Bronchoscopy challenges during the COVID-19 pandemic

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Figure 1
Cleveland Clinic personal protective equipment recommendations for COVID-19.

TABLE 1

Cleveland Clinic recommended priority tiers for bronchoscopy and pleural procedures

Emergency (Proceed same day)	Critical (Proceed 1-2 days)	Urgent (Most proceed within 1-2 weeks)	Semi-urgent (Some proceed; > 2 weeks)	Nonessential (Postpone or reschedule)
Central airway obstruction Critical tracheal stenosis Massive hemoptysis Tracheostomy complications Foreign body aspiration Aerodigestive fistula ICU: Therapeutic aspiration of clot or mucus occlusion Chest tube for pneumothorax	Symptomatic bronchial stenosis Malignant airway obstruction Advanced lung cancer diagnosis/staging Pulmonary infiltrates in immunosuppressed patients Sub-massive hemoptysis Inpatient with undiagnosed metastatic chest cancer Stent complications Lung transplant dehiscence Thoracentesis symptomatic pleural effusion Percutaneous tracheostomy	Early stage lung cancer diagnosis/stage Routine stent change Complex tracheostomy management Lobar atelectasis (not responding to CPT) Broncholithiasis Tunneled pleural catheter (PleurX)	Lung transplant rejection follow-up BAL for unresolving infiltrate (eg, MAC) Suspect sarcoidosis/beryllium Cryobiopsy for ILD Asthma “airway” evaluation Tracheostomy tube change/revision Bronchopleural fistula assessment Thoracentesis for hepatic hydrothorax management	Lung transplant surveillance Bronchoscopic lung volume reduction Bronchial thermoplasty Retrograde airway reconstruction Excessive dynamic airway collapse evaluation Bronchogenic cyst Custom 3D printed stent Valve removal (asymptomatic after BPF or BLVR)

BAL = bronchoalveolar lavage; BLVR = bronchoscopic lung volume reduction; BPF = bronchopleural fistula; CPT = chest physiotherapy; ICU = intensive care unit; ILD = interstitial lung disease; MAC = Mycobacterium avium complex

TABLE 2

Comparison of virus aerosolization risks between procedural sedation and general anesthesia for bronchoscopy

Procedural sedation	General anesthesia
Nebulized topicalization before the procedure	Intravenous administration (nebulized topicalization not used)
Potential for many liters of oxygen supplementation through a nasal cannula or face mask (potentially aerosolizing into open environment)	Ventilation through a semi-closed circuit
Nasopharyngeal (highest viral load), bronchoscopy	Bronchoscopy through either supraglottic airway or an endotracheal tube bypassing the nasopharynx
Cough during the procedure with open airway	Muscle relaxation is used, and contained in a contained airway and breathing circuit
Cough postoperatively with longer recovery period than general anesthesia	Cough postoperatively; however, shorter recovery period than procedural sedation (shorter-acting medications)

TABLE 3

COVID-19 infection control guidance for health-care professionals from the CDC⁸

Precaution type	Recommended infection control practices
Standard precautions (All healthcare personnel)	Hand hygiene PPE as indicated for procedures Respiratory hygiene Proper patient placement indicated Clean/disinfect equipment as Masks and eye shields with gowns if potential contact with body fluids Needles and sharps management
Contact precautions (eg, Clostridium difficile)	Single rooms PPE: Gown, gloves Limit patient travel Use disposable equipment
Droplet precautions (eg, influenza)	Single room and respiratory hygiene and cough etiquette PPE: Surgical mask Limit travel Source control (eg, mask on patient)
Airborne precautions (eg, tuberculosis)	Airborne infection isolation room (eg, negative pressure room) PPE: N95 or PAPR Limit travel Restrict personnel Source control (eg mask on patient)