Authors: Zhaomin Xu, Chang Liu, Chenhao Zhang, Miaomiao Gu, Yang Xue, Xibiao Yang, Yongfang Zhou
Categories: Original Article, Bronchoscopy, lobectomy, postoperative pulmonary complications (PPCs)
Source: Journal of Thoracic Disease
Bronchoscopy increased the risk of postoperative pulmonary complications in patients undergoing lobectomy for lung a retrospective cohort study
Authors: Zhaomin Xu, Chang Liu, Chenhao Zhang, Miaomiao Gu, Yang Xue, Xibiao Yang, Yongfang Zhou
Abstract
Background
Postoperative pulmonary complications (PPCs) are a leading cause of morbidity and mortality, particularly following thoracic surgeries like lobectomy for lung cancer. These complications not only increase patient suffering but also lead to longer hospital stays and higher healthcare costs. Bronchoscopy, a procedure that enables airway visualization, serves both diagnostic and therapeutic functions. In postoperative care, bronchoscopy helps clear secretions, identify and resolve airway issues, and assess lung re-expansion. This study aimed to investigate whether patients admitted to the intensive care unit (ICU) with routine treatment with bronchoscopy after lobectomy for lung cancer can reduce PPCs, shorten the length of hospital stay, and reduce hospitalization expenses.
Methods
This study was a single-center, retrospective cohort study of patients who underwent lobectomy for lung cancer and were subsequently admitted to the ICU between January and December 2021. PPCs, length of hospital stay, and hospitalization expenses were compared between patients treated with bronchoscopy (the bronchoscopy group) and without bronchoscopy (the non-bronchoscopy group). Additionally, the risk factors of postoperative pulmonary complications were analyzed.
Results
A total of 515 patients were included, with 179 patients in the bronchoscopy group and 336 patients in the non-bronchoscopy group. Patients in the bronchoscopy group experienced a higher incidence of PPCs [73 (40.8%) vs. 57 (17.0%); P<0.001], prolonged length of hospital stay [median (interquartile range): 11 (7–14) vs. 7 (5–9.8) days; P<0.001], and higher hospitalization expenses [median (interquartile range): 58,392 (51,248–64,998) vs. 53,563 (48,580–59,276) yuan; P<0.001] than patients in the non-bronchoscopy group. As shown by multifactor logistic regression analysis, postoperative bronchoscopy and tumor size were associated with increased risk of PPCs [odds ratio (OR) 2.71, 95% confidence interval (CI): 1.74–4.21, P<0.001; OR 1.20, 95% CI: 1.05–1.36, P=0.006, respectively], while video-assisted thoracoscopic surgery was associated with a decreased risk (OR 0.22, 95% CI: 0.11–0.45, P<0.001).
Conclusions
Bronchoscopy was associated with a higher risk of PPCs as well as with prolonged hospital stays and increased hospital expenses among postoperative patients who underwent lobectomy for lung cancer. It should be cautiously considered in clinical practice.
Introduction
Globally, lung cancer is the leading cause of cancer-related mortality (1). Lung cancer ranked first among all cancer types in China in 2018, with an estimated 2.09 million new cases. It also accounted for roughly 20% of all cancer deaths (2). For early lung cancer, surgery is the recommended course of treatment and can greatly enhance patient outcomes (3). Although surgical techniques and perioperative management have been improved, postoperative pulmonary complications (PPCs) remain one of the most concerning postoperative complications. PPCs occur in 13% to 30% of patients undergoing surgical resection of lung cancer, and the most frequent ones are respiratory infection and atelectasis (4-7). PPCs are the leading cause of morbidity and mortality following thoracic surgery, and have a substantial negative influence on patients’ health and the cost of health care services (8). Approximately 14% to 30% of patients developing PPCs after thoracic surgery will die within 30 days, in comparison with 0.2–3% of those without PPCs (9).
