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UMMC ICU Endoscopy Protocol During COVID-19 Pandemic

Last update: March 19, 2020

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Bronchoscopy

In order to provide consistent care while minimizing the risk of possible infection with COVID19, bronchoscopy procedures in ICUs will be stratified as below:

Emergent

  • Acute foreign body
  • Large amount/massive hemoptysis
  • Airway management during intubation

Urgent – 24-48 hours

  • Immunosuppressed host with new infiltrate tested - COVID neg
  • Lobar atelectasis not responding to conservative management
  • Need for tracheostomy revision
  • Small amount hemoptysis
  • Methods for COVID-19 Diagnosis

1) Nasopharyngeal and oropharyngeal swabs are the primary and preferred method for diagnosis; requirements are updated in UCSD pulse site. Sputum specimen can be submitted as well for COVID-19 testing. Induction of sputum is NOT advised.

2) Bronchoscopy has limited role in diagnosis of COVID-19 and only be considered:

  • Unexplained respiratory failure/ARDS/pneumonia of unknown origin” with negative Respiratory panel, negative sputum and blood cultures and negative COVID-19 test Mucus plugging impairing oxygenation
  • During airway management
  • Massive hemoptysis
  • Malignant or benign condition with resultant significant endobronchial/endotracheal obstruction.
  • Procedural Consideration in COVID19 positive or suspected patients
  • Procedure should be performed in negative pressure room
  • Use of a disposable scope is advised to decrease a need for contaminated equipment transport and an exposure to cleaning personnel.
  • Perform procedure on intubated and paralyzed patient to decrease aerosols during a procedure
  • Personal Protective Equipment (Applies for all personnel present in the room)
  • PAPR, gown, gloves, shoe covers in emergent (unknown COVID-19 status) or COVID19 positive procedures
  • Surgical face mask, hairnet/bonnet, eye protection, gown, gloves for urgent procedures on patients who tested COVID-19 negative
  • N95/Surgical face mask, hairnet/bonnet, eye protection, gown, gloves, and shoe covers for urgent procedure in urgent procedures where test for COVID-19 has not been performed due to lack of symptoms (or unable to verify) or patient was admitted with alternative diagnosis of respiratory failure.
  • Specimen collection and handling
    • If bronchoscopy is being performed for COVID 19 sample collection, a minimum of 2- 3 ml of specimen into a sterile, leak proof container for specimen collection is recommended. Specimen should be labelled with patient information, type of specimen, date of collection, initials.
    • Special caution is needed during specimen handling. MSDH COVID-19 test form should be filled and sent along with specimen to laboratory.
    • Once a specimen is obtained the container should not be re-opened to separate samples. If more than one specimen is needed collect a sample in a separate container
    • Alert lab personnel regarding suspected or known COVID-19 specimen processing and handling.
  • Other considerations
    • Place a surgical mask on a patient post procedure as cough after a bronchoscopy is common
    • Keep door to negative pressure room closed at all times.
    • Wipe all hard surfaces and re-usable parts of equipment (screen, screen stand etc) with bleach wipes
    • Please record all bronchoscopies in GPS (Global Pandemic SARS-CoV-2) Bronchoscopy Database https://redcap.vanderbilt.edu/surveys/?s=JCC4NAXD4K

Upper and lower GI Endoscopy

In order to provide consistent care while minimizing the risk of possible infection with COVID19, upper and lower GI endoscopy procedures in ICUs will be stratified as below:

Emergent

  • Hemodynamically unstable GI bleed
  • Foreign body/Food impaction
  • Cholangitis (to be scheduled in OR)

Urgent – 24-48 hours

  • Acute dysphasia with need for biopsies
  • Diarrhea with need for GI biopsies
  • Coffee ground emesis
  • Colonic pseudo obstruction with need for decompression
  • COVID 19 suspected or positive patients requiring endoscopy
    • Procedure should be performed in negative pressure room
    • Perform procedure on intubated and paralyzed patient to decrease aerosols during a procedure
    • PAPR, gown, gloves, shoe covers in emergent (unknown COVID-19 status) or COVID19 positive procedures
    • Only key personnel should be present in the room
    • Special caution is needed during specimen handling
    • Place a surgical mask on a patient post procedure
    • Keep door to negative pressure room closed at all times.
    • Wipe all hard surfaces and re-usable parts of equipment (screen, screen stand etc) with bleach wipes
    • Transport to OR/Endoscopy lab only in selected cases after an approval by a Division Chief and Chief Adult Perioperative Physician.
  • Patients with negative test or no clinical suspicion of COVID-19
    • Procedure should be performed with a door closed all the time
    • Only key personnel should be present in the room
    • Place a surgical face mask on patient during procedure if possible
    • Consider to intubate for the procedure with a plan of extubating post procedure
    • Surgical face mask/N95, hairnet/bonnet, eye protection, gown, gloves for urgent procedures on patients
    • Special caution is needed during specimen handling
    • Place a surgical mask on a patient post procedure, especially after extubation
    • Wipe all hard surfaces and re-usable parts of equipment (screen, screen stand etc) with bleach wipes

References

  • Group of Interventional Respiratory Medicine, Chinese Thoracic Society. Expert consensus for bronchoscopy during epidemic of 2019 Novel Coronavirus infection (Trial version). Chin J Tuberc Respir Dis, 2020, 43:Epub ahead of print                                                                                               
  • Repici et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc 2020 (accepted for publication)                                                
  • Wahidi et al. American Association for Bronchology and Interventional Pulmonology (AABIP) statement on the use of bronchoscopy and respiratory specimen collection in patients with suspected for confirmed COVID-19 infection
  • Tran K et al. Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A systematic review.

* Note: This document is a living protocol. Please always check for the latest version. For questions or concerns, please contact Michal Senitko, MD, or Sarah Glover, DO. 

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.