key: cord-1016657-g3ab0jrc
authors: Lim, Wei-Yang; Ng, Bryan; Lee, Chun-Kiat; Shen, Jiayi; Koh, Calvin; Lee, Pyng
title: Strategy for Safe Bronchoscopy during COVID pandemic
date: 2021-10-20
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2021.09.034
sha: dc777c4893c9bb9a0c65f3e8dfc2ea30b5fe908b
doc_id: 1016657
cord_uid: g3ab0jrc

Aerosol generating procedures are avoided for COVID-19 patients to lower the risk of transmission to healthcare providers. However, when bronchoscopy is indicated, it remains unclear if the procedure performed under general anesthesia leads to contamination of the surroundings and if standard endoscopy reprocessing methods are effective in eradicating SARS-CoV-2. We share our experience of bronchoscopic retrieval of airway foreign body under general anesthesia in a patient tested positive for novel 2019 coronavirus disease (COVID 19). We focus on anesthesia techniques to minimise aerosolization.

This case involves the removal of a foreign body within the airways via flexible bronchoscopy under general anesthesia, in the setting of a patient with COVID-19.

The COVID 19 crisis continues to exert enormous strain on the world's healthcare systems with many countries experiencing resurgence after successfully slowing outbreaks. Indubitably, HCW treating COVID 19 patients are at the highest risk for

infection. An early report found that HCW constituted 29% of patients hospitalized for COVID 19 pneumonia. [1] Overall incidence of infection among HCW is 3.8% [2] , and most are associated with aerosol generating procedures. [2] Transmission of SARS-CoV-2 by droplets or aerosols has critical implications. Data showed that speaking and coughing produced aerosols that harbored viable SARS-CoV-2, which could remain suspended in the air for hours. [3] Aerosol generating procedures expose HCWs to contagion. [4, 5] Bronchoscopy, an aerosol generating procedure is avoided till the individual is noninfectious. However when clinical urgency warrants the procedure, the team should proceed with safety measures in place to protect both patient and HCW. [6, 7] We share our centre's infection control strategy in foreign body retrieval from the airway in a patient with COVID 19.

A 59-year-old man presented to emergency with fever, cough and sore throat. He was a former smoker with asthma on inhaler therapy, worked in construction, and stayed within a crowded dormitory. He was a known contact of a COVID-19 patient, and his The team was kept minimal, comprising of 2 anesthetists, 2 nurses and 2 bronchoscopists in N95 masks, PPEs and powered air purifying respirators (PAPR).

PAPR together with N95 mask and PPE conferred greater protection in aerosolizing procedures such as intubation and bronchoscopy. [4] [5] [6] Before intubation, the patient in surgical mask was pre-oxygenated with intranasal administration of oxygen at 3l/min. Topical lidocaine spray to the vocal cords was omitted to minimize aerosolization. The patient was intubated using videolaryngoscopy with ETT (endotracheal tube) size 9 following rapid sequence induction (RSI) and IV lidocaine 1.5mg/kg to prevent cough. A swivel was attached to the ETT where the distal end led to a mechanical filter to minimize contamination, and the bronchoscopy team stayed in the OR anteroom until the patient was intubated.

Intermittent positive pressure ventilation with 100% oxygen alternating with periods of apnea was employed. Intermittent paralysis with IV atracurium was repeated every 30 minutes, mechanical ventilation paused every 10 minutes accompanied by cessation of gas flow to facilitate bronchoscope insertion and airway intervention. Mechanical J o u r n a l P r e -p r o o f ventilation was resumed when oxygen saturation fell below 91%, allowing the bronchoscopist about 10 minutes of work time.

A FB was lodged in the left lower lobe bronchus with overlying granulation tissue, and was retrieved via flexible bronchoscopy using cryoprobe and forceps. The bronchoscope-FB was removed enbloc as the patient was extubated. A disposable size 4 supraglottic airway (i-gel ® Intersurgical) was inserted to maintain ventilation. Check bronchoscopy through the supraglottic airway was performed (Fig 2) .Time taken for bronchoscopic retrieval of FB was 20 minutes. Upon successful retrieval of FB, anesthesia ceased and paralysis reversed. IV morphine 0.5mg/kg was given to minimize post-operative cough, and the patient was extubated awake. He wore a surgical mask and was monitored in the OR. Supraglottic airway was selected as it facilitated reversal of anesthesia with less cough and sympathetic activation. 

The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak

The Use of Bronchoscopy During the Coronavirus Disease

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

Bronchoscopy challenges during the COVID-19

Epub ahead of print

Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review

Society for Advanced Bronchoscopy