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Diagnostic Flexible Bronchoscopy in Adults: Indian Guidelines

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speciality medical dialogues

Indian Chest Society, National College of Chest Physicians (I) and Indian Association for Bronchology have jointly released recommendations for Diagnostic Flexible Bronchoscopy in Adults. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for Flexible Bronchoscopy based on a detailed appraisal of available evidence. The new guideline has appeared in the Journal of Lung India.

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes but these  practices vary widely across India and worldwide. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as the practical approach of bronchoscopy. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Following are the major recommendations: 

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Should bronchoscopy be performed in a dedicated room?

  • Flexible bronchoscopy should be performed in a suite dedicated to this purpose (3A).

What are the minimum essential requirements for setting up a bronchoscopy suite?

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  • A bronchoscopy suite should have dedicated areas for patient preparation, the performance of the procedure, and postprocedure monitoring (3A)
  • Every bronchoscopy suite should have all the essential equipment required for patient monitoring and resuscitation (3A)
  • A bronchoscopy suite should have dedicated areas for bronchoscope disinfection and storage of equipment (3A).

What should be the ventilation requirements for a bronchoscopy suite?

  • Wherever feasible, bronchoscopy should be performed in a room with negative pressure design (3A)
  • Bronchoscopy room should have a minimum of 12–15 fresh air exchanges per hour with the direction of airflow from room entrance to the back and outside (3A)
  • If recirculation of air is unavoidable, direct exhaust air thrown outside should be away from patient-care areas, and HEPA filters must be used (3A).

What personal protective measures should be adopted by operators performing routine and high-risk bronchoscopies?

  • Personal protective equipment should be worn by all personnel in the bronchoscopy suite (3A)
  • Use of N95 mask is recommended when there is suspicion of mycobacterial infection or high risk of droplet infection (3A)
  • Health personnel in proximity to the patient during bronchoscopy should ideally wear eye-shields (3A)
  • Needles should not be used to remove biopsy specimens from forceps (3A)
  • All staff should be vaccinated against hepatitis-B and receive annual influenza vaccine (3A)
  • Impermeable surgical gowns should be worn by bronchoscopists and health personnel in proximity to the patient during the procedure (3A).

What personal protective measures should be adopted by personnel who disinfect bronchoscopes?

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  • Staff concerned with cleaning and disinfection of bronchoscopes should wear adequate PPE including gowns, gloves, masks, and proper eye-shields (2A)
  • Latex or nitrile, powder-free gloves should be preferably used by persons engaged in disinfecting bronchoscopes (2A)
  • Hand-hygiene practices should always be followed before and immediately after removing PPE (UPP).

How should health status of personnel exposed to disinfectants in bronchoscopy unit be monitored?

  • All health personnel exposed to disinfectants in the bronchoscopy unit should undergo a baseline clinical evaluation (3A)
  • Baseline spirometry should be performed for all personnel exposed to disinfectants in the bronchoscopy unit (3A)
  • All staff engaged in bronchoscope disinfection should undergo periodic clinical assessment and spirometry if required (3A).

Should sputum examination be always performed in a patient with suspected tuberculosis before bronchoscopy?

  • Bronchoscopy should be performed in patients with suspected TB who are unable to produce sputum or when sputum analysis is unyielding (2A).

INDICATIONS, CONTRAINDICATIONS, AND COMPLICATIONS OF FLEXIBLE BRONCHOSCOPY; PATIENT MONITORING AND SAFETY ISSUES

Is routine testing of coagulation profile, platelet count, and hemoglobin essential before performing bronchoscopy?

  • Performing coagulation studies, platelet counts, and hemoglobin levels routinely before bronchoscopy is not recommended (3B)
  • Coagulation studies, platelet counts, and hemoglobin should be performed before bronchoscopy in patients with clinical risk factors for bleeding such as ongoing anticoagulation, bleeding diathesis, and chronic liver and kidney disease (UPP).

What should be the minimum platelet count for bronchoscopic sampling?

  • We recommend a platelet count of at least 20,000 per mm3 for performing BAL (3B)
  • We recommend a platelet count of at least 50,000 per mm3 for performing EBB/TBLB (3B)
  • BAL can be performed in subjects with platelet count <20,000 per mm3 if clinically indicated, after careful risk–benefit analysis. In patients with thrombocytopenia, oral route is preferred for performing bronchoscopy (UPP).

