Evaluation of clinical, radiological features and bronchoscopy results of pediatric patients who underwent flexible bronchoscopy for the diagnosis and treatment of atelectasi

İpek, Ö.F. Evaluation of clinical, radiological features and bronchoscopy results of pediatric patients who underwent flexible bronchoscopy for the diagnosis and treatment of atelectasis. Hacettepe University Faculty of Medicine, Thesis in Pediatrics, Ankara, 2023. Atelectasis is a term used to describe the volume loss due to the non-ventilated lung parenchyma that occurs with the collapse of the alveoli. Flexible bronchoscopy (FB) is an increasingly used method in the diagnosis and treatment of atelectasis. Studies on atelectasis in childhood are very few compared to adults in the literature. The aim of our study is to answer questions such as whether FB is an effective method for identifying the cause of atelectasis and treating atelectasis in children, when and primarily in which patient group it should be applied for benefit, and whether it is a safe method in critical patients. Between January 1, 2017, and December 31, 2022, 108 pediatric patients with atelectasis detected and FB performed for the cause and/or treatment of atelectasis at Hacettepe University Faculty of Medicine, Department of Pediatric Chest Diseases, were retrospectively evaluated. The median age of the patients was 4,6 years (9 days-16,5 years). The median age at FB was 4,9 years (14 days-18 years). The most common locations for radiological atelectasis in patients were the middle lobe of the right lung and the lower lobe of the left lung, with a rate of 40,7% each. Symptoms were detected in 95,4% of patients at admission, with dry cough being the most common symptom at 42.6% and high fever being the second most common symptom at 32,4%. The rate of admission with respiratory failure was higher in patients with a diagnosis of congenital heart disease (CHD) (62,5%). The rate of hypoxia at admission was higher in patients with a diagnosis of neuromuscular disease (62,5%). Pathological respiratory system examination findings were present in 74,1% of patients with atelectasis at the time of admission, with rales being the most common at 39,8%. 62% of patients had an underlying disease when atelectasis was detected; asthma and CHD were the most common diseases detected at 14,8% each. The rate of atelectasis in the middle lobe of the right lung was higher in those diagnosed with asthma and followed up with recurrent lung infections (75% and 71,4%, respectively). The rate of left total atelectasis was higher in patients with CHD (25%). Oxygen saturation when atelectasis resolved was significantly higher than when atelectasis was detected (96,93%). The time from detection of atelectasis to performing FB ranged from 1-2000 days, with a median of 55 days. At least one pathological finding was observed macroscopically in FB in 95,4% of the patients; infection was observed most frequently with a rate of 72,2%. In FB, 23,1% of the patients had bronchomalacia, 23,1% had airway anomaly, 16,7% had tracheomalacia, 15,7% had mucus plug, and 3,7% had a foreign body. The incidence of bronchomalacia (62,5%), tracheomalacia (37,5%) and airway anomaly (56,3%) in FB was higher in patients with a diagnosis of CHD than those without a diagnosis of CHD. A growth rate of 71,4% was observed in the bronchoalveolar lavage (BAL) culture sent from 105 patients. The most frequently grown microorganism was Haemophilus influenzae at a rate of 21,9%. The growth rate of Pseudomonas aeruginosa (25%) in BAL was higher in patients diagnosed with CHD, while the growth rate of Haemophilus influenzae (62,5%) and Moraxella catarrhalis (37,5%) in BAL in patients diagnosed with primary ciliary dyskinesia (PCD) was higher. A new diagnosis was added to 86,1% of the patients with FB findings, the most common of these was the diagnosis of infection with a rate of 61,1%. With FB, 22,2% of the patients were diagnosed with bronchomalacia, 14,8% with tracheomalacia, 10,2% with airway anomaly, 3,7% with foreign body aspiration (FBA), and 1,8% with bronchial "cast" diagnoses. Additional treatments were given to 83,3% of patients after FB. The most frequently recommended treatment was chest physiotherapy with a rate of 56,5%. 32,4% of the patients were given iv antibiotics, 23,1% oral antibiotics, 13% antireflux treatment, 2,8% inhaled ipratropium bromide. Tracheostomy was performed in 5,6% of patients after FB. Atelectasis of all patients who underwent tracheostomy completely resolved after a median of 16,5 days in the follow-up. In the control chest X-rays taken on the same day after FB, complete expansion was observed in 12% of patients (n=13), partial expansion in 26,9% (n=29), and no expansion in 61,1% (n=66). In the follow-up, complete expansion was observed in 36,5% of patients, partial expansion in 24,7%, and no expansion in 38,8%. Full expansion occurred after a median of 90 (2-2430) days, while partial expansion occurred after a median of 165 (10-1440) days. In the final control examination, 40,8% of all patients had fully recovered from atelectasis, 27,8% had partially recovered, and 31,4% showed no improvement. The time from atelectasis diagnosis to FB was shorter (122,92 days) in patients with partial or complete expansion than in those without any improvement. In those without expansion in the final control examination, the time from atelectasis diagnosis to FB was longer (243,24 days). The rate of complete expansion was higher (48,8%) in those without any additional pathological findings on chest X-rays or CT scans when atelectasis was detected. In those without infection findings and scoliosis accompanying atelectasis radiologically, the rate of complete expansion was higher (49,3% and 43,9%, respectively) in the final control examination. The rate of complete expansion was higher in patients diagnosed with CHD during follow-up and in the final control examination (69,2% and 75%, respectively). The rate of no expansion during follow-up was higher in patients diagnosed with immune deficiency (62,5%), and the rate of no expansion in the final control examination was higher in patients diagnosed with PCD (75%). The rate of complete expansion was lower (6,4%) in those with infection findings on FB. In patients who received iv antibiotics after FB, those who underwent tracheostomy after FB, and those who received intrabronchial dornase alfa during FB, the time to full expansion of atelectasis during follow-up was significantly shorter. Atelectasis recurred in 10 patients (9,3%) during follow-up, with a median time to recurrence of 49 (1-720) days. Six (5.6%) patients whose atelectasis did not improve on the same day and during follow-up after FB required repeat bronchoscopy. None of the patients with atelectasis in the right middle lobe had recurrence of atelectasis. Patients who had recurrence of atelectasis during follow-up were significantly younger. When independent variables were examined individually for the status of atelectasis expansion at any time, it was found that atelectasis was less likely to expand in patients with PCD diagnosis. Complications (hypoxia in three patients and bleeding in one patient) occurred in four patients (3.7%) during FB. FB can be safely applied in many units, including neonatal and pediatric intensive care units, for the diagnosis and treatment of various lung diseases, with underlying different diagnoses, starting from the neonatal period. Atelectasis is one of the main indications for FB. FB is highly functional in illuminating the etiology and treatment of atelectasis. FB has a very high functionality in the elucidation and treatment of the etiology of atelectasis. It is a very useful method in the diagnosis and treatment of atelectasis in cases that do not improve with appropriate chest physiotherapy, antibiotics and mucolytic treatments. FB should be performed as soon as possible in patients with atelectasis who do not respond to medical treatments and chest physiotherapy within two to three weeks. Keywords: Atelectasis, flexible bronchoscopy, etiology of atelectasis, expansion of atelectasis, flexible bronchoscopy time in atelectasis, pediatric chest diseases