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Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position

  • The Letter to this article has been published in Critical Care 2018 22:166

Prone positioning (PP) was shown to reduce mortality in mechanically ventilated (MV) patients with severe ARDS [1]. Despite its common use, safety concerns inhibit use of flexible bronchoscopy (FB) in patients with ARDS, and there are few reports of FB performed in PP [2]. We reviewed all adults receiving FB in PP in one institution between April 2016 and September 2017. The study was approved by the institutional review board. Four men and three women were identified (Table 1). In five patients, FB was indicated for clearance of thick secretions, and in two patients for microbial analysis. The mode of mechanical ventilation was not changed for FB, but FIO2 was universally set to 100%. All subjects had invasive hemodynamic and pulse oximetry monitoring. End-tidal carbon dioxide (EtCO2) was monitored in 3/7 subjects. With the subject’s head tilted to the side, the bronchoscope was advanced into the airways, repeatedly, and in short cycles, allowing time for oxygenation, ventilation, and lung recruitment between insertions. Therapeutic aspiration was performed in 6/7 subjects. Bronchoalveolar lavage was performed in two subjects. No significant hemodynamic compromise was observed during any of the procedures. Significant oxygen desaturation and rising EtCO2 were observed in one case (patient 4). Both derangements resolved with withdrawal of the bronchoscope and recruitment. No additional complications were documented. Figure 1 illustrates evolution of the PaO2:FIO2 ratio over time for each subject. Six subjects had antibiotics modified based on FB-obtained cultures. Consistent with previous data [3], 4/7 subjects survived 30 days following discharge from the ICU.

Table 1 Individual patient parameters, flexible bronchoscopy performance, and outcomes (n = 7)
Fig. 1

Evolution of PaO2 to FIO2 ratio from pre bronchoscopy (T1) to 24 h (T2) and 72 h (T3) post bronchoscopy (n = 7). IQR interquartile range, PaO2 partial pressure of arterial oxygen, FIO2 fractional concentration of inspired oxygen

Although PP is lung-protective, it may result in mobilization of secretions into the airways, impairing oxygenation and providing nidus for infection [4]. Despite documented risks [5], FB may be beneficial in this situation.

Several limitations need to be addressed when interpreting our data. This is a retrospective analysis. Although physiologic monitoring was automatically captured, ventilator data were not and ventilator output during FB could not be accurately analyzed. Additionally, EtCO2 was not measured in all cases during FB. Finally, PP was shown to reduce mortality in patients with moderate to severe ARDS, however, our study subjects’ oxygenation had started to improve by the time FB was performed (Fig. 1, T1). This likely reflects reluctance to perform FB in subjects with severe hypoxemia due to excessive risks.

Our report demonstrates the feasibility of FB performed in brief increments in carefully monitored patients with ARDS ventilated in PP. Further studies are needed to better delineate optimal ventilator management during FB in PP.



Acute respiratory distress syndrome

EtCO2 :

end-tidal carbon dioxide


Flexible bronchoscopy

FIO2 :

Fraction of inspired oxygen


Intensive care unit


Mechanical ventilation

PaO2 :

Partial pressure of arterial oxygen


Prone position


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This manuscript was presented as a thematic poster during the American Thoracic Society International Conference, Washington DC, USA, May 2017.


This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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OK-D, AS, and EMP contributed to the study concept and design. OK-D, CBS, AS, and EMP contributed to acquisition of data. OK-D, CBS, JJ, AS, and EMP contributed to analysis and interpretation of data. OK-D contributed to drafting of the manuscript. All declared authors contributed to critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.

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Correspondence to Or Kalchiem-Dekel.

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The study was conducted at University of Maryland Medical Center in accordance with Good Clinical Practice (Declaration of Helsinki 2002) and University of Maryland, Baltimore Campus Institutional Review Board approvals (IRB reference number HP-00073462). Patients were included from April 2016 to September 2017. A waiver of consent has been approved per 45 CFR 46.116(d).

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Kalchiem-Dekel, O., Shanholtz, C.B., Jeudy, J. et al. Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position. Crit Care 22, 54 (2018).

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