Administrative and logistic measures are crucial to ensuring safety while still maintaining IP activity.17 Some general precautions include:

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  All referrals and requests to the IP unit must preferably be made by telephone or digital means.

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  Upon schedule and 24−48 h prior to arrival at the IP Unit, patients should be contacted by telephone and submitted to a pre-screening checklist that includes questions about 1) recent symptoms suggestive of COVID-19 (e.g. fever, cough, chills, muscle pain, shortness of breath/difficulty breathing, headache, sore throat, loss of taste or smell); 2) contact with suspicious/confirmed SARS-CoV-2 cases; and 3) occupational exposure.

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  Patients who have recent respiratory and infectious symptoms and/or chest imaging suggestive of COVID-19, should have their elective procedures postponed and rescheduled after all symptoms are resolved.

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  On arrival at the IP Unit, all patients must be asked again for respiratory symptoms and have their temperature checked.

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  If possible, all patients should have at least one negative RT-PCR for SARS-CoV-2 in the 24−48 h preceding the exam. In patients with a positive RT-PCR SARS-CoV-2, the decision to procede with the intervention will be based on the urgency of the procedure (Chart 1 and Table 1).

  
  

  Chart 1.

  Proposed triage of IP procedures during the COVID-19 outbreak.

  (0.23MB).
  Table 1.

  Priorization of IP exams according to SARS-CoV-2 status and procedure urgency.
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  The IP unit should keep a record of deferred patients to reschedule their procedures according to the COVID-19 outbreak situation, as proposed in Table 2.

  Table 2.

  Schedule of IP procedures according to the stage of COVID-19 pandemic.

  COVID-19 in the community	IP Unit
  Exponential increase of new cases	Urgent cases – only
  Rapid increase of new cases	Urgent cases – only
  	Elective but not delayable – evaluate case-by-case
  Decrease in new cases	Urgent cases – full capacity
  	Elective, but not delayable – full capacity
  	Elective and delayable – resume partial capacity
  Absence of new cases in the last 2 weeks	Resume all cases with full capacity

IP procedures are considered to be consistently subjected to the highest risk of exposure. In this setting, full precautions must be taken to cover all different possible types of transmission (contact, droplet and airborne).26 Personnel involved in the reprocessing procedure must also wear protective equipment consisting of eye protection, respiratory mask FP2, long sleeved gown and double gloves.27,28 The recommendations for the use of PPE are shown in Table 3.

Samples from the upper and lower respiratory tract, including pleural effusion, are deemed to be the most potentially infectious. Consequently, they should be handled as Category 3 pathogen and double-bagged (first the specimen must be bagged in the patient’s room and then taken out of the room and placed in a separate pre-labeled specimen bag). All specimens must be manually delivered.28,29

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  The IP Unit should reduce and prioritise the allocation of human resources according to the outbreak evolution and hospital needs. The minimum number of staff required to ensure a correct operation must be clearly defined.

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  It is essential that all personnel follow, train and maintain competency in effective hand hygiene and every aspect of PPE (theoretical, training and simulation sessions) so that everyone is familiar with their role.

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  All interactions with patients, including informed consent, should be done with appropriate PPE and frequent hand washing. The staff should not reduce the level of awareness and protection, and the idea that patients with suspected COVID-19 should be handled in the same manner as confirmed cases must be reinforced.

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  A core team that includes only essential HCW should perform the procedure on SARS-CoV-2 positive patients. The most experienced staff should be responsible for the exam to reduce time and deal effectively with possible complications. Other healthcare personnel, such as residents, medical students and visitors should not be inside the unit and the examination room before, during or after the procedure.

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  Of note, the scheduled exams must be done during normal working hours (avoiding an emergency basis or setting) and in an appropriate, designated room that fulfils all the standards required for care.

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  Respiratory and contact isolation should be standard and mandatory for all patients. Outpatients and inpatients should always enter the IP Unit with a suitable face mask and keep it on at all times (until the beginning and after the end of the procedure) to minimize the risk of transmission. No unnecessary personal items should be brought into the IP unit.

