Introduction

Flexible bronchoscopy (FB) is an essential endoscopic technique in pediatric pulmonology since its introduction in the late 20th century.¹ It allows for direct visualization of the anatomical and functional aspects of the airway for diagnostic and therapeutic purposes, including sample collection for cytological and microbiological studies, and therapeutic interventions.^1-3 With the improvement of bronchoscopy equipment and technology, FB has gradually been applied to neonates and high-risk patients, including those undergoing lung transplantation and extracorporeal membrane oxygenation in intensive care units (ICU).^4,5 Moreover, anesthesia management lacks standardization, with different methods chosen based on the indications for bronchoscopy.^1,6,7 The growing need for an interdisciplinary approach to FB emphasizes the importance of establishing national standards and practice policies. Although international and national guidelines on FB indications, management, and techniques exist^1-3,6,7, recent European Respiratory Society Task Force statements and survey studies highlight significant inconsistencies in clinical practice.^3,8-13

Survey studies offer a cost-effective and efficient way to collect large-scale data, identify best practices, and highlight challenges, ultimately aiding in the development of evidence-based national guidelines.¹⁴ In Türkiye, pediatric FB has been increasingly adopted in both tertiary and secondary centers. However, a comprehensive understanding of current practices, including adherence to international standards, technical preferences, and procedural safety, is lacking. While a limited number of surveys have assessed pediatric FB practices^8-11, no such data are currently available from Türkiye. To address this gap, we conducted a nationwide survey among pediatric pulmonologists in Türkiye to evaluate the current approaches to FB, identify areas of variability, and highlight opportunities for standardization and improvement in clinical practice. This survey may also serve as a reference for new bronchoscopy units and help clinicians refer patients to centers with established FB programs.

Materials and Methods

Study design

This descriptive cross-sectional study was conducted using an online questionnaire created via Google Forms. The survey was developed based on existing bronchoscopy guidelines and previous pediatric bronchoscopy surveys.^1-3,8-10 It consisted of 80 questions divided into seven categories: demographics, patient preparation and preprocedural tests, bronchoscopy procedure, sedation/anesthesia, discharge process, bronchoscope cleaning, and comments. Participants responded using yes/no options, multiple-choice answers, or free-text (e.g., indications) responses where applicable. They could also provide comments and suggestions at the end of the questionnaire. No patient data were collected. The study was approved by the Ege University Faculty of Medicine Ethics Committee (Approval No: 23-5T/40, Date: 05.11.2023).

Since pediatric pulmonology is a relatively new subspecialty in Türkiye and the number of specialists performing flexible bronchoscopy is limited, we invited all 19 pediatric pulmonology centers known to perform the procedure to participate. The survey link, information sheet, and an electronic informed consent form were emailed to the clinical directors of these centers in March 2023. Access to the questionnaire was enabled only after the consent box was checked. Completion of the questionnaire indicated voluntary participation and constituted informed consent. Participants were asked to provide accurate and objective data on FB practices at their centers.

Only the city of each medical center was disclosed, while the center names remained confidential. Participation was voluntary, with no incentives offered. To improve the response rate, a follow-up email was sent four weeks after the initial request. Data collection lasted three months, and all participants approved participation in the study.

Statistical analysis

The answers extracted from Microsoft Excel spreadsheets were processed, and analyzed using Statistical Package for Social Sciences (SPSS for Windows Version 26) software. Descriptive data are given as numbers (n) and the percentage values (%). Values for continuous variables were given as either mean ± standard deviation (SD) or as median (interquartile range [IQR]), based on the normality of their distribution.

Results

Clinical directors from 19 pediatric pulmonology departments performing FB participated in the study. The median number of clinicians per center was nine (IQR: 1-13), with 76% female. Twelve centers (63.2%) were located in Türkiye’s three most populous metropolitan cities (Fig. 1). The median FB experience was 12.5 years (IQR: 1-30). Three centers (15.8%) had less than three years of FB experience, four (21.1%) had 6-10 years, six (31.6%) had 11-15 years, five (26.3%) had 16–20 years, and one (5.3%) had 30 years of experience.

A total of 3,118 FB procedures were performed in the previous year. Annual pediatric FBs per center had a median of 210 (min-max: 30-500; IQR: 80-250).

