Consent was obtained from patients or their surrogates for bronchoscopic procedures. Bronchoscopic BAL was performed in intubated ICU patients with flexible, single-use Ambu aScope (Ambu) devices. Patients were given sedation and topical anesthetic at the physician proceduralist’s discretion. Vital signs were monitored continuously throughout the procedure. The bronchoscope was wedged in the segment of interest based on available chest imaging or intra-procedure observations, aliquots of 30 ml of normal saline at a time, generally 90–120 ml total, were instilled and aspirated back. The fluid returned following the first aliquot was routinely discarded. Samples were split (if sufficient return volume was available) and sent for clinical studies and an aliquot reserved for research. A similar procedure was applied to non-bronchoscopic BAL (NBBAL); however, NBBAL was performed with directional (lateral) but not visual guidance, and as usual procedural care by a respiratory therapist rather than a pulmonologist44.

For bronchoscopies performed in COVID-19 patients, additional precautions were taken to minimize the risk to healthcare workers including only having essential providers present in the room, clamping of the endotracheal tube, transient disconnection of the inspiratory limb from the ventilator, and preloading of the bronchoscope through the adapter48. Sedation and neuromuscular blockade to prevent cough, was administered for these procedures at the physician’s discretion. In most cases of early bronchoscopy, the procedure was performed immediately after intubation, taking advantage of neuromuscular blockade administered for the intubation procedure.

For all patients with COVID-19, samples were collected from regions of greatest chest radiograph abnormality by a critical care physician using a disposable bronchoscope. The majority of samples prior to the pandemic were collected by respiratory therapists using a non-bronchoscopic bronchoalveolar lavage (NBBAL) catheter that is the same diameter as a standard bronchoscope with the catheter directed to the most radiographically affected lung. For both bronchoscopic and NBBAL, the recommended instillate volume was 120 ml and the initial aliquot was discarded if adequate return was obtained44.

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