Decision Support for the Capacity Management of Bronchoscopy Devices

Single-use vs. reusable flexible bronchoscopes for airway management and in critical care: a narrative review

INTRODUCTION

Flexible bronchoscopes have become essential in the operating theatre environment and in critical care. This narrative review compared single-use and reusable flexible bronchoscopes with a focus on safety, efficacy, cost-effectiveness and environmental impact.

METHODS

We searched MEDLINE, Embase and PubMed databases for studies related to flexible bronchoscopes for airway management or use in critical care. Human or animal studies of any design assessing single-use and reusable flexible bronchoscopes were included and qualitatively synthesised. We also searched manufacturer websites for relevant data.

RESULTS

We included 52 studies and data from six manufacturer websites. There was mixed evidence for safety, and data on usability also showed significant heterogeneity, with different parameters, manufacturers and models examined. Neither single-use nor reusable flexible bronchoscopes appeared convincingly superior to the other for safety or usability. Cost analyses showed that the rate of use of flexible bronchoscopes per year, along with several other factors, affects cost-effectiveness for each institution, though the risk of cross-contamination is an advantage of single-use devices. However, sufficient evidence on the rate of bronchoscopy-induced infection in the operating theatre and critical care environment is lacking. Due to the risk of cross-contamination, single-use flexible bronchoscopes must be sterilised or incinerated after use, and completely recyclable single-use models are not currently available.

CONCLUSIONS

Further research is required on safety, usability and life cycle assessment in the operating theatre and critical care environment, as well as on the rate of bronchoscopy-induced infection. Future comparative studies, including new manufacturers and designs, may lend further insights.

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.

Evaluation of a new developed disposable and portable bronchoscopy system

BACKGROUND

Bronchoscopy is critical in the treatment of patients with coronavirus disease (COVID-19), and its use is associated with the challenges of stringent sterilization and virus transmission risk. We developed a disposable and portable bronchoscope (YunSendo-R) and compared its safety and function with those of current reusable and single-use bronchoscopes using an animal model.

METHODS

We compared the YunSendo-R system with a commercially available reusable bronchoscope (Olympus, BF-H290) and single-use bronchoscope (Ambu, Ambu® aScope3™). Eight physicians used the three types of bronchoscopes to operate on Guangxi Bama mini pigs. Each operator performed bronchoscopy and completed a 10-point Likert scale questionnaire for evaluating visual ability and manoeuvrability. Operation time and scores were collected.

RESULTS

Operation time had no significant differences among the three bronchoscopes. In visual ability, the YunSendo-R bronchoscope showed superior performance to the Ambu bronchoscope in image clarity, colour contrast, and illumination (P < 0.05) and no significant difference in performance compared with the Olympus bronchoscope (P > 0.05). The YunSendo-R bronchoscope had similar manoeuvrability to the Olympus bronchoscope and better scope tip flexibility than the Ambu bronchoscope (P > 0.05). No relevant complications were reported.

CONCLUSION

We have developed a new bronchoscopy system with the advantages of disposability and portability, which was effective and safe in an animal model. It has better visual ability than the Ambu bronchoscope and similar visual ability and manoeuvrability to the Olympus bronchoscope. The YunSendo-R bronchoscope is a promising device for clinical practice, especially in reusable-endoscope-transmitted infectious diseases such as COVID-19.

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.

Pediatric bronchoscopy: recent advances and clinical challenges

Introduction: During the last 40 years equipment has been improved with smaller instruments and sufficient size working channels. This has ensured that bronchoscopy offers therapeutic and interventional options.Areas covered: We provide a review of recent advances and clinical challenges in pediatric bronchoscopy. This includes single-use bronchoscopes, endobronchial ultrasound, and cryoprobe. Bronchoscopy in persistent preschool wheezing and asthma is included. The indications for interventional bronchoscopy have amplified and included balloon dilatation, endoscopic intubation, the use of airway stents, whole lung lavage, closing of fistulas and air leak, as well as an update on removal of foreign bodies. Others include the use of laser and microdebrider in airway surgery. Experience with bronchoscope during the COVID-19 pandemic has been included in this review. PubMed was searched for articles on pediatric bronchoscopy, including rigid bronchoscopy as well as interventional bronchoscopy with a focus on reviewing literature in the past 5 years.Expert opinion: As the proficiency of pediatric interventional pulmonologists continues to grow more interventions are being performed. There is a scarcity of published evidence in this field. Courses for pediatric interventional bronchoscopy need to be developed. The COVID-19 experience resulted in safer bronchoscopy practice for all involved.

