Background: Although the imaging features of coronavirus disease 2019 (COVID-19) are starting to be well determined, what actually occurs within the bronchi is poorly known. Here, we report the processes and findings of bronchoscopy in a patient with COVID-19 accompanied by respiratory failure. Case Summary: A 50-year-old female patient was admitted to a tertiary care hospital in South India on February 3, 2021 for fever and shortness of breath for 4 days that worsened for the last 2 days. The severe acute respiratory syndrome coronavirus 2 nucleic acid test was positive in throat swabs by RTPCR. Routine blood examination showed leucocytosis, with raised markers of inflammation and d-dimer. Oxygen saturation was 80% at baseline and turned to 95% with mechanical ventilation. The patient underwent elective tracheostomy followed by flexible bronchoscopy. There were no abnormalities detected in the tracheal lumen till the level of carina and the tracheal cartilage rings were clear. The mucosa was hyperemic with dry granulations and thick white tenacious secretions. The trachea and bilateral bronchi were patent. There was no neoplasm or ulcerations noted. The patient’s condition did not improve after treatment and she succumbed to the disease. Conclusion: Bronchoscopy can be done under mechanical ventilation with use of proper personal protective equipment (PPE) in patients with COVID-19 lung disease. Considering the high viral load and risks of transmission of the disease to healthcare workers, it is not necessary to perform routine bronchoscopies in all patients with COVID-19 lung diseaseand can be performed on moderate or severe patients who does not improve on routine treatment. In our case, we found hyperemic mucosa with dry granulations and tenacious white secretions limited to the carina and primary bronchus on bronchoscopy.

Chinese health officials announced the detection of a case with novel coronavirus disease (COVID-19) in Wuhan, China on the 7th of January 2020 [1, 2]. The novel strain of human coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) has named by the International Committee on Taxonomy of Viruses (ICTV) 1, is the causative agent for this new infectious disease [3]. On February 11, 2020 World Health Organization (WHO) officially named the disease as Coronavirus Disease 2019 (COVID-19) [4]. After which WHO officially declared the disease a pandemic on March 11, 2020. Many reports showed higher infection rates among healthcare workers. 

The disease is transmitted from humans to humans by close contacts and respiratory droplets [5]. The common signs of COVID-19 include fever, cough, and shortness of breath were the common symptoms reported initially, however, smell and taste disturbances have also been reported as new symptoms in recent literature. The severity of the COVID-19 can be classified as mild, regular, severe, and critical [6]. Severe and critical cases require oxygen support and mechanical ventilation. Death is usually due to respiratory failure, but systemic inflammation, thromboembolism and multi organ failure can also be the cause in most of the cases.

The hematological and radiological imaging features of COVID-19 are well determined and are used for screening purpose in many centers. However, the bronchoscopic features of COVID associated lung disease are less reported. Bronchoscopy adds important information in this regard, but carries a high risk of aerosol generation and spread of the virus to the healthcare workers, so the use of bronchoscopy should be carefully assessed before use and avoided in necessary situations such as unexplained increase in airway pressure or lung collapse [7].

Here, we report the processes and findings of a patient who underwent tracheostomy followed by bronchoscopy for COVID-19 accompanied by respiratory failure. 

A 50-year-old female patient was admitted to a tertiary care hospital in South India following fever and cough for the last 3 days. Patient was a known diabetic, on oral hypoglycemic agents for the last 15 years. Physical examination at the time of admission showed morbid obesity and her body temperature was 37.6°C, pulse was 110 beats/ min, respiration was 30 breaths/min, blood pressure was 164/100 mmHg, and blood oxygen saturation was 96%. Prior to admission, patient underwent a Rapid Card Antigen testing for SARSCOV-2 antigen from throat swab which came positive. Following that, she was isolated and an RTPCR of her throat swab was taken which came positive for severe acute respiratory syndrome coronavirus 2 nucleic acid. Her chest x-ray showed pan lobar involvement with multiple consolidations [Figure 1] and high resolution computed tomography of chest showed features suspicious of COVID-19 (CORADS-4) with bilateral ground glass opacities. Her blood report showed neutrophilia with raised CRP and ferritin levels and deranged liver function tests and elevated D-dimers. Her HbA1c was 9% with random blood sugar of 212 mg/dl.

