Evaluate bronchoscopy patients for SARS

The Centers for Disease Control and Prevention (CDC) is advising providers to evaluate all bronchoscopy patients for severe acute respiratory syndrome (SARS). If you don’t, you could be at high risk for contracting the disease, which has killed 62 worldwide.

At press time, the World Health Organization reported that there were 1,804 SARS cases worldwide. In the United States, there are 85 cases under investigation, but no deaths, according to the CDC. At least two of the U.S. cases under investigation are health care workers, the CDC said.1 There were 129 probable or suspected cases of SARS in Canada, with four deaths, according to reports from Health Canada, the Canadian health department.2

The CDC doesn’t know to what extent all SARS patients are particularly infectious, but some appear to be "very highly infectious." said Julie Louise Gerberding, MD, MPH, director of the CDC and administrator of the Agency for Toxic Substances and Disease Registry. "For example, in Hanoi, there was one patient who was a source for health care worker transmission, and approximately 56% of the health care [workers] who had direct contact with the patient appeared to have acquired SARS," she said.1 Gerberding did not specify whether the patient had undergone bronchoscopy or another aerosol-generating procedure.

The cause of SARS is unknown and is being investigated. CDC officials believe that the major mode of transmission is through droplets spread when an infected person coughs or sneezes. However, agency officials are concerned about the possibility of airborne transmission across broader areas and the possibility that objects that become contaminated in the environment could serve as modes of transmission.1

At some Ontario hospitals, hundreds of health care workers were under voluntary self-isolation at press time. Due to lack of staff, as well as a desire to stop the spread of SARS, some hospitals were canceling elective surgery. "All Canadian cases have occurred in persons who have traveled to Asia or had contact with SARS cases in the household or in a health care setting," according to Health Canada.

During its U.S. investigation, the CDC received anecdotal reports that aerosol-generating procedures might have facilitated the transmission of SARS in some cases. Procedures that induce coughing can increase the likelihood that droplet nuclei are expelled into the air, the agency pointed out. The potentially aerosol-generating procedures include bronchoscopy, aerosolized medication treatments (such as albuterol), diagnostic sputum induction, airway suctioning, and endotracheal intubation.

"For this reason, health care personnel should ensure that patients have been evaluated for SARS before initiation of aerosol-generating procedures," the CDC said.3 Evaluation for SARS should be based on the most recent case definition for SARS, the agency says. At press time, a suspected case includes respiratory illness of unknown etiology with onset since Feb. 1, 2003, and the following criteria:

  • measured temperature > 100.5° F (>38° C);
  • And one or more clinical findings of respiratory illness (i.e., cough, shortness of breath, difficulty breathing, hypoxia, or radiographic findings of pneumonia or acute respiratory distress syndrome);
  • And travel within 10 days of onset of symptoms to area with documented or suspected community transmission of SARS [Peoples’ Republic of China (i.e., mainland China and Hong Kong Special Administrative Region); Hanoi; Vietnam; and Singapore. This list excludes areas with secondary cases limited to health care workers or direct household contacts.]
  • OR close contact within 10 days of onset of symptoms with a person with a respiratory illness who traveled to a SARS area or a person known to be a suspected SARS case. Close contact is defined as having cared for, having lived with, or having direct contact with respiratory secretions and/or body fluids of a patient known to be a suspected SARS case.4

In other words, be suspect of a patient with flu-like symptoms, a fever, AND who has traveled recently to Southeast Asia, says Joan Blanchard, RN, MSS, CNOR, CIC, perioperative nursing specialist at the Center for Nursing Practice at the Association of periOperative Registered Nurses (AORN) in Denver. "A patient with these symptoms would not be a candidate for surgery," she says. "If they did present to the ambulatory surgery center with these symptoms, and they had recently traveled to Southeast Asia, the nurse should speak to the physician. The surgery should be canceled."

Warning: Partly due to the broad criteria, the CDC cautions that most cases meeting criteria for SARS are expected to be unrelated to the current outbreak.5

References

1. Centers for Disease Control and Prevention. CDC Telebriefing Transcript SARS Update March 29, 2003. Web: www.cdc.gov/od/oc/media/transcripts/t030329.htm.

2. Health Canada. Update #16 — Severe Acute Respiratory Syndrome. Web: www.hc-sc.gc.ca/english/protection/warnings/2003/2003_11update16.htm.

3. Centers for Disease Control and Prevention. Infection Control Precautions for Aerosol-Generating Procedures on Patients Who Have Suspected Severe Acute Respiratory Syndrome (SARS). March 20, 2003. Web: www.cdc.gov/ncidod/sars/aerosolinfectioncontrol.htm.

4. Centers for Disease Control and Prevention. Severe Acute Respiratory Syndrome (SARS) Updated Interim Case Definition. Web: www.cdc.gov/ncidod/sars/casedefinition.htm. March 29, 2003.

5. Centers for Disease Control and Prevention. Outbreak of severe acute respiratory syndrome — Worldwide, 2003. MMWR 2003; 52:226-228. Web: www.cdc.gov/mmwr/preview/mmwrhtml/mm5211a5.htm.