Procedure Performance

All societies recommend postponing elective procedures in suspected or known COVID-19 patients. Bronchoscopy is considered to be a relatively contraindicated procedure in these situations as its bene t in face of infectious risk of operators is not clear [7].

Although rescheduling certain procedures is obvious, in other cases the decision is not straightforward and risks/bene ts must be weighted [6, 9].

Nonelective bronchoscopic procedures are mainly performed for microbiological evaluation in suspected superinfection and obstructive atelectasis [3]. Elective procedures mostly represent diagnostic (oncologic and microbiologic purposes) and therapeutic reasons [18].

Bronchoscopy inNonintubated Patients

In an ideal scenario, it is safer to perform all the procedures in intubated patients and with general anesthesia to minimize droplet emission. In the real world, this situation may not be possible and the procedure must be done in spontaneous ventilation and in a nonintubated patient. Considering this last situation, some recommendations are listed below:

•\ To reduce direct exposure, the operator should stand behind the patient.

•\ Oxygen supplementation should be done without humidi cation.

•\ Nebulized medications should be avoided before or after the procedure.

•\ Some guidelines suggest not to use lidocaine for pharyngeal anesthesia, while others suggest cough-suppressive drugs to reduce aerosolization [7].

•\ Appropriate sedation should be performed.

•\ A transnasal approach is preferred when possible, and a facial mask should be placed over the patients’ mouth (Fig. 8.2a). An oral aspiration cannula should be available. The use of nonvented oronasal masks with a dedicated

bronchoscopic entrance is also a possible option.

•\ In hypoxemic patients, bronchoscopy may be performed under noninvasive ventilation (NIV) (Fig. 8.2b).

•\ Other barrier systems have been used as alternatives to masks, with the aim of minimizing the dispersion of droplets, like the existence of a protective box placed over the patient’s head, but they need further investigations to prove their ef cacy (Fig. 8.2c).

•\ Bronchoscopy under high-fow oxygen is not recommended.

Bronchoscopy in Intubated Patients

About 5% of COVID-19 patients can develop respiratory failure and need mechanical ventilation [1]. In critically ill patients under invasive ventilation, ventilator-associated pneumonia occurs in up to 30%, and lobar collapse causing atelectasis is frequent and multifactorial. The combination of predisposing factors related to the underlying pathology, sedation, position, inadequate secretion aspiration and the high fraction of inspired oxygen will contribute to pulmonary atelectasis [19].

Performing a bronchoscopy in an intubated patient has some advantages: offers a secure airway, it is easier to oxygenate and reduces muscular workout and fatigue [20]. Several considerations may be considered:

•\ It is always preferred to perform the procedure under general anesthesia. In speci c and more complex cases, if there is no contraindication, consider muscle relaxation with a neuromuscular blocker.

•\ A cuffed endotracheal tube is preferred over the supraglottic devices; cuff pressure should be maintained between 25 and 30 cm H2O [21].

•\ The use of an adapter (e.g., swivel) may facilitate the entry of the bronchoscope, avoiding disconnection of the ventilator circuit and minimizing air leaks.

•\ Pressure-limited volumetric ventilatory modes with FIO2 100%, attempting to main-

tain constant PEEP during the procedure are desirable. Variations in ventilatory parameters can be performed dynamically after adequate patient-­related risk assessment.

•\ To avoid aerosol dispersion, a simple maneuver consists of clamping the ventilation circuit just before introduction of bronchoscope, repeating the same step just before withdrawal.

•\ When performing a bronchoalveolar lavage, the volume used should be reduced to a minimum, and it is worth mentioning that 2–3 mL

of recovery lavage is able to provide a SARS-­ CoV-2 diagnosis.

•\ Bronchoscope removal and reinsertion during the procedure should be avoided or reduced.

Other Procedures in IP Unit

In patients with suspected or con rmed COVID-­19, rigid bronchoscopy should be avoided, but there are scenarios where fexible

bronchoscopy would be considered dif cult or even impossible, such as some foreign body aspiration, massive hemoptysis, severe central airway obstruction, or migrated airway stents. In those cases, the procedure should always be performed in a negative pressure room, with controlled ventilation (if possible utilizing closed ventilation systems instead of jet ventilation) and using rubber caps on the ports of rigid scope to avoid air leaks.

Pleural procedures are not listed as aerosol generating procedure in the CDC recommendations, and they do not appear to be a prominent feature of COVID-19 [22, 23].

Thoracoscopy is not recommended as a principle and the risk bene t must be assessed. When required, the use of one-way valve trocars should be preferred.

Summary andRecommendations

The World Health Organization recommends the preparation of a checklist to be completed during the procedure to minimize the risk of infection by the participating staff. This vision must include the pre-procedure planning, the execution, and the post-procedure phase. It is mandatory that proper training be provided to all health care staff involved in IP.

The pre-procedure includes:

•\ Adaptation the IP (proper rooms and circuits); •\ Revise prioritization of all the procedures;

•\ Perform pre-screening checklist (symptoms, contact history, and occupational exposure);

•\ RT-PCR nasopharyngeal swab for SARS-­ CoV-­2 test 24–48 h preceding the exam; and

•\ Proceed according to priority and test results.

In the procedure execution phase:

•\ Gown adequate PPE and perform procedure at adequate endoscopy suite;

•\ Prepare in advance all equipment needed and plan the procedure;

•\ Minimize direct exposure:

––Stand behind the patient;

––Use appropriate sedation;

––Place surgical mask over patients’ mouth;

––Avoid nebulized drugs;

––In ventilated patients, prefer endotracheal tubes and clamp ventilation circuit when introducing and removing bronchoscope;

––Use disposable bronchoscopes in con-rmed or highly suspicious COVID-19 patients; and

––Minimize procedure duration.

•\ Reduce team to minimal necessary; and

•\ Medical doctors in training can be present during exam if they have previous adequate formation.

In the post-procedure timing:

•\ Collect samples in closed circuits, according to local infectious control guidelines;

•\ Reprocessing of bronchoscopes must be considered an aerosol-generating procedure;

•\ Disinfect foor and surfaces after each procedure;

•\ Allow adequate time (30 min) between procedures; and

•\ Perform sequential remove of PPE in a designated area.

Acknowledgements  The authors acknowledge H.N. Bastos and M. de Santis for the photos and H.N. Bastos, J.P. Boléo-Tomé, L.V. Rodrigues, S. Campaínha, and M. de Santis for the discussion of some topics.

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