Should antiplatelet agents be discontinued before bronchoscopy?

  • Clopidogrel, prasugrel, or ticagrelor should be discontinued at least 5 days before EBB and TBLB (2A)
  • Low-dose aspirin can be continued in patients planned for TBLB/EBB (2A)
  • Liaison with a concerned specialist is recommended for the modification of antiplatelet therapy in patients on dual-antiplatelet agents and at high risk of thrombosis (UPP).

In patients receiving anticoagulation, how should the therapy be modified before flexible bronchoscopy?

  • Warfarin should be stopped at least 5 days prior to transbronchial needle aspiration (TBNA) or bronchoscopic biopsy and a preprocedure INR of <1.5 should be ensured (3A)
  • Newer anticoagulants should be stopped at least 2 days before TBNA or bronchoscopic biopsy (3A)
  • We recommend bridging therapy with LMWH in patients on anticoagulation and at high risk of thrombosis. LMWH, when indicated, should be started 2 days after stopping warfarin. The last dose of LMWH should be administered 24 h before the procedure (3A)
  • BAL can be performed in patients on therapeutic anticoagulation after careful risk–benefit analysis, preferably via oral route (UPP).

How safe is bronchoscopy in patients with Asthma and Chronic Obstructive Pulmonary Disease?

  • Bronchoscopy can be safely performed in patients with asthma and COPD (2A)
  • Patient’s asthma treatment should be optimized before bronchoscopy, especially when BAL is to be performed (2A)
  • Treatment for COPD should be optimized before bronchoscopy (3A).

Should prebronchoscopy-inhaled bronchodilators be administered to all patients with obstructive airway disease?

  • Routine administration of bronchodilators before bronchoscopy is not recommended in patients with asthma or COPD who are adequately controlled (1A).

Is antibiotic prophylaxis required for bronchoscopy?

  • Routine use of prophylactic antibiotics is not recommended before bronchoscopy to prevent procedure-related infections (1A)
  • Patients should receive proper counseling and written advice regarding the management of postbronchoscopy fever (UPP).

What should be the optimum duration of fasting before flexible bronchoscopy?

  • A fasting duration of at least 2 h for clear liquids and 4 h for light meals is recommended before bronchoscopy (3A).

What are the other good clinical practices regarding patient preparation before flexible bronchoscopy?

  • Written informed consent should be obtained from every patient undergoing bronchoscopy (UPP)
  • Patients should be enquired regarding known allergies, comorbidities, and drug history (including anticoagulants or antiplatelets) (UPP)
  • Duration of fasting should be confirmed (UPP)
  • In all patients, IV access should be obtained and maintained until the patient is deemed fit to be discharged (UPP)
  • Routine vital signs such as BP, HR, SpO2, and respiratory rate should be recorded prior to the procedure (UPP).

What should be the preferred position of patients during bronchoscopy?

  • Bronchoscopy should preferably be performed with the patient in supine position (2A).

What should be the preferred route of insertion of bronchoscope?

  • Nasal and oral route are equally suitable for performing bronchoscopy (3A)
  • Oral route should be preferred for larger size bronchoscopes, for therapeutic procedures such as foreign body removal, or in patients with thrombocytopenia (UPP).

Is oxygen supplementation routinely required during flexible bronchoscopy?

  • Routine oxygen supplementation is recommended for patients with risk factors for desaturation, low baseline SpO2 (<90%), or significant desaturation during procedure (>4% decrease from baseline or SpO2 <90% for >1 min) (3A).

Which vital parameters should be monitored during bronchoscopy?

  • Continuous pulse oximetry, HR, and continuous (or repeated) noninvasive BP monitoring is recommended during bronchoscopy (3A)
  • Continuous or repeated ECG monitoring should be performed during bronchoscopy in patients with known cardiac disease or arrhythmias (3A).

How should the patients be monitored after flexible bronchoscopy?

  • All patients should be monitored for symptoms including dyspnea, chest pain, and hemoptysis after completion of bronchoscopy (3A)
  • All patients should have vital parameters (including consciousness, HR, respiratory rate, SpO2, and BP) recorded immediately after bronchoscopy and repeated as indicated (3A)
  • Patients should be kept under observation until they achieve preprocedure level of consciousness and acceptable vital parameters (3A).

