Risk and utility of flexible bronchoscopy in critically ill patients: an in-depth analysis

Flexible bronchoscopy (FB) is used in critically ill patients; however, there remains a gap in the literature regarding its use in exceptionally high-risk scenarios. This study aims to address this gap by evaluating the indications, benefits, and safety of FB in these challenging cases. This retrospective study analyzed all FB procedures performed in medical ICUs. An investigator-defined risk classification was used. Procedures were classified as high-risk if patients required an FiO 2 ≥ 60%, inhaled nitric oxide (iNO), or prone positioning. Cases involving extracorporeal membrane oxygenation (ECMO) support were independently categorized as ECMO scenarios. All other procedures were considered low-risk. We assessed the application, utility, and adverse events associated with FB across the three groups. Among 426 FB procedures performed on 341 patients, 50 (12%) were classified as high-risk, and 47 (11%) were conducted during ECMO support. Pulmonary infection (46%) was the most common indication across all groups. Bronchial washing (63%) and bronchoalveolar lavage (BAL, 20%) were the most frequently used techniques. Hypotension (16%) and hypoxaemia (16%) were the most frequent complications, with hypoxaemia occurring most often in high-risk cases. Most complications resolved without lasting consequences; however, two procedure-related deaths occurred. Notably, ECMO-supported procedures were associated with the lowest overall complication rate. This study observed diagnostic and therapeutic utility of FB across several indications within the investigator-defined study groups. Clinically important complications occurred in a subset of procedures, including two deaths in temporal association with FB, although most complications were manageable and resolved without lasting effects.