الفهرس 
Introduction
ANATOMY OF THE PEDIATRIC AIRWAYOnly 14 pages are availabe for public view
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Abstract
Chronic cough is a very common problem and is one of the most frequent reasons for many doctor visits in childhood. chronic cough in children has a major psycho-socioeconomic health burden with an increased prevalence from 8% to 20.78% in 17 years between 1999- 2016 year. chronic cough is defined as a cough lasting longer than 4 weeks without being resolved during this period. The possible underlying etiologies of chronic cough are included in a very wide spectrum, ranging from a simple, non-specific cough, to a cough with more serious causes. The most frequent etiologies of chronic cough in children < 14 years are protracted bacterial bronchitis (PBB) and asthma. By adolescence, adult causes such as gastroesophageal reflux disease (GERD), asthma, and upper airway cough syndrome (UACS) are encountered predominantly. Flexible bronchoscopy aids in the visualization of the airway anatomy (e.g., agenesis), the assessment of airway dynamics (e.g., malacia), in the localization and treatment of obstructions (e.g., mucus plugs), obtaining fluid samples [i.e., bronchoalveolar lavage (BAL)], and brushing/biopsy for microbiology and histopathology. In the present study we aimed to assess the children with chronic cough using flexible fiberoptic bronchoscopy in order to diagnose the underlying causes that remain otherwise unexplained by non-invasive diagnostic tests. Sixty children with refractory unexplained chronic cough were included in the current study. Flexible bronchoscopy was performed in two bronchoscopic units; Souhag University Children Hospital and Assiut University Hospital Bronchoscopy unit during the period from October 2017 through December 2019. In our study flexible bronchoscopy was diagnostic in 39 cases (65%). the most common finding on flexible bronchoscopy was structural airway anomalies in 15 cases (25%). The second most common finding in our study was visible bronchitis, which was noticed in 13 cases (21.66 %). Other positive findings include extrinsic compression on the airway in 6 cases (10 %), foreign body aspiration in 4 cases (6.67 %), mucous plug in 5 cases (5 %) and adenoid hypertrophy in 1 case (1.67 %). BAL cytology and PCR were done in 40 children. BAL neutrophilia was the most common finding in 25 cases (62.5 %) which refer to endobronchial infection. BAL culture and/or PCR showed pathogenic organism in 30 cases (75 %). the most frequently isolated organisms were Haemophilus influenza, Streptococcus pneumoniae and Rhinovirus. Flexible bronchoscopy is not only a diagnostic procedure; it also has therapeutic applications. During bronchoscopy, bronchial secretion and mucus plugs are aspirated from the inflamed bronchi, which lead to reventilation of atelectasis. Flexible bronchoscopy has a good safety profile with rarely reported life threatening or longstanding complications. In our study the most common was transient desaturation in 6 cases (10 %). Other complications include cough reflex in 3 cases (5 %) and bronchospasm in 2 cases (3.33 %).Flexible bronchoscope is a valuable tool in the diagnosis and treatment of chronic cough in children. It has a good safety profile without life threatening or longstanding complications. Our practice in this regard is in agreement with the reported results globally. In the diagnosis of chronic cough in children, flexible bronchoscope with BAL is more sensitive than HRCT scan, but the two modalities should be considered complimentary. Intervention and utilization of bronchoscopy should be encouraged after a careful consideration of which patients would benefit from this procedure and a rigorous estimate of its pros and cons. History of chronic wet cough, chocking, foreign body aspiration or stridor and the presence of persistent focal findings on HRCT are usually associated with positive findings on bronchoscopy. Flexible bronchoscopy is not only a diagnostic procedure; it also has therapeutic applications. During bronchoscopy, bronchial secretion and mucus plugs are aspirated from the inflamed bronchi, which lead to reventilation of atelectasis. It is expected in the future that bronchoscopy would have more role in correction of some anatomical abnormalities Flexible bronchoscopy is indicated for cases with chronic cough and persistent pneumonia in HRCT to remove excessive secretion and for microbiological study for determination of appropriate antimicrobial treatment and to detect possible underlying anatomical abnormalities. In cases with chronic cough and presence of unresolved atelectasis in HRCT, flexible bronchoscopy is essential for diagnosis and removal of possible obstructing agents like mucus plugs. BAL helped in differentiating between non-infections (i.e. esinophilic lung diseases) and infectious conditions (i.e. persistent pneumonia, protracted bacterial bronchitis) mainly by providing samples for cytology and culture to identify the infective microbe in cases of respiratory infection. Due to high prevalence of structural airway anomalies in the first year of life flexible bronchoscopy is indicated for infants presented with chronic cough. Performing Flexible bronchoscopy for children presented with chronic wet cough not responding to antibiotics to exclude airway anomalies i.e. airway malacia and to detect resistant endobronchial infection. chronic cough and persistent focal findings in HRCT is an indication for flexible bronchoscopy.