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.

Implementation of an Anaesthesia Quality Improvement Programme to Reduce Fibreoptic Bronchoscope Repair Incidents

Background

This study was aimed at investigating the effectiveness of the implementation of a comprehensive quality improvement programme (QIP) for reducing the repair rate of the fibreoptic bronchoscope (FOB).

Methods

A three-stage improvement strategy was implemented between January 2013 and December 2016. Stage one is the acquisition of information on violations of practice guidelines, repair rate, cost of repair, and incidence of unavailability of FOB during anaesthesia induction of the previous year through auditing. Stage two is the implementation of a quality improvement campaign (QIC) based on the results of stage one. Stage three is the programme perpetuation through monitoring compliance with policy on FOB use by regular internal audits. The effectiveness was retrospectively analyzed on a yearly basis.

Results

The annual repair rate, repair cost, and incidence of FOB unavailability before the QIP implementation were 1%, 18,757 USD, and 1.4%, respectively. After QIC, the repair rate in 2013 dropped by 81% (from 1% in 2012 to 0.19% in 2013, p < 0.05). The annual repair cost fell by 32% from 18,758 USD (2012) to 12,820 USD (2013). Besides, the incidence of FOB unavailability plummeted by 71% from 1.4% to 0.4% during the same period. The annual repair rates and incidence of FOB unavailability remained lower in subsequent three years than those before QIP implementation.

Conclusion

Implementation of a quality improvement programme was effective for reducing the rate and cost of FOB repair as well as unavailability rate, highlighting its beneficial impact on cost-effectiveness and patient safety in a tertiary referral center setting.

A Cost-Effectiveness Analysis Comparing the VivaSight Double-Lumen Tube and a Conventional Double-Lumen Tube in Adult Patients Undergoing Thoracic Surgery Involving One-Lung Ventilation

BACKGROUND

One-lung ventilation (OLV) procedures are essential for most thoracic surgeries, and the most common method is intubation with a conventional double-lumen tube (cDLT) and bronchoscopy to verify correct tube placement.

OBJECTIVE

The objective of this study was to conduct a cost-effectiveness analysis comparing the VivaSight double-lumen tube (DL) and a cDLT for OLV procedures.

METHODS

A cost-effectiveness analysis was conducted from a healthcare sector perspective in Denmark using a decision analytic model to assess the potential effects and costs of using VivaSight-DL as an alternative to a cDLT with a reusable bronchoscope. Costs were determined using a micro-costing approach. The effectiveness measure was the number of times that fiberoptic confirmation of the tube placement during intubation or surgery was unnecessary and thus avoided. The effectiveness input was from a randomized controlled trial (n = 52). Both deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of the results.

RESULTS

Fiberoptic confirmation of tube placement was only necessary in two (6.66%) procedures using VivaSight-DL. The cost of using VivaSight-DL was $US299.96 per procedure versus $US347.61 for a cDLT with a reusable bronchoscope. The incremental cost-effectiveness ratio was - $US51.06 per bronchoscopy avoided. The base-case analysis indicated that the use of VivaSight-DL was cost effective compared with the use of a cDLT with reusable bronchoscope. Sensitivity analyses showed that the results were robust and that VivaSight-DL was more effective and less costly.

CONCLUSION

This study suggests that VivaSight-DL is associated with cost savings and reductions in bronchoscope use to verify correct tube placement. The conclusion is based on the results from a single institution. To clarify whether VivaSight-DL is cost effective in larger or global clinical settings, further economic evaluations should be performed.