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  Family members and caregivers should not stay in the IP waiting rooms. In case of children or patients in need of support, the Unit can allow a single relative to enter the preparation area to provide aid.

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  The entry into the Unit of suppliers and medical devices sales representatives must be restricted.

The following reccomendations are expert opinion-based and should be adapted to local regulations and guidelines. In an optimal scenario, it is safer to perform elective bronchoscopy under general anesthesia and orotracheal intubation, clinical conditions permitting. If this is not possible, bronchoscopy can be performed under spontaneous ventilation. Some recommendations are listed below:

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  Operator should be standing behind the patient’s head to reduce direct exposure. Oxygen supplementation should be done without the use of humidification, either through a nasal cannula or preferably with an oxygen mask with an entrance to the bronchoscope (Fig. 2A).

  
  

  Figure 2.

  Strategies to minimize droplets dispersal during bronchoscopy. A. The bronchoscope may be introduced through an opening made at the oxygen mask, in this case with an additional plastic sheet covering the patient’s head. B. Transnasal approach, with oxygen supplementation through nasal cannula and a surgical mask placed over the patient’s mouth and the oral aspiration canulla. C. Bronchoscopy can be performed under ventilatory support, using a closed circuit ventilation and non-ventilated masks with a dedicated bronchoscope entrance. D. Transparent protective box may contain droplet particles inside. E. Protective box placed over the patient’s head during endobronchial ultrasound. F. Rigid bronchoscopy with rubber caps on the ports of the scope and a plastic covering.

  (0.62MB).
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  For flexible bronchoscopy, a transnasal approach should be preferred, and a surgical mask should be placed over the patient’s mouth to minimize droplet emission (Fig. 2B).

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  In hypoxemic patients, bronchoscopy can be performed under NIV, using a closed circuit ventilation (double circuit with viral filters in both arms) and non-ventilated masks with a dedicated bronchoscope entrance (Fig. 2C). High performance NIV ventilators with FiO2 regulation are preferable. From the end of the procedure, NIV should be continued for 1−2 h, titrating the FiO2 to obtain an SpO2 of around 94–95%.

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  Bronchoscopy under nasal high-flow oxygen therapy is not reccomended and thus should be avoided.

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  Nebulized medications should be avoided before or after the procedure.

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  Proper sedation should be used to minimize cough reflex and to increase patient cooperation.

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  An oral aspiration cannula should be available during the procedure (Fig. 2B).

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  A transparent protective box may enhance safety by containing dispersal of droplet particles (Fig. 2D). The box is placed over the patient’s head prior to bronchoscopy, with the anesthesia equipment already in place. The bronchoscope is inserted through the covered opening behind the patient (Fig. 2E).

The following recommendations are directed for patients under mechanical ventilation in an ICU setting due to respiratory failure. As reported, 5% of COVID-19 patients can develop respiratory failure and will need ventilatory support32; moreover, associated bacterial, viral and fungal co-infection should not be negleted.33 In critically ill patients under invasive ventilation, ventilator-associated pneumonia occurs in up to 30% and lobar collapse is frequent and multifactorial.34 The same adaptations apply to elective procedures under general anesthesia, performed in the Bronchoscopy Unit or Operating Theatre.

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  A cuffed endotracheal tube is preferred over supraglotic devices, such as a laryngeal mask; cuff pressure should be maintained between 25–30 cmH2O.35

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  General anesthesia with muscle relaxant is recommended to reduce the aerosol production.

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  FiO2 should be adjusted to 100%.

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  Volume control, pressure-limited mode is preferable and PEEP should be kept at the same level during the procedure. Adjustments can be made dynamically, with a prior assessment of the anticipated risks (e.g., lung derecruitment and desaturation, arrhythmias, pneumothorax).

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

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  Bronchoscope removal and reinsertion should be avoided during the procedure.

