








key: cord-327169-sz4ildnd
authors: Mondoni, Michele; Sferrazza Papa, Giuseppe Francesco; Rinaldo, Rocco; Faverio, Paola; Marruchella, Almerico; D'Arcangelo, Francesca; Pesci, Alberto; Pasini, Simone; Henchi, Sonia; Cipolla, Giuseppe; Tarantini, Francesco; Giuliani, Lisa; Di Marco, Fabiano; Saracino, Laura; Tomaselli, Stefano; Corsico, Angelo; Gasparini, Stefano; Bonifazi, Martina; Zuccatosta, Lina; Saderi, Laura; Pellegrino, Giulia; Davì, Matteo; Carlucci, Paolo; Centanni, Stefano; Sotgiu, Giovanni
title: Utility and safety of bronchoscopy during SARS-CoV-2 outbreak in Italy: a retrospective, multicenter study
date: 2020-08-28
journal: Eur Respir J
DOI: 10.1183/13993003.02767-2020
sha: 
doc_id: 327169
cord_uid: sz4ildnd

Utility and safety of bronchoscopy during SARS-CoV-2 outbreak

Funding: the work is funded by Università degli Studi di Milano in the context of the Registry for COVID19 Emergency (RECOVER) electronic database

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the related disease (coronavirus disease -2019, COVID-19) has been notified throughout Italy since February 2020.

Intensive care unit (ICU) admission rate increased following the high incidence of pneumonia-related respiratory failure [1] .

The diagnosis of pneumonia relies on viral detection in respiratory samples and on the assessment of abnormal findings on chest X-ray, ultrasounds, and computed tomography (CT) [2] [3] [4] [5] .

Viral diagnosis based on naso/oropharyngeal swabs shows suboptimal accuracy (sensitivity: 32-63%), owing to wrong handling of the specimen, sample collection during the late phase of the disease or low viral load [5] [6] [7] .

Bronchoscopy increases the sensitivity of the molecular diagnosis in comparison with that associated with nasopharyngeal swabs [6] . Furthermore, endoscopic techniques may be useful to manage serious pulmonary disorders (e.g., obstructive atelectasis, severe hemoptysis) [8] [9] [10] [11] [12] .

However, bronchoscopy generates aerosol and may increase the risk of SARS-CoV-2 transmission [8] [9] 12] .

Limited data are available in the scientific literature on the role of bronchoscopy in cases of SARS-CoV-2 pneumonia [6] [7] [8] [9] [10] [11] [12] .

The primary aim of the present study was to describe the diagnostic yield of bronchoscopy in patients with negative nasopharyngeal swab(s) and a clinical and radiological suspicion of COVID-19 pneumonia.

Indications of bronchoscopy in cases of confirmed COVID-19 patients and the assessment of the safety of bronchoscopy for healthcare workers (HCWs) were also evaluated.

An observational, retrospective, multicenter cohort study was carried out in Italy. The study protocol was approved by the ethical committees of the participating hospitals. A written informed consent was signed by recruited patients.

Adult patients who underwent bronchoscopy between 1 st March 2020 and 15 th April 2020 were consecutively recruited in six Italian hospitals. The indications of bronchoscopy were: -diagnosis of SARS-CoV-2 pneumonia in patients with previously negative nasopharyngeal swab (clinical and radiological suspicion of pneumonia); -need for undelayable procedures in COVID-19 patients (e.g., massive hemoptysis, post-obstructive atelectasis).

All bronchoscopies were performed according to the WHO guidelines: the number of persons in the room was decreased to achieve a size appropriate to the provision of adequate care and support (i.e., one physician and one nurse wearing FFP3 masks) [13] .

The diagnosis of COVID-19 was confirmed when molecular (i.e., real time PCR) results detected SARS-CoV-2 in any respiratory sample [4, 5] . The probability of COVID-19 was high in case of a negative PCR and COVID-19-related symptoms (i.e., fever, cough, fatigue, and/or shortness of breath), CT signs (i.e., ground-glass opacity, consolidation, reticulation/thickened interlobular septa, air bronchogram sign), with rapid clinical changes (progression or improvement in a short time period) [4, 7] .

The diagnostic yield of bronchoscopy was calculated dividing the number of patients with a molecular diagnosis of SARS-CoV-2 infection following the collection of bronchoscopic specimens by the number of patients with a suspected diagnosis of COVID-19 pneumonia.

