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 Table of Contents  
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 81-87

Diagnosis of children with persistent and atypical noisy breathing by using flexible bronchoscopy

1 Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
2 Department of Pediatrics, Faculty of Medicine, Sohage University, Sohage, Egypt

Date of Submission28-Mar-2020
Date of Decision10-Apr-2020
Date of Acceptance15-Apr-2020
Date of Web Publication5-Oct-2020

Correspondence Address:
MD Mai N.A Abonewair
Study Design, Data Analysis, Manuscript Writing and Preparation, Specialist in Pediatrics Department, Faculty of Medicine, Assiut University, Assiut, Code of City: 088
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AJOP.AJOP_22_20

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Background Noisy breathing is a very common complaint among children. It may carry a risk for life-threatening problems. Flexible bronchoscopy (FB) has become one of the most widely used diagnostic tools used by pediatric pulmonologists. Several forces are needed to be explored to help refine its use and reduce its complications.
Aim The paper aimed to evaluate the use of pediatric bronchoscopy as a safe diagnostic tool for persistent and/or atypical noisy breathing children, the possible complications, and how it helps to change the management.
Patients and methods A total of 100 children, aged from 1 month to 16 years, with persistent and/or noisy breathing were included in a prospective study using FB (May 2016 to May 2019) at a Tertiary Care Medical Center (Sohag University Hospital). The authors evaluated how bronchoscopy contributed to the patients’ diagnosis, what were the complications and limits in the center, and how the authors could deal with them.
Results Overall, 37% of patients had malacia disorders, 22% had airway inflammation, 20% had foreign body aspiration, 6% vocal cord dysfunction, 6% subglottic stenosis, 4% tracheal stenosis, 1% subglottic hemangioma, and in three cases, no abnormalities could be detected. Minor complications occurred in 20% of cases; the most common was desaturation (10%), followed by exaggerated cough reflex, laryngeal spasm, and bronchospasm.
Conclusion FB provided rapid and definitive diagnosis (confirming, ruling out, and discovering unexpected diagnosis) for the patients. It is a safe procedure and should be considered in the evaluation of children with persistent or atypical noisy breathing.

Keywords: complications, flexible bronchoscopy, noisy breathing, pediatric

How to cite this article:
Abonewair MN, Ali FA, Ahmed MM, Mohamed MA. Diagnosis of children with persistent and atypical noisy breathing by using flexible bronchoscopy. Alex J Pediatr 2020;33:81-7

How to cite this URL:
Abonewair MN, Ali FA, Ahmed MM, Mohamed MA. Diagnosis of children with persistent and atypical noisy breathing by using flexible bronchoscopy. Alex J Pediatr [serial online] 2020 [cited 2021 Feb 25];33:81-7. Available from: http://www.ajp.eg.net/text.asp?2020/33/2/81/297243

  Introduction Top

Noisy breathing in infants and children is a common clinical sign and symptom, indicating some degree of airway obstruction [1]. It is a loose term, which includes stridor, wheezing, and other ‘abnormal’ breathing sounds such as grunting, snuffling, rattling, and snoring [2].

Flexible bronchoscopy (FB) is an important diagnostic tool in respiratory tract diseases. It allows direct airway visualization, assessment of dynamics, endobronchial treatment of lesions, and sample collection for examination [3].

Bronchoscopy is an invasive procedure that requires anesthesia in children and carries some risk of complications [4]. Several gaps are still present, especially how to improve diagnostic capabilities and minimize complications [5].

  Aim Top

This study aimed to evaluate children presenting with persistent (children with continuous wheezing for at least 1 month or minimum three episodes of wheezing in 2 months are defined as persistent wheezy children [6],[7]) and/or atypical noisy breathing for accurate diagnosis and effective management using FB. We also justified the possible complications and methods of management.

  Patients and methods Top


Ethical approval for this study was provided by the Medical Ethics Committee, Faculty of Medicine, Assiut University, Assiut, Egypt (9/5/2016). The study started in May 2016 and was completed in May 2019. A written informed consent was obtained from the parent or guardian as an authorized representative after explaining the procedure before participation in the study.


This is a prospective study conducted on 100 children presented with persistent (> 4 weeks) and/or atypical noisy breathing (aged from 1 month to 16 years), from May 2016 to May 2019 and performed in the Bronchoscopic Unit, Sohag University Hospital, Egypt. Patients known to have bronchial asthma, clear history of foreign body aspiration (FBA), cystic fibrosis, or any disease that may explain the cause of noisy breathing were excluded.

