Therapeutic bronchoscopy vs. standard of care in acute respiratory failure: a systematic review

Background: We aimed to assess patient-important benefits and harms of therapeutic bronchoscopy vs. standard of care (no bronchoscopy) in critically ill patients with acute respiratory failure (ARF).

Methods: We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) according to the Cochrane Handbook and GRADE methodology, including a predefined protocol (PROSPERO no. CRD42016046235). We included randomized clinical trials (RCTs) comparing therapeutic bronchoscopy to standard of care in critically ill patients with ARF. Two reviewers independently assessed trials for inclusion, extracted data and assessed risk of bias. Risk ratios (RR) with 95% confidence intervals (CI) were estimated by conventional meta-analysis. The risk of random errors was assessed by TSA. Exclusively patient-important outcomes were evaluated.

Results: We included five trials (n = 212); all were judged as having high risk of bias. There was no difference in all-cause mortality between therapeutic bronchoscopy and standard of care (TSA adjusted RR 0.39; 95% CI 0.14 to 1.07; I² 0%), and only 3% of the required information size had been accrued. There was no difference in ICU length of stay. A shorter duration of mechanical ventilation was suggested by conventional meta-analysis, however TSA highlighted that only 42% of the required information size had been accrued, indicating high risk of random errors. No trials reported data on adverse events, hospital length of stay, quality of life or performance status.

Conclusions: The quantity and quality of evidence supporting therapeutic bronchoscopy in critically ill patients with ARF is very low with no firm evidence for benefit or harm.