Bronchoscopy during the COVID-19 pandemic: effect on current practices and strategies to reduce procedure-associated transmission.

Introduction: Bronchoscopy and related procedures have unambiguously been affected during the Corona Virus Disease 2019 (COVID-19) pandemic caused by Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS COV-2). Ordinary bronchoscopy practices and lung cancer services might have changed over this pandemic and for the years to come.Areas covered: This manuscript summarizes the utility of bronchoscopy in COVID-19 patients, and the impact of the pandemic in lung cancer diagnostic services, in view of possible viral spread during these We conducted a literature review of articles published in PubMed/Medline from inception to November 5th, 2020 using relevant terms.Expert opinion: Without doubt this pandemic has changed the way bronchoscopy and related procedures are being performed. Mandatory universal personal protective equipment, pre-bronchoscopy PCR tests, dedicated protective barriers and disposable bronchoscopes might be the safest and simpler way to perform even the most complicated procedures.

Bronchoscopy precautions and recommendations in the COVID-19 pandemic.

As the airways of SARS-CoV-2 infected patients contain a high viral load, bronchoscopy is associated with increased risk of patient to health care worker transmission due to aerosolised viral particles and contamination of surfaces during bronchoscopy. Bronchoscopy is not appropriate for diagnosing SARS-CoV-2 infection and, as an aerosol generating procedure involving a significant risk of transmission, has a very limited role in the management of SARS-CoV-2 infected patients including children. During the SARS-CoV-2 pandemic rigid bronchoscopy should be avoided due to the increased risk of droplet spread. Flexible bronchoscopy should be performed first in SARS-CoV-2 positive individuals or in unknown cases, to determine if rigid bronchoscopy is indicated. When available single-use flexible bronchoscopes may be considered for use; devices are available with a range of diameters, and improved image quality and degrees of angulation. When rigid bronchoscopy is necessary, jet ventilation must be avoided and conventional ventilation be used to reduce the risk of aerosolisation. Adequate personal protection equipment is key, as is training of health care workers in correct donning and doffing. Modified full face masks are a practical and safe alternative to filtering facepieces for use in bronchoscopy. When anaesthetic and infection prevention control protocols are strictly adhered to, bronchoscopy can be performed in SARS-CoV-2 positive children.

[Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection]. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

[Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection]. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Short-term Outcomes for Patients and Providers After Elective Tracheostomy in COVID-19-Positive Patients.

BACKGROUND: Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. The objective of the study was to demonstrate that percutaneous dilational tracheostomy (PDT) with a period of apnea in patients requiring prolonged mechanical ventilation due to COVID-19 is safe and can be performed for the usual indications in the intensive care unit. METHODS: This study involves an observational case series at a single-center medical intensive care unit at a level-1 trauma center in patients diagnosed with COVID-19 who were assessed for tracheostomy. Success of a modified technique included direct visualization of tracheal access by bronchoscopy and a blind dilation and tracheostomy insertion during a period of patient apnea to reduce aerosolization. Secondary outcomes include transmission rate of COVID-19 to providers and patient complications. RESULTS: From April 6th, 2020 to July 21st, 2020, 2030 patients were admitted to the hospital with COVID-19, 615 required intensive care unit care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. Eighteen patients were assessed for PDT, and 11 (61%) underwent the procedure. The majority had failed extubation at least once (72.7%), and the median duration of intubation before tracheostomy was 15 d (interquartile range 13-24). The median positive end-expiratory pressure at time of tracheostomy was 10.8. The median partial pressure of oxygen (PaO2)/FiO2 ratio on the day of tracheostomy was 142.8 (interquartile range 104.5-224.4). Two patients had bleeding complications. At 1-week follow-up, eight patients still required ventilator support (73%). At the most recent follow-up, eight patients (73%) have been liberated from the ventilator, one patient (9%) died as a result of respiratory/multiorgan failure, and two were discharged on the ventilator (18%). Average follow-up was 20 d. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19. CONCLUSIONS: and relevance: PDT for patients with COVID-19 is safe for health care workers and patients despite higher positive end-expiratory pressure requirements and should be performed for the same indications as other causes of respiratory failure.

Bronchoscopy safety precautions for diagnosing COVID-19 associated pulmonary aspergillosis-A simulation study.