PREMEDICATION

Should anticholinergic premedication (atropine or glycopyrrolate) be administered before flexible bronchoscopy?

  • Anticholinergic premedication should not be administered before flexible bronchoscopy (1A).

Should antitussives be administered before flexible bronchoscopy?

  • Dextromethorphan may be considered to optimize patient comfort before bronchoscopy (2B).

Should intravenous sedation be routinely administered to patients undergoing flexible bronchoscopy?

  • Administration of IV sedation should be considered to improve patient tolerance during bronchoscopy (2B)
  • Bronchoscopy can also be safely performed without IV sedation (2B).

Which agents can be used for sedation during flexible bronchoscopy?

  • Combination of midazolam or propofol with opioid is preferred over either alone (1A)
  • Choice of sedation (midazolam/propofol/dexmedetomidine/fentanyl) should be made depending on the operator preference and availability of anesthetists/trained medical personnel (UPP).

Can sedation be safely administered by proceduralist?

  • IV sedation with midazolam or fentanyl can be safely administered by the proceduralist (2A)
  • Propofol should be administered by an anesthetist or trained medical personnel (2A)

What precautions should be taken while administering intravenous sedation?

  • Assessment of the depth of sedation, BP, HR, respiratory rate, and SpO2 monitoring should be performed in all patients receiving sedation during bronchoscopy (3A)
  • Sedation should be cautiously administered in high-risk groups (UPP)
  • Minimum possible dose of sedative should be administered (UPP)
  • A log of sedative dosage administered should be maintained for each patient (UPP).

How should the optimum depth of sedation be assessed?

  • Use of a sedation scale is preferred to monitor the depth of sedation throughout bronchoscopy (UPP).

Which is the preferred agent for topical anesthesia during flexible bronchoscopy?

  • Topical anesthesia should be routinely used during bronchoscopy (1A)
  • Lignocaine is the preferred agent for topical anesthesia (3A).

What is the preferred method for nasal lignocaine administration?

  • 2% lignocaine gel is recommended for topical nasal anesthesia during bronchoscopy (1A).

What is the role of topical vasoconstrictor instillation before nasal bronchoscopy?

  • Use of topical vasoconstrictors is not recommended during nasal bronchoscopy (2A).

What is the preferred method for pharyngeal anesthesia during bronchoscopy?

  • Lignocaine spray (10%) is recommended for pharyngeal anesthesia during bronchoscopy (2A)
  • Three to five sprays of 10% lignocaine are recommended for pharyngeal anesthesia during bronchoscopy procedure (UPP)

Should nebulized lignocaine be administered for topical anesthesia during flexible bronchoscopy?

  • Nebulized lignocaine is not recommended for topical anesthesia during bronchoscopy (1A).

What is the preferred mode of delivery of lignocaine to vocal cords and trachea?

  • Either “spray-as-you-go” technique or cricothyroid injection is recommended for topical anesthesia of vocal cords and trachea (1A)
  • Either spray catheter or working channel of bronchoscope may be used for administering lignocaine during “spray-as-you-go” technique (UPP).

What is the optimum lignocaine concentration for “spray-as-you-go” technique?

  • 1% Lignocaine should be used for “spray-as-you-go” administration during bronchoscopy (1A).

What is the maximum permissible dose limit of lignocaine to be used?

  • The bronchoscopist should make an attempt to keep total administered lignocaine dose to the lowest possible levels, with a suggested upper limit of 8.0 mg/kg body weight (2A)
  • Bronchoscopists should routinely record the cumulative dose of lignocaine used and be aware of signs of lignocaine toxicity (UPP).

Which lobe (s) are preferable for performing bronchoalveolar lavage in patients with diffuse lung disease?

  • In diffuse lung involvement, BAL should be performed either from the right middle lobe or from the lingula (2A)
  • In patients with suspected P. jirovecii or CMV pneumonia with diffuse lung involvement, BAL should be performed bilaterally from more than one lobe, including the upper lobe (2A)
  • In focal/patchy lung involvement, the site of BAL should be guided by HRCT thorax findings (2A)

How much volume of saline should be instilled for performing bronchoalveolar lavage in adult patients?