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  In hypoxemic patients, if bronchoalveolar lavage is needed for diagnostic purposes, the volume used should be reduced to a minimum. If a SARS-Cov-2 diagnosis is needed, a minimum of 2−3 mL of recovered lavage is enough.26

Rigid bronchoscopy is used for diagnostic and therapeutic purposes, in procedures where flexible bronchoscopy would be deemed difficult or even impossible, like obtaining larger samples of endobronchial lesions, foreign body removal, management of central airway obstruction (including ablative techniques, like electrocautery, argon plasma coagulation, laser, cryotherapy, among others, and placement of airway stents) or massive hemoptysis.36

There are different ventilation strategies used during rigid bronchoscopy, although manual jet ventilation and high frequency jet ventilation are much the most frequent.37 Common to these two techniques is the fact that the proximal end of the bronchoscope is open to allow the passage of instruments, thus ventilation is achieved providing 100% oxygen under high pressure (usually 50 psi) through an open system.39,40 The use of these ventilation techniques means that aerosols are released into the room, making it a high-risk procedure.

In patients with suspected or confirmed COVID-19 diagnosis, rigid bronchoscopy should be avoided, except for urgent cases (Table 1). Clinical scenarios are mostly therapeutic, like acute foreign body aspiration, massive hemoptysis (when there is no place for embolization), severe symptomatic central airway obstruction (either benign or malignant) and migrated stents. In a clinically stable patient, upon suspicion of foreign body aspiration, one should consider non-contrast computerized tomography (CT) to confirm the presence of a foreign body before rigid bronchoscopy, to avoid unnecessary exams.38,39

In some centers, the rigid scope is used to perform other techniques, like Endobronchial Ultrasound-Transbronchial Needle Aspiration (EBUS-TBNA) or transbronchial cryobiopsy; this provides comfort to the operator and safety in case of major bleeding. The authors recommend performing these diagnostic procedures through cuffed endotracheal tube to minimize the risk of exposure. However, the operator must be ready to convert to rigid bronchoscopy, if necessary.

In a patient undergoing rigid bronchoscopy, it is recommended that:

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  Rigid bronchoscopy should always be performed in a negative pressure room.

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  Controlled ventilation is preferred, with the rigid bronchoscope used like an endotracheal tube.

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  Air leaks should be reduced using rubber caps on the ports of the rigid scope, as well as using a plastic covering (Fig. 2F) or filling the mouth with gauze.40 While this strategy is more appealing to minimize aerosol spread, the operator may find it challenging to handle instruments through the working channel.

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  On suspicion of malignant effusion, diagnostic pleural fluid aspiration should be performed, especially if the patient is a candidate for systemic therapy or if the effusion is symptomatic (Table 1).

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  Consider placement of indwelling pleural catheters for recurrent malignant pleural effusions, avoiding repeated hospital drainage or admission.

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  On suspicion of pleural infection, pleural fluid aspiration and analysis should be performed.

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  In case of benign pleural effusions, the risk-benefit should be discussed with the attending physician; procedures can be postponed if the patient is not symptomatic.

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  Thoracoscopy is not recommended as a principle; however, in the absence of alternative options, its risk-benefit must be assessed.

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  Spontaneous primary pneumothorax can be managed in outpatient care if the risk assessment allows and if there is local team experience; needle aspiration and discharge should be considered if the patient is minimally symptomatic.

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  When pleural drainage placement is necessary, if there is local expertise and the patient is at low risk, the use of pleural vent systems should be considered, thus allowing the patient to be managed at home.

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  Extra care must be taken when placing the chest tubes, in order to avoid open communication with the pleural space and the potentialemission of droplets and aerossols.

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  When chest tubes are placed in ventilated patients, consideration should be given to clamping the ventilator circuit before assessing the pleural cavity, so that positive pressure spreading of pleural air or fluid can be prevented.

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  Whenever possible, the use of non-wired pleural drainage should be considered; it can be connected to the drainage system before insertion into the pleural cavity (closed circuit).

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  When pleuroscopy is required, the use of one way valve trocars should be preferred to assess the pleural cavity and properly seal the entrance port of the pleuroscope.

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  In case of prolonged air-leaks, the use of wall suction should be weighted to create a closed system.