Patients fasted for 4 h of fluids and 6 h of food before the procedure. They were monitored by ECG, pulse-oxymeter, and noninvasive blood pressure devices and oxygenated by nasal cannula to keep O2 saturation above 95%. Full cardiorespiratory monitoring was implemented throughout the procedure.

The procedures were conducted under sedation using midazolam and propofol. Topical anesthetics were achieved by spraying lidocaine (2%) solution directly over the vocal cords and aryepiglottic folds. Normal saline was used in bronchoalveolar lavage (BAL) and hypertonic saline to re-canalize collapsed airways. BAL fluids were transported to the laboratory in isolated bags containing ice. At the end of the procedure, the patient was awakened while still fully monitored in postoperative care until he/she became fully conscious and tolerated oral feeding.

All procedures were performed using a standard flexible video bronchoscope (Olympus Corp, Tokyo, Japan), using a channel with external outer diameter of 3.8 and 2.8 mm, which is the smallest size with a suction channel. No biopsies were taken during any of the procedures.

Efficacy of evaluation parameters

  1. The primary efficacy outcome was the accurate diagnosis of persistent and/or atypical noisy breathing in children (e.g. symptoms from the first day of life; a child with wheezing who is not thriving; chronic wet cough; sudden onset of symptoms; continuous, unremitting symptoms; systemic illness; digital clubbing; severe chest deformity; stridor; fixed wheeze; or asymmetric signs on auscultation).
  2. Secondary outcomes were possible complications and how to deal with them;management changes based on bronchoscopic diagnosis, either medical, surgical, or other changes; and identification of significant differences between different common causes of noisy breathing.

Statistical analysis

Power of the study

Our primary end point was accurate diagnosis of persistent and/or atypical noisy breathing children. Secondary outcomes were possible complications and methods of management, significant difference between common causes of persistent and/or atypical noisy breathing in children and patients’ management changes based on bronchoscopic diagnosis either medical, surgical, or other therapy and further assessment needed. Based on previous studies [7],[8],[9], a target sample size was calculated. A power analysis estimated that a sample size of 80 patients would have an 80% power and at 0.05 level of significance to detect a significant difference between common causes of persistent and/or atypical noisy breathing in children, so we select 100 cases to overcome any dropout during the study.

Statistical tests

Data were collected and analyzed using SPSS (Statistical Package for the Social Sciences, version 20; IBM, Armonk, New York, USA). Continuous data were expressed in the form of mean±SD or median (range), whereas nominal data were expressed in the form of frequency (percentage).

χ2-test was used to compare the nominal data of different groups in the study, whereas Mann–Whitney and Kruskal–Wallis tests were used in case of notnormally distributed data. Level of confidence was kept at 95%, hence, P value was significant if less than 0.05.

  Results Top

Patients’ characteristics

Among 100 children with noisy breathing evaluated by FB, 67% were males. Median age was 16 months (1–84 months). The demographic data and clinical presentations of the studied patients are summarized in [Table 1]. The most common presentation of the patients was persistent wheezes (52%), followed by stridor (33%) and mixed noise (15%).
Table 1 Patients’ demographic data and clinical presentations

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Most of the patients received trials of medical treatments before they came to the hospital ([Figure 1]).
Figure 1 Frequency of medications used by studied children before bronchoscopic examination.

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[Figure 2] shows the frequency of airway findings in 100 cases.
Figure 2 Frequency of airway findings.

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[Figure 3] shows complications of the procedure with a small total number of complicated cases (20%). There were no deaths or events that prevented the completion of the procedures. All patients had a smooth postoperative course with no documented complications postoperatively.
Figure 3 Complications of the bronchoscopic examination in the studied groups.

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[Table 2] summarizes the overall bronchoscopic diagnoses in all cases.
Table 2 Final diagnosis in the studied cases of persistent noisy breathing.

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[Table 3] compares between different subgroups of the final diagnosis.
Table 3 Comparison between different subgroups of final diagnosis of noisy breathing

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[Table 4] summarizes the changes in management based on bronchoscopic diagnosis.
Table 4 Management changes based on bronchoscopic diagnosis

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  Discussion Top

The results of the current study reported a high percentage of anatomic and inflammatory findings detected by FB in children with persistent or atypical noisy breathing sounds. These findings are in concordance with previous studies of Boesch et al. [10] and Saglani et al. [11].

