Summarizing societal guidelines regarding bronchoscopy during the COVID-19 pandemic.

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for pandemic coronavirus disease 2019 (COVID-19), is predominantly transmitted via large droplets and fomites. However, healthcare workers (HCW) participating in aerosol-generating procedures such as bronchoscopy, endotracheal intubation, upper gastrointestinal endoscopy, otolaryngological procedures involving the upper airway and tracheotomy are also at risk for aerosol-transmitted infection. Given the well-documented asymptomatic SARS-CoV-2 infection with viral shedding, infectious aerosol might also be generated from asymptomatic patients as community prevalence rises. Several bronchology societies have issued guidelines regarding bronchoscopy during the COVID-19 pandemic.1-5 However, none are comprehensive and significant uncertainty remains regarding in whom to perform bronchoscopy and how to perform it safely in this rapidly changing clinical environment. No data specific to bronchoscopy in COVID-19 are yet available, so most recommendations are expert opinion derived from observations made during prior respiratory viral outbreaks including SARS, Middle East respiratory syndrome (MERS) and influenza. Tables 1 and 2 summarize existing guidelines regarding bronchoscopy in patients not suspected of harbouring SARS-CoV-2 and in those known or suspected to be suffering from COVID-19, respectively. All societies reviewed recommend postponing elective procedures and limiting the number of staff participating in any procedure to minimize the use of personal protective equipment (PPE) and reduce known or occult exposure to infectious aerosol. All considered known or suspected COVID-19 to be a relative contraindication to bronchoscopy, given the uncertainty of its benefit and clear risks to participating staff. Table 3 represents a consolidation of existing guidelines regarding bronchoscopy in patients with and without COVID-19. N95 or FFP3 if significant community prevalence Consider daily re-used N95 or FFP3 if low supply Avoid atomized or nebulized lidocaine Sedation to minimize cough Consider paralysis to minimize cough in general anaesthesia Avoid atomized or nebulized lidocaine Sedation to minimize cough Consider paralysis to minimize cough in general anaesthesia Consider air circulation time per local air controls Consider sterilizing surfaces In procedures which cannot be deferred, infection of HCW may occur from any of the three transmission modes discussed above. Protective measures against infectious aerosols include use of respirator-level respiratory protection, negative pressure rooms where feasible and avoidance of devices that purposefully produce aerosols including nebulizers or atomizers which can be contaminated with virus after a cough or sneeze with subsequent aerosolization. Recommendations to avoid open tube rigid bronchoscopy, jet ventilation and interruption of an otherwise closed ventilation circuit by repeatedly removing and re-introducing the bronchoscope are intended to reduce high-flow and high-shear conditions which generate aerosol droplets. Measures protecting against droplet transmission include covering the patient's nose and mouth with a simple medical mask (which can be slotted to permit transmask, transnasal or transoral flexible bronchoscopy), minimizing cough pharmacologically, and a full complement of barrier PPE (gown, gloves, cap and wrap-around eye protection). Fomite transmission may be reduced by using disposable bronchoscopes in known COVID-19 patients, sterilizing surfaces which might have been contaminated by respiratory secretions or droplets, proper removal of PPE and meticulous hand hygiene. There appears to be a particular dearth of information regarding optimal post-procedure decontamination procedures. Data specific to bronchoscopy in the COVID-19 era are urgently needed. National and international bronchology societies should work together to rapidly develop pertinent research endeavours and strive to provide their members with the most comprehensive and up-to-date recommendations possible. More than a few lives depend on them. We would like to acknowledge contributors to the COVIDBronch Initiative, an international network of airway specialists created to foster research and the rapid acquisition and dissemination of knowledge regarding the performance of airway procedures during the COVID-19 pandemic. No authors report any financial or non-financial conflicts of interest pertinent to this work. No aspect of this work has been previously published nor is under consideration by any other journals. Early drafts of included tables were previously shared among a small group of airway professionals via non-public social media.