gent strains, and COVID-19 speci c treatment, multiple leading health organizations released guidelines including the WHO, the International Society for Infectious Disease (ISID), and the United States Centers for Disease Control (CDC) on multiple topics including travel, social distancing, vaccinations, and masking. Guidelines for the care of both inpatients and outpatients with known or suspected COVID-19 became available at multiple levels, including institutionspeci c policies, city guidelines, country guidelines, and worldwide recommendations.

Leading respiratory medical associations and societies, including the European Respiratory Society (ERS), a joint statement from the American College of Chest Physicians (CHEST)/ American Association for Bronchology and Interventional Pulmonary (AABIP), the Society forAdvanced Bronchoscopy (SAB), the Canadian Thoracic Society (CTS), the German Respiratory Society (DGP), the Chinese Thoracic Society (CMA), the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), and the Argentinean Association for Bronchology (AABE) all released guidelines and reports with respect to the role of bronchoscopy in patients with known COVID-19 and those patient with a need for bronchoscopy with the incidental nding of COVID-19 positivity [6–12]. This chapter includes the approach to bronchoscopy in differing populations during the pandemic, as well as patient assessment and triage, safety measures and personal protection equipment (PPE), and questions remaining around bronchoscopy during a lengthy and challenging global pandemic.

Safety

Patient Safety

The same patient safety criteria and patient-­ speci c factors should be used when considering bronchoscopy in patients with or without COVID-19. Multiple studies have evaluated the safety of bronchoscopy in both critically ill and noncritically ill patients with COVID19 and found variable differences in outcomes

or adverse effects, with up to 8% having complications from the procedure, higher than in all-comers [13–16]. Similarly, patients recently recovered from COVID-19 also have increased surgical complications [17]. Overall, an individualized patient risk analysis accounting for patientand procedure-­speci c risks should be done before proceeding with bronchoscopy during COVID-­19 surges, as should be done in any infectious or noninfectious patient. Anticipating support needs, including personnel, support devices for oxygenation and/or ventilation, medication needs for analgesia and/or sedation, bronchoscopes, and other tools should all be discussed and accounted for.

Provider Safety

During the initial phases COVID-19 pandemic, there were wide variations in the both availability and use of personal protective equipment (PPE). Subsequently, during the initial period of the pandemic, when many aspects of the disease were also unknown and testing not widely or quickly available, many outpatient bronchoscopy practices were closed given that bronchoscopy is an aerosol generating procedure. Current provider PPE recommendations from the CTS, SAB, and the AABIP/CHEST guidelines for bronchoscopy recommend PPE in patients with con rmed or suspected COVID-19 include an N95 mask with goggles or a powered air purifying respirator (PAPR), gown, and gloves [6–8]. For team members performing high-risk aerosol generating procedures when COVID-19 is not suspected, the SAB recommends the same PPE when overall community rates are high, though the de nition for high rates is not explicitly given. The SAB guideline also reviews the importance of appropriate donning and dof ng to minimize exposure to contaminated particles including the importance of training and practice. Multiple studies have revealed that bronchoscopy in COVID-19 positive patients is safe for providers in regard to procedural transmission [13, 15, 18], with additional studies showing positive testing in healthcare providers highly associated with pro-