key: cord-0054828-2ed6sxy3
authors: Krall, Jennifer; Ali, Muhammad; Maslonka, Matthew; Pickens, Aaron; Bellinger, Christina
title: Bronchoscopy in the COVID-19 Era
date: 2020-12-30
journal: nan
DOI: 10.1097/cpm.0000000000000380
sha: 4a545577ba75fbf9f99673860f702b903d9c1d7b
doc_id: 54828
cord_uid: 2ed6sxy3

Bronchoscopy is an aerosol-generating procedure with important diagnostic and therapeutic indications. However, in the era of the coronavirus disease 2019 (COVID-19) pandemic, airway procedures can put health care providers at an increased risk of exposure and transmission of COVID-19. We have reviewed and summarized guidelines from various societies of respiratory medicine to stratify the indications for bronchoscopy and optimize preprocedural, procedural, and postprocedural preparation. Appropriate measures can help decrease exposure to health care workers when performing this aerosol-generating procedure.

exclusively referred to as aerosols) and large droplets. World Health Organization (WHO) has traditionally defined droplets as being > 5 µm in size. Droplet nuclei or aerosols, particles arising from desiccation of suspended droplets, are defined as being <5 µm in size. 6 Aerosol-generating procedures may also create opportunities for direct contact and fomite transmission. 7 Aerosolizing procedures pose the greatest risk for transmission of this virus, thereby placing health care professionals at an increased risk of exposure. As early as January 2020, the first providers who were caring for COVID-19 patients were documented as contracting the disease and tragically the first provider death was confirmed in an otolaryngologist practicing in Wuhan, China. 8, 9 Pulmonologists, otolaryngologists, oral surgeons, ophthalmologists, and anesthesiologists are among the specialties known to be at an increased risk for infection, given the procedures they perform in or near the upper aerodigestive tract. 10, 11 Bronchoscopy remains one of the highest risk procedures within this population of patients due to its detectible disruption of airway mucosa and the increased pressures utilized to oxygenate and ventilate patients during the procedure. Secondary to the close contact between the medical personnel involved in the bronchoscopy and the patient, coughing and suction can produce significant amounts of droplets or aerosols, contaminating indoor equipment, procedure room's air, all personnel present, and even resulting in a higher risk of patient-to-patient cross-infection. 12 Nonetheless, bronchoscopy remains an imperative and important method for the diagnosis and treatment of respiratory illnesses that in certain instances cannot be postponed pending further progression of disease and clinical deterioration. Therefore, it is critical to stratify the patients requiring prompt bronchoscopic intervention along with those patients who may benefit from a delayed procedure.

Many strategies have endeavored to minimize risk of transmission from airway procedures in COVID-19 patients. Examples described include a closed, in-line suction system to seal the bronchoscope during percutaneous tracheostomy, a reusable acrylic barrier enclosure during standard intubation, and utilizing disposable drapes to create a contained tent immediately around the patient. [13] [14] [15] To protect providers and patients alike, standardized approaches must be implemented to minimize the risk of exposure while preserving the ability to perform medically appropriate aerosolizing procedures such as bronchoscopy. 16 In this review, we will discuss guideline-driven outlined steps to ensure the least amount of risk for the health care team involved with bronchoscopy, including patient selection, preprocedural practices, postprocedural cleaning, and handling of the respiratory samples obtained.

Bronchoscopy is an aerosol-generating procedure that puts health care workers at an increased risk of exposure and infection, hence discussion and planning with all involved personnel before the procedure is essential to ensure the procedure runs smoothly and exposure risks are limited. Temperature, travel, exposure, and symptom screening should be considered. Patients should wear a surgical mask in the pre-procedure area, bronchoscopy suite, and in the recovery area. In the interest of conserving personal protection equipment (PPE) and minimizing staff exposure as much as possible, the participating personnel should be limited to only those needed for the procedure-bronchoscopist, bronchoscopy assistant, and anesthesia team, if necessary. No observers, students, apprentices, or trainees should be in the procedure room.

