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Infection control in the bronchoscopy suite: effective reprocessing and

disinfection of reusable bronchoscopes

Article in Current Opinion in Pulmonary Medicine · November 2022

DOI: 10.1097/MCP.0000000000000925

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REVIEW

C URRENT
OPINION Infection control in the bronchoscopy suite:
effective reprocessing and disinfection of
reusable bronchoscopes
Mamta S. Chhabria a, Fabien Maldonado b and Atul C. Mehta a

Purpose of review
With advancements in technology, flexible bronchoscopes have become thinner in diameter and in need of
more thorough reprocessing to prevent infection transmission than ever before. Many experienced
bronchoscopists are not aware of the critical steps involved in effective bronchoscope reprocessing and we
hope to bridge this gap by describing this process in detail.
Recent findings
Bronchoscope reprocessing includes several distinct steps (precleaning, leak testing, manual cleaning,
visual inspection, terminal reprocessing, rinsing and drying). Each step is comprehensive and needs to be
carried out systematically by trained personnel. Failure of any step can lead to serious downstream events
such as outbreaks and pseudo-outbreaks. Some experts now recommend sterilization when feasible,
although high-level disinfection remains the minimum standard. We also will review some literature on the
utility of borescopes, automated endoscope reprocessors and disposable bronchoscopes.
Summary
Our article will focus on the most recent recommendations for effective reprocessing and disinfection of
reusable bronchoscopes.
Keywords
bronchoscope related infection, bronchoscope reprocessing, infection prevention, reusable bronchoscopes

INTRODUCTION spores. The Food and Drug Administration’s (FDA)

As reported in the Centers for Disease Control and
Prevention’s (CDC) Sterilization and Disinfection
Guidelines, more healthcare-associated outbreaks
have been linked to endoscopes than to any other
medical device [1].
Over 500 000 bronchoscopies are performed
each year in the USA [2]. Many bronchoscopists,
however, are unfamiliar with local practices related
to bronchoscope reprocessing and disinfection [3].
The importance of infectious risks during broncho-
scopy were acutely highlighted during the COVID-
19 pandemic.
According to the Spaulding classification, bron-
choscopes come under the category of semi-critical
items: instruments that come in contact with intact
skin and mucous membranes [4]. In accordance
with the published guidelines and manufacturer
instructions, semi-critical instruments need to
undergo high-level disinfection (HLD), which
implies complete elimination of all microorganisms
in or on an instrument, except for a small number of
definition of high-level disinfection entails a steri-
lant used for a shorter contact time to achieve a 6-log
10 kill of an appropriate Mycobacterium species.
Manual cleaning followed by high-level disinfection
should eliminate enough pathogens to prevent
transmission of infection [5,6].
There is an ongoing debate among experts as to
whether sterilization of reusable bronchoscopes
should be pursued instead of HLD [7]. According
to a recent article based on expert opinion, sterili-
zation provides greater quality assurance than HLD
a
Department of Pulmonology and Critical Care Medicine, Respiratory
Institute, Cleveland Clinic, Cleveland, Ohio and bDivision of Allergy,
Pulmonary and Critical Care Medicine, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
Correspondence to Mamta S. Chhabria, MD, Cleveland Clinic Founda-
tion: Cleveland Clinic, Cleveland, Ohio, USA. Tel: +1 216 408 8704;
e-mail: drmamtasc@gmail.com
Curr Opin Pulm Med 2022, 28:000–000
DOI:10.1097/MCP.0000000000000925

