Continuous Bronchoscopy During Exercise in a Pediatric Patient: A Case Report

In this case report, we present – to our knowledge – the first continuous bronchoscopy during exercise (CBE) performed on a pediatric patient. A 13-year-old female athlete (168.5 cm, 85.15 kg) with a vascular ring was referred to the Exercise Respiratory Center at Cook Children’s for dyspnea on exertion (DOE) and expiratory wheezing leading to significant exercise intolerance. Her vascular ring was a double aortic arch, causing only mild (40%) anteriolateral compression of her mid-trachea. However, vascular rings can also cause tracheomalacia at the site of tracheal compression. Tracheomalacia is a known cause of DOE and expiratory wheezing, but cannot be sufficiently evaluated by static radiological images or flexible bronchoscopy under general anesthesia. We evaluated the potential causes of her exertional symptoms with a combined continuous laryngoscopy during exercise (CLE) and cardiopulmonary exercise test (CPET) followed by post-exercise spirometry and a CBE. The patient performed all exercise on a treadmill. The CLE was performed under topical nasal decongestion and topical nasal anesthesia. It consisted of flexible digital nasopharyngolaryngoscopy before and during incremental exercise to task failure. Following the CLE-CPET, the patient performed spirometry every 5 minutes for 15 minutes. After 30 total minutes of rest, she started the CBE under topical nasal decongestion and topical nasal, laryngeal, and tracheal anesthesia. The CBE consisted of the placement of a flexible digital bronchoscope through a nasal passage, past the vocal folds, and into the mid trachea with the site of anteriolateral compression from the vascular ring in view. With the scope in place, the patient completed the same exercise protocol on a treadmill that she performed during the CLE-CPET portion of the evaluation. The protocol started with 90 seconds of walking at 3 mph, followed by a step-wise speed-increase beginning at 4.5 mph and increasing by 0.5 mph every 90 seconds. The patient voluntarily terminated exercise after 45 seconds of running at 6.0 mph, achieving a [Formula: see text]O 2 peak of 34.5 mL/kg/min. She exhibited dyspnea scores of 9 and 10 on a modified 10-point Borg Scale at maximal exercise during the CLE-CPET and the CBE, respectively. Similarly, she reported a rating of perceived exertion (RPE) of 10 on the modified Borg Scale at the end of both exercise tests. The CLE revealed moderate supraglottic exercise-induced laryngeal obstruction (EILO), also called exercise-induced laryngomalacia. Therefore, the patient was referred for therapy with a speech language pathologist. The CPET showed a normal cardiorespiratory response to exercise. Post-exercise spirometry ruled out exercise-induced bronchoconstriction. The CBE confirmed mild (40%) anterior right-sided compression of the mid-to-distal trachea due to the vascular ring. However, the patient did not exhibit airway collapse during exercise. She was able to tolerate the procedure well; on a 5-point Likert scale, she reported discomfort due to the use of Lidocaine in the trachea (4), exercise with the bronchoscope in place (4), and the placement of the bronchoscope (5), with lesser discomfort due to the application of Lidocaine in the nose (2) and on the vocal cords (3). CBE can be used successfully and safely in pediatric patients to evaluate the collapsibility of the tracheal wall during exercise on a treadmill. Funding was provided through the Cook Children's Endowed Chair Program This abstract was presented at the American Physiology Summit 2025 and is only available in HTML format. There is no downloadable file or PDF version. The Physiology editorial board was not involved in the peer review process.