,4]. Midulla, et al. [5] also noted that airway malacias were the most significant causes of persistent unexplained respiratory distress in the neonate. Our findings of laryngomalacia being the most common etiology for stridor on FFB was similar to a previous report [6]. Raine, et al. [7] reported a diagnostic yield of 86% with FFB; a finding similar to the 87.5% noted in the present study. In contrast, Kabra, et al. [8] in a recent audit in children in India reported a diagnostic yield of 34%, but that study included children of all ages.

Bronchoalveolar lavage sample analysis can be particularly useful in directing treatment. The microbiological yield of 30.7% in the present study is lower than that reported by Terkawi, et al. [9] but higher than that reported by Yuan, et al. [10]. The differences noted can be due to antibiotic therapy, contamination or dilution of samples.

Our experience suggests that the procedure is very safe in experienced hands, as also noted in other studies [11,12]. FFB is a safe and useful procedure in the neonatal ICU that can help neonatologists to diagnose and manage persistent or unexplained respiratory problems in neonates.

Contributors: All authors contributed to data collection and manuscript writing. All authors approved the final version of manuscript and agree to be accountable for authenticity and integrity of the work.

Funding: None; Competing interest: None stated.

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