Highlight
Key points at a glance
In this prospective multicenter study from two German tertiary care centers, pulmonary endoscopy with reusable scopes generated a mean of 1479.7 g of waste per patient, with higher waste output for combined bronchoscopy plus endobronchial ultrasound (EBUS) than for bronchoscopy alone.
When extrapolated nationally, pulmonary endoscopies in Germany were estimated to generate 551.6 tons of waste per year, corresponding to approximately 270 tons of CO2 emissions.
Nearly three-quarters of all waste arose in the examination room, and 28.7% of the total waste stream was considered potentially recyclable, indicating that operational redesign rather than only reprocessing changes may yield the greatest gains.
Reusable gowns stood out as the most immediately actionable intervention, with the potential to reduce waste by 61.5% compared with disposable personal protective equipment. By contrast, replacing reusable bronchoscopes with single-use endoscopes would likely increase total per-procedure waste.
Background
Why bronchoscopy waste matters
Environmental sustainability is becoming an operational and ethical concern across medicine, and procedural specialties are increasingly under scrutiny because of their heavy reliance on packaging, single-use devices, and infection-control consumables. Endoscopy is a notable contributor. In pulmonary medicine, bronchoscopy and EBUS are indispensable for diagnosing lung cancer, staging mediastinal disease, evaluating infection, sampling peripheral lesions, and managing airway disorders. These procedures are clinically important, but their environmental footprint is rarely quantified with the same rigor applied to procedural outcomes or patient safety.
Waste from bronchoscopy is not limited to the bronchoscope itself. It accumulates across the entire care pathway: drapes, sterile packaging, suction systems, specimen containers, protective apparel, reprocessing materials, and post-procedure recovery supplies. This broader systems perspective is important because efforts to improve sustainability can fail if they focus too narrowly on one device category. For example, a disposable bronchoscope may reduce reprocessing steps but still increase overall solid waste.
Prior studies have suggested that a bronchoscopy procedure generates about 1.03 kg of waste on average, but the available evidence has been limited in size and geographic scope. The present study by Seeger and colleagues addresses a practical question with direct implications for hospital operations and national policy: how much waste do pulmonary endoscopic procedures generate in routine care using reusable scopes, where does that waste arise, and which interventions are likely to reduce it meaningfully in the German healthcare system?
Study Design
Design and setting
This was a prospective, multicenter observational study conducted over four weeks at each of two German tertiary care centers. The investigators collected, categorized, and weighed waste associated with pulmonary endoscopic procedures performed with reusable endoscopes.
Population and procedures
The analysis included 107 procedures in 79 patients. The procedures encompassed standalone bronchoscopy and combined bronchoscopy plus EBUS. Because EBUS typically requires additional accessories, sampling equipment, and often more complex procedural workflows, it is clinically plausible that it would carry a higher material burden than conventional bronchoscopy alone.
Waste assessment
Waste was prospectively collected and sorted by source and material type. The investigators also determined the proportion considered potentially recyclable. National waste production was then extrapolated using health insurance data, allowing the authors to move from center-level measurements to a health-system estimate.
Main outcomes
The primary outcomes were mean waste generation per patient and by procedure type. Secondary analyses examined the procedural locations where waste arose, the proportion potentially recyclable, and the modeled impact of alternative strategies, including the use of reusable gowns and the hypothetical substitution of single-use bronchoscopes.
Key Findings
Overall waste burden per patient
Across all measured pulmonary procedures, the mean waste generated was 1479.7 g per patient. This value is notably higher than earlier estimates around 1.03 kg per bronchoscopy, suggesting that prior work may have underestimated the total footprint or that local workflow differences meaningfully affect waste generation.
The increase also underscores an important methodological point: waste accounting can vary depending on whether investigators include only direct procedural consumables or also count reprocessing-related waste and post-procedure materials. The current study appears to have taken a broader and clinically realistic view of the care pathway.
Bronchoscopy alone versus bronchoscopy plus EBUS
Standalone bronchoscopy generated 1276.5 g of waste per procedure, while combined bronchoscopy plus EBUS generated 1849.7 g. The absolute difference of roughly 573 g is substantial. For centers performing large numbers of mediastinal staging procedures, this extra burden becomes operationally relevant.
Clinically, this finding is unsurprising. EBUS generally requires additional needles, sheath systems, packaging, specimen handling materials, and often more extensive preparation. The result does not argue against EBUS, which remains a high-value diagnostic and staging modality, but it does highlight the importance of targeting waste-reduction efforts toward the highest-intensity procedural pathways.
Where the waste comes from
The examination room accounted for 74.8% of total waste, making it by far the dominant source. Suction bags contributed 7.8%, while reprocessing and recovery areas together accounted for 17.4%.
This distribution carries practical significance. Discussions about reusable endoscopes often center on the environmental costs of reprocessing, but these data suggest that most waste is generated before reprocessing is even considered. In other words, the major opportunity may lie in procedure-room consumables, packaging, protective equipment, and workflow standardization rather than in the endoscope cleaning process alone.
