A study of the utility and safety of bronchoscopy in mechanically ventilated COVID19 ARDS: Transgressing the conventional guidelines

  1. Ravindra Mehta
  2. Sameer Bansal
  3. Ashwin Kumar
  4. Anmol Thorbole
  5. Chakravarthi Loknath
  6. Hariprasad Kalpakam

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Abstract

Background: Bronchoscopy has been done sparingly in COVID19 patients due to the risk of aerosol generation. We describe a study on targeted bronchoscopy in mechanically ventilated (MV) COVID-19 patients outlining the procedural, clinical, utilitarian and safety aspects. Methods: Bedside bronchoscopy was performed in suspected or confirmed COVID-19 cases on MV for specific indications. Demographic, clinical, bronchoscopic and laboratory findings were analysed. Results: 98 procedures were performed on 61 patients, mean age 62.1 years, 51 (83.6%) males. 42 patients (69%) had at least 1 co-morbidity. Major indications were new radiographic infiltrates with clinical deterioration, increased endotracheal tube (ETT) secretions and haemorrhagic secretions/hemoptysis. Common findings were copious secretions in 87 (88.8%), purulent in 61%, mucoid in 18%, haemorrhagic in 7% and frothy in 14% cases. On the management front, antibiotics were changed in 31 (31.6%) cases based on bronchoscopic findings. Other significant changes included reduction/stopping steroids and anticoagulation and ETT repositioning. The incidence of bacterial superinfection was high (54% culture positivity), a significant number (94%) with multi-drug resistant organisms. Fungi were seen in 7 cases (7.1%). Pneumocystis jiroveci was not seen and cytology did not show any viral inclusions. Therapeutic mucus plug removal was done in 30 cases (30.6%), and hemoptysis control in 4% cases. The procedures were safe and none of the HCW developed any COVID19 disease. Conclusion: Bronchoscopy in critically ill MV COVID-19 patients contributes on both diagnostic and therapeutic fronts and impacts management decisions. With adequate precautions and standard protocols, it is safe for both HCW and patients.

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  1. Version published to 10.18103/mra.v10i1.2660
  2. ScreenIT

    SciScore for 10.1101/2021.02.02.21250362: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: Approval for the study was granted by Institutional Ethics Committee Bio Medical Research Apollo Hospital, Bangalore.
    Consent: Procedure: Bronchoscopy after informed consent was performed by 3 different operators.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistics: Data was tabulated and analysed using SPSS (ver. 25.0, SPSS Inc).
    SPSS
    suggested: (SPSS, RRID:SCR_002865)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    A fundamental limitation in the MV-CARDS patients during the pandemic was restricted suctioning due to aerosol risk, limiting many aspects of diagnosis and ventilator management. (1) Bronchoscopic inspection led to immediate changes including change of antibiotics, reduction of immunosuppression and anticoagulation, modification of the fluid strategy, ETT tube adjustment and detection of unexpected findings, such as a malignant mass (Table 2). Microbiologically, the Gram’s stain and subsequent culture reports were used to adjust antibiotics in line with standard principles. Another important result was proving COVID positivity in washings when earlier NP swabs were negative. Few studies have been published on bronchoscopy in severe COVID-19 patients. Torrego et al performed 101 bronchoscopies in 93 COVID-19 patients early in the pandemic. (4) The median duration from MV to procedure was 6.6 days (range 1-17). Bruyneel et al. performed 90 bronchoscopies in 32 ICU patients between 6 March and 21 April 2020. (5) Baron et al. performed 28 bronchoscopies between March 31 and June 2020 on 24 COVID-19 patients. (6) The median time [IQR] from MV to BAL was 16 [10-21] days. In our study, median symptom-onset (SO) to hospitalization duration was 7 (IQR;4-10) days, SO to MV was 10 days (7 – 13.2) and SO to bronchoscopy was 14 days (10-20), while MV to bronchoscopy was 2.5 days (1-6.5). The timing of bronchoscopy in our study was based on clinical indications, with the observation that l...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  3. Version published to 10.1101/2021.02.02.21250362v1 on medRxiv