Flexible Bronchoscopy in the Intensive Care Unit: Controversies, Clinical Applications, and the Expanding Role of Intensivists

Abstract

Background: Flexible bronchoscopy (FB) has long been integral to pulmonology, but its bedside role in the intensive care unit (ICU) is expanding. Despite a lack of high-level evidence, FB remains a pivotal tool for airway visualization, sampling, and selected interventions in critically ill patients. Objective: This meta-narrative review critically appraises the clinical use, evolving indications, safety profile, and emerging controversies of FB in ICU settings, particularly regarding the role of non-pulmonologist intensivists. Methods: A structured literature search was conducted using PubMed, Scopus, and Google Scholar for studies published in the past 15 years. Emphasis was placed on observational studies, meta-analyses, and guidelines relevant to FB in ICU patients. Key controversies were grouped under thematic questions based on clinical relevance. Results: A total of 84 articles were retrieved, of which 47 met the predefined inclusion criteria. Seven key thematic domains were synthesized regarding the use of flexible bronchoscopy (FB) in the intensive care unit (ICU) setting. FB performed by trained intensivists was found to be safe and diagnostically effective across a range of ICU populations, including elderly and non-intubated patients. Although procedure-related hypoxemia was reported, it was largely manageable with appropriate precautions. FB demonstrated critical utility in the management of acute respiratory failure (ARF), acute respiratory distress syndrome (ARDS), and sepsis, particularly through bronchoalveolar lavage (BAL), airway secretion clearance, and, selectively, bronchoscopic lung biopsy. The adoption of disposable bronchoscopes may reduce infection risk and economic burden. Furthermore, the integration of advanced techniques such as endobronchial ultrasound (EBUS) and transbronchial cryobiopsy is emerging, although application in the critical care environment remains cautious and selective. Conclusions: With structured training and careful patient selection, FB is an adaptable and often underutilized tool in ICU medicine. Multidisciplinary competency development and institutional protocols can enhance its safe integration.