Bronchoscopy on Intubated COVID-19 Patients is Associated with Low Infectious Risk to Operators at a High-Volume Center Using an Aerosol-minimizing Protocol

Gao, Catherine; Bailey, Joseph; Walter, James M.; Coleman, John M.; Malsin, E.; Argento, A. Christine; Wunderink, Richard G.; Smith, Sean B.; Investigators, NU Covid

doi:10.1101/2020.08.30.20177543

Cited by 12 publications

(12 citation statements)

References 21 publications

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“…For bronchoscopies performed in COVID-19 patients, additional precautions were taken to minimize the risk to healthcare workers including only having essential providers present in the room, clamping of the endotracheal tube, transient disconnection of the inspiratory limb from the ventilator, and preloading of the bronchoscope through the adapter 48 . Sedation and neuromuscular blockade to prevent cough, was administered for these procedures at the physician's discretion.…”

Section: Nbbal and Bal Proceduresmentioning

confidence: 99%

Circuits between infected macrophages and T cells in SARS-CoV-2 pneumonia

Grant

Morales‐Nebreda

Markov

et al. 2021

Nature

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612

639

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Some patients infected with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) develop severe pneumonia and the acute respiratory distress syndrome (ARDS) 1 . Distinct clinical features in these patients have led to speculation that the immune response to virus in the SARS-CoV-2-infected alveolus differs from other types of pneumonia 2 . We collected bronchoalveolar lavage fluid samples from 88 patients with SARS-CoV-2-induced respiratory failure and 211 patients with known or suspected pneumonia from other pathogens and subjected them to flow cytometry and bulk transcriptomic profiling. We performed single-cell RNA-seq on 10 bronchoalveolar lavage fluid samples collected from patients with severe COVID-19 within 48 hours of intubation. In the majority of patients with SARS-CoV-2 infection, the alveolar space was persistently enriched in T cells and monocytes. Bulk and single-cell transcriptomic profiling suggested that SARS-CoV-2 infects alveolar macrophages, which in turn respond by producing T cell chemoattractants. These T cells produce interferon-gamma to induce inflammatory cytokine release from alveolar macrophages and further promote T cell activation. Collectively, our results suggest that SARS-CoV-2 causes a slowly-unfolding, spatially limited alveolitis in which alveolar macrophages harboring SARS-CoV-2 and T cells form a positive feedback loop that drives persistent alveolar inflammation.

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Section: Nbbal and Bal Proceduresmentioning

confidence: 99%

Circuits between infected macrophages and T cells in SARS-CoV-2 pneumonia

Grant

Morales‐Nebreda

Markov

et al. 2021

Nature

Self Cite

612

639

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“…(10) Bronchoscopy in COVID-19 patients when done with adequate precautions is relatively safe with low risk to HCWs. This fact is reinforced in various studies (11,12) Unique aspects of our study include the value of additional information obtained from bronchoscopy that influenced clinical management, especially in patients where there were . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.…”

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 78%

“…Our study of bronchoscopy in MV COVID-19 critically ill patients describes diagnostic and therapeutic aspects, including morphological details, microbiological and pathological aspects, and procedural and safety aspects. [10][11][12][13][14][15][16][17][18][19][20][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).…”

Section: E Cytology and Histopathologymentioning

confidence: 99%

Bronchoscopy in COVID19 ARDS patients on mechanical ventilation – a prospective study

