The coronavirus disease 2019 (COVID-19) pandemic has posited a significant risk to healthcare workers, particularly to those who perform bronchoscopy, among other open airway procedures. The virus, which travels by respiratory droplets and is possibly transmitted by air with aerosol generating procedures, has made bronchoscopy particularly risky, despite the necessity of the procedure for various diagnostic and treatment purposes.
Considering the paucity of data on safe bronchoscopy procedures during the COVID-19 pandemic, an expert panel from the American College of Chest Physicians (CHEST) and American Association for Bronchology and Interventional Pulmonology (AABIP) has published a guideline in CHEST on best practices recommendations for the procedure in the era of COVID-19. The guidance, mostly in the form of ungraded consensus-based statements, was created by a multidisciplinary team of experienced bronchoscopists, interventional pulmonologists, infectious disease specialists, intensivists, and respiratory therapists and trainees.
Personal Protective Equipment (PPE)
In the guideline, the CHEST/AABIP expert panel recommended the use of PPE for all healthcare workers who perform bronchoscopy, especially for healthcare workers who perform the procedure in patients with suspected or confirmed COVID-19 infection. The panel recommended either an N-95 respirator or a powered air purifying respirator.
In regions where the community spread of the virus is present, the guideline committee recommended N-95 respirators or powered air-purifying respirators vs surgical masks in the procedure room. This recommendation holds true regardless if the patient is asymptomatic or not. All N-95 respirators should be disposed of following a bronchoscopy procedure. Additionally, the use of a face shield, gown, and gloves during the procedure is also recommended by the panel.
Establish Presence of Infection
The panel suggested obtaining a nasopharyngeal specimen before employing bronchoscopy in patients with a suspected COVID-19 infection. Testing should be performed in all asymptomatic patients who reside in a region where community transmission of COVID-19 is present. This may not be possible in every circumstance, as testing is not available everywhere.
A face shield, gown, gloves, and N-95 respirators or powered air purifying respirators should be used during bronchoscopy procedures in patients with negative results. If test results are positive before the procedure, the guideline panel recommended postponing bronchoscopy if the procedure is not urgently required. In emergent bronchoscopy procedures for patients with test results that are positive for the virus, the committee recommended PPE before, during, and after the procedure.
The CHEST/AABIP guideline panel recommended clinicians obtain lower respiratory specimens from endotracheal aspirate or bronchoscopy with bronchoalveolar lavage to verify COVID-19 in patients with severe or progressive disease that requires intubation. This recommendation is also suggested for patients with severe or progressive disease who may have another condition that would change clinical management.
Perform Bronchoscopy in a Timely Manner
For bronchoscopy procedures that are needed to diagnose, stage, or characterize a known or suspected lung cancer in patients where community COVID-19 transmission is present, the CHEST/AABIP panel recommended performing the procedure in a “timely and safe manner.” The committee states that strategies to perform the procedure in a timely manner may need to take into account local availability of personal protective equipment, COVID-19 testing, and downstream resources necessary for treatment, including ventilators and hospital beds.
In patients with cancer who are negative for COVID-19 and present for bronchoscopy to a resource-depleted hospital, the guideline recommended referring these patients to other centers. In doing so, clinicians can ensure these patients will receive timely and safe care. Ensuring timely care should not lead to sacrificing care quality, the panel indicated, so efforts are needed to balance all dimensions of care with patient values and preferences.
Routine Bronchoscopy in Patients Recovered From COVID-19
The timing of routine bronchoscopy in patients who have recovered from a confirmed case of COVID-19 should be customized based on the procedure’s indication, the infection’s severity, and the duration since resolution of symptoms, the panel wrote. Although experts still do not know when to perform a bronchoscopy in recovered patients, the CHEST/AABIP panel suggested waiting ≥30 days from resolution of symptoms with tests from ≥2 consecutive nasopharyngeal swab specimens that are negative for SARS-CoV-2 and are collected ≥24 hours apart.
The CHEST/AABIP committee urged that the protective recommendations made in their statement may be rendered ineffective if healthcare workers are not properly trained on appropriate donning and doffing of PPE. Additionally, the expert panel recommended that specialty societies should come together to collate and rapidly disseminate “…clinical experiences and outcomes data under these unique circumstances” to help facilitate more robust data and direct evidence to inform future guidelines. Until then, the CHEST/AABIP panel wrote that clinicians who are “…searching for evidence on bronchoscopy during this challenging time of the COVID-19 pandemic should utilize this document as general guidance and adapt it to their local situation.”
Wahidi MM, Shojaee S, Lamb CR, et al. The use of bronchoscopy during the COVID-19 pandemic: CHEST/AABIP guideline and expert panel report [published online May 1, 2020]. CHEST. doi:10.1016/j.chest.2020.04.036