key: cord-0791707-2cnfsogg
authors: Chang, Stephanie H.; Jiang, Jeffrey; Kon, Zachary N.; Williams, David M.; Geraci, Travis; Smith, Deane E.; Cerfolio, Robert J.; Zervos, Michael; Bizekis, Costas
title: Safety and Efficacy of Bronchoscopy in Critically Ill Patients with COVID-19
date: 2020-10-08
journal: Chest
DOI: 10.1016/j.chest.2020.09.263
sha: de7f443485cd6fd6f7b640ded2c9a8203694eed3
doc_id: 791707
cord_uid: 2cnfsogg

nan

Coronavirus disease 2019 (COVID-19) can progress to severe respiratory failure requiring intubation and mechanical ventilation, with a grim prognosis in this subset of patients [1] [2] [3] [4] . Despite the perceived increased risk from aerosol-generating procedures, data from prior severe acute respiratory syndrome suggests no increased transmission from bronchoscopy [5] . There is a paucity of data regarding the actual risk and benefit of bronchoscopy for patients with COVID-19, leading to uncertainty regarding recommendations.

The hypothesis of this report is that bronchoscopy with intermittent apnea is safe for both patients and healthcare providers. This study reports our experience with therapeutic bronchoscopy in patients with severe COVID-19.

Langone Health (NYULH) Manhattan campus between March 13 th -April 24 th , 2020 with COVID-19 and respiratory failure requiring mechanical ventilation that underwent bronchoscopy.

COVID-19 was diagnosed by nasal pharyngeal swab for reverse transcriptase polymerase chain reaction (rtPCR) assays. Indications were concern for superimposed pneumonia, thick secretions with decreasing tidal volumes, evidence of endotracheal tube obstruction not resolved by suctioning, or significant bloody secretions. The NYULH institutional review board approved this human subjects study.

All procedures occurred in the intensive care unit (ICU) in a negative pressure room with personnel wearing full PPE (hair cover, fitted N95 mask, face-shield, gown, and gloves). Inroom personnel was minimized, consisting of the bronchoscopist with the bedside nurse immediately available but outside the room. Patients were pre-oxygenated for 2 minutes with a fraction of inspired oxygen of 1.0 to maximize apneic time. For patients not on sedation and/or J o u r n a l P r e -p r o o f neuromuscular blockade, peri-procedural anesthesia was administered using propofol and rocuronium to decrease risk of spontaneous breathing leading to aerosolization.

A disposable Ambu ® aSCope ™ 5 23-3/5 (Ambu Inc., Columbia, MD) and Ambu ® aView ™ (Ambu Inc., Columbia, MD) was the bronchoscope utilized. After pre-oxygenation, the ventilator was placed in standby mode, and the endotracheal or tracheostomy tube was disconnected from the ventilator. Bronchoscopy occurred in a routine manner to clear all secretions, clot, or mucus plugs. If the oxygen saturation decreased below 90%, bronchoscopy was interrupted and the patient was reconnected to the ventilator. After an additional period of pre-oxygenation, bronchoscopy was then completed. Bronchoalveolar lavage (BAL) samples were collected at the request of the treating ICU team or presence of purulent secretions.

The primary outcomes for this study were patient and healthcare provider safety, defined as freedom from peri-procedural complications and Covid-19 transmission, respectively.

Secondary outcomes included secondary infection with bacterial or fungal pneumonia.

Descriptive statistics were used to summarize the data and results, reported as medians and interquartile ranges, for all non-parametric data.

From March 13 th -April 24 th , 2020, 412 patients with confirmed COVID-19 were admitted to the NYULH Manhattan ICU, with 321 patients requiring intubation. 107 patients (33% of intubated patients) underwent bronchoscopy, with 241 bronchoscopies performed during the study period (Table 1) . No peri-procedural complication of severe hypoxia requiring bag-valve J o u r n a l P r e -p r o o f ventilation, pneumothorax, or intra-procedural arrhythmias occurred. Three patients required endotracheal tube advancement or replacement for dislodgement during the procedure.

Fifty four patients (50.5%) received a BAL, and 35 (65%) had a positive culture ( 

The bronchoscopy team included six cardiothoracic surgeons and four cardiothoracic surgery residents. One cardiothoracic surgery resident was COVID-19 positive by rtPCR prior to performing any bronchoscopies. The remaining nine team members are negative for COVID-19 via nasal pharyngeal swab for rtPCR assay, with at least one negative test performed two weeks after the last bronchoscopy.

This study demonstrates the safety and feasibility of performing bronchoscopy with intermittent apnea for patients with severe COVID-19. We noted a 33% rate of bronchoscopy in intubated patients, which is unusually high compared to non COVID-19 ARDS. This increased need may be secondary to thick distal secretions associated with COVID-19 or bloody secretions due to the anticoagulation given the reported increased thrombotic risk. Because of concern regarding the safety of these procedures and possible high risk of transmission of COVID-19, many providers were reluctant to perform bronchoscopy. A bronchoscopy technique J o u r n a l P r e -p r o o f designed to decrease the risk of aerosolization of SARS-CoV-2 was adopted. The protocol for neuromuscular blockade to decrease coughing and the performance of bronchoscopy under apnea was designed to minimize healthcare provider exposure to COVID-19. Although this protocol differs from common practice, this procedure was tolerated well by patients. No healthcare provider involved in the bronchoscopies became positive for COVID-19.

This series demonstrates a high prevalence of secondary infection with bacterial or fungal pneumonia. This rate of superinfection is important, as under-diagnosis of a second pneumonia may play a key role in the excessive mortality rate for intubated patients. BAL cultures had a higher positive culture rate (65%) compared to tracheal aspirate (45%). More interesting is the high rate of positive BAL with a negative tracheal aspirate culture, correlating to a 16% false negative rate of tracheal aspirate cultures. Nearly a third of BAL specimens collected demonstrated a secondary pneumonia in patients with no or negative tracheal aspirate

cultures. An additional 6% of BALs grew a different or second organism. This data directly contradicts the belief that tracheal aspirate is sufficient for diagnosis of superimposed pneumonias for patients with COVID-19.

Strengths of this report include that it demonstrates the safety of bronchoscopy to the healthcare provider, is the largest reported series of bronchoscopies in patients with severe COVID-19, and describes a high rate of superinfection. Additionally, the yield of positive BAL in patients with negative tracheal aspirates has not been previously described for COVID-19

patients. Limitations to this study are that it is a retrospective review, and a descriptive paper.

J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

Intensive care national audit & research centre

Letter to the editor. Poor survival in extracorporeal membranous oxygenation in acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19): pooled analysis of early reports

Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area

Risk factors for SARS transmission from patients requiring intubation: A multicenter investigation in Toronto

COVID-19: Coronaravirus disease 2019 ICU: Intensive care unit NYULH: New York University Langone Health PPE: Personal protective equipment rtPCR: Reverse transcriptase polymerase chain reaction

SHC had full access to the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis, including and especially any adverse effects.