Indications

Parameters related to bronchoscopy are shown in Table I. The most frequently reported indications were atelectasis (16 centers, 84.2%), bronchiectasis (15 centers, 78.9%), suspected foreign body aspiration (10 centers, 52.6%), and obtaining BAL in patients with immune deficiency (10 centers, 52.6%) (Fig. 2).

Interventional bronchoscopy

Based on participant reports, therapeutic FB constituted a median 35% (range 2–80%) of all FB procedures, indicating that diagnostic FB was performed approximately twice as often as therapeutic FB. Moreover, of the nine centers (47.4%) indicating that they can perform advanced bronchoscopic procedures, endobronchial and mucosal biopsy was reported by six centers (31.6%), bronchoscopic intubations by five centers (26.3%), foreign body removal by three centers (15.8%), and tracheal/bronchial stent insertion by two centers (10.5%). Detailed information on bronchoscopic interventions is presented in Table I.

Equipment and personnel

Sixteen centers (84.2%) used video-assisted flexible bronchoscopes. Every center had at least two bronchoscopes with different outer diameters (ODs). Seven centers (36.8%) had three different ODs available, while one center (5.3%) had four. The three commonly reported bronchoscope ODs were 4.9 mm (12 centers, 63.2%), 3.6 mm (6 centers, 31.6%), and 2.8 mm (5 centers, 26.3%).

When the availability of experienced, dedicated staff for pediatric FB (nurses, anesthesiologists, and anesthesia technicians) was assessed across 19 centers, three (15.8%) reported having none, four (21.1%) had a nurse only, one (5.3%) had an anesthesiologist only, one (5.3%) had an anesthesia technician only, three (15.8%) had a nurse and an anesthesiologist, and seven (36.8%) had all three dedicated staff members.

Twelve centers (63.2%) reported that bronchoscopies were mainly performed in operating rooms; in four centers (21.1%) bronchoscopies were carried out in bronchoscopy suites, and one center (5.3%) used an airway endoscopy suite. In two centers, more than one site was available. Additionally, nine centers (47.4%) performed FB for critically ill patients in the ICU.

Preprocedural evaluations

Routine preprocedural testing was conducted in 18 centers (94.7%): complete blood count was obtained in 16 centers (84.2%), coagulation parameters in 14 centers (73.7%), chest X-ray in 12 centers (63.2%), pulmonary function tests in four centers (21.1%), and serologic testing for hepatitis viruses, syphilis, and Human immunodeficiency virus (HIV) antibodies in four centers (21.1%). All respondents confirmed obtaining written informed consent from caregivers before FB. Additionally, 13 centers (68.4%) required notifying the bronchoscopy team or operating room personnel at least one day before the procedure.

Bronchoalveolar lavage

During FB, the most commonly used personal protective equipment included sterile gloves (89.5%), N95 masks (52.6%), and safety glasses (36.8%). Additionally, 63.2% of respondents reported performing the procedure while positioned behind the patient’s head—near the airway—facing the bronchoscopy monitor. The remaining respondents reported standing at the patient’s side during the procedure.

The aliquot counts for microbiological and cytological examinations were two (8 centers, 42.1%), three (5 centers, 26.3%), six (3 centers, 15.8%), one (2 centers, 10.5%), and four (1 center, 5.3%). Table I illustrates the variations in BAL techniques, and BAL fluid analysis. Cytology and tuberculosis tests were available in all centers; however, they were performed routinely in 11 centers (57.9%) and 13 centers (68.4%), respectively.

Cleaning and disinfection of bronchoscopes

For bronchoscope reprocessing, automated cleaning was reported by nine centers (47.4%), automated disinfection by 10 centers (52.6%), and manual drying by nine centers (47.4%) (Table II). Moreover, 15 centers (78.9%) sterilized the bronchoscopes and 14 centers (73.7%) sent random bacterial surveillance culture samples to reference laboratories.

Premedication and sedation

Thirteen centers (68.4%) implemented premedication, with considerable variability in drug selection, procedural approaches, and patient monitoring methods, as shown in Table III. Three centers (15.8%) routinely administered inhaled bronchodilators as preprocedural medication, while one center (5.3%) additionally used intranasal adrenergic drops, and another center (5.3%) used intravenous antihistamines in addition to bronchodilators. Pre-oxygenation was routinely performed prior to general anesthesia (GA). Among the three centers using moderate conscious sedation, two reported performing pre-oxygenation.

