key: cord-0775219-zejwyzqk authors: He, Mei; Xiong, Jie; Huang, Sufang; Bian, Yi; Yan, Peng; Redding, Sharon R. title: Airborne precautions recommended in Wuhan, China for bedside fiberoptic bronchoscopy examination of patients with COVID-19. date: 2020-04-10 journal: J Infect DOI: 10.1016/j.jinf.2020.03.055 sha: 9e0f97468aea6034be2c2d5bc44e8ea64aee80a3 doc_id: 775219 cord_uid: zejwyzqk nan Here we would like to share our experience of airborne precautions for bedside fiberoptic bronchoscopy examination. The pandemic COVID-19 has become a global threat with 170,0 0 0 confirmed cases globally as of Mar 16, 2020. In China, there were 80,0 0 0 comfirmed cases, in which 3226 were critically ill patients. 3 The mortality rate for the critically ill patients were reported as over 50% by World Health Organization. 4 One key reason might be the difficulty with expectoration of secretions. Autopsy showed that the alveolar cavity of patients with COVID-19 was full of serous and fibrin exudate. 5 The typical pathologic change was clear membrane formation. Methods to decrease retention of secretions in critically ill patients include percussion, a prone position and endotracheal suctioning. However, since endotracheal suction catheters only reach the main bronchus but not the smaller airways, fiberoptic bronchoscopy has been suggested for diagnosis and treatment when necessary. 6 This procedure has been shown to improve respiratory function which can lead to recovery. In addition, a higher rate of confirmed diagnosis of COVID-19 was noticed compared using throat swab. 7 Beside the existing value of fiberoptic bronchoscopy in diagnosis and treatment, the potential risk to the health care givers during this procedure should be considered. Aerosol contamination of the environment is increased because the patient's upper respiratory tract is exposed for an extended period. Airborne and contact precautions are critical for the health care team. In addition to strict environmental precautions, decontamination of equipment is another consideration. Tongji Hospital is the largest hospital in central China, and it is a designated center for care of critically ill patients with COVID-19. After the outbreak of the epidemic, two general wards were converted to temporary intensive care units (ICUs) with 72 beds for critical cases of COVID-19 in February 2020. Not all patients with COVID-19 should undergo a fiberoptic bronchoscopy examination. The client's basic condition, blood gas results, nucleic acid testing and extent of pulmonary secretions should be taken into consideration. The primary focus should be on limiting environmental contamination by aerosol spread of the virus. Four criteria were added which became indicators for use of bronchoscopy in the care of a patient with COVID-19: 1 receiving mechanical ventilation, 2 severe atelectasis found on chest xray revealing a large area of reduced transparency in both lung tissues, 3 suctioning does not clear secretions and PO 2 ≤40 mmHg, 4 throat swab is negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nuclei acid but patient was highly suspected for COVID-19. Any patient meeting the first criteria and any one of the other three was deemed appropriate for fiberoptic bronchoscopy. To avoid choking, patients were pain relieved and sedated by fentanyl, midazolam and/or diprivan to reach a Richmond Agitation-Sedation Scale (RASS) rating of ≤ −4. As closed endotracheal suctioning is commonly used in invasive mechanically ventilated patients with COVID-19, the suction tube should also be removed as it may obstruct the bronchoscope. Since ventilation is suspended when removing the suction catheter, two staff members should work together to contain any aerosol dispersion. It is important to make staff aware of the potential challenges to avoid aerosol exposure. Training for personnel included wearing a protective suit, isolation gown, goggles, shoe covers, surgical mask with face shield, gloves and positive pressure hood. Isolation packs included the required items. The appropriate technique for donning and removal of these items was also covered. Posters on the use of this equipment were also placed in appropriate areas. Staff checked each other before entering or returning from a contaminated area. Personnel involved in a fiberoptic bronchoscopy included one physician, one nurse and one nursing assistant. This procedure should be done ideally in a negative airflow room. Since the temporarily established ICUs for COVID-19 did not meet this criteria, modifications were made as following. Each room was equipped with two air exchange fans with an air velocity of 160L/s. 8 Additionally, an air sterilizer and ultraviolet radiation units were also used. Patient beds in this large open unit were at least 1 meter apart. Other supplies needed for the bronchoscopy were available in a pack, including sterile gloves, sterile scissors, dressings, disposable towels, gauze, syringes, specimen collection containers, disposable bowl, vials of normal saline and lidocaine, fiberoptic bronchoscope, spray bottle of chlorine-based antiseptic solution and alcohol-based hand sanitizer. Precaution strategies for fiberoptic bronchoscope were showed in Table 1 Minimize aerosol dispersion 5. Nurse assists physician to collect secretion specimens using closed collection method (see Fig. 1 ). Minimize scope withdrawal from the airway to reduce aerosol exposure 6. Similarly, assistant suspends ventilation prior to bronchoscope withdrawal from the airway. In view of the current method used for cleaning equipment and the COVID-19 epidemic, a new procedure was developed for disinfection of the fiberoptic bronchoscope. 9 Changes and rationales were described in Table 2 . The use of ultraviolet light, chlorine-based disinfectant and 75% alcohol have been confirmed to be effective in neutralizing the virus. 6 A 20 0 0 mg/L sodium hypochlorite disinfectant solution was used to wipe the bedside table and patients' stretchers; a 10 0 0 mg/L sodium hypochlorite solution was used to clean floors. Following the procedure, involved personnel were sprayed with a 10 0 0 mg/L sodium hypochlorite solution before removing their outermost isolation gown. The reusable positive pressure hoods were wiped using a 20 0 0 mg/L sodium hypochlorite solution, and then placed in biocontainment bags and send to the disinfection center. Since chlorine-based disinfectants are corrosive, the ventilator was disinfected using a 75% alcohol solution. To date, 22 fiberoptic bronchoscopy exams have been done on 16 patients. Microbiological testing of the bronchoscope was deemed appropriate after disinfection. A total of 18 specimens were collected with 16 were positive for SARS-CoV-2. Throat swabs and sputum specimens were done simultaneously. Nine of these throat swabs were positive while 12 of these sputum specimens were positive, respectively. All staff had no confirmed infection. The mortality rate for critically ill patients with COVID-19 is high. Retention of secretions represents an important challenge to health caregivers, but fiberoptic bronchoscopy examination might be valuable in optimize the prognosis of COVID-19 patients. It has already showed existing value in diagnosis and treatment. However, the potential risk to the health care givers during this procedure should be considered. This study explain detailed preparation, precaution strategies and decontamination of bronchoscope and environment and respective rationales. Our results proved its effectiveness in diagnosis and safety in staff protection both. This might provide helpful information to facilitate the using of fiberoptic bronchoscopy in the setting of pandemic COVID-19 outbreak worldwide. The authors declare no conflict of interest. YJINF [m5G Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city Characteristics of COVID-19 infection in Beijing Coronavirus disease 2019 (COVID-19) Situation Report-56 Coronavirus disease 2019 (COVID-19) Situation Report-41 Gross examination report of a COVID-19 death autopsy National Health Commission of People's Republic of China. 2020. The 7th scheme for diagnosis and treatment of new coronavirus pneumonia Laboratory testing for 2019 novel coronavirus (2019-nCoV) in suspected human cases Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Ministry of Health of People's Republic of China Standard for endoscope disinfection Peng Yan Tongji Hospital, Tongji Medical College This work is supported by the National Natural Science Foundation of China under Grant No. 71874063 .