Indications of major bronchoscopy societies.
Several bronchology societies have issued documents regarding bronchoscopy during the early phase of the COVID-19 pandemic.1,13-16 Based on the risk of aerosol transmitted infection all societies at that time recommended postponing elective procedures, limiting the number of procedures in COVID-19 patients, performing procedures in COVID-19 patients with the minimal sufficient staff and with the use of appropriate personal protective equipment (PPE). Deciding how to stratify elective procedures to minimize the risk of transmission while not compromising time-sensitive medical care has been a major challenge and experts recommended reviewing the need for all procedures on a case-by-case basis to assess the indication and urgency.14
Known or suspected COVID-19 infection was considered a relative contraindication to bronchoscopy, given the uncertain benefit and possible risks. Bronchoscopy in COVID-19 patients had three main roles: 1) the diagnosis of SARS-Cov-2 infection when other diagnostic tools were inconclusive; 2) the identification of co-infections or superinfections in patients with worsening respiratory conditions; 3) the treatment of bronchoscopic emergencies (massive bleeding, significant airway stenosis, airway secretions causing tracheobronchial obstruction etc).
The major bronchoscopy societies agreed on the need of limiting the use of BAL in the diagnosis of SARS-Cov-2 infection. However, based on the need to avoid false negatives, the societies made a point for a possible indication to perform BAL in cases of suspected COVID-19 when other diagnostic methods were inconclusive and in those situations in which the identification of coinfections could play an important role in the therapeutic decision.
None of these bronchology societies indications given during the early pandemic phase were comprehensive and significant uncertainty remained regarding in whom to perform bronchoscopy.17 At that time no data specific to bronchoscopy in COVID-19 were yet available, and the recommendations were experts’ opinions derived from observations made during prior respiratory viral outbreaks including other SARS, Middle east Respiratory Syndrome and influenza. However, in the rapidly changing clinical environment of the last two years, many centres equipped with appropriate PPE and experienced in the use of BAL, have performed BAL in known or suspected COVID-19 infection generating new evidence on the utility of bronchoscopy in COVID-19 that needs to be carefully considered.