Previous studies have demonstrated that male, smoking history, tumor size, operating time, emphysema, and chronic obstructive pulmonary disease (COPD) are independent risk factors for PPCs following lung cancer surgery (4,7,10-12). But there is still a lack of evidence for interventions to reduce PPCs. Identifying the PPCs’ modifiable risk factors is essential to establish the effective methods that decrease the incidence and negative impact of PPCs. PPCs include respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax; and respiratory infection and atelectasis are the most prevalent and serious PPCs, and patients with one or more PPCs, even mild PPCs, are associated with increased early postoperative mortality, intensive care unit (ICU) occupancy, and ICU/hospital stay (6,8,13,14). Clinically, patients who undergo general anesthesia and lung resection surgery commonly encounter postoperative residual secretions and atelectasis, which in turn increases the risk of subsequent pulmonary infections. Bedside, bronchoscopy is frequently performed in cases of residual secretions or obstructive atelectasis, and even for obtaining deep samples for lung infection in the ICU (15). However, this is an invasive procedure that may increase the risk of pulmonary infections (16). The occurrence of cross-contamination or infection following perioperative bronchoscopy usage is reported to be 2.8%, with the overall cost of each bronchoscopy usage of £249 sterling, and the expense of treating cross-infection of up to £511 sterling per patient (16). Considering this, the benefits and risks of bronchoscopy usage need to be thoroughly assessed. This study aimed to evaluate the impact of bronchoscopy on the occurrence of PPCs, the length of hospital stay, and hospitalization expenses for patients who underwent lobectomy for lung cancer, and to determine potential modifiable independent risk variables for PPCs. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2140/rc).
Methods
Data source and patient population
This was a single-center, retrospective cohort study. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics board of the West China Hospital of Sichuan University (No. 2021-41), and all patients provided written informed consent. Patients who denied access to their medical records for research purposes were excluded from this study. At the lung cancer center of West China Hospital of Sichuan University, all patients who underwent lobectomy were admitted to the ICU. The study included patients who underwent lobectomy and were admitted to the ICU from January 1, 2021, to December 31, 2021. Surgically removed specimens, computed tomography (CT)-guided needle lung biopsies, or bronchoscopic biopsies were used to pathologically confirm lung cancer. Patients were excluded according to the exclusion criteria as (I) patients undergoing a surgical procedure other than lobectomy; (II) experiencing another surgery within 3 months before the surgery; (III) receive any neoadjuvant therapy before surgery; (IV) patients with other malignant tumors; (V) preoperative infection conditions with clinical or laboratory evidence; (VI) patients with recurrent tumors.
Bronchoscopy procedures
In our study, we used reusable flexible bronchoscopes (model: BF-1TQ290; LF-TP, Olympus, Aizuwakamatsu, Japan). To prevent contamination during bronchoscopy, we implemented the following (I) all reusable bronchoscopes underwent high-level disinfection using an automated endoscope reprocessor (AER) with a validated disinfectant (o-phthalaldehyde disinfectant); (II) bronchoscopy procedures were performed using sterile technique, including the use of sterile gloves, gowns, and drapes; (III) bronchoscopes and accessories are stored in dedicated storage cabinets equipped with appropriate air filtration systems and disinfection solutions; (IV) all personnel involved in the procedures received training on infection control practices and the proper use of reusable bronchoscopes.
The decision for postoperative bronchoscopy was primarily made by the surgeons. Some surgeons performed bronchoscopy on all their patients, while others decided to do so for diagnostic and therapeutic purposes after conducting a comprehensive assessment based on the patient’s clinical condition, physical examination, and imaging studies. The specific indications (I) diagnostic cytology (e.g., bronchial washings, specimen culture) for diagnosing infections; (II) therapeutic removal of excessive secretions and mucus plugs to clear the airways. Some surgeons routinely arrange bronchoscopy for airway clearance on the first day after surgery for their patients. Others perform bronchoscopy to obtain deep lung pathogens when clinical signs and symptoms, such as fever, cough, sputum production, and abnormal lung sounds, are present. The bronchoscopy procedure involved the use of a flexible bronchoscope inserted through the patient’s tracheal intubation or nasal cavity. Local anesthesia was applied to the throat and vocal cords to minimize discomfort and the gag reflex. The procedure included a careful examination of the trachea, bronchi, and bronchioles, with the option to collect tissue samples or perform therapeutic interventions as needed. All patients were monitored before, during, and after the procedure to ensure safety and manage any potential complications. The procedure was performed by experienced operators to ensure accuracy and safety.
