Barrier enclosure device: One size does not fit all.

Sir,

We read with interest the correspondence by Thangakunam and Christopher about the use of barrier devices during bronchoscopy,[1] where they reference our article.[2] Our article was regarding the barrier enclosure device during patient preparation, which is not the focus of what Thangakunam and Christopher are trying to discuss. However, it provides an opportunity to discuss the role of such barrier devices in the era of COVID-19. The authors emphasize the need for a larger trial before adopting a change in practice regarding the use of a barrier device for performing bronchoscopy.[1] The authors also refer to a simulation study where the authors demonstrated higher airborne particles at 300 s with the aerosol box use.[3] They cite another study, which increased the time to airway intubation.[4]

We have described three different barrier devices, each specifically designed to perform airway intubation,[5] patient preparation before bronchoscopy,[2] and for performing bronchoscopy.[6] Each of these devices was modified to facilitate the ease of performing a specific procedure, ensuring the protection of the operator and the equipment. While designing the barrier device for performing bronchoscopy, we had three objectives: operator safety, equipment safety, and patient comfort. For the ease of bronchoscopic procedures, we made the circular holes in the device's posterior aspect (through which the operator inserts his/her hands) as oblong. Also, to prevent damage to the bronchoscope, we used cushioning around the circumference of the aperture used for inserting the bronchoscope through the barrier device. The height of the barrier device was designed to adjust for the height of the thoracic cage so as not to compromise the reach of the bronchoscope to the lower lobe segments. We made side holes for the bronchoscopy assistant's safety, to avoid direct exposure to the aerosol jet, if the patient coughed during the procedure. We kept the front of the barrier box open, which improves patient comfort and avoids claustrophobia. The front open system also provides the path of least resistance for the airborne particles, thereby moving the aerosol jet away from the operator.

Thus far, we have performed 323 bronchoscopic procedures [Table 1], including 71 endobronchial ultrasound procedures. We have also performed bronchoscopy in three patients with COVID-19. None of our health-care workers involved in the bronchoscopy suite have tested positive for COVID-19 antibodies. Notably, at the time of reporting, we have not encountered any damage to our equipment. Also, none of our patients reported any feeling of claustrophobia. In our experience, we have found that the enclosure device works as intended. However, more evidence from other centers is required for the widespread use of such enclosure devices.

Table 1

Our experience of performing bronchoscopy using the barrier enclosure device (n=323)

Parameters	Value
Age (years), mean±SD	47.5±16.8
Sex
Male	217
Basic diagnosis
Malignancy	126
Tuberculosis	34
Sarcoidosis	30
Chronic pulmonary	90
Aspergillosis
Postintubation tracheal	11
Stenosis
Nonresolving pneumonia	15
Hemoptysis	11
Peri-operative assessment	5
Interstitial lung disease	1
Procedures performed
Airway inspection only	8
Bronchoalveolar lavage	89
Endobronchial biopsy	99
Transbronchial lung biopsy	40
Bronchial brushing	1
Conventional TBNA	14
Convex probe EBUS	71
Laser	1

All the values are represented as numbers unless otherwise stated. EBUS: Endobronchial ultrasound, TBNA: Transbronchial needle aspiration, SD: Standard deviation

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.