key: cord-0734634-16doskzg
authors: Schverdfinger, Sofía; Bisso, Indalecio Carboni; Famiglietti, Romina; Grazia, Marcelo Di; Stefano, Sabrina Di; Heras, Marcos José Las
title: Tracheal aspirate with closed suction device: a modified technique developed during the COVID-19 pandemic
date: 2021-01-28
journal: nan
DOI: 10.1016/j.acci.2020.12.004
sha: 131aff5fe49cce5b397b4188962e9604bf78cba1
doc_id: 734634
cord_uid: 16doskzg

Antecedentes: Tanto la sobreinfección bacteriana como la neumonía asociada a la ventilación (NAV) son eventos frecuentes en los cuidados críticos. Durante la pandemia de COVID-19, las prácticas diagnósticas habituales, como el lavado broncoalveolar y el aspirado traqueal, están limitadas debido al alto riesgo de exposición que conllevan para el operador. Con el fin de poner el foco principal en la protección del personal sanitario, se desarrolla y utiliza una técnica de aspiración traqueal modificada (M-TA) para la adquisición de muestras microbiológicas del tracto respiratorio inferior con un dispositivo de aspiración cerrado. Métodos: Se realiza un estudio observacional retrospectivo para evaluar la eficacia de la M-TA. Resultados: Se analizaron un total de 33 muestras de M-TA. En el 66,6% de los casos, los resultados condujeron a un cambio en la toma de decisiones médicas. Se alcanzó una precisión del 100% en el diagnóstico de COVID-19 y una tasa de crecimiento bacteriano del 56% en las cultivas en las que se sospechó de VAP. Ningún personal sanitario desarrolló síntomas ni dio positivo a COVID-19 durante o después de la recogida de muestras. Conclusiones: La técnica de M-TA presentada podría considerarse como un procedimiento seguro y eficaz con bajo porcentaje de complicaciones. Background: Bacterial superinfection, as well as ventilation associated pneumonia (VAP), are both frequent events in critical care. During the 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 was developed and used for acquiring microbiological samples from the lower respiratory tract using a closed suction device. Methods: Retrospective observational study was conducted to evaluate effectiveness of an M-TA. Results: A total of 33 M-TA samples were analysed. 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 cultures where VAP was suspected. No health care personnel developed symptoms or tested positive for COVID-19 during or after sample collection. Conclusion: The M-TA technique presented could be considered as a safe and effective procedure with low percentage of complications.

tracheal aspiration (M-TA) technique was developed and used for acquiring microbiological samples from the lower respiratory tract using a closed suction device. Methods: Retrospective observational study was conducted to evaluate effectiveness of an M-TA. Results: A total of 33 M-TA samples were analysed. 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 cultures where VAP was suspected. No health care personnel developed symptoms or tested positive for COVID-19 during or after sample collection. Conclusion: The M-TA technique presented could be considered as a safe and effective procedure with low percentage of complications.

Keywords: COVID-19; Critical Care; pandemics; Pneumonia; Ventilator-Associated; Culture Techniques; infection Aspiración traqueal con dispositivo de aspiración cerrado: una técnica modificada desarrollada durante el brote de COVID-19.

Antecedentes: Tanto la sobreinfección bacteriana como la neumonía asociada a la ventilación (NAV) son eventos frecuentes en los cuidados críticos. Durante la pandemia de COVID-19, las prácticas diagnósticas habituales, como el lavado broncoalveolar y el aspirado traqueal, están limitadas debido al alto riesgo de exposición que conllevan para el operador. Con el fin de poner el foco principal en la protección del personal sanitario, se desarrolla y utiliza una técnica de aspiración traqueal modificada (M-TA) para la adquisición de muestras microbiológicas del tracto respiratorio inferior con un dispositivo de aspiración cerrado.

Métodos: Se realiza un estudio observacional retrospectivo para evaluar la eficacia de la M-TA.

Resultados: Se analizaron un total de 33 muestras de M-TA. En el 66,6% de los casos, los resultados condujeron a un cambio en la toma de decisiones médicas. Se alcanzó una precisión del 100% en el diagnóstico de COVID-19 y una tasa de crecimiento bacteriano del 56% en las cultivas en las que se sospechó de VAP. Ningún personal sanitario desarrolló síntomas ni dio positivo a COVID-19 durante o después de la recogida de muestras.

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 was conducted in medical records of patients with suspected or confirmed COVID-19 admitted to the intensive care unit (ICU) of high complexity between June 1, 2020 and August 1, 2020. All patients included in the analysis were more than 18 yearsold, underwent mechanical ventilation (MV), and required a lower respiratory tract microbiological sample due to suspected VAP or COVID-19 diagnosis. A description of epidemiological data, prior nasopharyngeal swab test-results and microbial rescue of M-TA from patients' medical records was included.

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.

In patients with confirmed COVID-19 in whom VAP was suspected, an M-TA was performed with the aim of microbiologically defining VAP. Otherwise, in patients with clinical suspicion of COVID-19 and an initial negative nasopharyngeal swab test, a M-TA was performed with the aim of achieving COVID-19 diagnosis. Also, in this group of patients, the true false reports were confirmed with serologic detection of IgG and IgM against SARS-CoV-2. Complications associated with the procedure were documented.

All healthcare personnel involved in performing M-TA underwent serologic testing for COVID-19 every 2 weeks during the study period.

In order to perform tracheal aspiration, 2 operators donned with personal protective equipment (Figures 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 following were the steps the suggested to perform tracheal aspiration:

1. Explain the process to the patient or relatives. 19. Set the alarms, secure adequate FiO2 and verify that the humidification system is working.

20. Labeled the microbiological sample with patient's data as well as with the legend "COVID-19" for its proper processing. 21. Dof personal protective equipment.

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.

Study did not receive funding sources.

33 patients were included in the study; 10 were female (30,3%) and 23 men (69,6%). Median Table 1 .

Of the 33 samples obtained, 22 (66,6%) led to a change in medical decision making. When technique was used for COVID-19 diagnosis, among a total of 8 patients 4 (50%) were a true positive and 4 (50%) true negative. Analyzing microbiological samples due to suspected VAP in confirmed COVID-19 patients, 14 out of 25 samples (56%) presented microbial growth in cultives. 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. Results of M-TA are shown in Table 2 . 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 healthcare personnel involved have developed symptoms nor tested positive for COVID-19 during or after the data collection. Continuous variables are presented as median (and interquartile range), and categorical variables as count (%).

APACHE II: Acute Physiology And Chronic Health Evaluation II.

Complications* 6% (2) Changed medical decision 66,6% (22)

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) Continuous variables are presented as median (and interquartile range), and categorical variables as count (%). VAP: Ventilator-associated pneumonia. 

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 Suspected or Confirmed COVID-19 Infection

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

Diagnostic accuracy of serological tests for covid-19: systematic review and meta-analysis

Confirmed COVID-19 diagnosis prior to tracheal aspirate

Mechanical ventilation duration, days