key: cord-1050160-nmy3v5o6
authors: Styrvoky, Kim; Dave, Siddharth; Abu-Hijleh, Muhanned
title: Flexible Bedside Bronchoscopy Using Closed Sheath System Devised From Ultrasound Probe Cover for Use in SARS-CoV-2 Patients
date: 2020-12-14
journal: J Bronchology Interv Pulmonol
DOI: 10.1097/lbr.0000000000000703
sha: d72954251019d825abb7ab3da9e576a9ce7c24f2
doc_id: 1050160
cord_uid: nmy3v5o6

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Bronchoscopy in confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients is relatively contraindicated and reserved for emergencies as recommended by multiple national and international expert opinions and societies. The risk of transmission to health care workers during aerosol-generating procedures is suspected to be extremely high. However, clinicians may encounter certain indications that warrant bedside bronchoscopy for these patients, such as the need to obtain lower respiratory samples in indeterminate and inconclusive SARS-CoV-2 nasopharyngeal swab or alternative testing. Other emergency conditions include therapeutic bronchoscopy in the setting of mucus plugging causing lobar or lung atelectasis, or to assist with performing tracheostomy placement. 1 Current consensus guidelines for clinicians performing bronchoscopy on SARS-CoV-2 patients recommend performing the procedure in negative pressure room, minimizing personnel, wearing appropriate personal protective equipment (powered air-purifying respirator or N95 mask, eye protection, gown, and gloves), and ensuring adequate sedation or paralytics to minimize patient cough. 2,3 However, bronchoscopy not only derives its risk from the aerosol-generating nature of the procedure, but also through manipulation of the scope, which often includes repeated advancing and retracting motions of the bronchoscope. This can cause lower respiratory secretions on the bronchoscope to be spread to operator's hands, drapes, or other adjacent surfaces. We propose a system to minimize exposure by utilizing a routine ultrasound probe cover to fashion a closed bronchoscopy system, similar to current usage of closed inline suctioning in intubated patients.

If available, we generally use a disposable bronchoscope. We recommend using a universal ultrasound probe cover (Fig. 1) as it is readily accessible in most intensive care settings, or could alternatively use any surgical, interventional, or endoscopy sheaths that are of adequate dimensions. If patient is stable, we would recommend holding ventilation during any steps in which ventilator circuit is open. One would first make a cut in the distal end of the ultrasound cover, then position the distal end of the sheath over the endotracheal tube bypassing the ventilator limb and then secure it distally to bronchoscope adapter on endotracheal tube with the enclosed tape (Fig. 2) . Then would insert bronchoscope into the proximal portion of the sheath and secure proximal sheath at the junction of the insertion tube and control section of the bronchoscope with enclosed tape, then apply transparent film dressing (Fig. 3) . This allows insertion and retraction of the bronchoscope during procedure within the protective sheath. After completion of bronchoscopy, one would retract the bronchoscope fully into the sheath and place the cap on the bronchoscope adapter. The tape on the distal aspect around the endotracheal tube would then be unwrapped, and the ultrasound sheath would be removed while wrapping the distal end of the sheath on itself and securing it closed with the tape. The complete system including disposable bronchoscope with attached sheath could then be disposed of as intact system.

We recommend using this technique with a disposable bronchoscope, as using a reusable bronchoscope would require removal of the sheath and cleaning the bronchoscope before sending to sterile processing. In addition, this technique may be best utilized for basic bedside procedures since there is a potential for increased difficulty in manipulation of bronchoscope within the sheath as well as limited usage of working channel to suction or instill saline into airways, with an inability to remove the bronchoscope fully to flush saline through port distally to clear any thick secretions. As has previously been shown in other barrier methods devised during the COVID-19 pandemic, qualitative efficacy of this technique to minimize health care worker exposure via secretions or aerosolization could potentially be demonstrated using fluorescent dye in simulated bronchoscopy. 4 We must emphasize that bronchoscopy in COVID-19 positive patients with the addition of a bronchoscope sheath devised from a universal ultrasound probe cover must be used in conjunction with other enhanced personal protective equipment and aerosolization mitigating techniques that are currently recommended by societal guidelines and statements. 

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

Summarizing societal guidelines regarding bronchoscopy during the COVID-19 pandemic

The use of bronchoscopy during the COVID-19 pandemic: CHEST/ AABIP Guideline and Expert Panel Report

Barrier enclosure during endotracheal intubation