Characterizing Bronchoscopy in Pediatric Critical Care: A Cohort Analysis of Practice and Outcomes

Background Flexible bronchoscopy (FB) has become an essential diagnostic and therapeutic tool in pediatric intensive care units (PICUs). Despite increasing adoption, comprehensive data on FB's current use, clinical impact and safety in critically ill children, particularly those supported by extracorporeal membrane oxygenation (ECMO), remain limited. We aimed to describe the utilization, findings, microbiological yield and complications of FB in critically ill pediatric patients, including its diagnostic and therapeutic applications and associated physiologic effects. Methods This retrospective cohort study included all children aged 0–18 years who underwent FB in a quaternary PICU between January 2019 and December 2024. Data were abstracted from the electronic medical record and analyzed descriptively. Physiologic variables before and after bronchoscopy were compared using paired differences (Δ = post − pre). Results A total of 179 patients underwent 246 bronchoscopies. The median age was 61 months (IQR 17-172), and the median time from PICU admission to bronchoscopy was 4 days (IQR 1-11). All patients were mechanically ventilated, and 26% were supported with ECMO. The most frequent indications were evaluation of infection (30.3%), focal imaging abnormalities (25.0%), and surveillance bronchoscopy (15.4%). Increased airway secretions were observed in 50% of procedures. Airway plug removal (22.8%), bronchoalveolar lavage (20.7%), and Dornase alfa instillation (7.7%) were the most common interventions. Multiple findings and interventions often occurred during a single procedure. Concordance between bronchoscopic and non-bronchoscopic lavage cultures was moderate, with highest agreement for Pseudomonas aeruginosa (67%) and Candida (100%). Complications were infrequent: minor bleeding (4.9%) and transient desaturation (4.5%) were most common; no pneumothorax or mortality occurred. Physiologic parameters showed minimal change post-procedure. Conclusions Flexible bronchoscopy is a safe and versatile diagnostic and therapeutic procedure in the PICU, including among ECMO-supported patients. The stable physiologic profile and low complication rate support its continued integration into multidisciplinary critical care practice.