Bronchoscopy is an aerosol-generating procedure that creates unique challenges for healthcare providers to reduce the potential spread of the COVID-19 respiratory pathogen. As part of the initial response, Cleveland Clinic postponed elective surgeries including bronchoscopy. We established a 5-tier system for prioritizing the urgency of bronchoscopy procedures.
When elective bronchoscopies were resumed, we established protocols to reduce aerosolization and potential virus transmission risks such as using an airborne infection-isolation room and changing to total intravenous anesthesia. Also, we established guidelines for periprocedural care and use of personal protective equipment including requirements for wearing N95 masks for all bronchoscopy procedures.
Introduction
Bronchoscopy is a challenging medical procedure in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) because it is an aerosol-generating procedure. Infection control is intrinsic to the daily practice of bronchoscopy teams as they routinely manage respiratory pathogens including those requiring standard or contact precautions typical in hospital patients.
For example, droplet isolation is commonly used during seasonal viral infections, and respiratory isolation is needed for pathogens such as tuberculosis. Existing guidelines about personal protective equipment (PPE), room and space considerations, and various levels of isolation are core competencies. Bronchoscopy is used to diagnose and treat many thoracic diseases including emergent procedures, so it is important to have procedures in place to manage patients with or suspicious for COVID-19, as well as those without COVID-19.
Since the COVID-19 pandemic has emerged, many published guidelines specific to bronchoscopy have been published. While there are similarities and differences in each, the core principles are all based on relatively limited knowledge of COVID-19, requiring authors to use data from historical insights with other infections and extrapolate them into known constructs. As with any guidelines, they represent the best intentions and summaries of the collective knowledge of the expert authors and the various methodologies they used.
The most notable major change was for the use, reuse, and conservation of PPE. Before wide-spread shortages occurred related to COVID-19, most PPEs were used once, and accreditation and infection control policies were strict on this measure. Also, the processes of donning and doffing PPE amidst increased protective measures have changed accordingly.
Prioritising bronchoscopy procedures
Early on in the COVID-19 pandemic, following guidance from the Ohio Department of Health, the Cleveland Clinic postponed elective (or nonessential) surgeries. Exceptions existed for surgeries that were life-saving, prevented permanent dysfunction, decreased the risk of metastasis, or decreased severe symptoms.
As bronchoscopy has a wide range of indications, we created a tier system that prioritizes the importance of bronchoscopy and related pleural procedures, based on exceptions outlined by state health officials. Each procedure is evaluated to determine its priority tier. If it meets the criteria to be performed, we only proceed with all safety measures in place to protect patients and healthcare providers. A similar tier system was published by the Society of Advanced Bronchoscopy that stratified patients based on urgency.
The American Association of Bronchology and Interventional Pulmonology (AABIP) declared that bronchoscopy is “contraindicated” as a first-line diagnostic procedure for patients with potential COVID-19.7 Instead, they recommend obtaining samples from the upper airway via swab techniques for the diagnosis of COVID-19. However, bronchoscopy may still have a limited role in confirming the diagnosis of COVID-19 if the first-line testing is inconclusive and to rule out other pathologies. These considerations are relative to the prevalence of disease and available hospital resources.
At the time of this writing, local and state authorities have authorized the resumption of elective procedures, under the assurance that hospital capacity is available to accommodate patients if a surge is observed and that there are enough PPEs available. This is an evolving local assessment and is not uniform across the United States. Thus, many of the procedures that were postponed are now being performed.