Anesthesiologists evaluated patients the day before the procedure in 16 centers (84.2%), and on the same day in three centers (15.8%). FB was predominantly performed under GA combined with local anesthesia (9 centers, 47.4%). However, three centers (15.8%) opted for moderate conscious sedation combined with lidocaine spray for local anesthesia. Of the 16 centers (84.2%) utilizing GA, nine (47.4%) also administered local anesthesia. Lidocaine was the sole agent used for local anesthesia, though the instillation sites varied (Table III).

Patient discharge

The discharge protocols for elective outpatient FB showed that four centers (21.1%) discharged patients the following day, whereas the remaining 15 (78.9%) performed same-day discharge—seven centers (36.8%) within 1–3 hours and eight centers (42.1%) within 6–12 hours post-procedure. None of the centers prescribed routine medications at discharge; however, five centers (26.3%) routinely performed a post-procedural chest X-ray.

Respondent feedback

Five respondents (26.3%) emphasized the need to enhance interventional procedures and increase the number of trained anesthesiologists and nurses. Additionally, three respondents (15.8%) advocated for the immediate development of national pediatric FB guidelines to standardize procedural approaches.

Discussion

This study presents the first nationwide epidemiologic overview of pediatric FB practices among pediatric pulmonologists in Türkiye. As all centers performing pediatric FB participated, our findings provide a realistic representation of current national practices. The survey revealed substantial heterogeneity in procedural approaches, highlighting the need for national standards to improve consistency, training, and patient outcomes.

Flexible bronchoscopy has been performed by pediatric pulmonologists in Türkiye for nearly three decades. However, the median number of procedures per center per year (210 in 19 centers) is markedly higher than that reported from Europe (35 in 198 centers), China (158 in 47 centers), and India (75 in 24 centers).^2,8,9 A detailed comparison with international survey data is provided in Table IV. Despite the high number of procedures per center, only 10 out of 81 provinces offer FB, meaning each center serves about eight provinces. These findings indicate challenges in referral pathways and raise concerns about service capacity. Whether this high number of procedures in a few centers results from serving a large population or reflects advanced expertise will become clearer through future comparative studies.

In our survey, atelectasis, bronchiectasis, suspected foreign body aspiration, and immune deficiency (to obtain BAL for microbiological evaluation) were the most common indications for FB. Compared with European data, FB for immunodeficient patients was more frequently reported in Türkiye.² This finding may be explained by the higher prevalence of primary immunodeficiencies in regions with increased consanguinity.^12,13 A recent study in Türkiye assessed the diagnostic value of FB and BAL in immunosuppressed children, revealing that microscopic examination of BAL specimens identified pathogens in 65.1% of cases despite prior antimicrobial therapy.¹⁴ Diagnostic complexity due to pathogen diversity underscores the importance of FB in immunosuppressed children with respiratory symptoms.^10,15-20

Advanced interventional procedures were performed less frequently than in European centers, particularly bronchoscopic intubation and transbronchial biopsy.² While pediatric airway anatomy presents unique challenges, international recommendations emphasize that such procedures should be performed by experienced pediatric bronchoscopists.³ As pediatric pulmonology continues to evolve in Türkiye, the frequency of these procedures is expected to rise with an increasing number of pediatric pulmonologists, well-trained bronchoscopy teams, and the development of national pediatric FB guidelines.^2,21

There is no consensus on the optimal sedation method for pediatric FB.^1,6-8,10 Mild sedation with topical anesthetics may be sufficient²²; however, deeper sedation is often required to suppress cough during FB.²³ Although the use of GA has increased with advances in anesthetic techniques⁶, it may mask dynamic airway abnormalities such as tracheomalacia and bronchomalacia. Our survey found that GA combined with local anesthesia is the most preferred approach. The benefit of combining topical local anesthesia with GA during FB remains controversial, as available evidence shows no clear efficacy in cough suppression and suggests a potential increase in perioperative respiratory adverse events.^24,25 Given the frequent use of GA in our country, a multi-center randomized study could assess the efficacy of local anesthesia in FB.

