Safety of Bronchoscopy During the COVID-19 Pandemic: An Update

Safety of Bronchoscopy During the COVID-19 Pandemic: An Update

By: Abhishek Sarkar, MD; Abhinav Agrawal, MD, DAABIP; Anne V. Gonzalez, MD, MSc, FCCP; Fabien Maldonado, MD, FCCP; and Christina MacRosty, DO
Interventional/Chest Diagnostic Procedures Network
Published: May 18, 2021

The COVID-19 pandemic has posed a significant challenge to the practice of bronchoscopy. Experiences from prior novel respiratory pathogens raised concerns about whether aerosol-generating procedures increased risk of infection in health care workers. However, most of the studies from past pandemics consisted of case series and other low-level GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) evidence.^1,2

Early in the COVID-19 pandemic, multiple international societies, including CHEST, the American Association for Bronchology and Interventional Pulmonology (AABIP), the World Health Organization (WHO), the Chinese Medical Association, and the Asociación Argentina de Broncoesofagología, published guidelines addressing this question.^3-5 Most of these recommendations were ungraded, consensus-based statements due to the state of evidence at the time. More than a year after the start of the pandemic, we reflect upon the original six PICO questions identified in the CHEST/AABIP 2020 guideline and expert panel report, as evidence regarding bronchoscopy during the COVID-19 pandemic has emerged.

What Does the Research Say?

In mid-2020, researchers in Spain and Italy published retrospective analyses of bronchoscopy practices in patients with COVID-19.^6,7 Both studies included approximately 100 patients with COVID-19 who underwent bronchoscopy following recommendations from WHO.⁵ The personal protective equipment (PPE) worn by personnel in both studies included gloves, gown, goggle or face shield, and filtering facepiece class 3 mask or N95 mask. In the Italian study, no health care workers were infected.⁶ In the study from Spain, one of two bronchoscopists was infected.^6,7 Neither study had systematic pre- and post-procedure testing of the bronchoscopy team members. The timing of testing the bronchoscopists for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was not standardized. The value of bronchoscopy for detecting additional infections in these patients remains debatable. In the Italian study, only 4% of bronchoalveolar lavage (BAL) results revealed a superimposed infection, whereas the Spanish study noted a 28.6% yield of superimposed infection in BAL.^6,7

In January 2021, Gao et al published a retrospective study of 35 bronchoscopists who performed BAL in intubated patients with COVID-19. Sixteen of the 35 bronchoscopists had at least one nasopharyngeal polymerase chain reaction (PCR) test for SARS-CoV-2, all of which were negative. Twenty-seven bronchoscopists underwent serology testing, and all but one bronchoscopist tested negative. The timing of testing was variable and was led by hospital infection control staff. Indications for testing providers included presence of COVID-19 symptoms, unintentional exposure, or pre-procedure screening. Notably, the institution utilized a bronchoscopy protocol in which patients were anesthetized with neuromuscular blockers and open circuits were minimized during the procedures. Providers wore PPE as recommended by the US Centers for Disease Control and Prevention (CDC), including gloves, eye protection, gown, hair protection, and N95 respirator.⁸

Chang et al published a retrospective analysis in the US evaluating provider infection rate after performing bronchoscopy in mechanically ventilated patients with COVID-19 who were under anesthesia with neuromuscular blockers and with the procedure performed under apneic conditions. Patients were pre-oxygenated with an FiO₂ of 1.0 for 2 minutes in preparation for apnea. Positive end-expiratory pressure (PEEP) was provided and procedural timing was not documented. Providers followed CDC recommendations for PPE, consisting of gloves, eye protection, gown, hair protection, and N95 respirator. Nine out of 10 providers had negative nasopharyngeal PCR testing, and the only positive PCR result came from a provider who had tested positive before performing bronchoscopies. In this study, 65% of BAL specimens (35/54) were positive for a secondary infection.⁹

Key Takeaways

The four studies highlighted herein support the recommendations from the CHEST/AABIP 2020 consensus statement. These studies confirm that utilizing gloves, gown, hair protection, eye protection, and N95 (or equivalent) respirator mitigates the risk of SARS-CoV-2 transmission to the bronchoscopist.^6-9 Similarly, three of these studies suggest an added value of bronchoscopy in detecting superimposed infections in patients with COVID-19.^7-9 Lastly, asymptomatic spread has been widely recognized.¹⁰ This emphasizes the need for operator testing prior to and after the bronchoscopy for the purpose of a clinical study focused on health care workers’ safety.

Research from the last year has provided invaluable insights into the efficacy and safety of bronchoscopy during the COVID-19 pandemic, but further prospective studies with standardized timing to screen bronchoscopists for SARS-CoV-2 infection are warranted to refine societal guidelines.