Some patients with poor clinical conditions or PPCs also underwent bronchoscopy, which might have influenced the results. To address this, we identified a “bronchoscopy with suspected infection group” using the following new or changed sputum, new or changed lung opacities, fever, and white blood cell count >12×10^9^/L (9). Bronchoscopy without suspected infection patients who underwent bronchoscopy and did not meet the criteria for suspected infection. Non-bronchoscopy patients who did not undergo bronchoscopy and also did not meet the criteria for suspected infection. We then conducted a subgroup analysis comparing the “bronchoscopy without suspected infection group” with the “non-bronchoscopy group” to assess the impact of bronchoscopy on postoperative pulmonary complications after lobectomy.
Data collection
We retrospectively reviewed the electronic medical records of all eligible patients and extracted their relevant demographic and clinical data. Preoperative comorbidity, smoking history, preoperative lung function, including forced expiratory volume in the first second as a percentage of the predicted value (FEV1, % pred), forced vital capacity as a percentage of predicted value (FVC, % pred) and FEV1/FVC%, American Society of Anesthesiologists (ASA) score, surgical condition, tumor location, tumor size, pathological type, and tumor-node-metastasis (TNM) stage (based on the 8th edition of TNM classification of lung cancer by the Union for International Cancer Control, UICC), laboratory data, PPCs, length of stay (LOS), in-hospital mortality, and hospitalization expenses were collected.
Reference standard for PPCs
PPCs were correlated with the European Consensus on Perioperative Clinical Outcomes and terms related to postoperative respiratory complications (9,14). PPCs (I) respiratory infection was defined as that patient had received antibiotics for a suspected respiratory infection and met one or more of the following new or changed sputum, new or changed lung opacities, fever, white blood cell count >12×10^9^/L; (II) respiratory failure was defined as postoperative PaO2 <8 kPa (60 mmHg) on room air, a PaO2:FiO2 ratio <40 kPa (300 mmHg) or arterial oxyhemoglobin saturation measured with pulse oximetry <90% and requiring oxygen therapy; (III) pleural effusion defined as chest radiograph demonstrating blunting of the costophrenic angle, loss of sharp silhouette of the ipsilateral hemidiaphragm in upright position, evidence of displacement of adjacent anatomical structures or a hazy opacity in one hemithorax with preserved vascular shadows in supine position; (IV) atelectasis defined as lung opacification with shift of mediastinum, hilum, or hemidiaphragm towards affected area, and compensatory over-inflation in adjacent non-atelectatic lung; (V) pneumothorax was as air in pleural space with no vascular bed surrounding visceral pleura.
Statistical analysis
Statistical analyses were performed using the R software package, and a P value less than 0.05 was accepted as the criterion of significance. Results were expressed as mean (standard deviation) or median and interquartile range (IQR) for continuous variables and as a percentage for categorical variables. Fisher’s exact test or χ^2^ test was used for the comparison of categorical variables. Student’s* t*-test or one-way analysis of variance (ANOVA) was used for the comparison of continuous data separately. The variables with P<0.05 in univariate analysis were entered into a multivariate logistic regression analysis to identify independent risk factors of PPCs. The results of the regression analysis were reported as the odds ratio (OR) and 95% confidence interval (95% CI).
