vider uncertainty of proper donning and dof ng protocols [19]. We recommend the most experienced team member perform bronchoscopy when needed for patients with known or highly suspected COVID-19, especially the critically ill. Experienced bronchoscopists are more procedurally ef cient, minimizing procedural time and therefore aerosolization as well as complications including worsening or new hypoxemia; bene t- ting both the patient and healthcare team.

Patient Selection and Screening

The initial stages of the pandemic resulted in many hospitals worldwide canceling all elective procedures due to concerns about patient and staff safety as well as equipment/staf ng availability. While many bronchoscopies are elective, most are for acute and urgent issues, including the diagnosis and/or staging of malignancy. True emergent needs for bronchoscopy such as severe, symptomatic airway obstruction; massive hemoptysis; or foreign body aspiration are less common. During the pandemic, the need to risk stratify each procedure to minimize risk of infection transmission and, in many cases, optimize the utilization of limited resources, became of utmost importance. As both asymptomatic or incidentally found COVID-19 positivity rates and resource availability waxed and waned during the initial years of the pandemic, bronchoscopists faced continued changing challenges of triage.

Current recommendations include those from the SAB, which gives some of the most speci c guidelines, recommending those procedures that are emergent as noted above continue to be done emergently in a same day procedure. They recommend remaining bronchoscopy procedures be strati ed to urgent, acute, subacute, and elective procedures [7]:

•\ Urgent procedures, including those for neutropenic fevers and undiagnosed in ltrates without improvement on antibiotics as well as transplant patients with concerns for acute infection, be performed within 2 days

•\ Acute procedures including those for new lung mass or nodule, including those with adenopathy with no other target present, those for suspected disease progression, symptomatic suspected sarcoidosis, and acute lobar atelectasis, to be performed within 2 weeks.

•\ Subacute procedures including bronchoscopic inspections for cough or minor hemoptysis, chronic lobar atelectasis, and stent surveillance can be delayed greater than 2 weeks.

•\ Elective procedures such as bronchial thermoplasty, bronchoscopic lung volume reduction, lavage for nontuberculous mycobacteria, and other atypical chronic infections with minimal symptoms, tracheostomy changes, and lung transplant surveillance should be rescheduled when possible.

Other societies have similar recommendations, if slightly less detailed. The AABIP/ CHEST guidelines also recommend considering local resource availability, including the availability of COVID-19 testing and PPE, as well as the possible need to utilize nearby resources, such as tertiary care centers, be taken into account [6]. Of course, there are multiple circumstances where a patient may not t perfectly into one of the above categories. Figure 9.1 illustrates a triage strategy when bronchoscopy is needed during times of pandemic or endemic COVID-19.

Lung Cancer Diagnosis and Staging

The role of bronchoscopy in lung cancer diagnosis, staging, repeat tissue sampling for molecular analysis and treatment response, and therapeutics via management of airway obstruction with debulking, stenting, photodynamic therapy, ducial placement, and brachytherapy leaves this particular population especially vulnerable during the COVID-19 pandemic and its surges. The American Society of Clinical Oncology (ASCO) gave cautious guidelines directing clinicians toward standard infection control practices as well as individualized decision-making refecting the patient’s best interest [20]. The European Society for Medical Oncology (ESMO) offered

Pathology examples and timeframe

Fig. 9.1  Triage of bronchoscopy in COVID-19 and positive patient considerations. Timing of bronchoscopy should be triaged on a case-by-case basis dependent on symptoms and pathology; COVID-19 status should then

be considered for each case dependent on these needs. Facility protocols and guidelines need to be considered when scheduling any bronchoscopy when COVID-19 community levels are elevated

prioritization of management of lung cancers, with tiers refecting high, medium, and low priorities in care [21]. The American College of Surgeons guidelines for triage consider semi-­ urgent cases as those where “survivorship would be compromised if surgery not performed within three months, including lung cancer or presumed lung cancer measuring greater than two centimeters­ with negative or positive nodes, post-­ induction therapy, need for surgical staging to start treatment, symptomatic mediastinal tumors or those enrolled in therapeutic clinical trials” [22]. Current data regarding COVID-19 infection in thoracic cancer patients suggest a particularly high mortality and hospitalization rate in this vulnerable population [23], making the role of vaccinations and minimizing exposures also of utmost importance to all providers who care for them.

Bronchoscopy forOutpatients

In patients suspected of both having COVID19 and requiring bronchoscopy for a separate reason, a nasopharyngeal or salivary specimen

should be obtained to con rm the diagnosis of COVID-19. If negative, a second specimen after 24–48 h may be useful in ruling out early infection with false negative testing. If testing is again negative, alternatives to COVID-19 infection such as other infections (infuenza, other respiratory viruses, noninfectious causes) should be considered and tested for. If positive, the proceduralist should review his/her/their institutional policies regarding how long to wait before a non-­ emergent procedure; as well as discuss with other care providers on the team including anesthesia, bronchoscopy staff, oncology, thoracic surgery, and radiation oncology. The guidelines above should not supersede institutional policy.

In those outpatients with transmissible COVID-19 requiring emergent bronchoscopy or bronchoscopy unable to await the above recommendations; PPE, bronchoscope processing, pre-, intra-, and post-procedure care should match that of every other SARS-CoV-2 patient including N95 respirators or PAPRs as well as negative airfow during the entire time they are in the healthcare facility which may affect the location of the pre-procedure time as well as the recovery prior to discharge.