Reports of asymptomatic carriers and studies showing early viral shedding in mild or prodromal stage of the disease are worrisome for potential viral spread during an aerosol-generating procedure. [17] [18] [19] As the COVID-19 testing capabilities have improved with a shortened turnaround time and health care facilities are gradually allowing elective procedures, pre-procedural COVID-19 testing should be obtained and verified along with a review of epidemiological and clinical markers of the active disease, ideally closely timed before the planned procedure, barring an emergent indication for bronchoscopy. 7, 20, 21 Debate remains on the balance of this resource use versus questionnaire screening, especially in areas where there is low prevalence and likely lower yield in testing. [22] [23] [24] Ultimately, the decision to implement pre-procedural COVID-19 testing should take testing capability, availability, and regional disease prevalence into consideration. Regardless, precautions should be taken to minimize transmission even with testing given the false negativity rate with testing.

Guidelines have been published for performing bronchoscopy in patients with low suspicion for COVID-19 or negative COVID-19 testing. 25 As patients with COVID-19 can be asymptomatic or presymptomatic, precautions should be taken to protect both the patient as well as the procedure personnel even in the setting of a pre-procedural negative test in an area where community transmission of COVID-19 infection is present. 26 Society guidelines (Table 1 ) recommend personal protective equipment (PPE) including N-95 respirator mask or powered air purifying respirators, face shield/eye protection, gown, and gloves. 12, [16] [17] [18] [19] [20] [21] [28] [29] [30] These are recommendations that have been put forth by both the major societies of respiratory disease and are similar to guidelines by anesthesia societies for aerosol-generating procedures. 31 These recommendations protect health care providers while allowing for continuation of clinical care.

Additional recommendations suggested by some societies include preference of transnasal approach using a slotted mouth and nose protector, avoiding rigid bronchoscopy with jet ventilation, and avoiding atomized lidocaine. 12, 21, 29 The individual patient and their indications should be considered in the setting of institutional resources when considering these recommendations.

Suspected or known COVID-19 positivity is considered to be a relative contraindication to bronchoscopy, given the clear risks to the participating staff. 32 Furthermore, only under rare circumstances should bronchoscopy be performed for the sole purpose of obtaining a specimen to test for COVID-19. 33 COVID-19 testing is recommended to be performed via nasal swabs. 12 Bronchoscopy should be limited to emergent or urgent indications ( Table 2 ). In the guidance put forth by the American Association for Bronchology and Interventional Pulmonology (AABIP), urgency of indications is outlined. 16 Emergent indications are considered to be moderately symptomatic or worsening tracheal/bronchial stenosis, symptomatic central airway obstruction, massive hemoptysis, and migrated stent. Urgent indications include lung mass or mediastinal/hilar lymphadenopathy suspicious for cancer, whole lung lavage, foreign object aspiration, mild to moderate hemoptysis, and suspected pulmonary infection in immunocompromised patients.

After taking into consideration risks and benefits, if the decision is made to proceed with a diagnostic or therapeutic bronchoscopy, measures can be taken to lower droplet transmission. 12, [16] [17] [18] [19] [20] [21] [28] [29] [30] Personnel should be strictly limited and the procedure should be performed in an airborne infection isolation room or negative pressure room. All personnel should properly don N-95 respirator and eye protection or a powered air purifying respirator, gown, and gloves. When doffing, the N-95 respirator, gown, and gloves should be discarded. When available and feasible, a disposable bronchoscope should be used. 21, 28 The patient's nose and mouth should be covered with a medical mask slotted for transnasal or transoral access. Cough should be minimized pharmacologically. Following proper doffing of PPE, meticulous hand hygiene should occur.

The Center for Disease Control and Prevention (CDC) has guidelines to determine when a recovered patient may have transmission-based precautions discontinued. 27 Presently, discontinuation of transmission-based precautions is recommended to be based on either a test-based strategy or a symptom-based strategy. For symptomatic COVID positive patients, transmission-based precautions can be discontinued if at least 73 hours has passed since recovery (resolution of fever without fever-reducing medication) and improvement in respiratory symptoms and at least 10 days has passed since the first symptoms appeared. The test-based strategy includes negative results of SARS-CoV-2 RNA molecular assay from at least 2 consecutive specimens obtained ≥ 24 hours apart in addition to the resolution of fever and improvement of respiratory symptoms. In patients who remain asymptomatic but test positive for COVID-19, a period of 10 days from the first diagnostic test or 2 negative specimens obtained ≥ 24 hours apart may be used. As the body of evidence increases, this is subject to change. Therefore, practices should follow the updated guidelines.

