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Revista de investigación clínica

versión On-line ISSN 2564-8896versión impresa ISSN 0034-8376

Rev. invest. clín. vol.72 no.3 Ciudad de México may./jun. 2020  Epub 04-Mayo-2021 

Letter to the editor

Operational Recommendations for the Attention and Prevention of SARS-CoV-2 Infection at Interventional Bronchoscopy Units

Olivia Sánchez-Cabral1 

Dina Martínez-Mendoza2 

Miguel Á Ramírez-Candelas1 

Krizia J. Jassen-Avellaneda1 

Silvia D. Ponce-Campos1 

Maria de los Ángeles Macías-Jiménez1 

Cira Santillán-Díaz1  * 

1Interventional Pulmonology Unit and National Institute of Respiratory Diseases (INER) “Ismael Cosío Villegas”, Mexico City, Mexico

2Epidemiology Surveillance Unit, National Institute of Respiratory Diseases (INER) “Ismael Cosío Villegas”, Mexico City, Mexico

Dear Editor

Highly specialized bronchoscopic procedures performed at Interventional Pulmonology Units are considered high risk due to the particle aerosolization. In response to the current world health situation, due to the infection of the new severe acute respiratory syndrome coronavirus and coronavirus disease (COVID-19) and despite the fact that bronchoscopy has a relatively contraindicated indication due to the risk of infection in health personnel and for its limited usefulness in COVID-19 diagnosis, is important to establish protocols on how to act in the operating centers for patients care with COVID-19, as well as for the prevention of infection in health personnel. The document shown in supplementary information contains recommendations proposed by experts from the Interventional Pulmonology Unit of the National Institute of Respiratory Diseases “Ismael Cosío Villegas” in Mexico City and by International Organizations. As shown in the guideline, the most important points to consider are as follows: prioritization of procedures, patient care, staff distribution, description of work areas, procedure room conditions, patient transfer, intervention flowchart, personal protection, and processing of bronchoscopy equipment.


Supplementary data are available at Revista de Investigación Clínica online ( These data are provided by the corresponding author and published online for the benefit of the reader. The contents of supplementary data are the sole responsibility of the authors.


During the severe acute respiratory syndrome coronavirus 2 pandemic, elective procedures will be suspended, only urgent procedures will be performed.

  • – Tracheostomy

  • – Foreign bodies

  • – Active hemoptysis

  • – Obstruction of the central airway

  • – Lobar atelectasis.


  1. During the pandemic, all patients should be considered COVID-19 positive

  2. Nasopharyngeal, oropharyngeal swabs, and tracheal aspirates (already performed by the treating service) should be the diagnostic method of choice

  3. Bronchoscopy is a relatively contraindicated procedure; it has limited utility in the diagnosis of COVID-19 since it is a high-risk procedure for personnel and should only be considered in the following scenarios1-7:

    • To have negative nasopharyngeal, oropharyngeal, and tracheal aspirate tests

    • If there is an alternative diagnosis that modifies the treatment

    • Life-threatening conditions: airway obstruction or massive hemoptysis

    • Aspiration of secretions that compromise ventilatory mechanics

    • Percutaneous tracheostomy.

  4. All hospitalized patients with an indication for orotracheal intubation during the shift, according to the clinical context, will be transferred to the bronchoscopy unit, where they will proceed to perform orotracheal intubation using a rapid intubation sequence, as well as a bronchioloalveolar lavage (in case of having indication). If you cannot transfer the patient, you must have a portable computer.

The rapid intubation sequence to be performed is proposed below8-12:

The patient wears surgical mask until induction begins

  1. Preoxygenation for 5 min with 100% of fractional of inspiration oxygen and monitoring of vital signs

    • Do not separate the facial mask from the patient’s face during preoxygenation.

  2. Rapid intubation sequence will be performed (fentanyl, midazolam, rocuronium, or succinylcholine) no ventilation

  3. Ensure deep neuromuscular block using neuromuscular transmission monitoring

  4. Trendelenburg position is given to the patient, and the bronchoscopist will be notified

  5. The bronchoscopist will perform intubation with indirect visualization using rigid lens intubation technique (this technique minimizes the risks of infection of health personnel related to intubation), verifying the appropriate placement

  6. The balloon of the tube is inflated

  7. Connect to the anesthetic circuit with a high-efficiency filter to start mechanical ventilation, which will be carried out according to the established protocol

  8. The patient will be ventilated to stabilize SaO2 (arterial oxygen saturation) and ETCO2 (exhaled carbon dioxide), for at least 3 min

  9. Mechanical ventilation is suspended

  10. Bronchoalveolar lavage will be performed in apnea (if indicated)

  11. At the end of the wash, the endotracheal tube is reconnected to the anesthetic circuit.

The sample must be compulsorily taken by trained personnel and must be considered highly infectious, so it is essential to wear personal protective equipment7. The sample types are shown in Table 1.

