Clinicians don PPE prior to a procedure.

Preventing Infection

How One Hospital Solved the Aerosolization Risk in Bronchoscopy During Pandemic

When healthcare workers feel safe, "bronchoscopy is performed without delay in patients and can prevent the diagnosis delay especially in malignancies, which is one of the important problems experienced during the pandemic period.”

When the first case of COVID-19 was diagnosed in Turkey on March 10, 2020, bronchoscopies screeched to a halt, as they did many places around the world.

But by April 1, one Turkish clinic had resumed bronchoscopies with the use of personal protective equipment (PPE) and an “intubation box.”

So say authors Serap Argun Baris, Gozde Oksuzler and others from Kocaeli University in a letter to the editor entitled “Fiberoptic Bronchoscopy Via Intubation Box During COVID-19 Pandemic.” The Journal of Surgical Oncology published the letter in March.

Because bronchoscopy is an aerosol-generating procedure, it poses a risk to healthcare worker safety. Airways of infected patients have been shown to carry a high viral load of COVID-19 in the nose, throat and trachea.

Without access to a negative pressure room, the physicians at Kocaeli University reported that their clinic successfully used an intubation box in a well-ventilated room. No healthcare workers became ill with COVID-19 as a result, they write in the letter to the editor.

An intubation box is a clear plastic box, about the size of a milk crate, that is placed over a patient’s head and shoulders before intubation. Holes in the box leave room for a clinician’s hands to perform the procedure while being shielded from viral droplets generated during intubation.

PPE including a face shield, gown, gloves and N-95 respirators as well as the intubation box helped healthcare workers feel safe during bronchoscopy. This was important to “ensure that bronchoscopy is performed without delay in patients and can prevent the diagnosis delay especially in malignancies, which is one of the important problems experienced during the pandemic period,” the authors write.

Kocaeli University healthcare workers cleaned the intubation box with disinfectant containing 80 percent alcohol and applied UV sterilization 15 minutes after each patient. Bronchoscopies were also performed with only an experienced pulmonologist and one nurse present, per guidance from professional societies to limit potential COVID-19 exposure.

All the patients who have had a bronchoscopy using this method were first questioned for COVID-19 symptoms and underwent a polymerase chain reaction (PCR) test for COVID-19 before the procedure. All patients tested negative. Testing is essential given the risk of asymptomatic patients transmitting the virus to other patients or healthcare workers.

Similarly, healthcare teams elsewhere in the world also resumed bronchoscopies after the initial outbreak of COVID-19 with new protocols in place based on guidance from a variety of societies and international panels.

The intubation box, aerosol box and surgical tent are among the systems that hospitals around the world used to keep patients and healthcare workers safe during the COVID-19 pandemic. In many cases, single-use bronchoscopes were at the center of the safety protocols because they eliminate the risk of cross-contamination.

A retrospective study at the New York University Langone Health Manhattan campus analyzed the effectiveness of using single-use bronchoscopes to perform bronchoscopy with intermittent apnea early in the global pandemic.

“The protocol for neuromuscular blockade to decrease coughing and the performance of bronchoscopy under apnea was designed to minimize health-care provider exposure to COVID-19. ...” the study says. “No healthcare provider who was involved in the bronchoscopies became positive for COVID-19.”

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