bilities of the procedure room and the air turnover time. Alterations in procedural time and recovery areas should be accounted for as compared to non-COVID-positive bronchoscopy procedures. All horizontal and work surfaces, monitors, and hardware should be disinfected with approved cleaners after bronchoscopy.

COVID Clearance: A Role for Bronchoscopy

As previously discussed, SARS-CoV-2 virus can be detected in patients post the initial infectious period for variable amounts of time. Both test-­ based strategies, requiring one or more negative respiratory RT-PCR tests, or symptom-based strategies, maintaining infectious precautions for a set amount of time post symptoms, have been employed in variable populations. In both patients and healthcare workers with symptomatic COVID-19, data show the average time to transition from RT-PCR positive to negative is 24 days after symptom onset, with up to 10% of patients having a positive test even 33 days after symptoms started [42]. Reinfection, given the duration of the pandemic, and variable immunity with new variants is also possible, warranting retesting in those with recurrence of symptoms or known exposures despite former status as resolved. Institutional guidelines on clearance should be followed; for example, in one of our institutions, two BAL specimens negative for SARS-CoV-2 have to be done more than 24 h apart for clearance to be established. Obviously, this errs on the side of caution.

Long COVID: A Role for Bronchoscopy

As the pandemic continues, there are reports of long-lasting COVID-19 symptoms in many patients, including those asymptomatic or with minor symptoms in the acute phase. Symptoms are widely variable, but most commonly include fatigue, headache, dyspnea, and anosmia. This so-called “long COVID” is reported to affect up

to 13% of patients for more than 28 days post infections and at least 12 weeks in more than 2% and there is now evidence to suggest age, body mass index, and female sex as well as experiencing more symptoms during acute illness increase the likelihood of prolonged symptoms [43]. There is currently scant evidence-based treatment available for long COVID, with rehabilitation and physical therapy thought to be helpful in certain populations and no pharmaceutical has yet been proven helpful [44]. In the absence of known bene cial therapies, there is not yet a role for bronchoscopy in long COVID. However, the identi cation of radiographic ndings consistent with another disease pattern, such as sarcoidosis, other interstitial lung diseases, indolent infections such as nontuberculous mycobacteria should be appropriately investigated.

Bronchoscopy andCOVID:

The Questions that Remain

The roles for bronchoscopy in different populations of COVID 19 patients has yet to be fully scrutinized. It will be complex to evaluate if those undergoing bronchoscopy in the intensive care unit had improved outcomes: ventilator free days, organ failure, antimicrobial usage, extubation, or mortality differences. The differences between institutional, regional, and national practices will make this dif cult to assess postpandemic. We the authors certainly witnessed intubated ICU patients with improvements postbronchoscopy from moribund states to eventual discharge from the hospital in the setting of therapeutic aspiration bronchoscopy for asphyxiation from mucus plugging or hemoptysis with blood clots in the airways. Similarly, the identi cation of co-­existing bacterial and fungal pathogens has led to changes in antimicrobials leading to clinical improvement in both ICU patients as well as those hospitalized on the foor, especially those with immunocompromise and/or co-morbidities. Finally, the next few years will be revealing the effect of the COVID-19 pandemic had on those without COVID-19 who rely on bronchoscopy