Flexible bronchoscopy in neonates with congenital diaphragmatic hernia

Background: Flexible bronchoscopy (FB) is increasingly utilized in the critically ill pediatric population. In infants with complex diseases, such as congenital diaphragmatic hernia (CDH) and extracorporeal membrane oxygenation (ECMO), FB may be beneficial through diagnosing airway anomalies and removal of mucous plugs, facilitating ECMO or ventilator weaning. Few studies on FB in critically ill neonates exist, and even fewer focus on neonates with CDH and ECMO.

Objective: This study aims to evaluate the safety, diagnostic, and therapeutic yield of FB in infants with CDH at a high-volume single center.

Methods: A retrospective review of infants with CDH treated at a specialized single center between October 2019 and August 2024 was conducted. Data included patient demographics, FB indications, and outcomes. Statistical analyses compared baseline characteristics and procedural outcomes between patients with and without FB.

Results: A total of 142 newborns were analyzed. Infants requiring FB (n=29, 20.4%) exhibited a higher disease burden, reflected by lower observed-to-expected lung-to-head ratio (p<0.001), intrathoracic liver herniation (p=0.002), ECMO (p<0.001), larger defect size (p=0.042), congenital anomalies (p=0.019), and heart defects (p=0.010). A total of 56 FBs were performed with the primary indications of prolonged weaning and pulmonary hemorrhage. Complications were minimal, and mainly consisted of self-resolved hypoxemia (16.1%). Bronchial casts were found in 31.6%. Tracheo-/bronchomalacia was diagnosed in 16 infants (55.2%). Significant additional anatomical findings were found in two patients (right main bronchus agenesis and laryngeal cleft). Postprocedural chest Xrays were unchanged in most cases (61.9%). A trend to achieve higher tidal volumes post-FB (p=0.090) without a change in peak inspiratory pressures (p=0.917) was noted [1] [2] [3].

Interpretation: In critically-ill neonates with CDH, neonatologist-performed FB had a minimal complication rate, with a high diagnostic and therapeutic yield. The necessity for FB may serve as an additional marker of CDH disease severity. Further research is needed to establish uniform assessment metrics, and explore continuous monitoring modalities such as electrical impedance tomography or lung ultrasound in the context of FB.

Publication History

Article published online:
19 May 2025

• Literatur

• 1 Nose K, Kamata S, Sawai T. et al. Airway anomalies in patients with congenital diaphragmatic hernia. Journal of Pediatric Surgery 2000; 35: 1562-1565
• 2 Hintz SR, Sheehan AM, Halamek LP. et al. Use of bronchoscopy for congenital diaphragmatic hernia patients on extracorporeal membrane oxygenation. Clinical Intensive Care 2002; 13: 103-108
• 3 Tho ALW, Rath CP, Tan JKG, Rao SC.. Prevalence of symptomatic tracheal morbidities after fetoscopic endoluminal tracheal occlusion: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2024; 109: 52-58