A systematic review and cost effectiveness analysis of reusable vs. single-use flexible bronchoscopes

Complications Associated with AMBU™ Scope Use: An FDA MAUDE Analysis

Ambu® aScope™ is a disposable flexible videoscope used for a wide range of medical procedures. However, adverse events associated with this device can occur. The Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was explored for patient-related adverse events associated with Ambu® aScope™ use between January 1, 2000 and December 15, 2023. Search terms included "Ambu" and "Ascope." Thirty unique adverse events were identified. Twenty-one of the events were associated with patient injury, and 9 with device malfunction. Eight patient-reported problems were documented as foreign bodies, 3 events as airway obstruction, desaturation, or hypoxic events, and 1 event as anxiety/cardiac arrest. The remaining 18 reported insufficient information other than associated with patient injury. We found that Ambu® aScope™ flexible nasolaryngoscopes and bronchoscopes are a common and effective tool for airway evaluations that may infrequently serve as a rare form of foreign body with potentially life-threatening consequences.

Costs involved in compliance with new endoscope reprocessing guidelines

BACKGROUND/AIMS

In March 2022, the Association for the Advancement of Medical Instrumentation (AAMI) released the American National Standards Institute (ANSI)/AAMI ST91:2021, their latest update on comprehensive, flexible, and semirigid endoscope reprocessing. These updated standards recommend the sterilization of high-risk endoscopes when possible and provide new recommendations for the precleaning, leak testing, manual cleaning, visual inspection, automated reprocessing, drying, storage, and transport of endoscopes.

METHODS

ANSI/AAMI ST91:2021 was compared with ANSI/AAMI ST91:2015 for major reprocessing differences that result in either time and/or cost increases. Time estimates were captured by explicit recommendation inclusion or taken from the literature. All the costs were estimated using publicly available resources.

RESULTS

The updated standards represent a potential 24.3-minute and 52.35 to 67.57 United States dollars increase per procedure in terms of reprocessing time and spending, respectively, not including capital investments. Capital costs per procedure were highly dependent on the procedure volume of the facility.

CONCLUSIONS

The new AAMI standards recommend several major changes, such as sterilization, for facilities to reprocess and manage endoscopes between uses. As more facilities increase their reprocessing methods to reflect the updated standards, they do so at a cost and introduce several delays. As the reprocessing landscape evolves, facilities should consider their true costs and alternative solutions, such as single-use endoscopes.

Feasibility of open cholangioscopy with disposable flexible endoscopes

OBJECTIVE

To determine the feasibility of open cholangioscopy using disposable flexible endoscopes in canine cadavers and describe the surgical approach.

STUDY DESIGN

Ex vivo experimental cadaveric study.

SAMPLE POPULATION

Eight canine cadavers.

METHODS

Cadavers ranging from 5.8 to 43.8 kg underwent open transcholecystic cholangioscopy using a disposable flexible endoscope with a 3.8 mm outer diameter and 1.2 mm working channel and the surgical approach was described. The most distal anatomical region of the biliary tree towards the duodenal papilla that was visualized with the endoscope was recorded in each cadaver. A 2.7 mm rigid endoscope and a 1.9 mm flexible endoscope were also trialed and findings recorded. Endoscopic tools were trialed and their usage recorded.

RESULTS

The disposable flexible endoscope was feasible for visualization of the junction of the common bile duct, cystic duct, and hepatic ducts in all eight dogs. Cholangioscopy using a 2.7 mm rigid endoscope did not provide further distal visualization. The 1.9 mm flexible endoscope was able to traverse down to the level of the major duodenal papilla in a 43.8 kg cadaver. Use of certain endoscopic tools can be considered through the disposable flexible endoscope although fluid instillation was affected.

CONCLUSION

A 3.8 mm disposable flexible endoscope could be placed through an open transcholecystic approach to provide intraluminal endoscopic evaluation up to the level of the junction of the common bile duct, cystic duct, and hepatic ducts in dogs without cholecystic disease.

CLINICAL SIGNIFICANCE

Open transcholecystic cholangioscopy with a disposable flexible endoscope could provide a low-cost diagnostic and therapeutic tool in cases of obstructive biliary disease up to the level of the common bile duct.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Brochoscopic Airway Clearance Therapy vs. Conventional Sputum Aspiration: The Future of Flexible Brochoscopes in Intensive Care Units?

(1) Background: The aim of our study is to investigate the effectiveness of bronchoscopic airway clearance therapy (B-ACT) on severe pneumonia (SP) patients with invasive mechanical ventilation (IMV) in the intensive care unit (ICU). (2) Methods: Our study retrospectively enrolled 49 patients with sputum aspiration and 99 patients with B-ACT, and the latter were divided into the ≤once every 3 days group (n = 50) and >once every 3 days group (n = 49). (3) Results: We found most laboratory blood results were significantly improved in the B-ACT group as compared with those in sputum aspiration group (p < 0.05). Patients in the B-ACT group and those in ≤once every 3 days group also had significantly better survival to hospital discharge than those in their counterpart groups (Logrank p < 0.001). In patients with cardiopulmonary diseases or positive cultures for bacteria, the B-ACT group and those in the ≤once every 3 days group had significantly better survival outcomes to discharge than those in their counterpart groups (Logrank p < 0.001). B-ACT and the average frequency of ≤once every 3 days had significantly better impact on survival outcomes than their counterpart groups (HR: 0.444, 95% CI: 0.238-0.829, p = 0.011; HR: 0.285, 95% CI: 0163-0.498, p < 0.001). (4) Conclusions: In the future, flexible bronchoscopes may paly an important role in ACT for SP patients with IMV.