Every HCW was carefully monitored for symptoms and clinical signs suggestive for COVID-19 for at least 15 days after the procedure.

An ad hoc electronic form was adopted to collect all study variables. Qualitative and quantitative variables were summarized with absolute (relative) frequencies and means (standard deviations, SD), respectively. This is to our knowledge the largest study on the diagnostic yield of bronchoscopy in patients with negative nasopharyngeal swabs and a clinical/radiological suspicion of SARS-CoV-2 infection. An etiological diagnosis is crucial to prevent viral transmission to susceptible individuals and decrease clinical complications in infected patients [1, 2] . Prompt respiratory isolation is needed to hamper the viral spread, whereas an early diagnosis of COVID-19 related complications (i.e., respiratory failure) is crucial for a good prognosis [1, 2] .

Our findings show that bronchoscopy might be useful in patients with suspected COVID-19 pneumonia and negative swabs, with an acceptable diagnostic performance of BAL and BW.

A recent study found a 71% detection rate of SARS-CoV-2 in 28 patients who underwent bronchoscopy in China, with 93% of positive PCR results in BAL samples [6] .

Our study shows a lower diagnostic yield but we performed a bronchoscopy only in patients with two previous negative swabs [6] .

Despite bronchoscopy has been relatively contraindicated during the COVID-19 pandemic, endoscopic procedures may not be postponed in some patient categories [11] .

Urgent/life-saving bronchoscopies were performed in 31 patients with a confirmed COVID-19 diagnosis for obstructive atelectasis, suspected concomitant lower respiratory tract infections, severe hemoptysis, suspected tracheal lacerations in patients mechanically ventilated, tracheostomy complications, and suspected concomitant pulmonary tuberculosis. Similar findings were recently described by Torrego et al.

in a Spanish cohort of COVID-19 patients who underwent bronchoscopy in ICU [12] .

Few data are available on bacterial and fungal co-infections with SARS-CoV-2 [14] . Lower respiratory tract co-infections were diagnosed with BAL in 4 patients. Prompt identification of co-infecting microorganisms is associated with an early prescription of antibiotics [14] .

Few bronchoscopy-related complications were recorded, with fever and mild respiratory failure being the most frequent.

The above-mentioned side effects can occur following a bronchoscopic procedure, in the line with the scientific evidence published before the pandemic [15, 16] . Neither severe complications nor deaths were described.

The WHO recommendations on airborne precautions for aerosol-generating procedures were strictly followed in the study centers: HCWs did not acquire any infections following the endoscopic procedures [13] .

In conclusion, our study shows that bronchoscopy is a useful technique in the diagnostic pathway of COVID-19 pneumonia when nasopharyngeal swabs are negative. Urgent/life-saving procedures may be safely and successfully performed for diagnostic and therapeutic purposes in COVID-19 patients. The risk of viral transmission to HCWs is low following the WHO guidelines on airborne precautions for aerosol-generating procedures.

COVID-19 Lombardy ICU Network. Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region

COVID-19 diagnosis and management: a comprehensive review

COVID-19): Role of Chest CT in Diagnosis and Management

Laboratory diagnosis of emerging human coronavirus infections -the state of the art

Detection of SARS-CoV-2 in Different Types of Clinical Specimens

Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases

The Use of Bronchoscopy during the COVID-19 Pandemic: CHEST/AABIP Guideline and Expert Panel Report

Performing Bronchoscopy in Times of the COVID-19 Pandemic: Practice Statement from an International Expert Panel

Bronchoscopy to assess patients with hemoptysis: which is the optimal timing?

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

Bronchoscopy in COVID-19 Patients with Invasive Mechanical Ventilation: A Center Experience

Infection prevention and control during health care when COVID-19 is suspected

Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing

British Thoracic Society Bronchoscopy Guideline Group. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE

Incidence of complications in bronchoscopy. Multicentre prospective study of 20,986 bronchoscopies

Declaration of interests: all authors declare no competing interests

The Authors want to acknowledge Dr. Beatrice Vigo, Mrs. Simona Gentile, Dr. Filippo Montanelli, Dr

Bronchoscopic detection rate of SARS-CoV-2 in patients with previous negative swabs and in the presence of a clinical and radiological suspicion of COVID-19 pneumonia, in the total cohort (78 patients) and according to BAL and BW



