Question 5

Created on Thu, 05/21/2015 - 09:47
Last updated on Thu, 08/27/2015 - 03:27
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A patient  presents to the ICU with haemoptysis. He has been intubated and a bronchoscopy is planned  to isolate the source of the bleeding. He has just been diagnosed as having pulmonary tuberculosis on the basis of a positive smear and has not received any treatment. Discuss the precautions to prevent your staff being infected with TB and the rationale for each.

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College Answer

•    The patient has smear positive untreated TB and is therefore highly infectious

•    The infection risk is greatly magnified by bronchoscopy which generates aerosols. It is therefore important to review the need for bronchoscopy .

•    Regardless of whether a bronchoscopy is carried out the following precautions should be taken:

•    Nurse in a single room with negative pressure ventilation and 12 air changes per hour
•    Bacterial filter in ventilator circuit and closed suction
•    All staff entering room should take personal respiratory precautions including fit tested N95/100 mask.

•    Infection warning signs
•    If bronchoscopy is undertaken:

•    Minimize generation of aerosols:

Prevent coughing (muscle relaxant)

Consider apnoeic oxygenation during bronchoscopy

•    Consider use of powered air purifying respirator if available and staff have been appropriately trained

Staff screen – In the event of accidental exposure during the procedure, consideration for a CXR, mantoux baseline and at 2 months.

Advice and help of the Occupational Health and Infectious diseases team should also be sought.

Discussion

The college seems to have derived their answer from the ACCP/AAB consensus statement on the prevention of flexible bronchoscopy-associated infections. This document regulates every last detail of bronchoscopy, down to record-keeping and the number of air exchanges in the negative pressure room.

  • Maintain standard precautions, including full barrier clothing - gloves, gown and eye protection.
  • Indications for the bronchoscopy must be carefully considered (i.e. can it be delayed until after the patient has been treated?) Given the story about haemoptysis, I would say not.
  • Fit-tested N95 particulate respirators should be worn at least by the bronchoscopist, and ideally by all staff involved.
  • A procedure log should be maintained which retains in it the names of the staff involved, the patient details, the name of the bronchoscopist, the serial number of the bronchoscope and the details of which automated endoscope reprocessor was used to clean it afterwards.
  • The bronchoscopy should be performed in a negative pressure room.
  • The negative pressure room should have at least 12 air exchanges per hour (or at least 6 exchanges if the room was constructed before 2001...)
  • The air must be discharged outside, or through a HEPA filter.
  • A liberal amount of topical anaesthetic should be used to minimise coughing
  • Alternatively, one could perform bronchoscopy with apneic oxygenation, using neuromuscular paralysis.
  • Mechanical cleaning of the bronchoscope should be scrupulous and should occur immediately after the procedure.
 

References

Mehta, Atul C., et al. "American College of Chest Physicians and American Association for Bronchology Consensus StatementPrevention of Flexible Bronchoscopy-Associated Infection." CHEST Journal 128.3 (2005): 1742-1755.

Culver, Daniel A., Steven M. Gordon, and Atul C. Mehta. "Infection control in the bronchoscopy suite: a review of outbreaks and guidelines for prevention."American journal of respiratory and critical care medicine 167.8 (2003): 1050-1056.

.Frumin, M. Jack, ROBERT M. EPSTEIN, and GERALD COHEN. "Apneic oxygenation in man." Anesthesiology 20.6 (1959): 789-798.