key: cord-0689294-8rn6di04 authors: Schverdfinger, S.; Carboni Bisso, I.; Famiglietti, R.; Di Grazia, M.; Di Stefano, S.; Las Heras, M. title: Tracheal aspirate with closed suction device: a modified technique developed during COVID-19 outbreak. date: 2020-08-26 journal: nan DOI: 10.1101/2020.08.24.20180802 sha: a20cc3d4c805f4158ba0c38484588f1a3757f4f8 doc_id: 689294 cord_uid: 8rn6di04 Background: Bacterial superinfection as well as ventilation associated pneumonia (VAP) are both frequent events in critical care. During COVID-19 pandemic, usual diagnostic practices such as bronchoalveolar lavage and tracheal aspirate are limited due to their associated high risk of exposure for the operator. In order to set primary focus on the protection of health care personnel, a modified tracheal aspiration (M-TA) technique is developed and used for acquiring a lower respiratory tract of microbiological samples with a closed suction device. Method: Retrospective observational study to evaluate effectiveness of M-TA is conducted. Results: A total of 33 M-TA samples were analyzed. In 66,6% of the cases, results led to a change in medical decision making. A 100% accuracy was achieved regarding COVID-19 diagnosis and a 56% bacterial growth-rate in cultives where VAP was suspected. No health care personnel have developed symptoms nor tested positive for COVID-19 during or after sample collection. Conclusion: M-TA technique presented could be considered as a safe and effective procedure with low percentage of complications. Coronavirus Disease 2019 (COVID-19) was defined as pandemic by the World Health Organization 1 and affected more than 20 million people globally with confirmed cases in 215 countries. Since the beginning of the outbreak, the risk of viral transmission to healthcare personnel at the front line has been a global concern 2 posing a challenge for healthcare systems in terms of managing human resources, supplies, and personal protective equipment. Therefore, it is key that all clinical decisions are based on prevention strategies to obtain the best value from the available resources 3 . The collection of samples from the surface of the respiratory mucosa with nasopharyngeal swabs is a standard procedure used for diagnosis of COVID-19 in adults and children. Nevertheless, early data suggested relatively poor sensitivity of initial reverse transcription polymerase chain reaction (RT-PCR) tests from swabs 4 . False-negative results of nasopharyngeal swabs have direct implications for infection control and isolation rooms management. In addition to the previous, among critically ill patients the bacterial superinfection as well as a ventilator-associated pneumonia (VAP) are frequent events 5 , and usual practices such as bronchoalveolar lavage and traditional tracheal aspiration are limited due to their associated high risk of exposure for the operator 6, 7 . Setting primary focus on the protection of health care personnel, a modified tracheal aspiration (M-TA) technique is developed and used for acquiring a lower respiratory tract microbiological sample with a closed suction device. This technique proved to be useful not only in aiding COVID-19 diagnostic confirmation in patients with negative RT-PCR from swabs, but also in other respiratory infectious diseases when COVID-19 status remains unknown. A retrospective analysis is conducted in medical records of patients with suspected or confirmed COVID-19 admitted to the intensive care unit (ICU) of a Level 3 University Hospital between June 1, 2020 and August 1, 2020. All patients included in the analysis are more than 18 years-old, underwent mechanical ventilation (MV), and required a lower respiratory tract microbiological sample for suspected bacterial superinfection or COVID-19 diagnosis. A description of epidemiological data, prior nasopharyngeal swab test-results and microbial rescue of M-TA from patients' medical records is included. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 26, 2020. . https://doi.org/10.1101/2020.08.24.20180802 doi: medRxiv preprint VAP suspicion was determined by the treating physician and was based on: new and persistent (48-h) or progressive radiographic infiltrate plus two of the following: temperature of 38°C or 36°C, blood leukocyte count of 10,000 cells/ml or 5,000 cells/ml, purulent tracheal secretions, and gas exchange degradation with increasing levels of positive endexpiratory pressure (PEEP) or fraction of inspired oxygen 8 1 and 2) . The PVC probe was introduced through the endotracheal tube or tracheostomy cannula until resistance was encountered (level of the carina in the trachea). This was followed by the release of the vacuum, and the probe was delicately removed using turning movements, until secretions were aspirated into the collector bottle. No saline solution was used for liquefy secretions, and strictly aseptic principles were followed. The M-TA technique performed is detailed in Supplementary Material 1. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 26, 2020. . https://doi.org/10.1101/2020.08.24.20180802 doi: medRxiv preprint The data collection for this study was completed as part of the ICU follow-up clinic up to August 1st, 2020. This study was approved by the Ethics Committee of Hospital Italiano de Buenos Aires in June 2020, under protocol number 5678. Continuous variables were expressed as medians and interquartile ranges or simple ranges, as appropriate. Categorical variables were summarized as counts and percentages. No imputation was made for missing data. Given the fact that the cohort of patients in the study was not derived from random selection, all statistics are deemed to be descriptive only. RStudio developed by R-Tools Technology Inc was used for analysis. 33 patients were included in the study; 10 were female (30,3%) and 23 men (69,6%). Median Table 1 . Among all 33 procedures performed, only 2 associated complications (6%) were observed: one hypotension episode due to propofol bolus, and one inability to obtain the sample due to absence of secretions. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 26, 2020. . In the event that VAP was suspected, there was a high rate of germ rescue in the samples obtained. A higher revenue rate was observed in comparison with the one reported for bronchoalveolar lavage and conventional tracheal aspirate technique 12 . It is relevant to pinpoint that a key factor in decreasing mortality associated with VAP is the administration of adequate antibiotics as early as possible 11 . Even though the size of the sample is small, the procedure described could be considered safe and effective with a low percentage of associated complications. Moreover, the technique developed involves minimal additional costs because it requires materials that are widely available. Finally, it is worth to mention that none of the health care personnel involved have developed symptoms nor tested positive for COVID-19 during or after the data collection. Data Availability Statement: all relevant data are within the manuscript and its Supporting Information files. Funding: authors received no specific funding for this work. Author Contributions: Dr. Schverdfinger had full access to all data in the study and takes responsibility for integrity of the data and accuracy of the data analysis. The research team wants to specially thank Ignacio Fernández Ceballos for developing the technique. Also we would like to thank Maria de los Ángeles Magaz, Pablo Beber, Iván . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 26, 2020. . . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 26, 2020. True positive, % (n) 50% (4) True negative, % (n) 50% (4) False positive, % (n) 0 False negative, % (n) 0 Direct observation, % (n) 68% (17) Microbial cultures growth, % (n) 56% (14) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 26, 2020. . . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 26, 2020. . https://doi.org/10.1101/2020.08.24.20180802 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 26, 2020. . https://doi.org/10.1101/2020.08.24.20180802 doi: medRxiv preprint WHO announces COVID-19 outbreak a pandemic Deaths in healthcare workers due to COVID-19: the need for robust data and analysis. Anaesthesia. Epub ahead of print 12 Prevention of nosocomial COVID-19: Another challenge of the pandemic COVID-19 Testing: The Threat of False-Negative Results Ventilator-associated Pneumonia in the ICU. Annual Update in Intensive Care and Emergency Medicine American Association for Bronchology and Interventional Pulmonology (AABIP) Statement on the Use of Bronchoscopy and Respiratory Specimen Collection in Patients with Bronchoscopy in Patients with COVID-19 with Invasive Mechanical Ventilation: A Single-Center Experience Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention Positive tracheal SARS-CoV-2 RNA test after three negative SARS-CoV-2 RNA tests in a patient with COVID-19 The efficiency of routine endotracheal aspirate cultures compared to bronchoalveolar lavage cultures in ventilator-associated pneumonia diagnosis