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KEY POINTS
 Reusable bronchoscopes require thorough reprocessing
between uses to prevent infection transmission.
 Reprocessing of bronchoscopes encompasses several
steps and require special training of personnel who
carry out reprocessing.
 The steps involved are precleaning, leak testing, visual
inspection, manual cleaning, terminal reprocessing
(high-level disinfection or sterilization), rinsing, drying
and storage.
 Failure at any step can lead to residual contamination
of bronchoscopes and potentially cause outbreaks and
pseudo-outbreaks.
 Quality assurance is of utmost importance and the
responsibility of each individual bronchoscopy suite.
as at the end of the process, sterilized items are
packaged and able to be stored for later use, while
items that have undergone HLD are wet and unpack-
aged [8]. Furthermore, the Spaulding classification
was developed in the 1950 s when many semi-crit-
ical items that are in use today had not been
invented. At that time, low temperature sterilization
techniques currently available for heat-sensitive
medical devices such as bronchoscopes did not
exist. Another problem with the Spaulding scheme
arises when semi critical items are used in conjunc-
tion with critical items (which are instruments that
breach mucous membranes and contact the blood
stream or other sterile areas of the body, e.g. biopsy
forceps used with bronchoscopes). The CDC con-
tinues to recommend at least HLD in the case of semi
critical items such as bronchoscopes and advises
that only FDA cleared sterilants/high-level disinfec-
tants are used [1].
Several outbreaks and pseudo-outbreaks have
been associated with contaminated bronchoscopes.
FIGURE 1. Visible defects noted on patient-ready bronchoscopes: (a) Rusty brown discoloration, (b) filamentous debris, (c)
Droplets, (d) Dents. (Photos Copyright Ofstead and Associates, Inc. 2018; used with permission).
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The CDC’s Division of Healthcare Quality Promo-
tion (DHQP) conducted 15 separate investigations
of bronchoscope-associated outbreaks between
2014 and 2019 involving around 150 patients.
The range of infections was vast; organisms
identified included nontuberculous mycobacteria,
Candida species, Exophiala species, Pseudomonas
aeruginosa, Enterobacter species, Raoultella planti-
cola, Stenotrophomonas maltophilia, Achromobacter
species, Mycobacterium tuberculosis and Aspergillus
&
species [9 ].
Ofstead et al. [10] examined 24 flexible broncho-
scopes after HLD and demonstrated that 100% of
them had visible defects and 14 fully reprocessed
bronchoscopes (58%) harboured microbial growth,
including mould, S. maltophilia and Escherichia coli/
Shigella species. This study was carried out in three
large tertiary hospitals in the USA and highlighted
the fact that very often infection control standards
are not being met [10].
Biofilm tends to form when bronchoscopes are
not washed well immediately after their use. This
refers to an accumulated mass of bacteria and extrac-
ellular material that is tightly adhered to a surface
and cannot be easily removed [1]. Biofilms notori-
ously form in the narrow inner channels of bron-
choscopes and in cracks/surface irregularities within
these channels. (Fig. 1 demonstrating visible defects
in patient ready bronchoscopes) They tend to har-
bour resistant organisms, including carbapenem-
resistant Enterobacteriaceae and related multi-drug
resistant organisms (’superbugs’) and have been
&
implicated in several reported outbreaks [11 ].
In this article, we will outline the current tech-
niques for bronchoscope reprocessing, current data
on the use of reusable bronchoscopes, borescopes
for visual examination and personal protective
equipment (PPE) utilization in bronchoscopy.
The manual steps involved in reprocessing are
detailed below and have been summarized in
Table 1.
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Infection control in the bronchoscopy suite Chhabria et al.

Table 1. Summary of key steps involved in reprocessing of reusable bronchoscopes

Step Methods Goals

Pre-cleaning (Done Aspirating enzymatic detergent into the inner channels and
at the bedside) manually scrubbing the external surface of the scope with
a sponge or cloth soaked in cleaner.
Leak testing The scope is pressurized with a leak tester and submerged
under water to detect defects.
Manual cleaning Mechanically cleaning the internal and external surfaces
of the bronchoscope using chemicals/enzymatic cleaners.
Visual inspection Look for defects, damage, oily residues, debris along the
length of the inner channels and external surfaces of
scopes.
Terminal reprocessing High-level disinfection can be carried out manually or using AERs.
Rinsing Rinsing of bronchoscope channels with water.
Drying Rinsing the inner channels and insertion ports with alcohol
followed by drying with forced air.
Prevents biofilm formation.
Detects damage to the internal and external
surfaces of the scope.
Achieve 3--4.5 log reduction of the microbial
load.
If defects and residues are noted, the scope
should be sent for repairs.
Achieve 6 log reduction of the microbial load.
Remove traces of chemicals used in the
cleaning process to prevent patient injury.
Thoroughly dry the scope to prevent replication
of residual organisms during storage.