References

1. Tran K, Cimon K, Severn M, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. Preprint. Posted online April 26, 2012. PMID: 22563403; PMCID: PMC3338532. doi: 10.1371/journal.pone.0035797
2. Thompson KA, Pappachan JV, Bennett AM, et al; EASE Study Consortium. Influenza aerosols in UK hospitals during the H1N1 (2009) pandemic--the risk of aerosol generation during medical procedures. PLoS One. 2013;8(2):e56278. Preprint. Posted online February 13, 2013. PMID: 23418548; PMCID: PMC3571988. doi: 10.1371/journal.pone.0056278
3. Wahidi MM, Shojaee S, Lamb CR, et al. The use of bronchoscopy during the coronavirus disease 2019 pandemic: CHEST/AABIP guideline and expert panel report. Chest. 2020;158(3):1268-1281. Preprint. Posted online May 1, 2020. PMID: 32361152; PMCID: PMC7252059. doi: 10.1016/j.chest.2020.04.036
4. Lentz RJ, Colt H. Summarizing societal guidelines regarding bronchoscopy during the COVID-19 pandemic. Respirology. 2020;25(6):574-577. Preprint. Posted online April 11, 2020. PMID: 32277733; PMCID: PMC7262091. doi: 10.1111/resp.13824
5. World Health Organization. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. World Health Organization; 2020. www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
6. Mondoni M, Sferrazza Papa GF, Rinaldo R, et al. Utility and safety of bronchoscopy during the SARS-CoV-2 outbreak in Italy: a retrospective, multicentre study. Eur Respir J. 2020;56(4):2002767. PMID: 32859682; PMCID: PMC7453732. doi: 10.1183/13993003.02767-2020
7. Torrego A, Pajares V, Fernández-Arias C, et al. Bronchoscopy in patients with COVID-19 with invasive mechanical ventilation: a single-center experience. Am J Respir Crit Care Med. 2020;202(2):284-287. PMID: 32412787; PMCID: PMC7365381. doi: 10.1164/rccm.202004-0945LE
8. Gao CA, Bailey JI, Walter JM, et al; NU COVID Investigators. Bronchoscopy on intubated COVID-19 patients is associated with low infectious risk to operators. Ann Am Thorac Soc. 2021. Preprint. PMID: 33448892. doi: 10.1513/AnnalsATS.202009-1225RL
9. Chang SH, Jiang J, Kon ZN, et al. Safety and efficacy of bronchoscopy in critically ill patients with coronavirus disease 2019. Chest. 2021;159(2):870-872. Preprint. Published online October 8, 2020. PMID: 33039461; PMCID: PMC7543920. doi: 10.1016/j.chest.2020.09.263
10. Johansson MA, Quandelacy TM, Kada S, et al. SARS-CoV-2 transmission from people without COVID-19 symptoms. JAMA Netw Open. 2021;4(1):e2035057. doi:10.1001/jamanetworkopen.2020.35057

Abhishek Sarkar, MD

• Pulmonary and Critical Care Medicine Fellow, Albert Einstein College of Medicine/Montefiore Medical Center in Bronx, NY

Abhinav Agrawal, MD, DAABIP

• Director of Interventional Pulmonology and Bronchoscopy, Assistant Professor of Medicine, and Assistant Professor of Cardiovascular and Thoracic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New Hyde Park, NY

Fabien Maldonado, MD, FCCP

• Professor of Medicine, Thoracic Surgery, and Mechanical Engineering, Vanderbilt University in Nashville, TN
• Interventional pulmonologist interested in lung cancer biomarker research, radiomics, and clinical trials in interventional pulmonology

Anne V. Gonzalez, MD, MSc, FCCP

• Associate Professor, Department of Medicine, McGill University in Montreal, Canada
• Director of Interventional Respirology and the lung cancer Rapid Investigation Clinic
• Research focuses on improving lung cancer outcomes through efficient and accurate diagnosis and staging, and judicious use of novel interventional pulmonary techniques

Christina MacRosty, DO

• Assistant Professor of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
• Clinical interest in benign and malignant pleural disease and bronchoscopic interventions for chronic obstructive lung disease
• Research interests include clinical and outcomes research in malignant pleural effusions and bronchoscopic lung volume reduction

Read more COVID in Focus: Perspectives on the Literature:

Aerosolization Risks of Noninvasive Ventilation in the Era of COVID-19

Pulmonary Vasculopathy and Thrombosis in Patients With COVID-19

Aerosol Generation Risk of Chest Physiotherapy and Airway Clearance Techniques in Patients With COVID-19