Abstract Rationale Intensivist-led flexible bronchoscopy (FB) programs demonstrate high diagnostic yield and therapeutic impact in critically ill children. Our center has an established FB service with a structured training curriculum incorporating didactics, VR simulation, supervised practice, and competency-based progression. Prior work from our unit has described simulation training quality and experience however, real-world outcomes and practice patterns have not been systematically studied. This study aimed to characterize the use, indications, and outcomes of FB and identify opportunities for process improvement in performance and patient safety. Methods We conducted a retrospective review of all children (0-18y) who underwent FB at SickKids PICU(41-beds) between Jan-2019 and Dec-2024. Data included demographics, indications, respiratory support, bronchoscopic findings, interventions, and complications.Additionally, a focused q3-monthly quality improvement (QI) audit first of 4 planned audits evaluated procedures between June 1–August 31 2025, assessing sedation and ventilation practices, documentation completeness, workflow processes and selection of two cases to review for education and training. Results 179 patients underwent 246 bronchoscopies from 2019–2024. Median age was 61(17-172) months. Underlying conditions included oncologic(21%), pneumonia(15%), chronic respiratory disease(15%), and lung transplantation(14%). All were mechanically ventilated, and 26% on ECMO. Median time from ICU admission to procedure was 4(1-11) days. Primary indications included infection evaluation(30%), persistent focal radiographic abnormalities(25%), and surveillance bronchoscopy(15%). Key findings were increased secretions(51%) and airway malacia(4.9%); one-third(33%) had no abnormality or interventions. Interventions included airway plug removal(22.8%), bronchoalveolar lavage(20.7%) and DNase instillation(7.7%). Complications were infrequent: minor bleeding 4.9%, desaturation 4.5%, hypotension 1.2%, and bradycardia 0.4%, with no pneumothorax or cardiac-arrest.During QI phase, 21 procedures were reviewed in 14 patients. Fellows performed 72% of procedures, demonstrating strong trainee involvement. Most bronchoscopies occurred during daytime, 29% after 18:00, reflecting urgent indications. Documentation was variable: bronchoscopy note– 95%, but intraprocedural anesthesia record– only 52%. High ventilatory support was common (48% with PEEP 8cmH2O; 20% with FiO2 60%). Manual ventilation during the procedure was undocumented in 76%. Scope-tube size mismatch and abnormal ETT position were noted in 2(10%) each. FB influenced management through avoidance of rigid-bronchoscopy, adoption of prone-positioning, and rapid ventilatory improvement after plug removal. Conclusions Flexible bronchoscopy is safely and frequently performed in a high-acuity PICU, with substantial diagnostic/therapeutic value and significant trainee participation. A targeted QI-review identified opportunities to improve documentation and equipment selection. Ongoing audits with interventions may further optimize performance, training, and safety. This integrated clinical-QI-education framework is scalable and may serve as a model for competency development in complex pediatric critical care procedures. This abstract is funded by: None
Nallasamy et al. (Fri,) studied this question.