Table 1 Description of the sample types7 

Type of sample Material Transport temperature Storage Comments
Pharyngeal and nasopharyngeal exudate Viral transport medium Dacron or rayon swabs with plastic handles (pharyngeal exudate) Dacron or rayon swabs with flexible handle (nasopharyngeal exudate) 2 - 8°C ≤ 5 days: 2 - 8°C > 5 days: −70°C Pharyngeal and nasopharyngeal exudate should be placed in the same tube to increase viral load.
Washed bronchioalveolar Sterile container with viral transport medium 2 - 8°C ≤ 48 h: 2 - 8°C > 48 h: −70°C There may be dilution of the pathogen, but it is still worth taking. A minimum of 2 ml is required (1 ml of bronchioalveolar lavage plus 1 ml of transport medium).
Tracheal aspirate, nasopharyngeal aspirate, or nasal wash Sterile container with viral transport medium 2 - 8°C ≤ 48 h: 2 - 8°C > 48 h: −70°C A minimum of 2 ml is required (1 ml of aspirate, plus 1 ml of transport medium).
Lung biopsy Sterile container with viral transport medium 2 - 8°C ≤ 5 days: 2 - 8°C > 5 days: −70°C 2 cm3 from the visibly most affected part.

Table 2 Description of the work areas 

Description of work areas

Area Description activities
Dressing rooms Site intended for the removal of cloth-ing and personal accessories as well as the placement of disposable surgi-cal suits.
Uncontaminated area • Computer area for administrative processes and case discussion.
• Location and placement area of personal protective equipment.
Contaminated area • Patient transfer hall.
• Equipment washing area.
• Procedure room.

Flowchart of work in the interventional bronchoscopy unit


Equipment distribution:

  1. Personnel inside the operating room (performing the procedure):

    1. Interventional/bronchoscopist and anesthesiologist.

  2. Equipment washing (bronchoscope and equipment in general)

    1. Washing support personnel.

  3. Medical work office

  4. Warehouse

    1. Nurse.


The bronchoscopy room must have negative pressure, as well as minimum air changes of> 12 times/h. The air must be removed directly to the outside or be strictly monitored by the highly efficient filtration system for particles in the air, before recirculation. It must be monitored and documented by the institution’s infection control personnel13.


All personnel must wear a surgical mask at all times.

  1. Maintain a distance of at least 2 m between staff and patients (if possible)

  2. Personnel must wash their hands with soap and water or disinfect with alcohol gel before and after contact with the patient, as well as before and after each procedure

  3. Limit personnel that are in contact with the patient (preferably two)

  4. Minimize contact time with the patient

  5. All personnel must wear the following equipment: cap, gloves, surgical masks with face mask, N95 mask, surgical suit and heat-sealed (disposable) protective suit, and shoe protector

  6. The room must remain 30 min alone after the procedure, and it will be exhaustive and disinfected

  7. The equipment will be limited to what is strictly necessary inside the room

  8. At the end of the procedure, the patient will leave the operating room directly to his treating service.


  1. The patient must be transferred by the team and medical personnel in charge

  2. Patients will enter and exit through the main door of the unit, directly to the room

  3. At the end of the procedure, you will be discharged directly to your clinical service, accompanied by medical personnel and transfer equipment

  4. No more than 1 patient will be allowed in the unit simultaneously, so there will be no recovery room.


  1. Mechanical washing

    1. Start immediately after the procedure to avoid drying or hardening of organic residues

    2. They must wear full personal protective equipment

    3. The outside part of the bronchoscope should be cleaned with a gauze soaked with 75% alcohol and suck it through the channel

    4. Suction ports and accessories must be separated, before leak test

    5. The bronchoscope will be placed in an airtight polyethylene bag, to be transferred from the procedure room to the washing area

    6. Perform a leak test (pressurized instrument, with water). Its presence indicates a violation of the integrity of its external or luminal part. Must be repaired before reuse

    7. Immerse the bronchoscope in enzymatic soap (according to the characteristics of each bronchoscope) for approximately 5 min