Environmental Impact of Bronchoscopy: Analysis of Waste Mass and Recyclability of Bronchoscopic Equipment and Consumables

BACKGROUND

Greenhouse gases (GHGs) are significant contributors to climate change, and CO2 equivalent (CO2-e) is measured to compare emissions from GHGs. The healthcare sector contributes 4.4% of global CO2-e emissions, mainly with energy consumption and, in lesser extent, waste production. In this regard, bronchoscopy procedures produce a large amount of waste and are responsible for a significant consumption of energy.

OBJECTIVE

We aimed at quantifying the impact on waste mass production, energy consumption, and recyclability of bronchoscopic procedures.

METHODS

We conducted a prospective single-centre observational study; for each type of procedure (performed with either reusable or single-use instruments), the number of items used, their weight, and recyclability were evaluated, as well as the material of which recyclable waste was made of. We then calculated the total amount of waste produced, its recyclability, energy consumption, and CO2-e produced over 10 days of activity in our Interventional Pulmonology Unit.

RESULTS

Sixty procedures generated 61,928 g of waste, of which only 15.8% was potentially recyclable. Single-use instruments generated nearly twofold more recyclable waste than reusable ones, 80% during the procedure phase. Reusable instruments generated 45% of waste during the reprocessing phase, of which 50% was recyclable. The recyclable material was totally composed of paper and plastic. During 10 days of activity, we consumed 64 kWh and produced more than 67 kg of CO2-e due to non-recyclable waste and energy consumption.

CONCLUSIONS

Our results confirm the compelling need to recycle as many materials as possible, even if the amount of recyclable waste is limited. In this respect, official documents issued by international societies are urgently needed to align our activity with climate requirements and improve the sustainability of our work.

Single-use flexible bronchoscopes vs traditional reusable flexible bronchoscopes: a prospective controlled study

BACKGROUND

Single-use flexible bronchoscopes(SFB) eliminate the risk of bronchoscopy-related infection compared with traditional reusable flexible bronchoscopes(RFB). At present, there is no comparative study between SFB and RFB in the aspects of biopsy and interventional therapy. This study aims to explore whether SFB can perform complex bronchoscopic procedures such as transbronchial biopsies just like RFB.

METHODS

We conducted a prospective controlled study. A total of 45 patients who required bronchoscopic biopsy in our hospital from June 2022 to December 2022 were enrolled. The patients were divided into the SFB group and the RFB group, and routine bronchoscopy, bronchoalveolar lavage, and biopsy were performed respectively. Data on the time of routine bronchoscopy, the recovery rate of bronchoalveolar lavage fluid(BALF), biopsy time, and bleeding volume were collected. Then we used the two-sample t-test and the χ² test to assess the performance differences between SFB and RFB. We also designed a questionnaire to compare the performance between SFB and RFB by different bronchoscope operators.

RESULTS

The routine examination time of SFB and RFB was 3.40 ± 0.50 min and 3.55 ± 0.42 min, respectively. There was no significant difference between the two groups (P = 0.308). The recovery rate of BALF was (46.56 ± 8.22) % in the SFB group and (47.00 ± 8.07) in the RFB group, without a significant difference between the two groups(P = 0.863). The biopsy time was similar(4.67 ± 0.51 min VS 4.57 ± 0.45 min) in both groups, with no significant difference(P = 0.512). The positive biopsy rate was 100% in both groups, with no significant difference. Overall, the bronchoscope operators were generally satisfied with SFB.

CONCLUSION

SFBs are non-inferior to RFBs in routine bronchoscopy, bronchoalveolar lavage, and biopsy. It is suggested that SFBs have a wider clinical application.

Single-use duodenoscopes compared with reusable duodenoscopes in patients carrying multidrug-resistant microorganisms: a break-even cost analysis

Background and study aims  Single-use duodenoscopes can prevent transmission of microorganisms through contaminated reusable duodenoscopes. Concerns regarding their economic and environmental impact impede the transition to single-use duodenoscopes. This study investigated the costs associated with two scenarios in which single-use duodenoscopes are used in patients carrying multidrug-resistant microorganisms (MDROs). Methods  Break-even costs for single-use duodenoscopes were calculated for two scenarios in which patients were screened for MDRO carriage before undergoing endoscopic retrograde cholangiopancreatography (ERCP). Only direct costs related to the endoscopy were taken into consideration. In Scenario 1, patients were screened through microbiological culturing with a lag time in receiving the test result. In Scenario 2, screening was performed using GeneXpert analysis providing a rapid read-out. Calculations were performed using data from a Dutch tertiary care center and also with US healthcare data. Results  In the Dutch situation, single-use duodenoscopes needed to be priced at a maximum of € 140 to € 250 to break-even. In the US analyses, break-even costs varied widely, depending on the duodenoscope-associated infection costs used, ERCP volume, and infection risk. The break-even costs in Scenario 1 ranged between $78.21 and $2,747.54 and in Scenario 2, between $248.89 and $2,209.23. Conclusions  This study showed that a crossover scenario in which single-use duodenoscopes are only used in patients carrying MDROs could be an economically viable alternative to a complete transition to single-use duodenoscopes. In the Dutch setting, single-use duodenoscopes need to be priced much lower than in the United States to reach a per-procedure cost that is comparable with a scenario using reusable duodenoscopes exclusively.

