Flexible Fiberoptic Bronchoscopy During Pediatric ECMO: Balancing Risk and Clinical Benefit

Letter to the Editor

We read with great interest to single-centre, retrospective study which was published by Gaetani et al in J Intensive Care Medicine. This study examined the use of flexible fiberoptic bronchoscopy (FFB), the findings, microbiological results and complications in quaternary pediatric intensive care unit (PICU) patients. ¹ This study has made a significant contribution to the literature by emphasising that the 246 FFB procedures performed on 179 patients — including those receiving extracorporeal membrane oxygenation (ECMO) support in the PICU — constitute a safe and versatile diagnostic and therapeutic method. It is noteworthy that 26% of patients required ECMO support and were clinically stable. However, we have two questions regarding this study. Firstly, what complications were observed in patients undergoing the FFB procedure, particularly in those receiving ECMO support, and how frequently did these complications occur? Secondly, the FFB procedure may be considered as a potential means to reduce the duration of mechanical ventilation or ECMO.

In this study by Gaetani et al examining bronchoscopies in PICU patients, it was reported that 35 of the 179 patients were on ECMO and that 63 bronchoscopy procedures were performed at the bedside by experienced teams. While these procedures were generally well tolerated, the study did not provide information on the potential benefits of FFB in reducing ECMO duration, initiating treatment targeting specific microbiological agents in bronchoalveolar lavage (BAL), or detecting anomalies in dynamic airway imaging. This is despite the risk of complications such as bleeding, pneumothorax or desaturation during the procedure. ¹

ECMO has become an essential life-support modality in children with severe respiratory failure requiring mechanical ventilation. According to the Extracorporeal Life Support Organization (ELSO) 2020 Pediatric Respiratory Guidelines, ECMO should be considered when predicted mortality approaches 50% and is strongly indicated when mortality risk nears 80% despite optimal conventional therapy. ² Earlier initiation may also be justified to prevent ventilator-induced lung injury and other treatment-related morbidities. Selection between veno-venous (VV) and veno-arterial (VA) support should be guided by hemodynamic status and oxygenation requirements.

FFB remains a valuable diagnostic and therapeutic tool in pediatric respiratory failure. Beyond radiologic imaging, it enables direct visualization of dynamic airway abnormalities, mucosal pathology, and endobronchial lesions, while BAL facilitates cytological and microbiological evaluation. However, in critically ill children, complications such as hypoxemia, bleeding, and pneumothorax have been reported. ³

With the increasing utilization and duration of ECMO support, airway complications—including mucus plugging, atelectasis, and clot formation following pulmonary hemorrhage—are encountered more frequently. In this context, serial FFB or rigid bronchoscopy (RB) is often required. Nevertheless, data regarding clinical efficacy and safety of bronchoscopy during pediatric ECMO remain limited. ⁴

In a recent study by Young A et al, involving 107 pediatric ECMO patients, 37 underwent a total of 99 bronchoscopic procedures. ⁴ Although complications were observed in nearly half of patients within 48 h, mortality rates were comparable between those who underwent bronchoscopy and those who did not. These findings suggest that bronchoscopy may serve as a rescue or stabilization strategy in patients with persistent pulmonary dysfunction who might otherwise not be considered for decannulation.

Similarly, Babhalgaonkar P et al evaluated 155 pediatric ECMO patients, 36 of whom underwent 92 FFB procedures. ³ Bronchoscopy was beneficial in improving airway clearance in 62% and identifying anatomical abnormalities in 53% of cases. Importantly, survival was higher in the FFB cohort (76%) compared to the non-FFB cohort (63%). Major complications were infrequent (7.6%), and most adverse events were self-limited. While bleeding events were reported, they were predominantly mild and did not universally necessitate procedure termination.

A central concern during ECMO is systemic anticoagulation, which raises the perceived risk of hemorrhagic complications during bronchoscopy. However, the ability to perform FFB at the bedside represents a significant practical advantage, as it avoids the need for operating room transfer and general anesthesia—both of which may pose additional physiological stress and logistical challenges in critically ill children. Prior experience reported by Kamat PP et al also suggests that, under careful monitoring, bronchoscopy can be performed safely in selected ECMO patients. ⁵ In this context, bedside FFB may offer meaningful diagnostic and therapeutic value while minimizing procedural burden. In patients receiving intensive systemic anticoagulation during ECMO support, FFB may be preferable to RB, as it is generally associated with a lower risk of bleeding complications.

Given that the smallest available outer diameter of flexible fiberoptic bronchoscopes is 2.8 mm, passage through the endotracheal tube (ETT) may not be feasible in very small children. In such cases, temporary extubation, placement of a laryngeal mask airway, and subsequent reintubation may be required. These additional airway manipulations could further complicate airway management and pose potential safety challenges in patients receiving ECMO support.

Taken together, current evidence—although limited and largely retrospective—suggests that FFB during pediatric ECMO may provide meaningful diagnostic clarification and therapeutic benefit without disproportionately increasing mortality risk. We believe that, when performed by experienced multidisciplinary teams, bronchoscopy should not be avoided solely due to anticoagulation concerns. Rather, individualized risk–benefit assessment is warranted.

Prospective multicenter studies are needed to better define indications, optimal timing, procedural protocols, and standardized safety parameters for bronchoscopy during pediatric ECMO. Until such data are available, cautious but proactive airway management may facilitate lung recovery and potentially expedite ECMO decannulation.

The authors are to be congratulated on their valuable contributions regarding the use of FFB in PICU patients, particularly those on ECMO. It is believed that the concerns and discussions surrounding this topic will shed light on the development of future indications for FFB use.