Intensivists in critical care units are increasingly using disposable, single-use bronchoscopes in their patients. Decreasing the risk of transmitting infection may be the prime motivator for this shift, but it would not be feasible unless these scopes are also cost-effective, convenient, and technically equivalent to conventional scopes.
Bronchoscopes are an invaluable tool in intensive care units to facilitate difficult intubations and tracheostomy procedures, diagnose infectious and neoplastic conditions and provide relief via suction and lavage, among other uses. As with other similar instruments, traditional flexible bronchoscopes are typically designed to be used, decontaminated and then reused. While this system is usually reliable, there remains a risk for cross-contamination and infection from flexible bronchoscopes.1 Indeed, there are published reports of pneumonia and sepsis and even patient deaths related to infection transmission during bronchoscopy.2,6 Lack of recognition and under-reporting make an assessment of the true incidence of infection difficult, but even the numbers that are known show this to be a risk worthy of further attention.
The tedious and meticulous requirements for cleaning and reprocessing reusable bronchoscopes provide the path to infection transmission.1 The process requires labor that could better be used elsewhere as well as special cleaners and procedures. With channels for infusion of liquids and suctioning of infectious material, crevices, elbows, angles, material that can degrade over time and threaded ports and caps, there are many potential opportunities for failure of the decontamination process. Storage of scopes that are not rigorously decontaminated also allows colonization of bacteria that can go on to cause disease.5 Cases of transmission of dangerous pathogens have been reported resulting in preventable and unacceptable morbidity and mortality. 1,2,6
Safety and infection prevention alone are enough reason to avoid reusable instruments for invasive procedures, but Intensivists also appreciate disposable bronchoscopes because of their convenience.4 In the ICU, care of very sick patients requires reliable, rapid access to needed equipment. It is unacceptable to find that an instrument isn’t clean, is already in use or has a new defect or malfunction when a critically ill patient needs a procedure. This can cause a devastating postponement of treatment with dire consequences. The convenience of having a new scope available and ready for use is good for both doctor and patient.
Compared to traditional scopes, not only are the single-use devices more readily available, but they also take less time and labor to set up, saving time and human resources that are so valuable in the ICU.3,4
Despite a superior infection safety profile, the option of disposable devices is often dismissed because it is assumed that reusable items offer a cost advantage over single-use instruments. Studies comparing the two actually don’t support this presumption though.3 After accounting for purchase, repair, cleaning and replacement expenses, the cost per use in cost-effectiveness analyses are comparable.3,4
Single-use bronchoscopes provide safety, convenience, availability and cost-effectiveness to give Intensivists in the ICU a better choice when performing bronchoscopy.
2. Arjun Srinivasan, M.D., Linda L. Wolfenden, M.D., Xiaoyan Song, M.D., Karen Mackie, R.N., Theresa L. Hartsell, M.D., Ph.D., Heather D. Jones, M.D., Gregory B. Diette, M.D., M.H.S., Jonathan B. Orens, M.D., Rex C. Yung, M.D., Tracy L. Ross, B.S., William Merz, Ph.D., Paul J. Scheel, M.D., Edward F. Haponik, M.D., and Trish M. Perl, M.D. An Outbreak of Pseudomonas aeruginosa Infections Associated with Flexible Bronchoscopes. N Engl J Med 2003; 348:221-227January 16, 2003
3. Terjesen, C.L., Kovaleva, J. & Ehlers, L. Early Assessment of the Likely Cost Effectiveness of Single-Use Flexible Video Bronchoscopes. PharmacoEconomics Open (2017) 1: 133. https://doi.org/10.1007/s41669-017-0012-9
4. Marshall, Dominic C. MBBS; Dagaonkar, Rucha S. FCCP; Yeow, Chan MMed; Peters, Anura T. BSc; Tan, Siew Kin BSc; Tai, Dessmon Y.H. FCCP; Keng Gohs, Soon FCCP; Lim, Albert Y.H. MD; Ho, Benjamin FCCP; Lew, Sennen J.W. MRCP; Abisheganaden, John FRCP; Verma, Akash MRCP. Experience With the Use of Single-Use Disposable Bronchoscope in the ICU in a Tertiary Referral Center of Singapore. Journal of Bronchology & Interventional Pulmonology: April 2017 – Volume 24 – Issue 2 – p 136–143
5. McGrath, B. A., Ruane, S., McKenna, J. and Thomas, S. (2017), Contamination of single-use bronchoscopes in critically ill patients. Anaesthesia, 72: 36–41, http://onlinelibrary.wiley.com/doi/10.1111/anae.13622/full
6. Tracy Agerton, Sarah Valway, Betty Gore, Carol Pozsik, Bonnie Plikaytis, Charles Woodley, Ida Onorato. Transmission of a Highly Drug-Resistant Strain (Strain W1) of Mycobacterium Tuberculosis Community Outbreak and Nosocomial Transmission via a Contaminated Bronchoscope. JAMA. 1997;278(13):1073–1077. doi:10.1001/jama.1997.03550130047035