A patient presents to the ICU with haemoptysis. He has been intubated and a bronchoscopy is planned to isolate the source of the bleeding. He has just been diagnosed as having pulmonary tuberculosis on the basis of a positive smear and has not received any treatment. Discuss the precautions to prevent your staff being infected with TB and the rationale for each.
• The patient has smear positive untreated TB and is therefore highly infectious
• The infection risk is greatly magnified by bronchoscopy which generates aerosols. It is therefore important to review the need for bronchoscopy .
• Regardless of whether a bronchoscopy is carried out the following precautions should be taken:
• Nurse in a single room with negative pressure ventilation and 12 air changes per hour
• Bacterial filter in ventilator circuit and closed suction
• All staff entering room should take personal respiratory precautions including fit tested N95/100 mask.
• Infection warning signs
• If bronchoscopy is undertaken:
• Minimize generation of aerosols:
Prevent coughing (muscle relaxant)
Consider apnoeic oxygenation during bronchoscopy
• Consider use of powered air purifying respirator if available and staff have been appropriately trained
Staff screen – In the event of accidental exposure during the procedure, consideration for a CXR, mantoux baseline and at 2 months.
Advice and help of the Occupational Health and Infectious diseases team should also be sought.
The college seems to have derived their answer from the ACCP/AAB consensus statement on the prevention of flexible bronchoscopy-associated infections. This document regulates every last detail of bronchoscopy, down to record-keeping and the number of air exchanges in the negative pressure room.
Mehta, Atul C., et al. "American College of Chest Physicians and American Association for Bronchology Consensus StatementPrevention of Flexible Bronchoscopy-Associated Infection." CHEST Journal 128.3 (2005): 1742-1755.
Culver, Daniel A., Steven M. Gordon, and Atul C. Mehta. "Infection control in the bronchoscopy suite: a review of outbreaks and guidelines for prevention."American journal of respiratory and critical care medicine 167.8 (2003): 1050-1056.
.Frumin, M. Jack, ROBERT M. EPSTEIN, and GERALD COHEN. "Apneic oxygenation in man." Anesthesiology 20.6 (1959): 789-798.