Bronchoscopy is not the recommended test of choice for diagnosing COVID-19. 12 However, if this testing modality is required, lower respiratory tract specimens sent for SARS-CoV-2 testing should include at least 2 to 3 mL of fluid and be placed in a sterile, dry container with appropriate labeling. 34 The samples should be transported to an appropriately qualified laboratory, accompanied by any required COVID-19 testing form, to ensure safe and proper processing. Routine viral testing and microscopic staining and examination can be processed in a biosafety level 2 (BSL-2) laboratory. 35 Post-procedural considerations are equally important for the safety of health care personnel and prevention of nosocomial transmission of COVID-19. According to one study, SARS-CoV-2 can remain aerosolized for up to 3 hours and was viable on plastic and stainless steel surfaces for up to 72 hours. 36 Following bronchoscopy, the patient should be recovered according to local protocol. All staff involved should then doff PPE and perform hand hygiene as described above. All horizontal and work surfaces, video monitors and hardware should then be disinfected with EPAapproved cleaners. As bronchoscopy is an aerosol-generating procedure, any bronchoscopy on a suspected or confirmed COVID-19 Bronchoscopy for any elective reason should be postponed until after full recovery and the patient is declared free of infection patient should be followed by an appropriate air turnover time.

Bronchoscopists should consult with their local infection control experts to determine this duration based on the ventilation capabilities of the room. Disposable equipment should be discarded and medical waste collected with routine biohazardous waste. 35 The AABIP recommends that single-use bronchoscopes be considered as first line, if available, for any suspected or confirmed COVID-19 patient. All reusable bronchoscopes should be reprocessed with standard manual cleaning followed by high-level disinfection. There are no current recommendations supporting the use of additional cleaning procedures. Reprocessing staff should be appropriately experienced and wear full PPE. 16 ,37

The COVID-19 pandemic has changed the approach to bronchoscopy to maximize the safety of involved health care providers. Patients continue to need urgent and emergent diagnostic and therapeutic bronchoscopy for a variety of indications even during a pandemic involving an easily aerosolized and transmissible virus. Bronchoscopy can be safely performed by taking the appropriate preprocedural, procedural, and postprocedural precautions and having a tiered approach to bronchoscopy to appropriately risk stratify urgent and emergent procedures. Ongoing data should be collected on exposures and transmission in this health care setting. If 2 COVID-19 PCR samples are negative and clinical suspicion persists In hospitalized patients with confirmed COVID-19, repeated upper and lower airway samples can be collected to demonstrate viral clearance, the frequency of which will depend on local resources When there is an alternative or added diagnostic suspicion that has clinical or therapeutic relevance for the patient (especially in immunocompromised patients) Lobar or total pulmonary atelectasis occurs Massive hemoptysis with hemodynamic instability that requires endoscopic maneuvers to control bleeding For the removal of a foreign body For the treatment of an obstruction of the central airway that is symptomatic or hinders the therapeutic management of the patient As an aid to ventilatory support measures, such as the need for endotracheal intubation or the performance of a percutaneous tracheotomy and the management of its complications The rest of the indications, when there is no clinical repercussion or does not make management difficult, should be postponed until the patient is free of the disease Argentine Association of Bronchoesophagology (AABE) 30 Extremely limited role in the diagnosis of COVID-19 and only be considered in intubated patients if the upper airway samples are negative and other diagnoses are considered to significantly change clinical management Relatively contraindicated in patients with suspected and confirmed COVID-19 infections. Bronchoscopy should be postponed until after full recovery and the patient is declared free of infection for indications including lung/bronchial mass, mediastinal/hilar lymphadenopathy, pulmonary infiltrates and mild to moderate airway stenosis Bronchoscopy (flexible and rigid) for urgent/emergent reasons should be considered only if bronchoscopic intervention is necessary for life saving. Indications include: life-threatening hemoptysis; severe stenosis of the airway; suspected secondary infectious etiology or malignant condition causing significant endobronchial obstruction

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