Acute Crit Care.  2024 Feb;39(1):179-185. 10.4266/acc.2023.01165.

Early bronchoscopy in severe pneumonia patients in intensive care unit: insights from the Medical Information Mart for Intensive Care-IV database analysis

• Ahn C
• Park Y
• Oh Y

• KMID: 2555237
• DOI: http://doi.org/10.4266/acc.2023.01165

Abstract

Background
Pneumonia frequently leads to intensive care unit (ICU) admission and is associated with a high mortality risk. This study aimed to assess the impact of early bronchoscopy administered within 3 days of ICU admission on mortality in patients with pneumonia using the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. Methods: A single-center retrospective analysis was conducted using the MIMIC-IV data from 2008 to 2019. Adult ICU-admitted patients diagnosed with pneumonia were included in this study. The patients were stratified into two cohorts based on whether they underwent early bronchoscopy. The primary outcome was the 28-day mortality rate. Propensity score matching was used to balance confounding variables. Results: In total, 8,916 patients with pneumonia were included in the analysis. Among them, 783 patients underwent early bronchoscopy within 3 days of ICU admission, whereas 8,133 patients did not undergo early bronchoscopy. The primary outcome of the 28-day mortality between two groups had no significant difference even after propensity matched cohorts (22.7% vs. 24.0%, P=0.589). Patients undergoing early bronchoscopy had prolonged ICU (P<0.001) and hospital stays (P<0.001) and were less likely to be discharged to home (P<0.001). Conclusions: Early bronchoscopy in severe pneumonia patients in the ICU did not reduce mortality but was associated with longer hospital stays, suggesting it was used in more severe cases. Therefore, when considering bronchoscopy for these patients, it's important to tailor the decision to each individual case, thoughtfully balancing the possible advantages with the related risks.

Keyword

bronchoscopy; intensive care units; mortality; pneumonia

Reference

1. Torres A, Cilloniz C, Niederman MS, Menéndez R, Chalmers JD, Wunderink RG, et al. Pneumonia. Nat Rev Dis Primers. 2021; 7:25.

2. Jain S, Self WH, Wunderink RG, Fakhran S, Balk R, Bramley AM, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015; 373:415–27.

3. Ferrer M, Travierso C, Cilloniz C, Gabarrus A, Ranzani OT, Polverino E, et al. Severe community-acquired pneumonia: characteristics and prognostic factors in ventilated and non-ventilated patients. PLoS One. 2018; 13:e0191721.

4. Martin-Loeches I, Torres A, Nagavci B, Aliberti S, Antonelli M, Bassetti M, et al. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med. 2023; 49:615–32.

5. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007; 44(Suppl 2):S27–72.

6. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and treatment of adults with community-acquired pneumonia: an official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200:e45–67.

7. Wayne MT, Valley TS, Arenberg DA, De Cardenas J, Prescott HC. Temporal trends and variation in bronchoscopy use for acute respiratory failure in the United States. Chest. 2023; 163:128–38.

8. Jolliet P, Chevrolet JC. Bronchoscopy in the intensive care unit. Intensive Care Med. 1992; 18:160–9.

9. Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med. 2018; 12:651–63.

10. Du Rand IA, Blaikley J, Booton R, Chaudhuri N, Gupta V, Khalid S, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013; 68 Suppl 1:i1–44.

11. Du Rand IA, Barber PV, Goldring J, Lewis RA, Mandal S, Munavvar M, et al. British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax. 2011; 66 Suppl 3:iii1–21.

12. Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Hanberger H, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J. 2017; 50:1700582.

13. Assefa M. Multi-drug resistant gram-negative bacterial pneumonia: etiology, risk factors, and drug resistance patterns. Pneumonia (Nathan). 2022; 14:4.

14. Dominedò C, Ceccato A, Niederman M, Gabarrús A, Cillóniz C, Martin-Loeches I, et al. Risk factors for MDR pneumonia according to the 2017 International ERS/ESICM/ESCMID/ALAT guidelines. Eur Respir J. 2019; 54(suppl 63):OA3304.

15. Dumoulin E. Recent advances in bronchoscopy. F1000Res. 2018; 7:F1000 Faculty Rev-1646.

16. Lee HW, Min J, Park J, Lee YJ, Kim SJ, Park JS, et al. Clinical impact of early bronchoscopy in mechanically ventilated patients with aspiration pneumonia. Respirology. 2015; 20:1115–22.

17. Megahed MM, El-Menshawy AM, Ibrahim AM. Use of early bronchoscopy in mechanically ventilated patients with aspiration pneumonitis. Indian J Crit Care Med. 2021; 25:146–52.

18. Guidry CA, Mallicote MU, Petroze RT, Hranjec T, Rosenberger LH, Davies SW, et al. Influence of bronchoscopy on the diagnosis of and outcomes from ventilator-associated pneumonia. Surg Infect (Larchmt). 2014; 15:527–32.

19. Bauer PR, Chevret S, Yadav H, Mehta S, Pickkers P, Bukan RB, et al. Diagnosis and outcome of acute respiratory failure in immunocompromised patients after bronchoscopy. Eur Respir J. 2019; 54:1802442.

20. Lucena CM, Martínez-Olondris P, Badia JR, Xaubet A, Ferrer M, Torres A, et al. Fiberoptic bronchoscopy in a respiratory intensive care unit. Med Intensiva. 2012; 36:389–95.

21. Schnabel RM, van der Velden K, Osinski A, Rohde G, Roekaerts PM, Bergmans DC. Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients. BMC Pulm Med. 2015; 15:107.

22. Facciolongo N, Patelli M, Gasparini S, Lazzari Agli L, Salio M, Simonassi C, et al. Incidence of complications in bronchoscopy: multicentre prospective study of 20,986 bronchoscopies. Monaldi Arch Chest Dis. 2009; 71:8–14.

23. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012; 7:e35797.

24. Mikacenic C, Fussner LA, Bell J, Burnham EL, Chlan LL, Cook SK, et al. Research bronchoscopies in critically ill research participants: an official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2023; 20:621–31.