Results
Patient enrollment
Following the inclusion and exclusion criteria, a total of 589 patients were admitted to the ICU for pulmonary lobectomy, of whom 18 were excluded from the trial because of receiving neoadjuvant therapy and 56 were excluded for non-cancerous nodules (n=56). Finally, a total of 515 patients were analyzed, with 179 patients in the bronchoscopy group and 336 patients in the non-bronchoscopy group (Figure 1).
Baseline characteristics of the study population
Among the enrolled 515 patients, 237 (46.0%) were male. The average age and body mass index (BMI) were 61 years (range, 53–67 years) and 23.5±3.0 kg/m^2^. Thirty-seven patients (7.2%) were current smokers and 141 patients (27.4%) had previously smoked. Preoperative comorbidities COPD in 13 patients (2.5%); emphysema in 77 patients (15%); hypertension in 120 patients (23.3%); diabetes in 50 patients (9.7%); and coronary heart disease (CHD) in 13 patients (2.5%). The study population’s mean FEV1, % pred, FVC, % pred and FEV1/FVC% were 98.3%±17.8%, 97.0%±18.1%, and 83.5%±9.1%, respectively. The ASA score was two points in 447 cases (86.8%) and the operation time was 2 (IQR, 2–3) hours. Three hundred and twenty-three patients underwent the video-assisted thoracoscopic surgery (VATS) (62.7%). Tumors were most frequently located in the right lung (64.9%) and tumor size was 2.5 (IQR, 1.8–3.5) cm. The majority of patients underwent resection for AC (80.6%) and had clinical stage IA or IB disease (70.5%). Compared with the non-bronchoscopy group, the bronchoscopy group had more males (P=0.004) and a higher average age (P=0.002). Preoperative comorbidities, including COPD, hypertension, diabetes, and CHD, were not significantly different between the non-bronchoscopy group and the bronchoscopy group, but emphysema (P<0.001) was higher in the bronchoscopy group. The FEV1, % pred, FVC, % pred were significantly lower in the bronchoscopy group than in the non-bronchoscopy group (P<0.001; P=0.001, respectively). The operation time was significantly longer (P<0.001) and the tumor size was larger (P<0.001) in the bronchoscopy group than in the non-bronchoscopy group. The smoking status (P<0.001): never smokers 96 (53.6%)* vs. 241 (71.7%), ex-smokers 71 (39.7%) vs. 70 (20.8%); surgical approach (P<0.001): thoracotomy 100 (55.9%) vs. 74 (22.0%), VATS 66 (36.9%) vs. 257 (76.5%); pathological type (P=0.002) and TNM stage (P<0.001): IIA/B 34 (19.0%) vs. 31 (9.2%), IIIA/B/C 36 (20.1%) vs. *35 (10.4%) showed significant differences between the bronchoscopy group and the non-bronchoscopy group. Detailed data are shown in Table 1.
A small number of patients who underwent bronchoscopy were suspected of infection, so subgroup analysis was performed on the bronchoscopy without suspected infection group and the non-bronchoscopy group. Baseline characteristics are shown in Table S1. Of the 473 patients, 216 (45.7%) were male, and the median age of the cohort was 59 (IQR, 52–67) years. The mean BMI was 23.4±3.0 kg/m^2^. Thirty-three patients (7.0%) were current smokers and 125 (26.4%) were ex-smokers. Preoperative comorbidities included COPD 11 patients (2.3%), emphysema 68 patients (14.4%), hypertension 106 patients (22.4%), diabetes 44 patients (9.3%) and CHD 11 patients (2.3%). The study population’s mean FEV1, % pred, FVC, % pred, and FEV1/FVC% were 98.9%±17.4%, 97.5%±17.8%, and 83.6%±9.0%, respectively. ASA scores in 409 cases (86.5%) were two points and the operation time was 2 (IQR, 2–3) hours. Three hundred and eighteen patients (67.2%) underwent the VATS. Tumors were located in the right lung in 307 patients (64.9%) and the tumor size was 2.5 (IQR, 1.8–3.5) cm. Adenocarcinoma was the most common histological type of cancer (81.4%). The