AER, automated endoscope reprocessors.

INITIAL STEPS to infection transmission and chemical exposure to

They include the steps that precede manual cleaning.
Pre-cleaning
Flexible bronchoscopes are particularly difficult to
clean because of their intricate design and narrow
working channel. Although these improvements in
design have made bronchoscopes easier to manoeu-
vre inside the tracheobronchial tree, they are also
more prone to damage because of their delicate
nature. The initial step of precleaning is very impor-
tant to prevent the formation of biofilm. This step is
achieved by aspirating enzymatic detergent or ster-
ile water into all the inner channels of the broncho-
scope and manually wiping down the external
surface of the bronchoscope with a lint free cloth,
sponge or gauze soaked in enzymatic detergent/
sterile water immediately upon completion of the
bronchoscopy (Fig. 2a). All suction ports and biopsy
attachments should be detached before this step. It
is typically done at the bedside to avoid delays in
this important step. This manoeuvre prevents dry-
ing of the blood, secretions or purulent material on
the surface of the instrument. Following this, the
bronchoscope is placed in a labelled container and
transferred to a separate area for further reprocessing
[12].
Leak testing
This is a vital processing step, which detects damage
to the external surfaces and internal channels of the
bronchoscope, which allows water, chemicals or
organic material to accumulate and potentially lead
mucous membranes. There are data to suggest that
leak testing helps reduce repair costs and extend the
life of the bronchoscope [13]. For this step, the
bronchoscope is pressurized with a leak tester and
submerged in water to look for air bubbles. If a leak is
detected, the device is sent back to the manufacturer
for repairs (Fig. 2b).
MANUAL CLEANING
This refers to mechanically cleaning internal and
external surfaces of the bronchoscope. This includes
utilization of water and detergents or enzymatic
cleaners to thoroughly flush each internal channel
of the bronchoscope and scrub external surfaces.
Specific channel cleaning brushes that fit into the
inner channels are available with different broncho-
scopes. Meticulous cleaning should decrease micro-
bial load by 3.5–4 log reduction. Improper cleaning
is implicated in the causation of outbreaks by lead-
ing to the failure of the downstream process of high-
&&
level disinfection/sterilization [14 ].
VISUAL INSPECTION
Bronchoscope channels are very narrow and
encased in opaque materials making visual inspec-
tion particularly challenging. Visual inspection
under high magnification and good lighting should
be performed every reprocessing cycle. Ofstead et al.
[10] noted that after routine use, almost all bron-
choscopes have visible defects in their channels,
including retained fluid; brown, red or oily residue;
scratches; damaged insertion tubes and distal ends;

