The need for bronchoscopic services for children in low and middle-income countries

Flexible bronchoscopy is widely used in industrialized high-income countries to investigate and manage neonates and children with complex respiratory disease. In contrast to this, bronchoscopy services in low- and middle-income countries (LMIC) are only available in a few select centers where it is almost exclusively used for diagnostic purposes. With development of neonatal and pediatric high and intensive care units (ICU) in LMIC, together with the high burden of infectious diseases causing complicated respiratory disease, pediatric bronchoscopy services urgently need to be developed to support these services. Infants and children in LMIC suffer from especially tuberculosis (TB) and HIV-related lung diseases, have limited access to health care, and the necessary diagnostic services to correctly manage these children are poorly developed. These limitations lead to a delay in diagnosis that results in an increased number of children with severe and complicated respiratory disease. In many LMIC, especially in Sub-Saharan Africa, basic bronchoscopy services are not available even at a single center. This means that a number of children in LMIC do not have access to basic services such as the removal of inhaled foreign bodies (personal experience). In this editorial, we argue for the urgent need to develop bronchoscopic services in LMIC.

Indications for bronchoscopy in children in LMIC

The burden of TB and HIV is the highest in LMIC. Flexible bronchoscopy has been recently showed to be of significant value in the diagnosis and management of children with complicated airway disease caused by Mycobacterium tuberculosis [1]. Approximately 8–38% of children suffering from TB have symptomatic fixed airway obstruction with 27% of these children presenting with life-threatening airway obstruction [2–4]. In children with life-threatening airway obstruction, an immediate diagnosis and endobronchial decompression of the obstructing lymph nodes is required to relieve the airway obstruction [4]. The cause of the life-threatening fixed airway obstruction is not obvious at presentation and has to be differentiated from other causes of airway obstruction which even in LMIC include congenital or acquired airway stenosis other than those caused by TB. Without a skilled bronchoscopist, the challenge of making the correct diagnosis will not be solved resulting in excess morbidity and mortality. In children with symptomatic non-life-threatening airway obstruction resulting from TB mediastinal lymph node compression of the airways, approximately 30% of children will require surgical decompression of enlarge lymph nodes [4]. Bronchoscopic evaluation of the airways is required to determine which children will benefit from transthoracic decompression as only those in which the central airways have been compressed by more than 75% of the estimated airway size require surgery [1,4]. The WHO estimates that approximately 1 million children annually develop TB. From the literature, we estimate that between 80,000 and 320,000 children annually have symptomatic airway compression. Of these, between 26,000 and 105,000 children annually will require transthoracic lymph node decompression as part of their management. More concerning is the fact that between 7000 and 28,000 children annually present with acute life-threatening airway obstruction due to the TB lymph node compression of the airways which require immediate diagnosis and decompression of the offending glands. These figures emphasize the need for improving imaging and bronchoscopy services to children in the developing world. Our pulmonology service in a region of Southern Africa which is responsible for approximately 1 million children annually performs about 300 bronchoscopies of which 20% are for TB related lung disease (personal communication). Although it is universally accepted that the diagnosis of childhood pulmonary TB can be difficult, the advent of GeneXpert has added another diagnostic tool. We have recently shown that GeneXpert done on bronchoalveolar (BAL) specimens increases the diagnostic yield [5]. This approach increased the diagnosis of pulmonary TB by 14%. With drug resistance increasing in all high-burden countries, the rapid diagnosis and treatment of drug-resistant TB remains paramount. The increased yield with GeneXpert on BAL samples partially addresses this challenge. Unusual complications due to TB rarely occur but when present cause a significant morbidity and mortality [6,7]. Transbronchial interventions such as endoscopic closure of a bronchio-esophageal fistula or persistent stump leak after pneumonectomy have been performed preventing major surgery [8].

Tracheobronchial TB occurs due to TB inflammation of the mucosa and can lead to tracheobronchial strictures. This is common in adults and rarely described in children. Symptomatic tracheobronchial strictures can be treated with balloon dilatation of the airway [9].

In LMIC, due to the burden of infectious diseases, the differential diagnoses for various clinical presentations differ from those in highly developed countries. In HIV-infected children, airway obstruction is caused by tumors such as Kaposi sarcomata, viral papillomata, and enlarged mediastinal lymph nodes caused by TB or Cryptococcus neoformans [10,11]. The correct management of these children requires an accurate diagnosis that is best obtained via fiber-optic bronchoscopy. The cause of the airway obstruction is even not often self-evident at bronchoscopy. To get an accurate histological diagnosis requires the bronchoscopists to adapt to known procedures to achieve an accurate diagnosis. Transbronchial needle aspirate (TBNA) was previously done exclusively in adults with malignant lung disease. The use of TBNA in children had previously been limited by the size of the working channel of the pediatric fiber-optic bronchoscopes. The 4-mm fiber-optic bronchoscope with its 2-mm working channel can be safely used in children of 1 year and older to perform TBNA. We have demonstrated that TBNA of subcarinal lymph nodes has been safely performed and increase the diagnostic yield [12]. The availability of endobronchial ultra sound (EBUS), which has been used in older children, might further increase this diagnostic yield but no studies have been done in younger children [13].

