In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff while reducing the risk of infection. COVID patients often suffer from respiratory insufficiency and increased intrapulmonal secretion. A bronchoscopy is one of the standard procedures for resolving respiratory tract obstruction in intensive care medicine. On the downside, this procedure has a high potential for producing aerosol formations due to disconnections of the ventilator tubes, which creates an increased risk of infection to the medical staff. The indications for a bronchoscopy should be limited to the absolute minimum. This video gives a guidance for reducing personal infection risk without neglecting patient safety when performing a bronchoscopy. 

The indications to perform a bronchoscopy must be very strict, i.e. to suction secretions, open atelectasis, or in situations of a blocked airway. It should not be used as a routine procedure in COVID-19 patients for diagnostic purposes or to collect samples.

1. All materials should be prepared and tested before entering the patient room.
2. Don personal protective gear (gown, cap, goggles, gloves) and additional gear for working with an open airway: FFP3 / N-95 mask, visor, second pair of gloves.
3. If possible, explain the process to the patient and obtain their consent.
4. Check the hemodynamic monitoring and activate the QRS-Sound of the monitor.
5. Pre-oxygenate with FiO₂ 1.0.
6. Adapt the ventilator parameters for the procedure (i.e. volume controlled ventilation), including the alarm settings.
7. Check the suction unit and connect a fingertip connector.
8. Place the bronchoscopy monitor on the opposite bedside to ensure a direct view towards the monitor.
9. Don sterile gowns and gloves and place a sterile covering on the patient. The procedure should be performed as aseptically as possible to avoid a bacterial pulmonary infection.
10. Prepare the needed materials and place them on the sterile area. Prepare the bronchoscope, connect the suction tube to the bronchoscope with a secretion trap between them, and fill three 20mL syringes with 0.9% NaCl over the minispike.
11. Induct or deepen the anaesthesia, and consider muscular relaxation.
12. STOP the whole team: Follow a 10 seconds for 10 minutes principle (discuss problems, opinions, facts, plan). 
13. Insert a bite blocker with double gloves and remove the outer pair of gloves after insertion.
14. Apply lubricant and anti-fogging agent to the bronchoscope.
15. Stop the ventilator and have the endotracheal tube held in place by an assistant.
16. Change to a bronchoscopy angle piece and insert the bronchoscope into the angle piece and breathing tube.
17. Start ventilation.
18. Advance the bronchoscope while orienting to the tracheal support rings and inspect both lungs one by one. Attention should be paid to contact vulnerability of the mucosa, secretions, and blood. If necessary, secretions can be mobilized and sucked to optimize the view.
19. To perform a bronchial lavage, insert 10mL of 0.9% NaCl into the deep respiratory tract and aspirate the lavage to a secretion trap for further diagnostics. The secretion trap has to be sealed and exchanged if more probes are required.
20. When finished with the examination, stop the ventilator.
21. Remove the bronchoscope and reattach the closed suction unit.
22. Check the connection of the ventilator tubes before starting the ventilation.
23. Start ventilation, perform a recruitment maneuver to reduce atelectasis, and adjust the ventilator settings.
24. Perform a lung sonography or chest x-ray to exclude complications like pneumothoraxes.
25. Dispose of the materials and get the specimen collectors ready for transfer to the laboratory for further diagnostics.