The main presenting noisy breathing indication in the present work was wheezes (52%), followed by stridor (33%) and mixed noisy breathing (15%). El-Assal et al. [7] and Priftis et al. [12] reported similar findings, where persistent wheeze was the main indication of bronchoscopy followed by stridor. Wood et al. [13] had reported that stridor was the main indication for bronchoscopy followed by persistent wheezes. These findings could be explained by the fact that the studied cases were of the younger age group and hence the diagnosis of stridor was more common.

Anatomical respiratory tract anomalies such as malacia are considered one of the common reasons of persistent noisy breathing. It results in airway collapse, causing barking cough, stridor, recurrent/persistent wheezes, and infections. In the present study, malacia disorders were detected in 37% of the cases, and laryngomalacia was the most common cause 18%. These results were parallel with Cakir et al. [8] who reported that 34% of cases with persistent wheezes had malacia disorders. Moreover, Pfleger and Eber [14] reported the same findings in their study.

Patients with undiagnosed neglected FBA may present with persistent wheezes [15]. Typical history of FBA may be absent, and hence, diagnosis may not be so readily apparent. FB seems to be the best diagnostic procedure for these patients [16]. Overall, 20% of the patients of the current study were diagnosed to have neglected FBA, and none of them had a suggestive history. This is in agreement with Cakir et al. [8], who found 14 cases of FBA of 113 patients with persistent wheezing without a positive history of FBA. Moreover, Naragund et al. [17] reported that 63.6% of their patients were diagnosed as having neglected FBA together with negative history of FBA. This is explained by the fact that children in a vulnerable age group (most of our patients <3 years age) are ambulatory and may be out of parental observation during the acute aspiration episode. Moreover, the occurrence of FBA may be followed by a symptom-free period, which leads to misdiagnosis, and the FBA remains unnoticed, especially when chest radiograph findings are normal [18].

The most common site for FBA in the current study was right main bronchus, which is in agreement with the results of Saki et al. [19], Baram et al. [20], and Hamed et al. [21]. This could be explained by the position of the left bronchus, which is attached to the trachea, with a more acute angle than the right one and that the right bronchus had a wider diameter in comparison with the left one [22].

Macroscopic picture concomitant with mucosal airway inflammation (redness and erythema) was detected in 22% of the patients. In parallel with these findings, El-Assale et al. [7] reported that 30% of their cases had inflamed mucosa of major airways, and Wood et al. [13] reported that the second most common finding of bronchoscope was inflammation of the airway.

In the current study, BAL was performed in 16% of children; 43.73% had no growth of organisms, 25% had Staphylococcus, 25% had Klebsiella, and 6.25% had  Escherichia More Details coli.

It was found that 82% of the studied cases received antibiotics and steroids for variable duration before the final diagnosis by bronchoscope. This situation represents an extreme abuse of drugs without referral to basic guidelines. We should engorge our ability to identify alternative explanations and definite diagnosis for wheezing/stridor to reduce the misuse of medical therapies [13]. Modification of medical and surgical management was clearly based on bronchoscopy findings and BAL results ([Table 4]).Bronchoscopy, like all invasive procedures, carries a risk of complications either from the anesthetic medications, inserted bronchoscope, and extensive lavage. In the present study, 20% of cases developed minor complications, with no life-threatening events. The most common procedure complications in our study were desaturation with incidence 10%, followed by exaggerated cough reflex in 5%, Laryngeal spasm in 3% and Bronchospasm in 2% of cases ([Figure 3]). These findings match with the reported complications cited by different studies [11],[22].


  1. All pediatricians should be aware of the indications and utilities of flexible fiberoptic bronchoscopy (FFB) in pediatric patients.
  2. Patients with persistent wheezes should be reevaluated thoroughly and investigated using a bronchoscope as a diagnostic tool.
  3. We should highlight the need for a high index of suspicion for FBA as this entity can mimic various pathologies and a negative radiograph does not rule out the diagnosis of FBA.
  4. In cases where a diagnosis of FBA is not certain, FFB should be the diagnostic modality of choice.
  5. Proper preoperative preparation and monitoring during and after FFB should be followed to minimize complications


The authors are grateful to the colleagues and staff of the Pediatrics Bronchoscopy Unit at Sohag Univesty Hospital for their co-operation in data collection.

The research was supported by Assiut Faculty of Medicine.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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