Transbronchial biopsy (TBB) is widely used in the high-income countries for the long-term management of children that have undergone lung transplantation to diagnose organ rejection and lung infections. In the LMIC, organ transplantation is rarely performed, yet TBB remains a useful procedure to diagnose interstitial lung disease especially in HIV-infected children. Lymphocytic interstitial pneumonitis (LIP) is commonly seen in HIV-positive children, older than 2 years, who have not yet started antiretroviral therapy [11]. LIP’s radiological picture overlaps with that of miliary TB making an accurate diagnosis essential. TBB is useful in this situation to confirm the diagnosis of LIP and exclude TB. TBB is feasible as most HIV-infected children with suspected LIP are older than 2 years, allowing a 4-mm bronchoscopy with 2-mm working channel to be used, which increases the size of the biopsy specimen. Although there is about a 10% risk of a pneumothorax, the benefit of the procedure outweighs the risk, especially in acutely ill children where a rapid accurate diagnosis is required. The small sample size limits the diagnostic yield from TBB. The largest possible biopsy forceps should be used to obtain adequate lung tissue as this has been shown that histopathological diagnosis can be reliably made using this biopsy technique [14].

In LMIC, the number of PICUs and NICUs is increasing. Their establishment has increased the survival of neonates and children. The consequence of the increased survival is that in surviving neonates and children previously undiagnosed congenital and iatrogenic airway disease is becoming increasingly evident. The spectrum of disease ranges from airway disease associated with congenital heart disease, acquired trachea-bronchomalacia requiring long-term ventilation to subglottic stenosis requiring tracheostomy. Fiber-optic bronchoscopy in the ICU is required to assess the airways of these neonates and children to assure correct management [15–20]. Performing a bronchoscopy safely in the ICU requires a different skill set as in the ICU there is an increased risk of developing complications and managing them in an unfamiliar environment. Certain interventions are likely to take longer to be introduced in LMIC. Currently in our practice, airway stents are not used due to the high complication rate and the fact that biodegradable stents are not available.

Pediatric pulmonologists practicing in LMIC are often faced with clinical scenarios not often encountered in high-income countries. In LMIC, medical staffs responsible for intubating neonates and children often have limited skills in the care of intubated airways. This limitation results in airway injuries that present later as either subglottic or tracheal stenosis. These children often develop critical airway narrowing requiring the pediatric pulmonologist to perform life-saving endoscopic dilatation. Another scenario is the ingestion of caustic or acid liquids which result in severe burning of the airways, especially upper airways. This results in significant airway-related injury requiring repeated endoscopic management.

Pediatric pulmonologists are required to remove inhaled foreign bodies as colleagues in the surgical divisions are often not trained or have the experience of doing interventional bronchoscopy in children. The most useful bronchoscope for removing foreign bodies is the 4.0-mm hybrid video bronchoscope with its 2-mm working channel as reasonably sized forceps and retrieval baskets can be used. The 2.8-mm video scope is also suitable for the removal of foreign bodies, but the size of the retrieval equipment through the 1.2-mm working channel limits its usefulness. In our experience, 90% of foreign bodies can be removed via a fiber-optic bronchoscope. The remaining 10% require the use of a rigid bronchoscope illustrating the need to have access and be trained in the use of a rigid bronchoscope.

Resources required to develop a pediatric service in an LMIC will include the bronchoscopy theater, bronchoscopy equipment, and a supply of disposable equipment supported by a nursing and anesthetic team. Once the theater has been set up, the running costs are affordable as the biggest investment is acquiring the bronchoscopy equipment. With proper care, endoscopic equipment can last a long time.

Scope of the problem in LMCI

In LMIC, health services are often overrun by infectious diseases such as TB, HIV, and pneumonia that limit the financial resources available to develop new specialized services. The present economic recession is exacerbating the situation making it unlikely that the specialized services neonates and children require will be developed in the near future. This situation is further complicated by the rising levels of education and expectation among parents who use the Internet to see what treatment is available for their sick children in other parts of the globe. We argue that pediatric bronchoscopy would make a difference to the care of children with complicated congenital and acquired lung disease. Very limited data is available regarding access to care and the current state of availability of bronchoscopy in LMIC. An assessment for the need of this essential service is required. While we realize that establishing pediatric bronchoscopy units is financially challenging, we advocate for the development of centralized bronchoscopy units in LMIC. Even in LMIC where adults have access to bronchoscopy services, these much-needed services are not available to children.

Finding a solution for the problem

Developing pediatric bronchoscopy services and training competent pediatric bronchoscopists require a concerted effort by pediatric pulmonologists worldwide. The model of having training courses, as run in Europe and the United States, needs to be duplicated in the LMIC. Developing training units in LMIC would be cost-effective and participants would be exposed to the lung diseases that commonly occur in LMIC. It is our experience that where areas of excellence in LMIC are developed, they improve not only the quality of respiratory care for children who access them but also the respiratory care of the surrounding communities and regions. These centers stimulate research the results of which, when implemented, improve the respiratory health of many children in LMIC. Bronchoscopy centers in LMIC could also be used to expose pulmonologists from high-income countries to medical conditions rarely encountered in their home countries.

Companies that manufacture bronchoscopy equipment, especially modern equipment such as EBUS, make significant profits in the high-income countries. These companies should be prepared to develop a charitable trust, administered by established professional societies, to develop bronchoscopy facilities in LMIC. Equally important is that members of professional societies should be prepared to aid with training programs to improve and retain bronchoscopy skills of their colleagues in LMIC. This is morally correct as the largest burden of lung disease is in the LMIC and these countries, therefore, have the largest number of children who would benefit from this initiative. It is unethical to deny these children the right to access pediatric pulmonology and pediatric bronchoscopy services. Worldwide pulmonologists should support a campaign #Scope for all children.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.