pathological stage in more than half of the patients was stage I (all stage IA/B: 71.9%; stage IIA/B: 12.1%; stage IIIA/B/C:13.1%; stage IVA/B: 3.0%). Compared with the non-bronchoscopy group, the bronchoscopy without suspected infection group had more males (P=0.003), older age (P=0.02), and less cumulative smoking (P<0.001). Preoperative comorbidities, including emphysema (P<0.001), FEV1, % pred (P<0.001), and FVC, % pred (P=0.003) were lower in the bronchoscopy without suspected infection group compared to the non-bronchoscopy group. The operation time (P=0.001) was significantly longer and the tumor size (P<0.001) was larger in the bronchoscopy without suspected infection group than the non-bronchoscopy group. The smoking status (P<0.001): never smokers 74 (54.0%)* vs. 241 (71.7%), ex-smokers 55 (40.1%) vs. 70 (20.8%); surgical approach (P<0.001): thoracotomy 67 (48.9%) vs. 74 (22.0%), VATS 61 (44.5%) vs. 257 (76.5%); pathological type (P=0.002), and TNM stage (P<0.001): IA/B 80 (58.4%) vs. 260 (74.4%), IIA/B 26 (19.0%) vs. 31 (9.2%), IIIA/B/C 27 (19.7%) vs. *35 (10.4%) showed significant differences between the bronchoscopy without suspected infection group and the non-bronchoscopy group. Detailed data are shown in Table S1.
Postoperative outcomes
Table 2 shows the postoperative outcomes between the bronchoscopy group and the non-bronchoscopy group. PPCs occurred in 130 patients (25.2%). The most common PPC was respiratory infection, which affected 60 patients (50.8%), followed by pneumothorax in 31 patients (23.8%). Pleural effusion in 15 patients (11.5%), atelectasis in 15 patients (11.5%), with respiratory failure ranked last in 3 patients (2.3%). Compared to the non-bronchoscopy group, the incidence of PPCs in the bronchoscopy group was higher (40.8%* vs. 17.0%; P<0.001). More patients in the bronchoscopy group experienced pulmonary infection (56.2% vs. 43.9%; P<0.001) and pleural effusion (P=0.046) than in the non-bronchoscopy group. However, there was no difference in other PPC types between the patients in the bronchoscopy group and the non-bronchoscopy group. Patients in the bronchoscopy group had significantly longer hospital stay [11 (IQR, 7–14) vs. 7 (IQR, 5–9.8) days] compared to patients in the non-bronchoscopy group. Hospitalization expenses were higher [58,392 (51,248–64,998) vs. *53,563 (48,580–59,276) yuan; P<0.001] in the bronchoscopy group than those in the non-bronchoscopy group.
Table 3 displays postoperative outcomes between the bronchoscopy without suspected infection group and the non-bronchoscopy group. PPCs occurred in 108 patients (22.8%). The most common PPC was respiratory infection in 55 patients (50.9%), which was followed by pneumothorax in 26 patients (24.1%), atelectasis in 15 patients (13.9%), pleural effusion in 9 patients (8.3%) and respiratory failure in 3 patients (2.8%). There was no significant difference in the incidence of PPCs between the bronchoscopy without suspected infection group and the non-bronchoscopy group [51 (37.2%)* vs. 57 (17.0%); P=0.31]. However, the bronchoscopy without suspected infection group had statistically significantly higher incidences of respiratory infections [30 (58.8%) vs. 25 (43.9%); P<0.001] than the non-bronchoscopy group. The incidence of pneumothorax in the bronchoscopy without suspected infection group was lower than that in the non-bronchoscopy group [12 (23.5%) vs. 14 (24.6%); P=0.047]. Compared to patients in the non-bronchoscopy group, patients in the bronchoscopy without suspected infection experienced significantly longer hospital stay [10 (IQR, 7–13) vs. 7 (IQR, 5–9.8) days, P<0.001] and higher hospitalization expenses [57,328 (IQR, 49,781–63,906) vs. *53,562 (IQR, 48,581–59,251) yuan; P=0.002].