  • At least 100 ml of normal saline should be instilled while performing BAL, and total quantity should not exceed 200 ml (2A)
  • The required amount of fluid should be instilled in 2–5 aliquots and smaller aliquots should be used in patients with COPD (UPP).

What is the optimal method and pressure for suction application during bronchoalveolar lavage?

  • Either manual suction or wall suction can be used for aspiration of fluid during BAL (2A)
  • If manual aspiration is being performed, tubing should be added to the hand-held syringe (2A)
  • If negative pressure is applied using continuous wall suction, the pressure should be kept <100 mmHg and adjusted to prevent airway collapse (3A).

What volume and percentage of bronchoalveolar lavage fluid return should be considered satisfactory?

  • A minimum of 10% of fluid return should be achieved during BAL (2A).

What is the role of postbronchoscopy sputum analysis following bronchoalveolar lavage?

  • PBS examination should be performed in patients with sputum smear-negative PTB undergoing bronchoscopy, in addition to other diagnostic bronchoscopic procedures (2A).

Should bronchial washings and bronchial brushings be routinely performed in all patients with suspected lung malignancy?

  • In suspected lung malignancy with visible endobronchial abnormality, bronchial washings and brushing should be routinely obtained in all patients (2A)
  • In suspected malignancy with nonvisible or peripheral lesions, BW and BB should be performed under fluoroscopic guidance, wherever facilities are available (2A).

How much saline should be instilled for obtaining adequate bronchial washings?

  • A minimum of 20 ml of fluid should be instilled for obtaining BW (UPP)
  • For endobronchially invisible lesions, greater amount of saline may be instilled (UPP).

Should bronchial washings and brushings be performed before or after an endobronchial biopsy?

  • Bronchial washings should be performed both before and after EBB to achieve maximal diagnostic yield (2A)
  • Bronchial brushings should be performed before EBB for maximal yield (2A).

What is the minimum number of bronchial brushings to be performed for optimizing the diagnostic yield?

  • A minimum of 2–4 bronchial brushings are needed to achieve optimal yield and minimize complications (3A).

Should liquid-based cytology preparation and cell block be preferred over standard cytological technique in suspected lung cancer patients?

  • LBC and CB preparation of bronchoscopic samples are recommended in suspected lung cancer wherever facilities are available (3A).

What should be the sequence of various bronchoscopic sampling procedures for visible endobronchial lesions?

  • TBNA should be the first procedure followed by BAL, BW, BB, EBB, and TBLB (UPP)
  • If endobronchial needle aspiration (EBNA) is planned, it should be taken before EBB (UPP)
  • In diffuse lung diseases, if BAL is planned for cellular analysis, it should be the first procedure to be performed (UPP).

Which nodal stations and nodal size should be considered for conventional transbronchial needle aspiration?

  • c-TBNA should be considered in patients with lymph node size of ≥1 cm in short axis at 4R or 7 locations and size of ≥2 cm at hilar or interlobar nodal locations (10/11) (2A)
  • For lymph node size <1 cm in short axis at 4R or 7 and <2 cm in short axis at other locations, endobronchial ultrasound-fine needle aspiration (EBUS-TBNA) should be considered (2A)

What should be the optimum needle size for performing conventional transbronchial needle aspiration?

  • We recommend the use of 19G needle during c-TBNA to obtain either histology or cytology specimen (2A).

What should be the minimum number of needle passes per node to achieve optimum yield?

  • We recommend performing 3–4 aspirates per node for optimum yield during c-TBNA (2A)
  • Additional aspirations should be obtained if required for other necessary investigations (UPP).

Should rapid on-site examination (ROSE) be routinely performed during conventional transbronchial needle aspiration?

  • Rapid on-site evaluation (ROSE) should be used to reduce additional diagnostic bronchoscopy procedures during c-TBNA (2A)

What is the role of vacuum suction in conventional transbronchial needle aspiration?

  • It is recommended to routinely apply vacuum suction during c-TBNA (UPP)
  • The use of automatic aspiration is preferable to manual aspiration during c-TBNA (UPP).

What are the indications of performing needle aspiration from endobronchial lesions?

  • We recommend the use of EBNA along with other bronchoscopic diagnostic modalities in patients with exophytic necrotic endobronchial lesions and SMLs (2A).