Systematic Review and Cost-Consequence Analysis of Ambu aScope 5 Broncho Compared with Reusable Flexible Bronchoscopes: Insights from Two US University Hospitals and an Academic Institution

OBJECTIVE

The aim of this study was to perform a systematic review, meta-analysis and cost-consequence analysis of the single-use bronchoscope, Ambu aScope^TM 5 Broncho, in relation to reusable flexible bronchoscopes (RFB) available within three high procedure volume university hospitals and academic institutions in the USA.

METHODS

The primary outcome was incremental cost and the secondary outcome was incremental cross-infection risk of use for both the single-use flexible bronchoscope (SUFB) and RFBs. Cost estimates included capital, repair, and reprocessing costs derived from a prospective observational micro-costing approach within three large university hospitals and academic institutions. All costs were valued in 2022 US dollars (USD). A meta-analysis based on literature covering cross-contamination and infection from 2010 to 2020 investigated cross-infection risk following bronchoscopy procedures with RFBs. Capital costs were discounted at 3% over 5-8 years. All parameters were evaluated using both univariate deterministic and probabilistic sensitivity analyses.

RESULTS

In high-volume hospitals, RFBs were cost minimizing compared to SUFBs. Probabilistic sensitivity analysis showed that RFBs were cost saving in 88% of iterations. Univariate analyses illustrated sensitivity of the base-case result to the procedure volume. Data from sensitivity analyses suggest that the two interventions are cost neutral at a break-even point of 756 procedures per year or 46 procedures per bronchoscope per year.

CONCLUSION

Assuming equivalent clinical performance, single-use flexible bronchoscopes are not cost minimizing when including the costs associated with cross-infection in high-volume US university hospitals and academic institutions. Overall, the benefits of conversion from RFBs to SUFBs are dependent on the annual procedure volume of individual hospitals, expected cross-infection risk, and purchase price of the aScope 5 Broncho.

[Video-assisted Double-lumen Tubes in Robot-assisted Oesophageal Surgery]

Robot-assisted esophagectomies are still considered high-risk procedures requiring complex surgical and anesthesiological planning and coordination. The operative space during the thoracic operative part is created by one-lung ventilation. Due to special patient positioning and intraoperative repositioning maneuvers, however, access to patient airway or double-lumen tube manipulation, if necessary, is only possible to a certain extent. In this work, we present our experiences establishing a video-guided double-lumen tube for esophageal surgery. From our point of view, the use of video-guided double-lumen tubes is very suitable increasing patient safety and coordination in the operational team during esophagectomy.

Cross-contamination rate of reusable flexible bronchoscopes: A systematic literature review and meta-analysis

Background

Bronchoscopy is generally a safe and efficient procedure. However, the risk of cross-contamination with reusable flexible bronchoscopes (RFB) has been detected in several outbreaks worldwide.

Aim

To estimate the average cross-contamination rate of patient-ready RFBs based on available published data.

Methods

We performed a systematic literature review in PubMed and Embase to investigate the cross-contamination rate of RFB. Included studies identified indicator organisms or colony forming units (CFU) levels, and total number of samples >10. The Contamination threshold was defined according to the European Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy Nurse and Associates (ESGE-ESGENA) guidelines. To calculate the total contamination rate, a random effects model was applied. Heterogeneity was analysed via a Q-test and illustrated in a forest plot. Publication bias was analysed via the Egger’s regression test and illustrated in a funnel plot.

Results

Eight studies fulfilled our inclusion criteria. The random effects model included 2169 samples and 149 events (positive tests). The total RFB cross-contamination rate was 8.69% ± 1.86 (standard division [SD]) (95% confidence interval [CI]: 5.06–12.33%). The result showed significant heterogeneity of 90% and publication bias.

Discussion

Significant heterogeneity and publication bias is likely associated with varying methodology and aversion towards publishing negative findings, respectively. Based on the cross-contamination rate an infection control paradigm shift is needed to ensure patient safety. We recommend to follow the Spaulding classification and classify RFBs as critical items. Accordingly, infection control measures such as obligatory surveillance, and implementing single-use alternatives must be considered where feasible.

Single Use or Disposable Flexible Bronchoscopes: Bench Top and Preclinical Comparison of Currently Available Devices

BACKGROUND

Data regarding the risk of infection related to reusable bronchoscopes, the global drive toward disposable technology and the COVID-19 pandemic have led to an increase in the use and production of single use or disposable bronchoscopes. An in-depth comparison of all available devices has not been published.