Univariate and multivariate analyses of risk factors for PPCs
We evaluated the variables that were significantly associated with PPCs in univariate analysis (P<0.05). Univariate regression analysis (Table 4) showed that male (P=0.02), smoking status (P=0.001), emphysema (P=0.03), FEV1, % pred (P=0.005), FVC, % pred (P=0.01), VATS (P<0.001), operation time (P=0.001), tumor size (P<0.001), TNM IIA/B (P=0.01), IIIA/B/C (P<0.001), IVA/B (P=0.03), bronchoscopy (P<0.001) were potential predictive factors for PPCs.
Multivariate logistic regression analysis was used to identify preoperative variables independently associated with PPCs. Variables significantly independently indicated that bronchoscopy and tumor size increased the risk of PPCs (odds ratio 2.71, 95% CI: 1.74–4.21, P<0.001; odds ratio 1.20, 95% CI: 1.05–1.36, P=0.006, respectively), while VATS associated with decreased risk of PPCs (odds ratio 0.22, 95% CI: 0.11–0.45, P<0.001) (Table 4).
Discussion
We found that compared with the non-bronchoscopy group, the bronchoscopy group had a higher incidence of PPCs in patients with lung cancer undergoing lobectomy, which prolonged hospital stay and increased hospitalization expenses, and also increased the risk of respiratory infection. Multivariate logistic regression analysis showed that bronchoscopy, tumor size, and thoracotomy were independent risk factors for PPCs.
Although surgical techniques and perioperative management have improved, PPCs remain one of the most concerning postoperative complications. PPCs occur in 13% to 30% of patients undergoing surgical resection of lung cancer, which delays the recovery of patients and increases the hospitalization expenses (4-7,17). Previous studies have demonstrated that male, smoking history, tumor size, operating time, emphysema, and COPD are independent risk factors for PPC following lung cancer surgery (4,7,10-12). But there is still a lack of evidence for interventions to reduce PPCs. The most common PPCs are pulmonary infection and atelectasis (6), However, bronchoscopy is an invasive operation. Whether bronchoscopy increases the risk of infection, its relationship with PPCs and the prognosis of patients is not clear. Our study found that the incidence of PPCs was significantly increased in the bronchoscopy group compared with the non-bronchoscopy group, especially the incidence of respiratory infections. Even if patients with suspected infection were excluded, the incidence of respiratory infection, hospital stay and hospitalization expenses in the bronchoscopy without suspected infection group were significantly higher than those in the non-bronchoscopy group. Prior research has also confirmed that bronchoscopy to remove secretions increases the risk of respiratory infection after lung cancer resection (18). Probably, the explanation is that there exists a potential hazard of cross-contamination or infection due to the perioperative utilization of bronchoscopy (16). Our study suggests that the indication of bronchoscopy for clearing secretions should be cautiously considered. Previous studies have shown that patients undergoing thoracic surgery should prioritize improving respiratory endurance and clearance of lung secretions by exercising inspiratory muscle strength and deep breathing exercises, postoperative activities, and chest physiotherapy, thereby reducing the risk of PPCs in respiratory tract infection (19-21). Early postoperative pain is the main cause of ineffective ventilation and cough, postoperative pain control is a common recommendation for preventing postoperative respiratory infections (21-23).
