Bronchoscopes are one of the most commonly-used instruments in the hospital. Their frequent use and high cost necessitate reprocessing. But a brand new, reusable bronchoscope can cost hospitals upwards of $20,000—not to mention ongoing repair costs and accessories. As technology advances, costs have climbed to accommodate video capabilities and high-precision lenses. These new features require delicate components that may be more susceptible to damage. Fragile components are also more difficult to clean. Still, every bronchoscopy must begin with a clean, disinfected instrument.

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Bronchoscopes have myriad niches that can foster microbial growth. Suction valves, channels, and tubing are stubborn sources of contamination. These areas resist traditional cleaning methods and are difficult to scrub. The instruments also have many moving parts. Over time, loose caps and ports may shelter organisms from disinfection. “Bronchoscopes are designed with narrow working channels, ports with obtuse angles, and linings vulnerable to damage and subsequent biofilm formation, forming obstacles to proper cleaning and disinfection or sterilization,” writes one team of providers. Each bronchoscope requires different cleaning strategies based on its features. Bronchoscopes contaminated with hepatitis, human immunodeficiency virus, or mycobacteria will also require different cleaning regimens.

Any contamination on a bronchoscope has the potential to infect the airway and could lead to VAP. But not all patients need bronchoscopies for the same reason—some may have pulmonary hemorrhage, ulcers, or lesions that put them at increased risk for infection by contaminated bronchoscopes. Others may have acute trauma elsewhere in the body but healthy airways that place them at lower risk of infection. Hospitals are faced with implementing bronchoscope-reprocessing protocols that cover everyone. These will vary by disinfectants used, bronchoscopy volume, and facilities available.

Unfortunately, most reusable bronchoscopes cannot tolerate the same autoclave temperatures and disinfectants that other instruments can. They must be reprocessed in a step-wise fashion that requires meticulous manual cleaning followed by treatment in a designated reprocessing machine. This approach is exceptionally time-consuming. The Food and Drug Administration recommends, at a minimum, that bronchoscopes undergo “high-level disinfection” with a liquid disinfectant containing glutaraldehyde, peracetic acid, hydrogen peroxide, and/or ortho-phthaldehyde. Specific guidelines are ever-changing but updated online. The FDA considers bronchoscopes “semi critical” as they come in contact with mucus membranes. They do not require sterilization, as with surgical equipment, but they must be disinfected. Some thought leaders suggest that endoscopes—including bronchoscopes—be upgraded to “critical” devices that require sterilization. One study found that even when reprocessing protocols align with current CDC guidelines, contamination remains. “A shift toward the use of sterilized bronchoscopes is recommended,” wrote the authors.

Manual pre-cleaning is paramount immediately after a bronchoscopy. Automated reprocessors cannot remove all contaminants on their own. After transportation to the reprocessing area, detailed manual cleaning precedes high-level disinfection to remove biologic matter before it has a chance to dry. Hospital staff must remove bronchoscope attachments, scrub the outside of the scope, and use custom brushes to get inside channels. The bronchoscope must be immersed in detergent to check for leaks. All cleaning swabs, brushes, and water must be discarded after use. Reused brushes have caused outbreaks. Poor adherence to reprocessing protocols can be deadly. One outbreak of drug-resistant M. tuberculosis was due to a single bronchoscope that was never immersed in disinfectant. A review of 14 M. tuberculosis outbreaks caused by contaminated bronchoscopes point to other causes, most commonly non-sterile rinse water and over-reliance on automated reprocessors.

After manual cleaning, bronchoscopes should be connected to automated reprocessors. These machines run high-level disinfectants through the instrument (that must be rinsed off afterward). Yet not all bronchoscopes are compatible with all automated reprocessors. And even automated reprocessors can become contaminated. Biofilms in reprocessors resist even aggressive cleaning measures. When one group had a Mycobacterium chelonae biofilm in their hospital bronchoscope reprocessor, they tried introducing sterile water in wash and rinse cycles, increasing disinfectant exposure duration, and replacing disinfectant. It wasn’t until they manually rinsed bronchoscopes exiting the reprocessor with 70% alcohol that they could eliminate the outbreak strain.

It’s important to note that reprocessing bronchoscopes does not always decontaminate them. Even when following guidelines exactly, contamination can persist. One study found 58% of bronchoscopes used across three study sites had microbial contamination after disinfection procedures. The study sites regularly—and unknowingly—used damaged, contaminated scopes during procedures. Reprocessing bronchoscopes is also tedious. It also requires careful coordination between bronchoscopists, nurses, ancillary staff, infection control practitioners, and instrument manufacturers. All team members must stay up-to-date on published guidelines and communicate to recognized adherence breaches and ensure patient safety. Poor adherence to reprocessing guidelines puts patients at risk for serious infection.