METHODS

A benchtop comparison of the Ambu^®aScope^TM, Boston Scientific^® EXALT^TM Model B, the Surgical Company Broncoflex^© Vortex, Pentax^® Medical ONE Pulmo™, and Vathin^® H-Steriscope^TM (all 2.8 mm inner dimension other than the Pentax single-use flexible bronchoscope (3 mm)) was undertaken including measurement of maximal flexion and extension angles, thumb force required and suction with and without biopsy forceps. Thereafter, preclinical assessment was performed with data collected including experience, gender, hand size, and scope preference.

RESULTS

The Vathin single-use flexible bronchoscope had the biggest range of tip movement from flexion to extension with and without forceps. The Boston single-use flexible bronchoscope required the maximal thumb force but had the least reduction of tip movement with forceps. The Boston single-use flexible bronchoscope significantly outperformed all other scopes including the standard Pentax scope and was the only scope capable of suctioning pseudo-mucus around the forceps. Although there was no significant difference in preference in the overall group, females and those with smaller hand size preferred the Pentax and males the Broncoflex single-use flexible bronchoscope.

CONCLUSIONS

Currently available single-use flexible bronchoscopes differ in several factors other than scope sizes and monitor including suction, turning envelope, and handle size. Performance in the clinical setting will be key to their success.

Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

The Cost of Flexible Bronchoscopes: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Until 2009, only reusable bronchoscopes were marketed, but the introduction and widespread adoption of single-use flexible bronchoscopes (SFBs) as an emerging technology has since accelerated. Several studies have described the costs of reusable flexible bronchoscopes (RFBs) and SFBs. This meta-analysis aimed to compile the current published evidence to analyse the cost of different scenarios using RFBs and SFBs.

METHODS

All published literature describing the cost of RFBs or SFBs was identified by searching PubMed, Embase and Google Scholar, limited to those between 1 January, 2009 and 6 November, 2020. Included studies should report the total cost of RFBs. Continuous data were extracted for relevant outcomes and analysed using RStudio^® 4.0.3 as the standardised mean difference and standard error of the mean in a mixed-effects model. Risk of bias was assessed based on the reporting quality.

RESULTS

In the systematic literature review, 342 studies were initially identified, and 11 were included in the final analysis. The mean RFB procedure cost was $266 (standard error of the mean: 34), including capital investments, repairs and reprocessing costs of $91, $92 and $83, respectively. The mean SFB procedure cost was $289 (standard error of the mean: 10). The incremental cost was $23 (standard error of the mean: 33) and was not significant (p = 0.46). Because of the economy of scale, RFB is more likely to be cost minimising compared with SFB when performing 306 or 39 procedures per site or RFB, respectively.

CONCLUSIONS

In this study, we found no significant difference in the cost of use between RFBs and SFBs and a high risk of bias.

The Efficacy and Safety of Remimazolam Tosilate Versus Dexmedetomidine in Outpatients Undergoing Flexible Bronchoscopy: A Prospective, Randomized, Blind, Non-Inferiority Trial

Purpose: This study aimed to compare the efficacy and safety of remimazolam tosilate-remifentanil (RT-RF) vs dexmedetomidine-remifentanil (Dex-RF) for outpatients undergoing fiberoptic bronchoscopy (FB).

Patients and methods: We conducted a double-blind, randomized, prospective study involving a total of 146 outpatients undergoing FB divided into two groups. The RT-RF (RR) group (n = 73) received an initial dose of 12 mg/kg/h of RT for 10 min followed by a maintenance dose of 1–2 mg/kg/h, while the Dex-RF (DR) group (n = 73) received an initial dose of 0.5 μg/kg of Dex for 10 min followed by a maintenance dose of 0.2–0.7 μg/kg/h. All outpatients also received 0.05–0.2 μg/kg/min RF to maintain the Modified Observer’s Assessment of Alertness and Sedation (MOAA/S) scale <3. The primary outcome was rate of successful FB completed. Secondary outcomes were time metrics, hemodynamics, intubating conditions, oxygen saturation, coughing severity, number of remedies, total dose of fentanyl, RF, RT, and Dex, incidence of dreaming, patient and bronchoscopist satisfaction, willingness to repeat bronchoscopy, and adverse events.

Results: The FB successful completion rate was 94.52% (95% CI: 89.20–99.90) in the RR group and 91.78% (95% CI: 85.30–98.20) in the DR group. Compared with patients in the DR group, the onset time, time to fully alert, and hospital discharge were all significantly shorter in the RR group (p < 0.01), and hemodynamics were more stable in the RR group. Intubating conditions, clinically acceptable intubating conditions, lowest oxygen saturation, coughing severity, consumption of fentanyl and RF, number of remedies, and patient and bronchoscopist satisfaction were similar between the groups (p > 0.05), as were demographic characteristics, incidence of dreaming, willingness to repeat bronchoscopy, and adverse events (p > 0.05).

Conclusion: RT-RF has non-inferior efficacy, better time metrics and hemodynamic stability for outpatients undergoing FB than Dex-RF.

