Bronchoscopy in suspected severe acute respiratory syndrome-Coronavirus 2 pneumonia with atypical and indeterminate computed tomography presentation: indispensable or dispensable?

BACKGROUND: The final diagnosis of COVID-19 pneumonia relies on a clinical and radiological picture, along with SARS-CoV2 RNA detection in the oral and nasal-pharyngeal swab. The latter, has a high rate of false negative results, even in presence of symptoms and radiological abnormalities suggestive for COVID-19. In case of an atypical or indeterminate radiological pattern, the need of excluding COVID-19 and ruling out other differential diagnoses would be necessary. In such settings, the role of invasive procedures for obtaining samples from the lower respiratory tract such flexible bronchoscopy has been debated, due to the risk of contagion. The aim of this study was to evaluate the role of flexible bronchoscopy with bronchial washing during the pandemic of COVID-19. We aimed to define the value of bronchial washing in patients with an atypical or indeterminate chest CT-scan pattern for viral pneumonia. METHODS: We retrospectively reviewed patients with an atypical or indeterminate CT scan pattern for COVID-19 pneumonia and a negative test for SARS-CoV2 RNA on oral/nasal-pharyngeal swabs, who underwent bronchoscopy for bronchial washings to exclude or confirm the diagnosis of SARS-CoV2 pneumonia. RESULTS: Among the 44 patients included with an atypical or indeterminate chest CT-scan pattern for COVID-19 pneumonia, no SARS-CoV2 RNA was detected in the bronchial washing. CONCLUSIONS: The role of bronchoscopy in the diagnosis of COVID-19 pneumonia is negligible in indeterminate or atypical patterns on chest CT scan. However, we should not shy away from these invasive procedures in these profiles of cases to exclude bronchoscopically diagnosed differential diagnoses like other infections and non-infectious causes.