What type of forceps should be used for performing endobronchial biopsy?

  • Either cup or alligator forceps may be used to obtain EBB (3A)
  • Fenestrated forceps may be preferred to reduce the frequency of crush artifacts (UPP).

Should topical hemostatic/vasoconstrictor agents be routinely instilled before endobronchial biopsy to reduce the risk of bleeding?

  • Routine instillation of topical hemostatic/vasoconstrictor agents to prevent bronchoscopic biopsy-related bleeding is not recommended (3A)
  • Topical epinephrine or cold saline instillation or intratumoral tranexamic acid may be attempted to prevent bleeding in high-risk endobronchial lesions (e.g., lesions with increased superficial vascularity or spontaneously oozing) (UPP).

What should be the minimum number of endobronchial biopsies for achieving optimum yield?

  • For achieving optimum yield, at least 4–5 specimens should be obtained while performing EBB (3A)
  • Additional samples for molecular testing and microbiological investigations should be obtained as and when indicated (UPP).

Should endobronchial biopsy be routinely performed in patients with suspected sarcoidosis undergoing transbronchial lung biopsy?

  • EBB should be performed in addition to TBLB in all patients with suspected sarcoidosis (1A).

What type of forceps should be used for transbronchial lung biopsy?

  • Alligator forceps may be preferred for performing TBLB (2B).

What should be an adequate number of transbronchial lung biopsy samples?

  • At least 5–6 biopsy samples of moderate-to-large size should be obtained during TBLB (3A)

What should be the preferred lobe (s) for performing transbronchial lung biopsy?

  • For focal lung lesions, TBLB should preferably be performed from the bronchial segment with maximal radiological abnormality (UPP)
  • In diffuse lung disease, TBLB should be performed from the basal segment (s) of lower lobes (UPP)

Does fluoroscopy guidance add to the yield and safety of transbronchial lung biopsy?

  • For diffuse lung disease, TBLB may be safely performed without fluoroscopic guidance (2B)
  • TBLB with fluoroscopy guidance may be considered for focal parenchymal lesions, wherever available (2B).

Should “float sign” be used to assess the quality of transbronchial lung biopsy specimen?

  • Float sign should not be used to ascertain the adequacy of TBLB specimens (3A).

Should postprocedure chest radiograph be routinely performed following transbronchial lung biopsy?

  • Routine chest radiograph is not essential in asymptomatic patients following TBLB. All symptomatic patients should undergo a chest radiograph to rule out pneumothorax (3A).

What is the role of thoracic ultrasound following transbronchial lung biopsy for excluding pneumothorax?

  • Wherever feasible, bedside thoracic ultrasound may be used to exclude pneumothorax following TBLB (2B).

Is there a need for a structured training program for basic flexible bronchoscopy?

  • We recommend that a structured program be implemented for basic flexible bronchoscopy training (2A).

What is the preferred method for basic flexible bronchoscopy training?

  • For structured training program in basic flexible bronchoscopy, we recommend that VR simulators or anatomical model-based training methods may be incorporated into the conventional apprenticeship model (3B).

What is the minimum number of procedures required to achieve and maintain basic flexible bronchoscopy competence?

  • We recommend performing a minimum of 100 flexible bronchoscopy procedures (50 supervised and 50 independent) to attain basic competency (3A)
  • We recommend performing a minimum of 25 bronchoscopy procedures per year to maintain competency (3A).

Should bronchoscopy be used to diagnose ventilator-associated pneumonia?

  • Routine bronchoscopy-guided sampling for the diagnosis of VAP is not recommended (1A)
  • Bronchoscopy may be considered in patients not responding to empirical antibiotic therapy, or an alternate diagnosis is being considered (UPP).

Should bronchoscopy be used for the management of lung atelectasis or collapse in intensive care unit patients?

  • The routine use of bronchoscopy for managing lung atelectasis or collapse in the ICU setting is not recommended (2A)
  • Bronchoscopy can be used in the management of complete lung or lobar collapse, not responding to aggressive chest physiotherapy (UPP).

What is the optimum size of a bronchoscope and endotracheal tube for performing flexible bronchoscopy in intensive care unit patients?