Systematic Review Registration: [http://www.chictr.org.cn/showproj.aspx?proj=66673], identifier [ChiCTR2000041524].

Gastrointestinal endoscope contamination rates - elevators are not only to blame: a systematic review and meta-analysis

Background and study aims  Duodenoscopes that are contaminated due to inadequate reprocessing are well-documented. However, studies have demonstrated poor reprocessing of other kinds of endoscopes as well, including echoendoscopes, gastroscopes, and colonoscopes. We estimated the contamination rate beyond the elevator of gastrointestinal endoscopes based on available data. Methods  We searched PubMed and Embase from January 1, 2010 to October 10, 2020, for studies investigating contamination rates of reprocessed gastrointestinal endoscopes. A random-effects model was used to calculate the contamination rate of patient-ready gastrointestinal endoscopes. Subgroup analyses were conducted to investigate differences among endoscope types, countries, and colony-forming unit (CFU) thresholds. Results  Twenty studies fulfilled the inclusion criteria, including 1,059 positive cultures from 7,903 samples. The total contamination rate was 19.98 % ± 0.024 (95 % confidence interval [Cl]: 15.29 %-24.68 %; I ²  = 98.6 %). The contamination rates of colonoscope and gastroscope channels were 31.95 % ± 0.084 and 28.22 % ± 0.076, respectively. Duodenoscope channels showed a contamination rate of 14.41 % ± 0.029. The contamination rates among studies conducted in North America and Europe were 6.01 % ± 0.011 and 18.16% ± 0.053 %, respectively. The contamination rate among studies using a CFU threshold > 20 showed contamination of 30.36 % ± 0.094, whereas studies using a CFU threshold < 20 showed a contamination rate of 11 % ± 0.026. Conclusions  On average, 19.98 % of reprocessed gastrointestinal endoscopes may be contaminated when used in patients and varies between different geographies. These findings highlight that the elevator mechanism is not the only obstacle when reprocessing reusable endoscopes; therefore, guidelines should recommend more surveillance of the endoscope channels as well.

Performance of a new single-use bronchoscope versus a marketed single-use comparator: a bench study

BACKGROUND

Single-use flexible bronchoscopes eliminate cross contamination from reusable bronchoscopes and are cost-effective in a number of clinical settings. The present bench study aimed to compare the performance of a new single-use bronchoscope (Boston Scientific EXALT Model B) to a marketed single-use comparator (Ambu aScope 4), each in slim, regular and large diameters.

METHODS

Three bronchoscopy tasks were performed: water suction and visualization, "mucus" mass (synthetic mucoid mixture) suctioned in 30 s, and "mucus" plug (thicker mucoid mixture) suction. Suction ability, task completion times, and subjective ratings of visualization and overall performance on a scale of one to 10 (best) were compared. All bronchoscopy tasks were completed by 15 physicians representing diversity in specialization including pulmonary, interventional pulmonary, critical care, anesthesia, and thoracic surgery. Each physician utilized the six bronchoscope versions with block randomization by bronchoscope and task.

RESULTS

Aspirated mean mass of "mucus" using EXALT Model B Regular was comparable to that for an aScope 4 Large (41.8 ± 8.3 g vs. 41.5 ± 5.7 g respectively, p = 0.914). In comparisons of scopes with the same outer diameter, the aspirated mean mass by weight of water and "mucus" was significantly greater for EXALT Model B than for aScope 4 (p < 0.001 for all three diameters). Mean ratings for visualization attributes were significantly better for EXALT Model B compared to aScope 4 (p-value range 0.001-0.029).

CONCLUSION

A new single-use bronchoscope provided strong suction capability and visualization compared to same-diameter marketed single-use comparators in a bench model simulation.

Percutaneous dilatational tracheostomy with single use bronchoscopes versus reusable bronchoscopes – a prospective randomized trial (TraSUB)

Background

Apart from conventional reusable bronchoscopes, single-use bronchoscopes (SUB) were recently introduced. Data suggest that SUB might prevent from the risk of cross contamination (i.e. multiresistant pathogens, SARS CoV-2) and save costs. We aimed to investigate visualization, ventilation, handling characteristics, changes in patients’ gas exchange, and costs associated with both types of bronchoscopes during percutaneous dilatational tracheostomy (PDT).

Methods

In this prospective, randomized, noninferiority study, 46 patients undergoing PDT were randomized 1:1 to PDT with SUB (Ambu aScope) or reusable bronchoscopes (CONV, Olympus BF-P60). Visualization of tracheal structures rated on 4-point Likert scales was the primary end-point. Furthermore, quality of ventilation, device handling characteristics, changes in the patients’ gas exchange, pH values, and costs were assessed.

Results

Noninferiority for visualization (the primary endpoint) was demonstrated for the SUB group. Mean visualization scores (lower values better) were 4.1 (95% confidence intervals: 3.9;4.3) for SUB vs. 4.1 (4.0;4.2) for CONV. Noninferiority of ventilation (estimated by minute volume and SpO₂) during the procedure could be shown as well. Mean score was 2.6 (2.0;3.1) for SUB vs. 2.4 (2.1;2.7) for CONV (lower values better). No significant differences regarding handling (SUB: 1.2 (1.0;1.4), CONV: 1.3 (1.1;1.6)), blood gas analyses and respiratory variables were found. Cost analysis in our institution revealed 93 € per conventional bronchoscopy versus 232.50 € with SUB, not considering an estimate for possible infection due to cross-contamination with the reusable device.

