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      Fiberoptic bronchoscopy via intubation box during COVID‐19 pandemic

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          Abstract

          Dear Editor, We read with interest the article titled “Bronchoscopic procedures during COVID‐19 pandemic: experiences in Turkey” published in the Journal of Surgical Oncology. 1 Transmission of SARS‐CoV2 virus is generally via respiratory droplets, but airborne transmission may be possible with aerosol‐generating procedures. 2 As an aerosol‐generating procedure, bronchoscopy has a high risk of aerolization and risk for COVID‐19 transmission since the airway of infected patients has been shown to have a high viral load, especially in the nose, throat, and trachea. 3 , 4 In our clinic, bronchoscopy has been performed via intubation box for protecting the bronchoscopy team from aerolization risk from the early days of the pandemic to day and we want to share our experiences of fiberoptic bronchoscopy procedure during the first wave of COVID‐19 pandemic. The first COVID‐19 case occurred on March 10, 2020 in our country. Bronchoscopy appointments were postponed during the first 2 weeks of the pandemic in our clinic due to the high transmission risk of this unpredictable virus. However, to prevent delay in diagnosis especially in malignancy suspected patients, the bronchoscopy procedure was started on April 1 by providing appropriate conditions and using personal protective equipment (PPE) including a face shield, gown, gloves, and N‐95 respirators. Asymptomatic cases are an important challenge for the risk of transmitting to other individuals and healthcare workers, although they appear healthy. According to the CHEST/AABIP Guideline and Expert Panel Report, it is recommended to test for COVID‐19 infection before bronchoscopy, even if the patient is asymptomatic. It is recommended to perform procedures using PPEs in patients with negative test results before bronchoscopy. 3 In our study, all patients were questioned for COVID‐19 symptoms and undergone polymerase chain reaction (PCR) test for COVID‐19 before bronchoscopy and all of them were negative for COVID‐19. There is a decrease in cancer screening, diagnosis, and treatment period during the first months of the pandemic related to travel restrictions, postponements of routine controls or diagnostic procedures, the anxiety of transmission risk in both patients and healthcare workers. 5 , 6 According to the CHEST/AABIP Guideline and Expert Panel Report, it is recommended that bronchoscopy should be performed in a timely and safe manner for both diagnosis and staging indication in cases with suspected lung cancer. 3 In our clinic, bronchoscopy has been performed since the first weeks of the pandemic to prevent diagnosis delay, especially in malignant patients. And malignancy was the most common indication for bronchoscopy (69.3%). As known, premedication of bronchoscopy includes nebulized lidocaine but nebulization itself is an aerosol‐generating procedure. So nebulized lidocaine administration is not recommended for premedication because it increases the risk of aerolization. 7 We did not use nebulized lidocaine in our clinic. Only intranasal or intraoral lidocaine was applied for topical anesthesia and to minimize cough. Sedation was achieved by applying midazolam intravenous 2–3 mg before the procedure. Recent publications recommend that bronchoscopy procedures should be performed in a negative pressure room with a reduced number of staff in the bronchoscopy team to minimize the risk of transmission. 7 , 8 No observers, students, or trainees should be in the bronchoscopy area. 8 The procedure should be performed in the shortest time and with the least number of sampling procedures necessary to achieve the clinical goal. 7 In our clinic, bronchoscopy was performed by an experienced pulmonologist and bronchoscopy nurse. The mean duration of the procedure was nearly 5 min during bronchial lavage while it was approximately 10–15 min in mucosa biopsy, fine needle aspiration, or bronchoalveolar lavage procedures. The COVID‐19 outbreak has led to the development of various devices (intubation box, aerosol box, and surgical tent) and alternative searches to protect healthcare workers from the risk of contamination during tracheal intubation or procedures with a risk of aerolization such as bronchoscopy. 9 , 10 Since we did not have a negative pressure room, bronchoscopy was performed via intubation box during bronchoscopy for protecting the bronchoscopy team from aerolization risk in a well‐ventilated room (Figure 1). The intubation box was cleaned with a disinfectant containing 80% alcohol, and UV sterilization was applied 15 min after each patient. Figure 1 Flexible bronchoscopy via intubation box [Color figure can be viewed at wileyonlinelibrary.com] Between April 1 and June 15, 49 patients underwent diagnostic fiberoptic bronchoscopy. There were 38 men (77.6%) and 11 women (22.4%). The mean age of the patients was 59.02 ± 12.6 years. The most common indication for bronchoscopy was malignancy (69.3%), followed by infections including tuberculosis and pneumonia (18.4%). Twenty‐eight percent of the cases had normal bronchoscopic findings while bronchoscopic findings suggest malignancy (endobronchial lesion or mucosal tumor infiltration) in 38.7% of cases. Bronchial lavage (77.6%) and bronchial mucosa biopsy (57.1%) were the most common procedures. In this study population, multiple procedures were performed in 27 (55.1%) of the cases. One patient had an emergency admission with fever 6 days after the procedure and her COVID‐PCR test was positive. She had undergone bronchoalveolar lavage and subcarinal fine‐needle aspiration. No positivity was detected in the bronchoscopy team who performed the procedure after the patient's positivity. Since the first COVID‐19 case in our country, there have been no COVID‐19 cases in our bronchoscopy team. Although the study data includes only one center and reflects a small number of cases, it is thought to be important because it is the only center in the city where bronchoscopy is performed in the early period of the pandemic and cases are referred to here for bronchoscopy from other centers. In conclusion, it is thought that bronchoscopic procedures can be performed safely by taking the necessary precautions to reduce the risk of aerolization during both premedication and the procedure. The use of PPE and intubation box during bronchoscopy helps to keep healthcare workers safe. Feeling safe by the healthcare team can also ensure that bronchoscopy is performed without delay in patients and can prevent the diagnosis delay in especially malignancies, which is one of the important problems experienced during the pandemic period. CONFLICT OF INTEREST The authors declare that there are no conflict of interests. ETHICS STATEMENT Ethical approval was obtained from Kocaeli University Local Ethical Committee. The image used in the figure was taken during bronchoscopy and written consent was obtained from the patient.

