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Online Articles: Letters

Experience With Barrier Enclosure Device During Flexible Bronchoscopy

Sehgal, Inderpaul S. MD, DM; Dhooria, Sahajal MD, DM; Prasad, Kuruswamy T. MD, DM; Muthu, Valliappan MD, DM; Aggarwal, Ashutosh N. MD, DM; Agarwal, Ritesh MD, DM

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Journal of Bronchology & Interventional Pulmonology: April 2021 - Volume 28 - Issue 2 - p e26-e28
doi: 10.1097/LBR.0000000000000714
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To the Editor:

We read with interest the article “American Association for Bronchology and Interventional Pulmonology (AABIP) Statement on the Use of Bronchoscopy and Respiratory Specimen Collection in Patients with Suspected or Confirmed COVID-19 Infection” published in the Journal. Bronchoscopy, an aerosol generating procedure, places the operator at a high risk of infection by the type 2 severe acute respiratory syndrome coronavirus (SARS-CoV-2).1 In this regard, the recent AABIP guidelines on the safe performance of bronchoscopy during the coronavirus infectious disease-19 (COVID-19) pandemic are likely to be useful to the bronchoscopists worldwide.2 However, in a recent study involving critically ill COVID-19 patients who required bronchoscopy, one of the 2 bronchoscopists got infected despite using the personal protective equipment (PPE), as recommended in the AABIP guideline.3 To further decrease the operator risk, some authors have described placing a surgical mask over the patient’s mouth to reduce the dispersion of aerosols.4 However, this strategy hinders the provision of oxygen and suctioning of oral secretions, if needed, during the procedure. Although, a barrier enclosure device has been utilized for endotracheal intubation,5,6 operator experience with a dedicated device for performing bronchoscopy is lacking. Herein, we describe our initial experience with one such barrier device that can be used for safe performance of bronchoscopy.

The barrier device is a trapezium made of transparent plastic material that would cover the patients’ head. The enclosure device has one opening to allow passage of hand to hold the bronchoscope and another circular opening at the top through which the flexible bronchoscope can be passed (Fig. 1). In addition, the sides have one circular opening to facilitate provision of oxygen supplementation, oral suctioning, and chin lift (if required) during the procedure. The side holes can also be used to stabilize the bronchoscope while performing biopsy or transbronchial needle aspiration. The barrier device can be reused after high level disinfection. The box can be disinfected with either 1% sodium hypochlorite solution or 70% isopropyl alcohol or 70% ethyl alcohol followed by soap and water. The plastic flaps covering the holes are disposable and can be discarded after each patient.

Shows the barrier box with one square opening at the head end (height and width, 10 cm; A) for facilitating the operator to hold the bronchoscope freely and one circular opening (diameter, 10 cm; B) on each side for stabilizing the scope during sampling and for provision of oxygen supplementation. The length and the width of the box is 53 cm (C) and 48 cm (D), respectively. The height is 38 cm (E) and 50 cm (F) at the posterior (toward the operator) and anterior open end, respectively. The top of the box has a small circular aperture (5 cm, G) to allow passage of the bronchoscope. The position of the aperture on the top is 18 cm from the posterior (toward the operator) end of the box.

We have performed 27 bronchoscopies using the barrier box, both diagnostic and therapeutic (Table 1). While we have encountered minor difficulties, they tend to decrease with continued practice (Table 2, Fig. 2). In a previous report, aerosol generated during intubation could contaminate the floor and the monitor located >2 m away.5 The dispersion was limited to the inner surface of the barrier device when airway intubation was performed after enclosing the patient’s head in the barrier device.1 We believe that the barrier device should be used by the bronchoscopists in addition to the PPE recommended in the AABIP guidelines while performing bronchoscopy.

TABLE 1 - Preliminary Experience of Performing Bronchoscopy Using the Barrier Enclosure Device (n=27)
Age in years, mean±SD 46.5±16.6
Male sex 19
Basic diagnosis
 Malignancy 13
 Tuberculosis 6
 Sarcoidosis 2
 Chronic pulmonary aspergillosis 2
 Postintubation tracheal stenosis 3
 Interstitial lung disease 1
Procedures performed
 Airway inspection only 8
 Bronchoalveolar lavage 6
 Endobronchial biopsy 11
 Transbronchial lung biopsy 2
 Bronchial brushing 1
 Convex probe EBUS 7
 Laser 1
All the values are represented as numbers unless otherwise stated.
EBUS indicates endobronchial ultrasound.

TABLE 2 - Difficulties Encountered During Barrier Box Bronchoscopy and Suggested Solutions
Difficulty Solution
Initial difficulty in maneuvering the bronchoscope Improves with time. Practicing on a manikin can shorten the learning curve
Difficulty in negotiating the distal subsegments Raise the head of the patient by placing a flat pillow (Fig. 2)
Endotracheal intubation in case of impending respiratory arrest is not possible Remove the barrier box and intubate

Shows the patient in the barrier box without any head elevation (A). One can observe that the bronchoscope has no working length left for negotiation in subsegments (arrow in A). B, The same patient with the head elevated by means of a simple pillow. The bronchoscope now has increased working length (arrow in B) and can be easily negotiated in the subsegments.

Inderpaul S. Sehgal, MD, DM

Sahajal Dhooria, MD, DM

Kuruswamy T. Prasad, MD, DM

Valliappan Muthu, MD, DM

Ashutosh N. Aggarwal, MD, DM

Ritesh Agarwal, MD, DM
Department of Pulmonary Medicine Postgraduate Institute of Medical Education and Research, Chandigarh, India


1. Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020;382:1199–1207.
2. Wahidi MM, Lamb C, Murgu S, et al. American Association for Bronchology and Interventional Pulmonology (AABIP) Statement on the use of bronchoscopy and respiratory specimen collection in patients with suspected or confirmed COVID-19 Infection. J Bronchology Interv Pulmonol. 2020. DOI: 10.1097/LBR.0000000000000681. [In press].
3. Torrego A, Pajares V, Fernandez-Arias C, et al. Bronchoscopy in COVID-19 patients with Invasive mechanical ventilation: a center experience. Am J Respir Crit Care Med. 2020;202:284–287.
4. Steinfort DP, Herth FJF, Irving LB, et al. Safe performance of diagnostic bronchoscopy/EBUS during the SARS-CoV-2 pandemic. Respirology. 2020;25:703–708.
5. Canelli R, Connor CW, Gonzalez M, et al. Barrier enclosure during endotracheal intubation. N Engl J Med. 2020;382:1957–1958.
6. Sehgal IS, Yaddanapudi LN, Dhooria S, et al. Barrier protection during airway intubation. Indian J Crit Care Med. 2020;24:485–486.
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