Conclusion

In our study, visualization and overall performance of the SUB during PDT were noninferior to reusable bronchoscopes. Therefore, PDT with SUB is feasible and should be considered if favored by individual institution’s cost analysis.

Trial registration.

ClinicalTrials.gov, NCT03952247. Submitted for registration on 28/04/2019 and first posted on 16/05/2019.

Major complications of airway management: a prospective multicentre observational study

We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.

Airway management for one lung ventilation during COVID-19 pandemic: a survey within Italian anesthesiologists

BACKGROUND

Airway management for thoracic surgery represents a high risk setting for SARS-CoV-2 infection diffusion due to complex and invasive airway instrumentation and techniques.

RESULTS

An 18-item questionnaire was submitted to the 56 members of the Thoracic subcommittee of the SIAARTI Cardio-Thoraco-Vascular Research Group to provide a snapshot of current situation and national variability of devices and procedures for airway management during the COVID-19 pandemic. The response rate was 64%. Eighty-three percent of anesthetists declared that they modified their airway management strategies. The Hospital Management considered necessary to provide a complete level 3 personal protective equipment for thoracic anesthetists only in 47% of cases. Double-lumen tube and bronchial blocker were preferred by 53% and 22% of responders to achieve one-lung ventilation respectively. Over 90% of responders considered the videolaryngoscope with separate screen and rapid sequence induction/intubation useful to minimize the infection risk. Thirty-nine percent of participants considered mandatory the bronchoscopic check of airway devices. Vivasight-DL was considered comfortable by more than 50% of responders while protective box and plastic drape were judged as uncomfortable by most of anesthetists.

CONCLUSIONS

The survey reveals many changes in the clinical practice due to SARS-CoV-2 outbreak. A certain diffusion of new devices such as the VivaSight-DL and barrier enclosure systems emerged too. Finally, we found that most of Italian hospitals did not recognize thoracic anesthesia as a high-risk specialty for risk of virus diffusion.

Single-Use and Reusable Flexible Bronchoscopes in Pulmonary and Critical Care Medicine

Flexible bronchoscopy plays a critical role in both diagnostic and therapeutic management of a variety of pulmonary disorders in the bronchoscopy suite and the intensive care unit. In the set-ting of the ongoing viral pandemic, single-use flexible bronchoscopes (SUFB) have garnered attention as various professional pulmonary societies have released guidelines regarding uses for SUFB given the concern for risk of viral transmission when using reusable flexible bronchoscopes (RFB). In addition to offering sterility, SUFBs are portable, easily accessible, and may be more cost-effective than RFB when considering the potential costs of treating bronchoscopy-related infections. Furthermore, since SUFBs are one time use, they do not require reprocessing after use, and therefore may translate to reduced cleaning and storage costs. Despite these advantages, RFBs are still routinely used to perform advanced diagnostic and therapeutic bronchoscopic procedures given the need for optimal maneuverability, handling, angle of deflection, image quality, and larger channel size for passing of ancillary instruments. Here, we review the published evidence on the applications of single-use and reusable bronchoscopes in bronchoscopy suites and intensive care units. Specifically, we will discuss the advantages and disadvantages of these devices as pertinent to fundamental, advanced, and therapeutic bronchoscopic interventions.

The Role of Bronchoscopy in the Diagnosis and Management of Patients with SARS-Cov-2 Infection

Bronchoscopy has several major diagnostic and therapeutic indications in pulmonology. However, it is an aerosol-generating procedure that places healthcare providers at an increased risk of infection. Now more than ever, during the spread of the coronavirus disease 2019 (COVID-19) pandemic, the infectious risk during bronchoscopy is significantly raised, and for this reason its role in diagnostic management is debated. In this review, we summarized current evidence regarding the indications for bronchoscopy and the measures that should be applied to decrease risk exposure. Indeed, seeing the long-lasting period of the pandemic, resuming standard of care for all patients is required.

Comparison of a tube core and Magill forceps for nasotracheal intubation: a randomised controlled trial

Background

Magill forceps are frequently used to complete nasotracheal intubation (NTI). We aimed to identify a tube core that could conveniently facilitate the NTI process without using Magill forceps.

Methods

Sixty patients scheduled for oral and maxillofacial surgeries were enrolled in our study and divided into two groups (30 per group) with no differences with regard to demographic data. In the Magill forceps group (Group M), a wire-reinforced endotracheal catheter was inserted into the trachea using Magill forceps. However, in the tube core group (Group T), a tube core bent to the physiological curve of the nasal cavity and lubricated with aseptic paraffin oil was inserted into the endotracheal catheter and was then withdrawn after the endotracheal catheter was advanced through the glottis under direct vision.