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FIGURE 2. Initial steps in reprocessing. (a) Pre-cleaning, (b) Leak testing.
and filamentous debris in channels. These defects
harbour pathogens that have been implicated in
numerous outbreaks [15]. This has given rise to
borescopes, which are thin flexible inspection devi-
ces that can be used to examine the inner channels
of the endoscopes and have now been instituted for
use in some facilities. Implementation of this tech-
nology is limited given extensive training and time
required to bring technicians to competency. In
view of this, there are emerging data on utilization
of artificial intelligence and deep learning to iden-
tify endoscope working channel defects and resi-
&
dues [16 ]. Markers(analytes) and monitoring
systems to detect organic residues are also available.
If any defects are noticed on visual inspection, the
bronchoscope should be removed from circulation
immediately and sent back to the manufacturer
for repairs.
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TERMINAL REPROCESSING
As discussed above, for bronchoscopes, HLD is the
recommended minimum standard. In certain insti-
tutes, this step can be furthered by performing ster-
ilization. HLD is achieved by perfusing all channels
of the bronchoscope with high-level disinfectant/
chemical sterilant in such a manner that air pockets
are eliminated and there is contact of the germicide
with the material of the inner channel. This can be
carried out either manually or with the help of
automated endoscope reprocessors (AERs).
The surface is exposed for the time recom-
mended by the specified product. The FDA main-
tains a list of acceptable disinfectants/sterilants
along with their appropriate contact time at a given
temperature, which can be used for reprocessing
bronchoscopes [17]. Dilutions of chemical sterilants
can occur over time; commercial test kits are
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FIGURE 3. Automated endoscope reprocessors.
available to verify concentrations of these solutions
periodically. Biopsy instruments require steriliza-
tion, as they breach the mucous membrane and
come in contact with the blood stream. Rigid bron-
choscopy equipment also requires sterilization.
AERs may help solve some of the challenges
associated with manual reprocessing by standardiz-
ing and automating several manual steps in bron-
&&
choscope reprocessing [14 ]. This thereby reduces
the likelihood that essential steps may be skipped
and also the risk incurred by personnel by exposure
to high-level disinfectants and chemical sterilants.
However, AERs are not yet widely used and not all
bronchoscopes are compatible with these devices. It
is essential to check specific manufacturer recom-
mendations before utilizing AERs. Furthermore, suf-
ficient space to house these units, which require
water and ventilation is needed to ensure their
appropriate functioning, which may not be possible
in all bronchoscopy suites. When available, AERs
should be utilized to perform HLD (Fig. 3).
RINSING
This step involves rinsing the bronchoscope and all
its inner channels with water (sterile water or fil-
tered water as used in AERs) to get rid of the chem-
icals utilized in the prior step. Improper rinsing
leaves toxic residue in the channels of broncho-
scopes and has been implicated in patient injury
including anaphylaxis [8].
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DRYING
This step involves further rinsing of the insertion
channels and inner channels with alcohol and dry-
ing with forced air. A common issue that has been
identified as a potential cause for outbreaks is inad-
equate drying of endoscopes and their channels
prior to storage. This essential step, if not done
properly can lead to replication and survival of
remaining pathogens during storage [18,19]. As
such, there is no standardized definition of a ‘dry’
endoscope and a recent article called for endoscope
manufacturers and researchers to provide clear dry-
ing instructions and practical drying verification
&
tests [20 ]. Currently, this step is heterogeneously
practiced across institutions given the lack of
clear standards.
STORAGE
Reprocessed bronchoscopes are hung vertically for
storage (Fig. 4). Storing in such a manner helps pre-
vent recontamination and facilitates drying. Storage
should be done in accordance with manufacturer
instructions. Incidentally, professional societies such
as the Healthcare Infection Control Practices Advi-
sory Committee (HIPAC) and Association for the
Advancement of Medical Instruments (AAMI) also
offer storage recommendations. Cabinets with circu-
lating high efficiency particular absorbing (HEPA)
filtered air are considered superior to cabinets with
&
static air in preventing recontamination [20 ]. The
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FIGURE 4. Storage cabinets for reprocessed bronchoscopes. Bronchoscopes should be kept in an upright position. The
cabinets should be clean, dry and well ventilated. Shelf life should be strictly adhered to.
