Background: Children with Down syndrome (DS) often undergo flexible bronchoscopies (FB) due to common respiratory symptoms.

Objective: To examine the indications, findings and complications of FB in pediatric DS patients. 

Methods: A retrospective case-control study on FB performed in DS pediatric patients between 2004-2021 in a tertiary center. DS patients were matched to controls (1:3) based on age, gender and ethnicity. Data collected included demographics, comorbidities, indications, findings and complications.

Results: Fifty DS patients (median age 1.36 years) and 150 controls (median age 1.27 years) were included. Obstructive sleep apnea evaluation and oxygen dependence were more common indications among DS (38% vs. 8%, 22% vs. 4%, p<0.01, respectively). Normal FB was less frequent in DS compared with controls (8% vs. 28%, p=0.01). Soft palate incompetence and tracheal bronchus were more frequent in DS (12% vs. 3.3%, p=0.024, 8% vs. 0.7%, p=0.02, respectively). Complications were more frequent in DS (22% vs.9.3%, IRR 2.36, p=0.028). In DS, cardiac anomalies (IRR 3.96, p<0.01), pulmonary hypertension (PHTN) (IRR 3.76, p=0.006), and PICU hospitalization before the procedure (IRR 4.2, p<0.001) were associated with higher complication rates. In a multivariate regression model, history of cardiac disease and PICU hospitalization before the procedure, were independent risk factors for complications with an IRR of 4 and 3.1, respectively (p=0.006, p=0.05).

Conclusion: DS pediatric patients undergoing FB are a unique population with specific indications and findings. DS patients with cardiac anomalies and PHTN are at the highest risk for complications.