In our study, propofol was the most frequently used agent for both induction and maintenance of anesthesia, consistent with its established safety and efficacy in pediatric FB.^23,26 Among 13 centers using propofol for maintenance, eight combined it with sevoflurane, and only one used it with remifentanil. However, evidence remains inconclusive regarding its optimal use alone or in combination^27,28, Sedation methods and agent preferences varied widely across centers and international studies.^2,8,9 This study highlights differences in anesthesia practices due to varying experiences among bronchoscopists and anesthesiologists. We believe that our findings may contribute to individualized sedation strategies and support efforts toward standardizing FB practices.

Premedication was routinely used in most centers, with midazolam being the preferred agent. Although there is no consensus on premedication use in pediatric FB^1,6-8,10, previous studies have examined the effects of premedication agents on cough, anxiety, and recovery time.^26-34 Midazolam has been shown to improve procedural tolerance and reduce the incidence and severity of the cough reflex.^26,31,35 In addition, combining midazolam with propofol has been shown to decrease propofol’s induction dose, reducing its cardiovascular and respiratory side effects.^36,37 Minimizing discomfort before FB improves both child and parental satisfaction, making premedication particularly beneficial in anxious or uncooperative children.

The optimal number of aliquots, saline volume per aliquot, and sampling sites for BAL remain unclear in the literature.^1,6,10 Our findings align with general recommendations, suggesting 1 mL/kg per aliquot (maximum 20 mL) and favoring the right middle lobe and lingula for sampling.^1,38 Routine cytological and microbiological analyses were inconsistently performed despite guideline recommendations.^1,7 Therefore, a national FB guideline is needed to standardize BAL fluid practices and improve diagnostic yield.

Bronchoscope reprocessing methods also differed, with both manual and automated approaches in use. While most centers performed microbiological surveillance cultures, evidence supporting their routine use remains limited.^1,39 Alcohol flushing, which was rarely used, is known to reduce positive culture rates.⁴⁰ Since bacterial surveillance cultures are time-consuming and costly, alcohol flushing may offer a practical alternative to reduce contamination and drying time.

This study has several limitations. First, self-reported responses introduce potential bias due to differences in interpretation, recall, and reporting. Although we captured anesthesia practices at a center level, the survey did not ask GA-using centers how they modify their approach when dynamic airway disease is suspected, such as preserving spontaneous breathing or opting for minimal sedation. Additionally, the questionnaire did not include details on suction pressures or fluid retrieval percentages during BAL, both of which are essential for diagnostic accuracy. The lack of clarity regarding sample handling—whether initial or subsequent samples were analyzed according to recommended standards—may also impact diagnostic reliability.

In conclusion, current pediatric FB practices in Türkiye demonstrate significant variability across centers, particularly in sedation protocols, interventional procedures, BAL techniques, and reprocessing methods. Moreover, comparison with survey results from other countries allowed us to observe both similarities and differences in procedural approaches. These findings highlight the need for standardized national guidelines, expanded training programs, and multidisciplinary collaboration to improve procedural quality and patient safety.

Acknowledgements

We sincerely thank all participating centers and the clinical directors who completed the national survey and provided valuable data for this study. We are especially grateful to Ayşe Tana Aslan, Ayşen Bingöl, Güzin Cinel, Haluk Çokuğraş, Bülent Karadağ, and Sedat Öktem, the center directors who contributed data but were not involved in data analysis or manuscript preparation. We also appreciate Gülçin Kabaçam, MSc in preparing the figure for the map demonstrating centers performing FB in Turkey.

Ethical approval

The study was approved by Ege University Faculty of Medicine Ethics Committee (date: November 5, 2023, number: 23-5T/40).

Author contribution

The authors confirm contribution to the paper as follows: Study conception and design: EO, FG; data collection: EB, EÇ, NÇ, PE, SEP, SG, GKÖ, AAK, MK, FÜ, AÖ, BÖ, SP, VŞ, TŞE, ZSU, EY, and HY; analysis and interpretation of the results: EÇ, NÇ, SG, EY; draft manuscript preparation: EO, FG, GKÖ. All authors reviewed the results and approved the final version of the manuscript.

Source of funding

The authors declare the study received no funding.

Conflict of interest

The authors declare that there is no conflict of interest.