Role of Fiberoptic Bronchoscopy-Guided Bronchoalveolar Lavage with Local Gentamicin Instillation in the Treatment of Ventilator-Associated Pneumonia

Abstract Background: Ventilator-associated pneumonia (VAP) is a frequent and serious complication among mechanically ventilated critically ill patients, associated with prolonged mechanical ventilation, longer ICU stay, and increased morbidity and mortality. Fiberoptic bronchoscopy enables direct airway clearance, accurate microbiological sampling, and targeted local antimicrobial delivery, and may serve as a valuable adjunct to conventional VAP treatment. Aim of the Work: To evaluate the therapeutic effect of fiberoptic bronchoscopy-guided bronchoalveolar lavage (BAL) with local gentamicin instillation, as an adjunct to conventional treatment, in mechanically ventilated patients with VAP. Patients and Methods: A prospective randomized comparative study was conducted on mechanically ventilated adult patients with VAP admitted to the Critical Care Unit of Al-Zahraa University Hospital between May 2025 and May 2026. Ninety patients were randomized into two equal groups; after two patients were transferred to another hospital, 88 patients (44 per group) were included in the final analysis. Group A received conventional VAP treatment only, while Group B received conventional treatment plus fiberoptic bronchoscopy-guided BAL with local intrabronchial gentamicin (5 mg/kg), repeated every other day for 7 days. Oxygen saturation (SpO₂), FiO₂, PaO₂, PaO₂/FiO₂ (P/F) ratio, peak airway pressure, body temperature, total leukocytic count (TLC), and C-reactive protein (CRP) were assessed before and after treatment. Results: Baseline demographic and clinical characteristics were comparable between groups. After treatment, Group B showed significantly higher SpO₂ (91.77 ± 3.33% vs. 86.00 ± 3.99%, P<0.0001), PaO₂ (101.75 ± 7.48 vs. 90.69 ± 9.05 mmHg, P=0.009), and P/F ratio (2.57 ± 0.88 vs. 1.88 ± 0.71, P<0.0001), together with lower FiO₂ requirements (43.68 ± 15.04% vs. 55.57 ± 19.89%, P=0.002) and peak airway pressure (25.57 ± 5.93 vs. 30.00 ± 4.83 cmH₂O, P=0.010). TLC and CRP decreased more markedly in Group B, with significant between-group differences after treatment and at final follow-up. Group B also achieved earlier and more pronounced normalization of body temperature. Conclusion: Adding fiberoptic bronchoscopy-guided BAL with local gentamicin to conventional VAP treatment was associated with greater improvement in oxygenation and respiratory mechanics, more rapid resolution of fever, and a greater reduction in inflammatory markers compared with conventional treatment alone, supporting its use as an effective adjunctive therapy in appropriately selected mechanically ventilated patients with VAP.