OBJECTIVES: With the outbreak of coronavirus disease 2019 (COVID-19), clinicians have used personal protective equipment to avoid transmission of severe acute respiratory syndrome coronavirus 2. However, they still face occupational risk of infection, when treating COVID-19 patients. This may be highest during invasive diagnostic procedures releasing aerosols and droplets. Thereby, the use of diagnostic procedures for Covid-19 associated aspergillosis may be delayed or impeded, as use of bronchoscopy has been discouraged. This leads to avoidance of a crucial procedure for diagnosing invasive aspergillosis. We intent to visualise aerosol and droplet spread and surface contamination during bronchoscopy and address which measures can avoid exposure of health-care workers. METHODS: We created a simulation model to visualise aerosol and droplet generation as well as surface contamination by nebulising fluorescent solution detected by using ultraviolet light- and slow-motion capture. We repurposed covers for ultrasound transducers or endoscopic cameras to prevent surface and ambient air contamination. RESULTS: In our bronchoscopy simulation model, we noticed extensive aerosol generation, droplet spread and surface contamination. Exposure of health-care workers and contamination of surfaces can be efficiently reduced by repurposing covers for ultrasound transducers or endoscopic cameras to seal the tube opening during bronchoscopy in mechanically ventilated patients. CONCLUSION: Adequate personal protective equipment and safety strategies allow to minimise contamination during bronchoscopy in mechanically ventilated COVID-19 patients.

The Use of Bronchoscopy During the Coronavirus Disease 2019 Pandemic: CHEST/AABIP Guideline and Expert Panel Report.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has swept the globe and is causing significant morbidity and mortality. Given that the virus is transmitted via droplets, open airway procedures such as bronchoscopy pose a significant risk to health-care workers (HCWs). The goal of this guideline was to examine the current evidence on the role of bronchoscopy during the COVID-19 pandemic and the optimal protection of patients and HCWs. STUDY DESIGN AND METHODS: A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that addressed specific topics on bronchoscopy related to COVID-19 infection and transmission. MEDLINE (via PubMed) was systematically searched for relevant literature and references were screened for inclusion. Validated evaluation tools were used to assess the quality of studies and to grade the level of evidence to support each recommendation. When evidence did not exist, suggestions were developed based on consensus using the modified Delphi process. RESULTS: The systematic review and critical analysis of the literature based on six PICO questions resulted in six statements: one evidence-based graded recommendation and 5 ungraded consensus-based statements. INTERPRETATION: The evidence on the role of bronchoscopy during the COVID-19 pandemic is sparse. To maximize protection of patients and HCWs, bronchoscopy should be used sparingly in the evaluation and management of patients with suspected or confirmed COVID-19 infections. In an area where community transmission of COVID-19 infection is present, bronchoscopy should be deferred for nonurgent indications, and if necessary to perform, HCWs should wear personal protective equipment while performing the procedure even on asymptomatic patients.

Bronchoscopic procedures during COVID-19 pandemic: Experiences in Turkey.

BACKGROUND: Globally, coronavirus disease-2019 (COVID-19) is a new, highly contagious, and life-threatening virus. We aimed to demonstrate how we proceeded with bronchoscopic procedures without published guidelines at the inception of the pandemic period. MATERIALS AND METHODS: All bronchoscopic procedures applied from the first case seen in Turkey (11 March-15 May) were evaluated retrospectively. Patient data on indications, diagnosis, types of procedures, and the results of COVID-19 tests were recorded. RESULTS: This study included 126 patients; 36 required interventional bronchoscopic techniques (28.6%), 74 required endobronchial ultrasonography (EBUS; 58.7%), and 16 required flexible fiberoptic bronchoscopy (12.7%). All interventional rigid bronchoscopic techniques were performed for emergent indications: malignant airway obstruction (66.7%), tracheal stenosis (25%), and bronchopleural fistula (8.3%). Malignancy was diagnosed in 59 (79.7%), 12 (50%), and 4 (25%) patients who underwent EBUS, interventional procedures, and fibreoptic bronchoscopy, respectively. All personnel wore personal protective equipment and patients wore a surgical mask, cap, and disposable gown. Of the patients, 31 (24.6%) were tested for COVID-19 and all the results were negative. COVID-19 was not detected in any of the patients after a 14-day follow-up period. CONCLUSION: This study was based on our experiences and demonstrated that EBUS and/or bronchoscopy should not be postponed in patients with known or suspected lung cancer.

Consensus Document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on Tracheotomy in Patients with COVID-19 Infection. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Performing Bronchoscopy in Times of the COVID-19 Pandemic: Practice Statement from an International Expert Panel.

These recommendations for physicians who perform bronchoscopy will help to protect those patients (un)-affected by the current COVID-19 pandemic, minimize the risk of transmission, and maintain clinical care for all patients.