Repeated bronchoscopy with BAL may improve weaning success in intubated elderly patients with severe pneumonia

BACKGROUND: With advancing age, elderly patients often experience a decline in respiratory muscle strength and reduced ability to cough and clear sputum, leading to retention of respiratory tract secretions, which may further aggravate pulmonary infections.Despite the recognized efficacy of Bronchoalveolar Lavage (BAL) in removing respiratory secretions, objective bedside methods to evaluate secretion clearance after bronchoscopy are still lacking in very elderly patients with severe pneumonia. Electrical Impedance Tomography(EIT) allows for real-time, dynamic monitoring of lung ventilation, offering useful guidance for clinical decision-making. METHODS: We conducted a prospective randomized controlled trial that enrolled 60 intubated, very elderly patients with severe pneumonia.Patients were randomized via a random number table to receive either bronchoscopy group (BAL group) or without bronchoscopy group (N-BAL group).All patients received conventional management (including routine suction and antimicrobial therapy). Those in the BAL group also underwent bedside fiberoptic bronchoscopy with suction and BAL.The primary outcome measures included the weaning success rate and ICU length of days, secondary outcome measures included ICU mortalityn,the modified clinical pulmonary infection score (Modified CPIS), inflammatory markers (including C-reactive protein [CRP] and procalcitonin [PCT]), respiratory mechanics parameters(including Dynamic compliance [Cdyn] and airway resistance [Raw] Oxygenation index (OI = PaO/FiO), and the region of interest (ROI4). RESULTS: Following the 5-day study protocol (with bronchoscopy on days 1, 3, and 5), the BAL group showed significantly greater improvement,the BAL group demonstrated significant improvements in the pre-specified primary outcomes compared to the N-BAL group. The BAL group had a significantly higher rate of successful weaning (60.0% vs. 33.3%, p = 0.038) and a shorter mean ICU length of stay from enrollment (14.93 ± 3.04 vs. 16.67 ± 3.38 days, p = 0.041).For secondary outcomes, the BAL group showed significantly greater post-treatment improvements, including lower Modified CPIS (p = 0.012), lower PCT (p < 0.001) and CRP (p < 0.001) levels, improved Cdyn (p = 0.002), decreased Raw (p < 0.001), and a higher oxygenation index (OI) (p = 0.003). ICU mortality was not different between groups (p = 0.488).Furthermore, the BAL group exhibited a higher proportion of ROI4 distribution values in specific ventilatory areas on EIT (p = 0.008). CONCLUSION: In very elderly patients with severe pneumonia, intermittent fiberoptic bronchoscopy can significantly improve respiratory function, thereby increasing the rate of successful extubation and overall treatment efficacy. TRIAL REGISTRATION: This study has been registered in national medical research registration and filing information system of China, www.medicalresearch.org.cn, Trail registration number:MR-33-21-016317,registered on 02 Decembe 2021.