Pulmonary Procedures During the COVID-19 Pandemic: A Work Group Report of the AAAAI Asthma Diagnosis and Treatment (ADT) Interest Section

Abstract

The COVID-19 pandemic has placed increased demands on the ability to safely perform pulmonary procedures in keeping with Centers for Disease Control and Prevention (CDC), American Thoracic Society (ATS), and the Occupational Safety and Health Administration (OSHA) recommendations. Accordingly, the American Academy of Allergy, Asthma & Immunology (AAAAI) Asthma Diagnosis and Treatment convened this work group to offer guidance. The work group is composed of specialist practitioners from academic and both large and small practices. Individuals with special expertise were assigned sections on spirometry, fractional exhaled nitric oxide, nebulized treatments, and methacholine challenge. The work group met periodically to achieve consensus. This resulting document has recommendations for the allergy/asthma/immunology health care setting based on available evidence including reference documents from the CDC, ATS, and OSHA.

Keywords: COVID-19; FeNO (exhaled nitric oxide); Methacholine challenge; Nebulized medication; Pulmonary function testing; Pulmonary procedures; SARS-CoV-2; Spirometry.

Figure 1

Preprocedural testing such as NAAT, location, scheduling, cleaning procedure, and additional considerations are listed in the left-hand column with checks for these listed items under the procedure where they are indicated. ∗Consider waiving the COVID-19 NAAT preprocedure test if the patient and staff are fully vaccinated and boosted. Any risk is further mitigated if the local prevalence of the virus is low, and the patient is not demonstrating significant acute airway symptoms. ∗∗For example, 12 air exchanges/h will remove 99% of room air in 46 minutes; 6 air exchanges/h will remove 99.9% of room air in 69 minutes. FeNO, Fractional concentration of exhaled nitric oxide; HEPA, high-efficiency particle arrest; MDI, metered dose inhaler; NAAT, nucleic acid amplification test; PEF, peak expiratory flow.

Figure 2

The risk continuum for each factor (patient or community consideration) denoted is meant to be a relative assessment. Each column denotes patient or community factors that a clinician can consider when determining the relative risk for viral transmission before performing a pulmonary procedure. ∗Pulmonary procedure should be deferred if preprocedure symptoms/exposure screen is highly suggestive of COVID-19 or if NAAT is positive. ∗∗CDC-defined local transmission rates (new cases/100,000 persons in the last week): low 0 to 9.99, medium 10 to 49.99, substantial 50 to 99.99, and high ≥100. FeNO, Fractional concentration of exhaled nitric oxide; NAAT, nucleic acid amplification test.

Figure 3

Pulmonary procedure room modifications. (A) Pulmonary procedure room with anteroom allowing visual and intercom communication between the staff and patient with high-flow exhaust (exterior). (B) Pulmonary procedure room with anteroom allowing visual and intercom communication between the staff and patient with high-flow exhaust (interior). (C) Pulmonary procedure Plexiglas chamber in the examination room with high-flow exhaust. (D) Pulmonary procedure examination room with high-flow exhaust.

Figure 4

Metered dose inhaler with a single-use valved holding chamber. Example shown is: https://www.macgill.com/products/respiratory/peak-flow-meters-spacers/liteaire-dual-valved-holding-chamber.html. The arrow points to the valved holding chamber.

Figure 5

Nebulizer with a 1-way valve and expiratory filters.