Her breathlessness worsened on the second day of admission and her saturation was not maintained on room air, she was intubated with 8 size endotracheal tube and connected to ventilator on pressure support mode. She received injection Remdesevir, meropenem, azithromycin and low molecular weight heparin. On the 11th day of intubation, she was planned for tracheostomy in view of prolonged mechanical ventilation and requirement of high inspiratory pressure, PEEP with FiO2 of 100%. So her repeat RTPCR of her throat swab was sent on the 10th day which was still positive for SARSCOV-2 nucleic acid. A single one-piece personal protective suit with eye cover, face shield and N-95 masks were used by all the three surgeons from ENT side, both the anesthetists and the nursing staff throughout the procedure. Patient was shifted to the negative pressure operating room with a blood oxygen saturation of 40% in room air and relaxants were given and pre oxygenated with 100% oxygen before the start of the procedure. Intravenous injection of fentanyl, ondansetron and vecuroniuum were used by the anesthetist for sedation and analgesia. Patient underwent open tracheostomy and size 7.5 portex cuffed tracheostomy tube was inserted. The mechanical ventilator was set to the SIMV mode, with FiO2 100%, VT 480 mL, f 20 times/min, PS 12 cm H2O, and PEEP 5 cm H2O. The flexible bronchoscope was inserted through the working access of the universal joint that was connected to the tracheal catheter. On flexible bronchoscopy, there were no abnormalities detected in the lumen of trachea till the level of carina and the tracheal cartilage rings were clear. The mucosa was hyperemic with dry & granular changes [Figure 2].

These mucosal changes were predominantly noted in the carina and primary bronchus whereas the terminal bronchus were free of the hyperemia and granulations. White tenacious secretions were found in the right and left main bronchus [Figure 3], and the bronchial lumen was patent after sputum aspiration and bronchial wash with dilute betadiene. The trachea and bilateral bronchi were patent. There was no neoplasm or ulcerations noted.

The patient's condition did not improve following treatment and succumbed to the disease after 3 days of tracheostomy due to sudden cardiac arrest.

The natural history of COVID-19 is still poorly understood. Patients can have a wide spectrum of illnesses from mild rhinitis to multi organ failure and death. The incidence of a severe form of disease can be attributed to many risk factors like advanced age, immune compromised state and presence of comorbid conditions and late presentation. Our patient had a poor outcome because of the age group, severe form of disease and presence of comorbid conditions like obesity and diabetes mellitus. Our patient was an obese female in her fifth decade of life who was a diabetic on treatment for the same. Bronchoscopy helps in clearing the secretions in patients with pneumonia and ventilation problems [8]. Flexible Bronchoscopy in this patient showed no secretions in the trachea and bilateral bronchi, while the mucosa showed hyperemia with granulations and congestion. Moderate amounts of white tenacious secretions were noted in the right bronchus which was consistent with the autopsy findings of COVID-19 patients [9]. Bronchoscopy could directly visualize the lesion and accurately and completely remove the airway secretions in our patient and helped in giving a bronchial wash. Chen QY et al reported a case report of bronchoscopy in COVID-19 patient and the typical bronchoscopic findings were reported as hyperemia, mucosal abrasion and the presence of white gelatinous secretions in the bronchi [10]. Bronchoscopic appearance in our patient was also similar to this, but granulations in the main bronchi and carina has not been reported in literature till now. The bronchoscopy physician and anesthetist could come in contact with the respiratory secretions, and bronchoscopy might induce aerosol spread, and thus the risk of transmission of the disease is extremely high. It has been suggested that bronchoscopy in patients with COVID-19 should be strictly kept for emergency and necessary situations [7].Diagnostic bronchoscopy was done in this patient to look for the cause for persistent drop in saturation following mechanical ventilation. Because this patient was shifted to the operating room for a planned elective tracheostomy, bronchoscopy and bronchial lavage was done on the same sitting. From our experience, the following items were concluded; personal protection equipment, proper donning and doffing techniques and following of proper hand hygiene could help in reducing the transmission of the disease to the healthcare workers in spite of the patient undergoing invasive airway procedures with high viral load. Secondly, the use of muscle relaxants, anxiolytics and proper sedation helps in reducing the cough reflex of the patient thereby reducing aerosol generation in the operating room. Third, the bronchoscope was inserted through the working access of the universal joint connected to the tracheostomy tube which was properly lubricated which could increase the ease of the procedure and help isolate the airway and external environment. Finally, the availability of experienced anesthetists and surgical team help in reducing the confusion in operating room and the time for procedure thereby reducing the risk of exposure and transmission.

Elective tracheostomy is not usually advocated for COVID-19 patients who need prolonged intubation. However, patients with poor prognosis who need prolonged ventilator support are advised to undergo elective planned tracheostomy with experienced anesthesia and surgical team in order to reduce the operating time, chance of complications and risk of aerosol generation and transmission of disease. Diagnostic flexible bronchoscopy in our patient showed the characteristic findings associated with COVID bronchitis described in literature [Figure-4].

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Corresponding Author: Nikhil Sivanand, Mahatma Gandhi Medical College and Research Institute, India 

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