Surgical procedures involving the chest are associated with an increased risk of postoperative atelectasis. This condition can occur due to various factors following surgery, such as mucus plugs, infection, or insufficient lung expansion, general anesthesia, postoperative pain, and reduced mobility can also contribute to the development of atelectasis, which may lead to impaired gas exchange and loss of lung volume in one or more lobes of the lung (24,25). Previous studies have shown that bronchoscopy is required for postoperative atelectasis and can be used to treat atelectasis and pleural effusion, especially when bronchial obstruction or infection is suspected (25-27). Pleural effusion is a common complication after lung surgery. While bronchoscopy isn't a direct cause, it can help diagnose and manage conditions like infections or fistulas that may lead to pleural effusion. However, the primary causes are often related to surgical factors, postoperative inflammation, infection, and fluid management (28). Prolonged air leakage (PAL) is another common complication. Bronchoscopy can identify and manage sources of air leakage, such as bronchopleural fistulas. However, the main cause is usually related to the surgical procedure itself (29). Previous published studies have also confirmed the presence of atelectasis caused by poor sputum drainage and airway obstruction, bronchoscopy can enter the patient’s lower respiratory tract, suction sputum, remove sputum plugs, and sputum scabs, even local saline or drug lavage can be given to achieve the purpose of lung recruitment (25,30-32).
Besides, we found that tumor size and thoracotomy were independent risk factors for PPCs. Tumor size is a significant prognostic factor for PPCs, possibly because resection type and scope are determined based on the tumor size (33,34). Larger surgical scope, greater trauma and more lung surface wounds will aggravate postoperative weakness and impair the ability of expectoration. VATS lobectomy significantly reduces the incidence of PPCs, including pneumonia and atelectasis, compared with thoracotomy lobectomy. Possibly related to multifactorial components, such as the damage of cellular immunity, the decrease of acute phase response, ventilatory impairment, dyspnoea, decreased exercise tolerance, and pain (35-37). Meanwhile, multivariate logistic regression analysis showed that bronchoscopy was an independent risk factor for PPCs. Our study found that bronchoscopy is associated with an increased risk of PPCs, including infections. Previous research has also identified bronchoscopy as a potential source of healthcare-associated infections, even when reusable bronchoscopes are properly disinfected (38). However, bronchoscopy remains a valuable tool for diagnosing and managing PPCs such as atelectasis, pleural effusion, and pneumothorax (25,28,29). Therefore, the decision to perform postoperative bronchoscopy should be based on the individual patient’s clinical condition and specific indications for the procedure. Routine bronchoscopy for secretions drainage to manage residual secretions should be considered a contraindication. The airway can be cleared by strengthening analgesia, exercising inspiratory muscle strength, and performing deep breathing exercises (19-21). In cases where patients have atelectasis or there is a strong suspicion of infection requiring deep specimen collection or other complications, the benefits of bronchoscopy may outweigh the risks, and it can be considered. Standardizing the operation and disinfection management processes is crucial.
Our study has several limitations. First, our data were from a retrospective, single-center study, which may limit the generalizability of our findings to other populations. Second, due to historical limitations in the integration of electronic health records, patients’ clinical status prior to bronchoscopy [i.e., Acute Physiology and Chronic Health Evaluation II (APACHE II) score, etc.] was not systematically collected in our retrospective cohort, which may impact causal inference. Third, differences in past clinical practices led some surgeons to perform bronchoscopy on all patients, while others decided to do so after conducting a comprehensive assessment based on the patient’s clinical condition, physical examination, and imaging studies. To address this issue, we excluded the patient group with “suspected infection” and compared the impact of PPCs between the bronchoscopy group without suspected infection and the non-bronchoscopy group. Fourth, although this study indicates that routine bronchoscopy may increase the risk of complications, the results should be interpreted with caution. Furthermore, to emphasize residual confounding and the need for prospective studies with granular clinical data, more prospective trials employing stricter patient selection criteria, including randomized controlled trials or large-scale cohort studies, are necessary to rigorously evaluate this association, confirm causality, and inform clinical practice.
Conclusions
Our study suggests an association between bronchoscopy and an increased risk of postoperative pulmonary infection in patients after lobectomy, which prolonged the length of hospital stay and increased hospital expenses, especially the risk of respiratory infection, and bronchoscopy was an independent risk factor for PPCs prospective trials are needed to confirm causality and guide clinical practice.