  • During bronchoscopy in intubated patients, the diameter of the ETT should be at least 2.0 mm more than the OD of the bronchoscope (UPP)
  • Use of flexible bronchoscope with a minimum working channel of 2 mm is preferable for bronchoscopy in endotracheally intubated patients (UPP).

What changes should be made in ventilator settings during flexible bronchoscopy in mechanically ventilated patients?

  • During bronchoscopy in mechanically ventilated patients, the FiO2 should be increased to 100% at least 5–10 min before the procedure and continued till the immediate recovery period or as necessary thereafter (3A)
  • The ventilator should be adjusted to a mandatory mode (3A)
  • The Vt may be increased by 100–150 ml (UPP)
  • Pressure limits/inspiratory pressures should be increased to ensure adequate tidal volume delivery (3A)
  • PEEP should be kept at minimum possible while allowing adequate oxygenation (3A)

What are the minimum essential patient parameters to be monitored during flexible bronchoscopy in intensive care unit?

  • The minimum essential parameters that should be continuously monitored during and after bronchoscopy in the ICU are SpO2, cardiac rhythm using ECG, and BP (UPP).

Should flexible bronchoscopy guidance be routinely used for performing percutaneous dilatational tracheostomy in the intensive care unit?

  • Bronchoscopy guidance is recommended during percutaneous tracheostomy (2A).

What is the utility of noninvasive ventilation in flexible bronchoscopy among hypoxemic patients in intensive care unit?

  • Bronchoscopy in mild-moderate ARDS should be performed with non-invasive ventilation (NIV) assistance (1A)
  • NIV-assisted bronchoscopy should be performed by an experienced operator (UPP)
  • While performing bronchoscopy with NIV, backup facilities for invasive ventilatory support should be readily available (UPP).

Where should bronchoscope disinfection be performed?

  • We recommend that flexible bronchoscopes should be cleaned and disinfected in specific, separate designated areas (3A).

Which agents should be used for precleaning and cleaning of bronchoscopes?

  • Precleaning and cleaning of flexible bronchoscopes should be performed using either nonenzymatic or multienzymatic detergent solutions containing a\t least four enzymes (2A).

How frequently should leak testing be done?

  • Leak testing should be performed ideally after every bronchoscopy procedure (3A).

What should be the preferred method (manual or automated) for bronchoscope disinfection?

  • Disinfection of flexible bronchoscopes may be performed either manually or using AER (2A)
  • If resources permit, AER is preferred over manual disinfection in view of better safety profile to healthcare staff (UPP)

Which is the preferred agent for bronchoscope disinfection?

  • The use of peracetic acid (PAA) is recommended for disinfection of flexible bronchoscopes with a contact time of 5 min (3A)
  • Glutaraldehyde (2%) and OPA (0.5%) can be used as alternative disinfectant agents with contact time of 20 and 5 min, respectively (UPP).

What is the role of alcohol purge as the final step after disinfection?

  • It is recommended that 70% of alcohol purge be performed as the final step of bronchoscope disinfection (3A).

What type of water should be used for final rinse following bronchoscope disinfection?

  • It is recommended that RO water/sterile water be used for final rinse of the flexible bronchoscope after disinfection (3A).

How should reusable bronchoscope accessories be disinfected?

  • Either manual methods or AER may be used for disinfection of bronchoscope accessories (3A)
  • Reusable accessories such as forceps should be thoroughly cleaned, disinfected, and sterilized after each use (3A)
  • Cytological needles and cytology brushes should preferably be single use since they cannot be sterilized (3A)
  • Bronchoscope cleaning brushes should preferably be used only for a single patient; in case reused, they should be sterilized after each procedure (3A).

Where should bronchoscopes be stored when not in use?

  • During storage, flexible bronchoscopes should be hung vertically without any valves attached (3A)
  • Ventilated drying cabinets are preferred for storing bronchoscopes when not in use (3A)
  • Alternatively, roomy, well-ventilated cabinets can be used to store bronchoscopes (3B).

How should bronchoscope infection surveillance be performed?

  • It is recommended to carry out periodic active bronchoscope infection surveillance, preferably at 1–3-month intervals (3B).

For more details click on the link: doi: 10.4103/lungindia.lungindia_108_19




Source: Inputs from Journal Lung India

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