Bronchoscopy and the Risk of SARS-CoV-2 Infection for the Staff

Dear Editor,The main route of transmission of SARS-CoV-2 is by droplet infection. Bronchoscopy is one of the procedures that leads to a particularly pronounced aerosol formation and represents a high risk of infection. Therefore, many professional societies have published recommendations for protective measures during bronchoscopy [1]. Until now, there has been no supporting evidence for the recommended measures. Prospectively collected data of a high-volume bronchoscopy center, the Thoraxklinik Heidelberg, were descriptively analyzed. The question was to what extent the measures introduced were effective in minimizing the risk of infection to personnel during bronchoscopy in the pandemic time. Before the pandemic, more than 4,000 per standard-of-practice mostly rigid bronchoscopies under jet ventilation in general anesthesia were performed annually in two endoscopy suites. After a short decline in bronchoscopy numbers initially, these remained constant in the course afterward with short dips at the peaks of the respective local corona waves. During April 1, 2020, to March 31, 2022, a total of 7,224 bronchoscopic procedures (bronchoscopies on intensive care unit excluded) have been performed (shown in Fig. 1). The first SARS-CoV-2 positive patient was detected in the region on March 20, 2020, and starting on April 1, 2020, all bronchoscopies were performed only with FFP3/FFP2 masks, disposable surgical gowns, gloves, and appropriate eye protection. The endoscopy suites are furthermore equipped with a standardized ventilation system (2-stage air filtration, no recirculation). During the first year, whenever possible, the procedures were changed to endotracheal tube bronchoscopies under general anesthesia. In the second year, bronchoscopies were gradually switched to rigid bronchoscopies according to house standard again. Starting on May 1, 2020, all patients received polymerase chain reaction (PCR) smears the day before bronchoscopy, and since there was sufficient availability of antigen tests, the endoscopy staff was examined regularly (1–2/week) with nasal antigen tests and confirmation PCR if necessary. Diagnostic and non-vital bronchoscopies in COVID-positive patients were postponed for 4–6 weeks per individual choice, depending on urgency and PCR negativity. Urgent bronchoscopies were performed with FFP3 and the abovementioned protective clothing. In summary, 28 patients with PCR-proven SARS-CoV-2 infection underwent bronchoscopy. After an initial reduction of the personnel in the endoscopy suite, the whole staff (12 assistants, 18 bronchoscopists, 14 anesthetists in total) was again involved during the 2-year period. Fortunately, the analysis of the regularly performed testing shows that no member of the staff became infected during a 2-year observation period. Even during high-jet ventilation rigid bronchoscopy, certainly a maximum aerosol-producing procedure, there was no transmission to examiner, assistant, or anesthetist. Bronchoscopy should certainly still be considered an aerosol-producing procedure with an increased risk of infection. However, by consequently implementing the abovementioned measures, complete prevention of contamination in a high-volume bronchoscopy center performing a wide spectrum of bronchoscopy procedures can be achieved. In summary, the recommended SARS-CoV-2 protection measures can be considered effective in protecting personnel from contamination.Judith Brock has received honoraria for lectures from Boehringer Ingelheim, Streamed Up, Astra Zeneca, and Intuitive Surgical. Frederik Trinkmann received travel support from Actelion, Berlin Chemie, Boehringer Ingelheim, Chiesi, Novartis, Mundipharma, and TEVA as well as speaker or consultation fees from AstraZeneca, Berlin Chemie, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Fisher and Paykel Healthcare, GlaxoSmithKline, Janssen-Cilag, Novartis, Roche, and Sanofi-Aventis, all outside the submitted work. Konstantina Kontogianni has received honoraria for lectures from AstraZeneca, Berlin Chemie, Boston Scientific, and Olympus. Jonas Herth has no conflicts of interest to declare. Felix Herth has research support from Olympus Medical, Pulmonx, Broncus, Uptake Medical, Roche Diagnostics, BMBF, DFG, EU, Klaus-Tschirra Stiftung, and BMG. Lecturing and consulting activities from Pulmonx, Uptake Medical, Astra Zeneca, Boehringer Ingelheim, Novartis, Berlin Chemie, Chiesi, Medupdate, Erbe, Olympus Medical, J&J, Karger, LÄK, Boston Scientific, Dinova, Nanovation, Free Flow Medical, Eolo, and Intuitive. The authors confirm that they have no conflicts of interest to declare related to this article.There was no funding source, and no ethics committee approval was necessary.Felix Herth had the idea for this project and mainly conducted the literature search. Konstantina Kontogianni mainly guided the patient flow during SARS-CoV-2 pandemic and did validation as well as interpretation of the data. Jonas Herth has collected the data. Frederik Trinkmann analyzed the data and created the figure. Judith Brock wrote the manuscript and conducted literature search. All contributed to data interpretation, formal analysis, and writing of the letter.