To the Editor:
We read the article “Experience With the Use of Single-Use Disposable Bronchoscope in the ICU in a Tertiary Referral Center of Singapore” with interest.1 The authors have retrospectively compared the utility of a single-use disposable bronchoscope with standard video-bronchoscope for various procedures in ICU like percutaneous tracheostomy, collection of specimen for microbiological evaluation, bronchial toilet, hemoptysis, and intubation. The authors found that microbiological yield and cost of the procedure was similar between both techniques with significant difference in median interval between identification of need to start of the procedure (10 vs. 66 min; P=0.01) and less number of personnel required for disposable bronchoscopic procedure.
The cost of any reusable bronchoscope comprises 3 components; first, cost of purchasing the equipment, second, cost of maintenance and repair, and third, cost of processing and storage. In the present study, authors have compared only standard video-bronchoscope with single-use disposable bronchoscope and did not compare with fiberoptic bronchoscope. In spite of doing this, there was no significant difference in the cost per procedure among both. If fiberoptic bronchoscope is used instead of standard video-bronchoscope, the cost per procedure would be low as it has lower maintenance cost, less personnel are required to transport and handling of the system and it takes lesser time to install.
Most of the damages to reusable bronchoscopes are because of poor handling by untrained staff that can be prevented. Choure et al2 reported that 69% of damage to the bronchoscopes were preventable that lead to repairing cost of $49 per procedure. This can be overcome by adequate training of the staff and physicians about handling of the equipment. Untrained physicians should be trained using single-use disposable bronchoscopes as improper handling of equipment by physicians in training results in greater maintenance and repair cost.3
Furthermore, data derived from the studies which have compared single-use disposable bronchoscopes with conventional video-bronchoscope were limited either to certain countries or even to a hospital setting. Applicability of data derived from these studies to a wider extent is limited because of variation in pricing of bronchoscopes and cost of manpower across countries. Thus cost-effectiveness needs to be studied in different countries and centers.
Although single-use bronchoscope carries advantage of no risk of cross-transmission of infection and readily availability for use, institutes where higher load of bronchoscopic procedures, the cost of the procedure is significantly low. Various studies derives this break-even point at which cost of both procedures would be same and reported to be >200 per year.4,5 So institutions which are performing <200 bronchoscopies a year, single-use disposable bronchoscope should be primarily used as cost-effective measure whereas use of single-use and reusable bronchoscope should be combined in institutions where >200 procedures per year are performed. Edenharter et al6 proposed a mathematical model to develop decision support tool for optimal mix of single-use and reusable bronchoscope in ICU setting.
In present day scenario, disposable bronchoscopes are need of the hour for various procedures in ICU for the prevention of cross-contamination. Careful selection of such patients is required to optimize resource utilization, particularly in resource constraint settings.
Ashok Kuwal, MD*
Naveen Dutt, MD†
*Pacific Institute of Medical Sciences, Udaipur
†All India Institute of Medical Sciences Jodhpur, Rajasthan, India
1. Marshall DC, Dagaonkar RS, Yeow C, et al. Experience with the use of single-use disposable bronchoscope in the ICU in a Tertiary Referral Center of Singapore. J Bronchol Interv Pulmonol. 2017;24:136–143.
2. Choure AJ, Manali ED, Krizmanich G, et al. High price of bronchoscopy: cost of maintenance and repair of flexible bronchoscopes. J Bronchol Interv Pulmonol. 2005;12:147–150.
3. Gupta D, Wang H. Cost-effectiveness analysis of flexible optical scopes for tracheal intubation: a descriptive comparative study of reusable and single-use scopes. J Clin Anesth. 2011;23:632–635.
4. Tvede MF, Kristensen MS, Nyhus-Andreasen M. A cost analysis of reusable and disposable flexible optical scopes for intubation. Acta Anaesthesiol Scand. 2012;56:577–584.
5. McCahon RA, Whynes DK. Cost comparison of re-usable and single-use fibrescopes in a large English teaching hospital. Anaesthesia. 2015;70:699–706.
6. Edenharter GM, Gartner D, Pförringer D. Decision support for the capacity management of bronchoscopy devices: optimizing the cost-efficient mix of reusable and single-use devices through mathematical modeling. Anesth Analg. 2017;124:1963–1967.