Results

All NTIs were completed successfully, and Magill forceps were not used on any patient in Group T. There was a significant difference in total NTI time between the two groups (Group M, 59.7 (5.1) s vs Group T, 52.4 (3.1) s). Mild epistaxis was observed in 6 patients in Group M and 5 patients in Group T (6/30 vs 5/30, respectively). No damage to oral tissue or teeth was observed in either group.

Conclusions

We conclude that using a tube core, consisting of a disposable sterilised stylet, is a convenient choice for NTI.

Trial registration

Patient enrolment was conducted after registration in the Chinese Clinical Trial Registry (www.Chictr.org.cn, ChiCTR190002 7387). This trial was prospectively registered on 11 November 2019.

Sans Standardization: Effective Endoscope Reprocessing

Bronchoscopy is a commonly performed procedure within thoracic and critical care medicine. Modern bronchoscopes are technologically advanced tools made of fragile electronic components. Their design is catered to allow maximum maneuverability within the semi-rigid tracheobronchial tree. Effective cleaning and reprocessing of these tools can be a challenge. Although highly functional, the design poses several challenges when it comes to reprocessing. It is a very important step, and lapses in the procedure have been tied to nosocomial infections. The process lacks universal standardization; several organizations have developed their own recommendations. Data have shown that key stakeholders are not fully versed in the essentials of endoscope reprocessing. A significant knowledge gap exists between those performing bronchoscopy and those who are stewards of effective endoscope reprocessing. To service as a resource for bronchoscopists, this study summarizes the steps of effective reprocessing, details the important elements within a health-care facility that houses this process, and reviews some of the current data regarding the use of disposable endoscopes.

A new single-use disposable duodenoscope (EXALT™Model D) for the treatment of an anastomotic biliary stenosis in a liver transplant patient

A 54-year-old man was admitted by painless jaundice at our hospital four weeks after undergoing liver transplantation. Magnetic resonance imaging cholangiography demonstrated the presence of anastomotic biliary stenosis.

A Consecutive Case Series of Rescue Intubations With the Articulating Total Control Introducer for Precision Tracheal Access

Effective rescue after failed intubation is important to limit the number of attempts and patient risk. Nothing is known about the Total Control Introducer's (TCI) effectiveness as an intubation rescue device. A single system's airway management database was studied. The TCI was used for rescue in 34 cases. Overall success was 33 of 34 (97%). First-pass success was 32 of 33 (97%). First-pass rescue was successful in 12 of 12 (100%) after video and direct laryngoscopy had failed. In this case series, the TCI was found to be a highly effective rescue technique after failed direct and video laryngoscopy.

A prospective, observational, cohort study of airway management of patients with COVID-19 by specialist tracheal intubation teams

PURPOSE

Because of the anticipated surge in cases requiring intensive care unit admission, the high aerosol-generating risk of tracheal intubation, and the specific requirements in coronavirus disease (COVID-19) patients, a dedicated Mobile Endotracheal Rapid Intubation Team (MERIT) was formed to ensure that a highly skilled team would be deployed to manage the airways of this cohort of patients. Here, we report our intubation team experience and activity as well as patient outcomes during the COVID-19 pandemic.

METHODS

The MERIT members followed a protocolized early tracheal intubation model. Over a seven-week period during the peak of the pandemic, prospective data were collected on MERIT activity, COVID-19 symptoms or diagnosis in the team members, and demographic, procedural, and clinical outcomes of patients.

RESULTS

We analyzed data from 150 primary tracheal intubation episodes, with 101 (67.3%) of those occurring in men, and with a mean (standard deviation) age of 55.7 (13.8) yr. Black, Asian, and minority ethnic groups accounted for 55.7% of patients. 91.3% of tracheal intubations were performed with videolaryngoscopy, and the first pass success rate was 88.0%. The 30-day survival was 69.2%, and the median [interquartile range] length of critical care stay was 11 [6-20] days and of hospital stay was 12 [7-22] days. Seven (11.1%) MERIT healthcare professionals self-isolated because of COVID-19 symptoms, with a total 41 days of clinical work lost. There was one reported incident of a breach of personal protective equipment and multiple anecdotal reports of doffing breaches.

CONCLUSION

We have shown that a highly skilled designated intubation team, following a protocolized, early tracheal intubation model may be beneficial in improving patient and staff safety, and could be considered by other institutions in future pandemic surges.

Single-Use (Disposable) Flexible Bronchoscopes: The Future of Bronchoscopy?

The coronavirus disease (COVID-19) pandemic has highlighted the importance of reducing occupational exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The reprocessing procedure for reusable flexible bronchoscopes (RFBs) involves multiple episodes of handling of equipment that has been used during an aerosol-generating procedure and thus is a potential source of transmission. Single-use flexible bronchoscopes (SUFBs) eliminate this source. Additionally, RFBs pose a risk of nosocomial infection transmission between patients with the identification of human proteins, deoxyribonucleic acid (DNA) and pathogenic organisms on fully reprocessed bronchoscopes despite full adherence to the guidelines. Bronchoscopy units have been hugely impacted by the pandemic with restructuring of pre- and post-operative areas, altered patient protocols and the reassessment of air exchange and cleaning procedures. SUFBs can be incorporated into these protocols as a means of improving occupational safety. Most studies on the efficacy of SUFBs have occurred in an anaesthetic setting so it remains to be seen whether they will perform to an acceptable standard in complex respiratory procedures such as transbronchial biopsies and cryotherapy. Here, we outline their potential uses in a respiratory setting, both during and after the current pandemic.

