COVID 19 manifests itself mainly as a lower respiratory tract illness and has a high morbidity and mortality. COVID 19 is predominantly transmitted by air droplets and open airway procedures such as bronchoscopy and poses a significant risk to health care workers
3,13.
Although there is an increased risk of infection for the health care workers during bronchoscopy, it is health care workers’ primary responsibility to diagnose and treat the patients 14. Bronchoscopy is an aerosol-generating procedure and should only be performed when necessary and if the result is going to change the treatment decision. To provide a guidance for health care workers, several bronchology societies have issued statements or guidelines regarding bronchoscopy during the COVID 19 pandemic 5-11.
In a commentary reviewing the societal guidelines regarding bronchoscopy during COVID 19 pandemic, procedural steps and protections were summarized 11. All the elective procedures were recommended to be postponed. Specific indications considered elective are mild tracheal or bronchial airway stenosis; clearance of mucus; suspected sarcoidosis without indication for immediate treatment; chronic interstitial lung disease; suspected atypical mycobacteria infection; chronic cough; tracheobronchomalacia evaluation; bronchial thermoplasty; bronchoscopic lung volume reduction 7. Where as severe airway stenosis, symptomatic central airway obstruction, massive hemoptysis, migrated stent were emergent indications for bronchoscopy. On the other hand concern for an alternate aetiology of respiratory disease which would change management; suspicion of superinfection; lobar or entire lung atelectasis concerning for mucus plugging were considered as bronchocopy indications in the guidelines 5-11. In our bronchoscopy unit we performed bronchoscopy to a vide variety of indications including cases that could be postponed, because of our prediction that the pandemia will last long, following the recommended precautions.
Screening of symptoms, sick contacts and pre procedural vitals were recommened. Although not all the guidelines recommend it, American Association for Bronchology and Interventional Bronchoscopy (AABIP) also recommends that a nasopharyngeal specimen should be taken before the procedure 7. We screened all the patinets for symptoms, sick contacts and preprocedure vitals as well as at least one COVID‐19 PCR test via oropharyngeal/nasopharyngeal swab.
During the procedure ideal setting was a negative pressure room which is not possible in most of the centers but it is recommended by AABIP and Spanish Society of Pneumology and Thoracic Surgery (SEPAR) 7,9. Limited and minimum necessary personnel contacting the patient and use of a slotted mask for the patient during procedure is recommended. For the protection of the personnel, N95 or FFP3 masks; eye protection with glasses or full face shield; gloves, and caps were all recommended. For the anesthesia avoiding atomized or nebulized lidocaine and enough sedation to minimize cough are recommended. Flexible bronchoscopy is preferred over rijid bronchoscopy and in cases where rijid bronchoscopy is obligatory, then it is advised to be done by closed-circuit ventilation, avoiding jet ventilation 11.
In our hospital all procedures were done with minimum necessary personnel and all personnel preventive measures were applied as stated in the guidelines. Flexible bronchoscopy was preffered to rijid bronchosopy unless an indication for rijid bronchsocopy existed. To shorten the contact time as much as possible no fellow was accepted during this period in to the bronchoscopy unit and mean procedure time in our series was 30 minutes which was enough for the evaluation of the patient and sampling of the lesion if needed.
When it comes to post procedural precautions, although there is not any concensus, in our hospital scope disinfection was done with standard high level disinfection and surfaces in contact with patient or secretions are sterilized after each procedure. Each patient is recovered in the same room where the bronchoscopical procedure was done. After the patient discharged, room was cleaned with standard high level disinfection and then ventilated for 20 minutes after each procedure. Next patient was taken after drying of the contact areas. In our hospital all schedueled patients were evaluated at least one time for PCR evaluation and twice if the procedure in nonurgent and screening of symptoms, sick contacts and evaluating pre procedural vitals were done.
Our mean bronchoscopy number in our bronchoscopy unit was around 35 per day during last summer. After the new guidelines were published our bronchoscopy unit started to apply bronchoscopies to elective cases not to delay the diagnosis and treatment. But after precautions that were taken during COVID 19 pandemia 12 patients per day were taken into our bronchoscopy unit. So these precautions cut down the number of bronchoscopy cases.
Diagnosis of COVID 19 depends on detection of viral RNA by rRT-PCR. Although it is known that there is a continued debate about the effectivity, sensitivity and specificity of these tests 15. Result of the tests can be affected by lots of parameter like as sampling method, contamination, transfer to the laboratory, use of unvalidated method in the evaluation, timing of the infection, interpretation mistakes 16. Different RT-PCR sensitivity was reported and interpretation of these tests in asymptomatic patients without suspicion of the disease becomes harder because of the false negativity problem. False-negative test results may occur in up to 20% to 67% of patients 17. On the other hand, it was known that some of the asymptomatic patients can be diagnosed with PCR tests. But in some other patients false negativity will give you a false trust. So although the test result was negative all the precautions and protection had to be applied for each patient in pandemic situation. So In our hospital we evaluate at least one PCR result prior to bronchoscopy, and if the procedure is nonurgent a second PCR was also seen to decrease false negativity. We use personnel protective equipment as defined as in the CDC regardless of the result.
Prevelance of asymptomatic COVID 19 in the population is important 18. If the asymptomatic disease is rare then the detailed test wont be cost effective. If the asymptomatic patient with nonurgent bronchoscopy was detected to be positive then the procedure can be postponed to protect the health care workers. By this way sensitive patient population that can get into contact in the bronchoscopy unit will also be protected.
The biggest limitation of the study is its retrospective design. Bronchoscopy patients were evaluated by their doctors when they come to the outpatient clinic with their pathological results and PCR test was done in patients who need to undergone another intervention or who have symptoms like cough, fewer, loss of taste or smell. So asymptomatic patients and patients without need for further evaluation were not evaluated by PCR. Also bronchoscopy unit staff underwent PCR evaluation in complaint of any symptom. In other words, routine PCR evaluation will give more definite results in a prospective designed study.
In conclusion, guidelines recommend that infection risk can be minimalized with postponing elective or semi elective bronchoscopies. They generally highlight that bronchoscopy is strongly discouraged if alternative method for the diagnosis or treatment due exist. Bronchoscopy is suggested when it is absolutely necessary. It is predicted that this pandemia will last long so postponing procedures was not considered as a solution. Providing appropriate medical care to patients and protecting healthcare workers is mandatory in the pandemia setting. Our patient infection ratio is low (%0.49) and none of our health care workers were infected. This shows that under carefull circumstances bronchoscopy can be done in COVID 19 pandemia.
Procedures must be done by adhering protected measures as much as possible. Although it was known that resources are not unlimited, pretesting before bronchoscopy is ideal to protect health care workers and other patients. We also believe that protection of healthcare staff is very important and we want to emphasize the benefits of pre-procedure PCR evaluation at least once but preferably twice and proper PPE use for bronchoscopic procedure.