Mehta

Bansal

Kumar

et al. 2021

Preprint

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Background: Bronchoscopy has been done sparingly in COVID19 patients due to the risk of aerosol generation, with few reports describing its clinical utility. We describe a large case series of 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; only positive cases were included in the study. Demographic, clinical, bronchoscopic and laboratory findings were noted and analysed. Results: 98 procedures were performed on 61 patients, mean age of 62.1 years, 51 (83.6%) males. 42 patients (69%) had at least 1 co-morbidity. Major indications for bronchoscopy 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. Morphologically, hyperaemic airways were seen in 85 (86.7%) cases, ranging from mild (61%) to moderate-severe (39%). On the management front, antibiotics were changed in 31 (31.6%) cases based on bronchoscopic findings. Other significant changes included reduction or stopping of steroids and anticoagulation, fluid, and diuretic adjustment and ETT repositioning. The incidence of bacterial superinfection was also high (54% culture positivity for various bacteria), 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 with no complications, and none of the HCW developed any COVID19 infection. Conclusion: Bronchoscopy in critically ill MV COVID-19 patients contributes on both diagnostic and therapeutic fronts and can significantly influence management decisions. With adequate precautions and standard protocols, it is safe for both HCW and patients.

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“…We modified our standard bronchoscopic BAL technique for ventilated patients in order to minimize aerosol generation. 18 We defined early bacterial superinfection as detection by culture or multiplex PCR of a respiratory pathogen known to cause pneumonia, in addition to SARS-CoV-2, on a BAL specimen collected within 48 hours after intubation. We defined VAP as detection of a new respiratory pathogen in BAL fluid obtained more than 48 hours after intubation.…”

Section: Patient Cohortmentioning

confidence: 99%

“…16 We modified the standard bronchoscopic BAL technique in patients intubated for COVID -19 pneumonia-related respiratory failure to minimize operator exposure to infectious aerosols. 18 We retrospectively analyzed data from a cohort managed during the initial local COVID-19 surge to determine the prevalence and microbiology of bacterial superinfection at the time of intubation and subsequent bacterial VAP.…”

Section: Introductionmentioning

confidence: 99%

Bacterial superinfection pneumonia in SARS-CoV-2 respiratory failure

Pickens¹,

Gao²,

Cuttica³

et al. 2021

Preprint

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BackgroundSevere community-acquired pneumonia secondary to SARS-CoV-2 is a leading cause of death. Current guidelines recommend patients with SARS-CoV-2 pneumonia receive empirical antibiotic therapy for suspected bacterial superinfection, but little evidence supports these recommendations.MethodsWe obtained bronchoscopic bronchoalveolar lavage (BAL) samples from patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. We analyzed BAL samples with multiplex PCR and quantitative culture to determine the prevalence of superinfecting pathogens at the time of intubation and identify episodes of ventilator-associated pneumonia (VAP) over the course of mechanical ventilation. We compared antibiotic use with guideline-recommended care.ResultsThe 179 ventilated patients with severe SARS-CoV-2 pneumonia discharged from our hospital by June 30, 2020 were analyzed. 162 (90.5%) patients had at least one BAL procedure; 133 (74.3%) within 48 hours after intubation and 112 (62.6%) had at least one subsequent BAL during their hospitalization. A superinfecting pathogen was identified within 48 hours of intubation in 28/133 (21%) patients, most commonly methicillin-sensitive Staphylococcus aureus or Streptococcus species (21/28, 75%). BAL-based treatment reduced antibiotic use compared with guideline-recommended care. 72 patients (44.4%) developed at least one VAP episode. Only 15/72 (20.8%) of initial VAPs were attributable to multidrug-resistant pathogens. The incidence rate of VAP was 45.2/1000 ventilator days.ConclusionsWith use of sensitive diagnostic tools, bacterial superinfection at the time of intubation is infrequent in patients with severe SARS-CoV-2 pneumonia. Treatment based on current guidelines would result in substantial antibiotic overuse. The incidence rate of VAP in ventilated patients with SARS-CoV-2 pneumonia are higher than historically reported.

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Bronchoscopy on Intubated COVID-19 Patients is Associated with Low Infectious Risk to Operators at a High-Volume Center Using an Aerosol-minimizing Protocol

Cited by 12 publications

References 21 publications

Circuits between infected macrophages and T cells in SARS-CoV-2 pneumonia

Circuits between infected macrophages and T cells in SARS-CoV-2 pneumonia

Bronchoscopy in COVID19 ARDS patients on mechanical ventilation – a prospective study

Bacterial superinfection pneumonia in SARS-CoV-2 respiratory failure

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