    8. The external surface must be cleaned manually with the enzymatic detergent, then use a cleaning brush through all the ports (perform several times until no organic debris is observed and discard)

    9. Rinse all channels with the same enzyme soap

    10. Rinse external part and channels with water to remove the enzymatic cleaner and prepare for disinfection.

  2. Disinfection.

    • According to the above, the bronchoscope is a semi-critical device (devices that come into contact with intact mucous membranes and do not normally penetrate the sterile tissue), therefore requiring high-level disinfection

    • Disinfection with orthophthaldehyde will be performed

    • Disinfection for 20 min in 2% alkaline glutaraldehyde at 20°C provides adequate disinfection, if before this use detergent

    • In general, solutions can be reused for 14-28 days

    • The potency of the solution must be periodically tested by commercially available test kits (must be discarded if the concentration is less than 2%)

    • The solution must be tested at the beginning of each day of use

    • After disinfection or sterilization, rinse the bronchoscope and internal canal with sterile water

    • Ideally, the instrument dries by purging the canal with 70% alcohol and compressed air

    • Flexible bronchoscopes should be hung valveless vertically in a spacious cabinet with adequate ventilation to prevent moisture

    • Do not store them in cases that cannot be disinfected13.

In conclusion, due to the high risk of infection that bronchoscopic procedures perform during the COVID-19 pandemic in health personnel, it is essential that the interventional bronchoscopy units have action protocols. The most important points to consider are as follows: prioritization of procedures, patient care, staff distribution, description of work areas, procedure room conditions, patient transfer, intervention flowchart, personal protection, and processing of bronchoscopy equipment.


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2. Infection Control. Disinfection of Healthcare Equipment. Guideline for Disinfection and Sterilization in Healthcare Facilities;2008. Available from: [Last accessed on 2020 Apr 03]. [ Links ]

3. Zhejiang University School of Medicine, Alibaba and the Jack Ma Foundation. Handbook of COVID-19 Prevention and Treatment Compiled According to Clinical Experience. China:Zhejiang University School of Medicine, Alibaba and the Jack Ma Foundation;2020. [ Links ]

4. Joseph T, Ashkan MM. International Pulmonologist’s Consensus on COVID-19. India:Amrita Institute of Medical Sciences;2020.</p> [ Links ]

5. Coronavirus Disease 2019. Clinical Care Guidance. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). Available from: [Last accessed on 2020 Apr 03]. [ Links ]

6. Surgical and Procedural Guidelines. UMMC ICU Endoscopy Protocol During COVID-19 Pandemic. Available from: [Last accessed on 2020 Apr 03]. [ Links ]

7. Dirección General de Epidemiología. Lineamiento Estandarizado Para la Vigilancia Epidemiológica y Por Laboratorios de COVID-19. Mexico:Dirección General de Epidemiología;2016.</p> [ Links ]

8. Greenland JR, Michelow MD, Wang L, London MJ. COVID-19 Infection:implications for perioperative and critical care physicians. Anesthesiology. 2020;132:1346-61. [ Links ]

9. Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, et al. Intubation and ventilation amid the COVID-19 outbreak:wuhan’s experience. Anesthesiology. 2020;132:1317-32. [ Links ]

10. Luo M, Cao S, Wei L, Tang R, Hong S, et al. Precautions for intubating patients with COVID-19. Anesthesiology. 2020;132:1616-8.</p> [ Links ]

11. World Health Organization. Confederación Latinoamericana de Sociedades de Anestesiología, Protocolo COVID-19. Geneva:World Health Organization;2020. [ Links ]

12. Peng PW, Ho PL, Hota SS. Outbreak of a new coronavirus:what anaesthetists should know. Br J Anaesth. 2020;124:497-501. [ Links ]

13. Mehta AC, Prakash UB, Garland R, Haponik E, Moses L, Schaffner W, et al. American college of chest physicians and American association for bronchoscopy concensus statement:prevention of flexible bronchoscopy-associated infection. Chest. 2005;128:1742-55. [ Links ]

14. Báez MM. Protocolo de Bioseguridad y Biocustodia Para el Manejo de Pacientes Durante la Toma de Muestras de Casos Sospechosos de Enfermerdad por 2019-nCov. Mexico:Instituto de Diagnóstico y Referencia Epidemiológicos;2020. [ Links ]

Received: May 14, 2020

* Corresponding author: Cira Santillán-Díaz E-mail:

Creative Commons License Instituto Nacional de Cardiología Ignacio Chávez. Published by Permanyer. This is an open ccess article under the CC BY-NC-ND license