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Pediatric Microlaryngoscopy and Bronchoscopy in the COVID-19 Era

Educational Objective
To understand how pediatric microlaryngoscopy and bronchoscopy techniques need to adjust during the COVID-19 pandemic
1 Credit CME
Key Points

Question  How should pediatric microlaryngoscopy and bronchoscopy techniques be altered during the COVID-19 era?

Findings  A case series of 8 pediatric patients underwent microlaryngoscopy and bronchoscopy using techniques to minimize and contain aerosolized respiratory secretions during the procedure, including covering the patient with a plastic sheet, avoidance of direct laryngoscopy, early intubation with a cuffed tube, and modifications to interventions, such as supraglottoplasty. The techniques were used successfully, and no adverse events occurred.

Meaning  Modified microlaryngoscopy and bronchoscopy techniques were associated with satisfactory patient outcomes and theoretically are associated with reduced risk to the otolaryngology theater team during the COVID-19 pandemic.


Importance  As an aerosol-generating procedure, traditional pediatric microlaryngoscopy and bronchoscopy techniques must be adapted in order to reduce the risk of transmission of severe acute respiratory syndrome coronavirus 2.

Objective  To describe a modified technique for pediatric microlaryngoscopy and bronchoscopy for use in the COVID-19 era and present a case series of patients for whom the technique has been used.

Design, Setting, and Participants  Observational case series of pediatric patients undergoing emergency or urgent airway procedures performed at a tertiary pediatric otolaryngology department in Australia. Procedures were completed between March 23 and April 9, 2020, with a median (range) follow-up of 24.5 (11-28) days.

Exposures  Modified technique for microlaryngoscopy and bronchoscopy, minimizing aerosolization of respiratory tract secretions.

Main Outcomes and Measures  The main outcome was the feasibility of technique, which was measured by ability to perform microlaryngoscopy and bronchoscopy with comparable success to the usual technique (ie, adequate examination of the patient for diagnostic procedures and ability to perform interventional procedures).

Results  The technique was used successfully in 8 patients (median [range] age, 160 days [27 days to 2 years 6 months]); 5 patients were male, and 3 were female. Intervention was performed on 6 patients; 2 balloon dilations for subglottic stenosis, 2 injections of hyaluronic acid for type 1 clefts, and 2 cold-steel supraglottoplasties. No adverse events occurred.

Conclusions and Relevance  In this case series, feasibility of a modified technique for pediatric microlaryngoscopy and bronchoscopy was demonstrated. By reconsidering the surgical approach in light of specific COVID-19 infection risks, this technique may be associated with reduced spread of aerosolized respiratory secretions perioperatively and intraoperatively, but the technique and patient outcomes require further study.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: April 20, 2020.

Corresponding Author: Katherine Pollaers, MBBS, MSurg, Perth Children’s Hospital, 15 Hospital Ave, Nedlands WA 6009, Australia (katherine.pollaers@gmail.com).

Published Online: April 28, 2020. doi:10.1001/jamaoto.2020.1191

Author Contributions: Dr Pollaers had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Pollaers, Vijayasekaran.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Pollaers, Vijayasekaran.

Critical revision of the manuscript for important intellectual content: Herbert, Vijayasekaran.

Statistical analysis: Vijayasekaran.

Administrative, technical, or material support: Herbert, Vijayasekaran.

Study supervision: Herbert, Vijayasekaran.

Conflict of Interest Disclosures: None reported.

Disclaimer: The views expressed in this article are the views of the authors and not an official position of the institution.

Additional Contributions: We thank the patient for granting permission to publish the clinical photographs.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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