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          SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients

          To the Editor: The 2019 novel coronavirus (SARS-CoV-2) epidemic, which was first reported in December 2019 in Wuhan, China, and has been declared a public health emergency of international concern by the World Health Organization, may progress to a pandemic associated with substantial morbidity and mortality. SARS-CoV-2 is genetically related to SARS-CoV, which caused a global epidemic with 8096 confirmed cases in more than 25 countries in 2002–2003. 1 The epidemic of SARS-CoV was successfully contained through public health interventions, including case detection and isolation. Transmission of SARS-CoV occurred mainly after days of illness 2 and was associated with modest viral loads in the respiratory tract early in the illness, with viral loads peaking approximately 10 days after symptom onset. 3 We monitored SARS-CoV-2 viral loads in upper respiratory specimens obtained from 18 patients (9 men and 9 women; median age, 59 years; range, 26 to 76) in Zhuhai, Guangdong, China, including 4 patients with secondary infections (1 of whom never had symptoms) within two family clusters (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). The patient who never had symptoms was a close contact of a patient with a known case and was therefore monitored. A total of 72 nasal swabs (sampled from the mid-turbinate and nasopharynx) (Figure 1A) and 72 throat swabs (Figure 1B) were analyzed, with 1 to 9 sequential samples obtained from each patient. Polyester flock swabs were used for all the patients. From January 7 through January 26, 2020, a total of 14 patients who had recently returned from Wuhan and had fever (≥37.3°C) received a diagnosis of Covid-19 (the illness caused by SARS-CoV-2) by means of reverse-transcriptase–polymerase-chain-reaction assay with primers and probes targeting the N and Orf1b genes of SARS-CoV-2; the assay was developed by the Chinese Center for Disease Control and Prevention. Samples were tested at the Guangdong Provincial Center for Disease Control and Prevention. Thirteen of 14 patients with imported cases had evidence of pneumonia on computed tomography (CT). None of them had visited the Huanan Seafood Wholesale Market in Wuhan within 14 days before symptom onset. Patients E, I, and P required admission to intensive care units, whereas the others had mild-to-moderate illness. Secondary infections were detected in close contacts of Patients E, I, and P. Patient E worked in Wuhan and visited his wife (Patient L), mother (Patient D), and a friend (Patient Z) in Zhuhai on January 17. Symptoms developed in Patients L and D on January 20 and January 22, respectively, with viral RNA detected in their nasal and throat swabs soon after symptom onset. Patient Z reported no clinical symptoms, but his nasal swabs (cycle threshold [Ct] values, 22 to 28) and throat swabs (Ct values, 30 to 32) tested positive on days 7, 10, and 11 after contact. A CT scan of Patient Z that was obtained on February 6 was unremarkable. Patients I and P lived in Wuhan and visited their daughter (Patient H) in Zhuhai on January 11 when their symptoms first developed. Fever developed in Patient H on January 17, with viral RNA detected in nasal and throat swabs on day 1 after symptom onset. We analyzed the viral load in nasal and throat swabs obtained from the 17 symptomatic patients in relation to day of onset of any symptoms (Figure 1C). Higher viral loads (inversely related to Ct value) were detected soon after symptom onset, with higher viral loads detected in the nose than in the throat. Our analysis suggests that the viral nucleic acid shedding pattern of patients infected with SARS-CoV-2 resembles that of patients with influenza 4 and appears different from that seen in patients infected with SARS-CoV. 3 The viral load that was detected in the asymptomatic patient was similar to that in the symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients. These findings are in concordance with reports that transmission may occur early in the course of infection 5 and suggest that case detection and isolation may require strategies different from those required for the control of SARS-CoV. How SARS-CoV-2 viral load correlates with culturable virus needs to be determined. Identification of patients with few or no symptoms and with modest levels of detectable viral RNA in the oropharynx for at least 5 days suggests that we need better data to determine transmission dynamics and inform our screening practices.
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            Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic

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              The aerosol box for intubation in coronavirus disease 2019 patients: an in‐situ simulation crossover study

              Abstract The coronavirus disease 2019 pandemic has led to the manufacturing of novel devices to protect clinicians from the risk of transmission, including the aerosol box for use during tracheal intubation. We evaluated the impact of two aerosol boxes (an early‐generation box and a latest‐generation box) on intubations in patients with severe coronavirus disease 2019 with an in‐situ simulation crossover study. The simulated process complied with the Safe Airway Society coronavirus disease 2019 airway management guidelines. The primary outcome was intubation time; secondary outcomes included first‐pass success and breaches to personal protective equipment. All intubations were performed by specialist (consultant) anaesthetists and video recorded. Twelve anaesthetists performed 36 intubations. Intubation time with no aerosol box was significantly shorter than with the early‐generation box (median (IQR [range]) 42.9 (32.9–46.9 [30.9–57.6])s vs. 82.1 (45.1–98.3 [30.8–180.0])s p = 0.002) and the latest‐generation box (52.4 (43.1–70.3 [35.7–169.2])s, p = 0.008). No intubations without a box took more than 1 min, whereas 14 (58%) intubations with a box took over 1 min and 4 (17%) took over 2 min (including one failure). Without an aerosol box, all anaesthetists obtained first‐pass success. With the early‐generation and latest‐generation boxes, 9 (75%) and 10 (83%) participants obtained first‐pass success, respectively. One breach of personal protective equipment occurred using the early‐generation box and seven breaches occurred using the latest‐generation box. Aerosol boxes may increase intubation times and therefore expose patients to the risk of hypoxia. They may cause damage to conventional personal protective equipment and therefore place clinicians at risk of infection. Further research is required before these devices can be considered safe for clinical use.
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                Author and article information

                Contributors
                serapargun2002@yahoo.com
                Journal
                J Surg Oncol
                J Surg Oncol
                10.1002/(ISSN)1096-9098
                JSO
                Journal of Surgical Oncology
                John Wiley and Sons Inc. (Hoboken )
                0022-4790
                1096-9098
                02 March 2021
                : 10.1002/jso.26431
                Affiliations
                [ 1 ] Department of Pulmonary Disease, School of Medicine Kocaeli University Kocaeli Turkey
                Author notes
                [*] [* ] Correspondence Serap Argun Baris, Department of Pulmonary Disease, School of Medicine, Kocaeli University, Umuttepe, 41000 Kocaeli, Turkey.

                Email: serapargun2002@ 123456yahoo.com

                Author information
                https://orcid.org/0000-0002-4429-9441
                https://orcid.org/0000-0002-6462-7094
                https://orcid.org/0000-0003-2744-9898
                https://orcid.org/0000-0001-7706-9311
                Article
                JSO26431
                10.1002/jso.26431
                8013401
                33650676
                a9112fc9-36df-4ac6-a50c-6a9e8a936f9b
                © 2021 Wiley Periodicals LLC

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                : 07 February 2021
                : 08 February 2021
                Page count
                Figures: 1, Tables: 0, Pages: 2, Words: 1353
                Categories
                Letter to the Editor
                Letter to the Editor
                Custom metadata
                2.0
                corrected-proof
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.0.1 mode:remove_FC converted:01.04.2021

                Oncology & Radiotherapy
                Oncology & Radiotherapy

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