Airway devices are instruments used to access, examine, and treat parts of respiratory system – nasal cavity, larynx, and bronchi. These instruments are used in emergency, outpatient, and inpatient settings to ensure airway patency and ventilation of the lungs, facilitate intubation, anaesthesia, clinical investigations, and treatments of different degrees of invasivity. Ear, nose, throat (ENT) scopes, laryngoscopes and bronchoscopes are examples of airway devices ranging from simple rigid mechanical implements to complex flexible instruments containing fibre optics, electronics, and internal channels. Traditionally airway devices are considered semi-critical according to Spaulding classification as they are supposed to come in contact with mucosal epithelium of the airways but not with sterile body tissues. In today’s healthcare airway devices are often used in invasive procedures involving examination of deep bronchi, breach of blood vessels, biopsies, and minor surgical interventions.

As estimated by the FDA up to 500,000 bronchoscopies are performed annually in the USA while it is assumed bronchoscopes are utilized in a million or more procedures per year1. In the UK up to 2.8 million patients receive general anaesthesia and maybe subject to intubation every year2. Number of nasal endoscopies done with the USA Medicare & Medicaid Services surpassed 500,000 in 2016 as annual procedure numbers increased by 9.3% over 15 years3.

Such large numbers of procedures involving airways are inevitably leading to infection transmission and infection outbreaks. First reports of bronchoscope-related infection transmission were published in 1978 just as bronchoscopy was introduced in routine clinical practice4. Since then, number of reports on infection or device contamination associated with reprocessed flexible bronchoscopes has been steadily growing and surpassed 200 in 20175.

Safe and efficient decontamination is the key factor in preventing infection transmission via airway devices. Single use bronchoscopes, ENT instruments and laryngoscopes as well as single use accessories are manufactured in controlled environment in line with international standards and terminally sterilized using Ethylene Oxide or irradiation. If stored and used in accordance with the manufacturers’ instructions risk of infection transmission via a single use device is extremely low. Reusable instruments are still widely used in airway procedures as they may be preferred by clinicians, are more environmentally friendly and are a cheaper option if compared with single use instruments9. However, recent research suggests that reusable bronchoscopes can on average cost more per procedure when costs of treating hospital infections are taken into account10.

In theory reprocessing of a reusable medical device is straightforward process which renders the device safe for subsequent patient use. In real life situations proper cleaning, disinfection and sterilization are tampered with by multiple challenges. Compliance with reprocessing guidelines and good decontamination outcome relies on instruments being processed without delays by competent, educated, properly supervised staff who understand risks of infection transmission, decontamination processes supported by adequate resources, and devices themselves being regularly serviced and properly maintained.  Staff shortages, insufficient resources, lack of training, lapses in instrument maintenance, careless attitude all create opportunities for microorganisms to survive decontamination by forming biofilms or by being protected by residual bioburden in case of inadequate or delayed cleaning. Several studies have shown that non-compliance with reprocessing guidelines may lead to endoscope-related health care-associated infections, but even compliant high level disinfection processes turned out inadequate in decontamination of flexible endoscopes resulting in infection transmission, injury and death14, 15, 16.