Comment on the use of bronchoscopy in the postoperative management of lung cancer patients

Abstract

Zhang et al. explore “Effectiveness of bronchoscopy-assisted postoperative respiratory management in patients with lung cancer and impaired cough strength” in a high-risk population. The study is clinically relevant, but its sample size and lack of standardized objective assessments decrease its generalizability and reproducibility. The study discusses different interventions for respiratory clearance. The study discusses various interventions for respiratory clearance. However, the inclusion of noninvasive airway clearance techniques (e.g., physiotherapy or mechanical exsufflation) and bronchoscopy, guided by standard clinical guidelines and protocols, particularly for patients with neuromuscular conditions such as post-polio syndrome, could improve its clinical effectiveness. The study reported that 25% of patients had atelectasis because they did not get effective respiratory rehabilitation, which questions the effectiveness of the intervention on its own. These are gaps and limitations; thus, further studies that use standard guidelines and well-compared approaches are needed to benefitclinical practice.

Dear Editor,

We read with great interest the study “Effectiveness of bronchoscopy-assisted postoperative respiratory management in patients with lung cancer and impaired cough strength: a retrospective cohort study” by Zhang et al^[1]. By focusing on a population at high risk of respiratory complications they address a significant clinical gap in thoracic surgery. Thereby offering a timely and valuable contribution to thoracic surgery and postoperative care.

However, we could point out a few areas where the study could be further strengthened. The study highlights the role of bronchoscopy-assisted suctioning in enhancing airway patency and secretion clearance, yet it does not adequately reference clinical guidelines supporting bronchoscopy as a standard intervention for secretion management. These benefits must be weighed against concerns including increased risks of postoperative pulmonary infections, cost-effectiveness, and prolonged hospitalization as argued by Xu^[2], whose study included a larger sample size of 179 patients as compared to 12 patients in the present study. A larger cohort could have improved the generalizability of the results. Xu^[2] suggests bronchoscopy for secretion clearance should be cautiously considered.

Furthermore, this study uses a self-made subjective cough strength scale (0–5), no objective parameters are used. Despite its seeming structure, this method is not standardized. On the other hand, Liu et al^[3]., demonstrated that postoperative peak expiratory flow is a valid, objective measure of cough ability after surgery and an effective predictor of postoperative pulmonary complications.

Although Zhang et al. discussed how they assessed airway competence after extubation, they do not explicitly clarify whether recommended noninvasive approaches like physiotherapy or cough-assist methods were used or failed before proceeding to bronchoscopy. Interestingly they also mention the Enhanced Recovery After Surgery Society and the European Society of Thoracic Surgeons guidelines which emphasize the importance of rehabilitation and early postoperative care including inspiratory muscle training, deep-breathing exercises, and early mobilization for patients with compromised respiratory function^[4].

Moreover, one patient in their cohort had post-polio syndrome a recognized neuromuscular disorder for which the 2023 ACCP/CHEST (An American College of Chest Physicians Clinical Practice) guideline suggests a sequential, noninvasive airway-clearance protocol beginning with lung-volume recruitment, manually assisted cough, and mechanical insufflation exsufflation. Zhang et al. do not report using any of these foundational rehabilitation or immediate postoperative measures^[5].

Authors report atelectasis or exudate in 25% (3 out of 12) of bronchoscopy-assisted patients while also emphasizing that none required hospital readmission which downplays their core argument’s clinical significance. Atelectasis is a well-established precursor to pneumonia and respiratory decline. A recent meta-analysis in lung cancer surgery patients showed that structured respiratory rehabilitation including breathing exercises reduces atelectasis risk by 65%. Nonetheless, such complications occurring despite bronchoscopy and without mentioning any explicit use of rehab services severely challenge the interventions claimed effectiveness^[6].

In summary, the present study presents initial descriptive information about bronchoscopy-guided treatment; however, its methodological drawbacks and loss of an index-guided strategy approach suggest that further investigation is necessary to establish its clinical value.

This article is compliant with the TITAN Guidelines 2025^[7].

Ethical approval

Not required.

Consent

Informed written consent was taken.

Sources of funding

None.

Author contributions

S.I.U.H.R.: study concept, data collection, analysis and writing. S.H.U.H.S.: study concept, data collection, analysis and writing. H.A.Q.: study concept, data collection and writing. H.A.: data collection and writing. A.P.: writing and submission.

Conflicts of interest disclosure

None.

Research registration unique identifying number (UIN)

N/A.

Guarantor

Syed Ibraheem ul Hassan Ramzi and Syed Hameed-Ul-Hassan Shah are guarantors for this work.

Peer and provenance statement

None.

Data availability statement

N/A.