Single-Use (Disposable) Flexible Bronchoscopes: The Future of Bronchoscopy?

The coronavirus disease (COVID-19) pandemic has highlighted the importance of reducing occupational exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The reprocessing procedure for reusable flexible bronchoscopes (RFBs) involves multiple episodes of handling of equipment that has been used during an aerosol-generating procedure and thus is a potential source of transmission. Single-use flexible bronchoscopes (SUFBs) eliminate this source. Additionally, RFBs pose a risk of nosocomial infection transmission between patients with the identification of human proteins, deoxyribonucleic acid (DNA) and pathogenic organisms on fully reprocessed bronchoscopes despite full adherence to the guidelines. Bronchoscopy units have been hugely impacted by the pandemic with restructuring of pre- and post-operative areas, altered patient protocols and the reassessment of air exchange and cleaning procedures. SUFBs can be incorporated into these protocols as a means of improving occupational safety. Most studies on the efficacy of SUFBs have occurred in an anaesthetic setting so it remains to be seen whether they will perform to an acceptable standard in complex respiratory procedures such as transbronchial biopsies and cryotherapy. Here, we outline their potential uses in a respiratory setting, both during and after the current pandemic.

Rate and impact of duodenoscope contamination: A systematic review and meta-analysis

BACKGROUND

Multiple infection outbreaks have been linked to contaminated duodenoscopes worldwide. However, the contamination rate of patient-ready duodenoscopes varies highly amongst published studies testing this subject. We aimed to estimate the contamination rate of reprocessed patient-ready duodenoscopes for endoscopic retrograde cholangio-pancreatography (ERCP) based on currently available data.

METHODS

We searched the PubMed and Embase databases from January 1, 2010 until March 10, 2020, for citations investigating contamination rates of reprocessed patient-ready duodenoscopes. Studies not assessing other types of endoscopes than duodenoscopes were excluded from the analysis. Study eligibility and data extraction was evaluated by three reviewers independently. A random-effects model (REM) based on the proportion distribution was used to calculate the pooled total contamination rate of reprocessed patient-ready duodenoscopes. Subgroup analyses were carried out to assess contamination rates when using different reprocessing methods by comparing single high-level disinfection (HLD) with double HLD and ethylene oxide (EtO) gas sterilization. Additionally, we investigated the contamination rate between studies conducted following an outbreak compared to non-outbreak-initiated studies.

FINDINGS

We identified 15 studies that fulfilled the inclusion, which included 925 contaminated duodenoscopes from 13,112 samples. The calculated total weighted contamination rate was 15.25% ± 0.018 (95% confidence interval [Cl]: 11.74% - 18.75%). The contamination rate after only using HLD was 16.14% ± 0.019 (95% Cl: 12.43% - 19.85%) and after using either dHLD or EtO the contamination rate decreased to 9.20% ± 0.025 (95% Cl: 4.30% - 14.10%). Studies conducted following an outbreak (n=4) showed a 5.72% ± 0.034 (95% Cl: 0.00% - 12.43%) contamination rate, and non-outbreak-initiated studies (n=11) revealed a contamination rate of 21.50% ± 0.031 (95% Cl: 15.35% - 27.64%).

INTERPRETATION

This is the first meta-analysis to estimate the contamination rate of patient-ready duodenoscopes used for ERCP. Based on the available literature, our analysis demonstrates that there is a 15.25% contamination rate of reprocessed patient-ready duodenoscopes. Additionally, the analysis indicates that dHLD and EtO reprocessing methods are superior to single HLD but still not efficient in regards to cleaning the duodenoscopes properly. Furthermore, studies conducted following an outbreak did not entail a higher contamination rate compared to non-outbreak-initiated studies.

FUNDING

The authors received no financial support for the research, authorship, and/or publication of this article.

Expert panel consensus statement on the applications and precaution strategies of bronchoscopy in patients with COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus with higher transmissibility compared with SARS coronavirus (SARS-CoV) and Middle East respiratory distress syndrome coronavirus. Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is an unprecedented global crisis that has not been experienced, which is still disrupting health systems, economies, and societies around the world by the rapid spread. Bronchoscopy plays an important role in diagnosis and therapy of pulmonary diseases, especially in patients with severe pulmonary infection, however, application of bronchoscopy in patients suspected or confirmed SARS-CoV-2 infection is extremely limited for the potential airborne transmission from aerosol generated during the procedure. This consensus statement was completed by expert panel of Interventional & Minimally Invasive Respiratory Committee of China Medical Education Association, and the issues were summarized as seven key topics to define the indications of bronchoscopy and matters needing attentions on the bronchoscopy procedures in patients with COVID-19, as well as the protective precaution strategies to avoid nosocomial SARS-CoV-2 infection.

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.