shelf life of reprocessed scopes before they require
another cycle of reprocessing ranges from 7 days to
12 weeks according to different professional societies
[21,22] (Fig. 4).
OTHER IMPORTANT CONSIDERATIONS
FOR FAILSAFE REPROCESSING AND
INFECTION PREVENTION
Water quality
The AAMI Technical Information Report 34 details
water quality standards suitable for effective reproc-
essing and highlights that at least two categories of
water may be needed: utility or tap water for the
initial steps of cleaning and flushing; and critical
water (extensively treated water) for the final step of
rinsing [23].
We want to emphasize at this point that it is
critical to follow manufacturer’s instructions for use
(IFUs) at each step. For example, Olympus America
mandates that the steps of precleaning, leak testing
and manual cleaning within 60 min of scope
removal to prevent biofilm formation (the so-called
‘dry out time’). If manual cleaning does not begin
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within 60 min of precleaning, the additional step of
prolonged soaking becomes necessary [24].
Documentation and quality assurance
measures
Good documentation is essential for quality assur-
ance and patient tracing in case of an outbreak of
infection related to bronchoscopy. Documentation
should include methods used for HLD/sterilization,
start and end time of manual reprocessing relative to
bronchoscopy end time, endoscope and patient
identifiers and details on maintenance and repair
&&
of endoscopes and reprocessing failures [25 ].
Reprocessing personnel should receive competency
testing at least on an annual basis and assessments
should be based on manufacturer’s IFU’s and spe-
cific reprocessing methods and chemicals utilized at
that particular centre [26].
Personal protective equipment use in
bronchoscopy
Bronchoscopy is an aerosol-generating procedure
and studies have demonstrated that healthcare
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Infection control in the bronchoscopy suite Chhabria et al.
professionals are exposed to ultrafine and respirable
aerosols for short durations during the procedure,
and there in an increased potential for contact trans-
mission [26]. This raised more concern during the
COVID-19 pandemic, which lead to revised guide-
lines on PPE use that are currently followed. The
Chest/AABIP 2020 consensus statement released in
2020 recommended utilizing gloves, gown, hair
protection, face shield/eye protection and N95 (or
equivalent) respirator for all bronchoscopies, regard-
less of the patient’s COVID-19 status [27].
SPECIAL CHARACTERISTICS OF
BRONCHOSCOPY SUITES
A recent article published by Abdelmalek et al. [28]
describes the ideal characteristics of a bronchoscopy
suite to enable well tolerated and efficient practices.
All bronchoscopy suites should be able to achieve
negative pressure ventilation and adhere to the
CDC’s definition of ‘Airborne Infections Isolation’
as maintained at the Cleveland Clinic [28].
Other considerations include the separation of
dirty areas (where initial cleaning and reprocessing
takes place) from clean areas (storage cabinets) to
enable a ‘one way workflow’, thereby preventing
cross contamination. The dirty areas should have
adequate space, water, plumbing, ventilation,
chemical storage space, eye wash stations and work
stations to handle the procedural volume of the
& 28:1081–1084.
centre [29 ].
DISPOSABLE BRONCHOSCOPES
Several single-use bronchoscope models are now
available, and their use can bypass the need for
effective reprocessing and infection transmission
concerns. These are safer in comparison to reusable
bronchoscopes in immunocompromised patients
[30]. However, cost analyses have determined that
reusable bronchoscopes are more cost-effective
especially at high-volume centres [31] Furthermore,
most advanced bronchoscopy procedures can only
be performed with reusable bronchoscopes.
CONCLUSION
All physicians take the Hippocratic oath upon inau-
guration into the medical profession, and one of the
cornerstones of this oath is ‘First, do no harm’. As an
extension of this oath, all bronchoscopists should be
well aware of the steps that encompass the herculean
task of reprocessing bronchoscopes to protect
patients from unnecessary harm. Effective broncho-
scope reprocessing should be emphasized in all bron-
choscopy units, and all personnel working there
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should be trained on how their roles and actions affect
infection transmission in the bronchoscopy suites.
Clear guidelines must be established in every centre,
and steps must be taken to ensure quality assurance
and prevent reprocessing failures.
Acknowledgements
The authors would like to thank Dr Louis Lam, Pulmo-
nary and Critical Care Staff Physician, Respiratory Insti-
tute, Cleveland Clinic for Figs. 2–4 included in this
article. Figure 1 is used with permission of Ofstead
and Associates, Inc. 2018.
Financial support and sponsorship
None.
Conflicts of interest
None.
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Volume 28  Number 00  Month 2022