National extrapolation
Using German health insurance data, the authors estimated that pulmonary endoscopies generate 551.6 tons of waste annually in Germany. This was associated with an estimated 270 tons of CO2 emissions. Although such extrapolations depend on assumptions about procedure volumes and representativeness, the numbers are large enough to establish pulmonary endoscopy as a meaningful contributor to healthcare-associated waste.
For hospital leaders and policymakers, this kind of estimate is particularly useful because it translates unit-level waste into a system-level signal. Sustainability efforts often struggle for attention when framed as small per-case changes. By contrast, hundreds of tons of waste per year are easier to incorporate into procurement, quality improvement, and environmental reporting strategies.
Recycling potential
Overall, 28.7% of the waste stream was considered potentially recyclable. This is an important but qualified finding. “Potentially recyclable” does not mean that the materials are actually recycled in current practice. In hospitals, recycling is constrained by contamination concerns, local regulations, waste segregation accuracy, and the downstream capabilities of waste contractors.
Still, a recyclable fraction approaching one-third suggests that current disposal practices may be missing a significant opportunity. Better segregation at the point of care, standardized bin placement, simplified staff instructions, and procurement choices that favor recyclable materials could all improve capture rates. Whether these measures are cost-effective will depend on local infrastructure, but the data support feasibility for targeted pilot programs.
Effect of reusable gowns
The most striking waste-reduction finding was that reusable gowns used as personal protective equipment could reduce waste by 61.5%, with statistical significance reported at p < 0.001. This is a very large effect size for a single operational change.
The appeal of this intervention is that it does not require a change in procedural indication, diagnostic strategy, or core equipment. It is an implementation and procurement decision. For infection prevention teams, however, the operational success of reusable gown systems depends on laundering logistics, local hygiene standards, staffing workflows, and cost accounting that includes the full life cycle rather than only purchase price. Even so, among the interventions examined in this study, reusable PPE appears to offer the clearest near-term benefit.
Single-use bronchoscopes would likely worsen waste generation
A clinically important aspect of the analysis was the modeled comparison with single-use endoscopes. If disposable bronchoscopes had been used instead, reprocessing waste would have been minimized, but overall waste would likely have increased. The authors estimated an additional 111.8 g of residual waste per procedure, representing a 16.0% increase, plus 15.1 g of paper waste, a 13.0% increase, and 1.1 g of plastic waste, a 0.5% increase.
This result is especially relevant because single-use bronchoscopes are increasingly adopted in selected settings, particularly intensive care, emergency airway management, infectious-risk scenarios, or when immediate scope availability is critical. The present findings do not negate those use cases. Instead, they caution against assuming that disposability is environmentally preferable simply because it avoids reprocessing. From a waste perspective, the opposite may be true.
Clinical and Operational Interpretation
What this means for respiratory practice
For pulmonologists and bronchoscopy unit directors, the study shifts the sustainability discussion from abstract concern to measurable process improvement. The main message is not that bronchoscopy is uniquely problematic, but that it is sufficiently material-intensive to justify targeted redesign. Three strategies appear most actionable.
First, procedural bundling may reduce repeated setup and duplicated consumables. If clinically appropriate, combining planned diagnostic tasks within one session could lower cumulative waste per patient compared with multiple separate encounters. This approach must remain patient-centered; it should not compromise safety or procedural quality simply to reduce material use.
Second, reusable protective equipment appears to be a high-yield intervention. Since examination-room waste dominated the total waste profile, changes in gowning and other room-based consumables may provide larger benefits than efforts focused solely on endoscope reprocessing.
Third, recycling infrastructure should be treated as a quality-improvement issue rather than an afterthought. A recyclable fraction of 28.7% suggests room for gains, especially if materials can be redesigned or purchased with end-of-life disposal in mind.
How this fits into the reusable versus disposable device debate
The broader literature on endoscopy and anesthesia has shown that environmental performance depends on life-cycle boundaries, local electricity mix, sterilization practices, transport, and waste management. In some contexts, single-use devices may offer infection-control or access advantages, but environmental superiority cannot be assumed. The present study strengthens the case that, at least for bronchoscopy in German tertiary-care practice, reusable scopes accompanied by optimized workflows are likely preferable from a waste standpoint.
That conclusion should still be interpreted with nuance. Waste mass is not identical to total environmental impact. A full life-cycle assessment would ideally include water use, energy consumption, detergent chemistry, manufacturing emissions, transportation, and disposal methods. A heavier waste stream may not always correspond to the highest carbon footprint, though in this study the authors also estimated CO2 implications at the national level. Even so, decisions about scope selection should integrate infection prevention, availability, repair burden, procedure volume, economics, and life-cycle analysis rather than waste weight alone.
Strengths and Limitations
Strengths
The study has several strengths. It was prospective, multicenter, and based on direct measurement rather than assumption-based modeling alone. It also evaluated the full procedural environment, including examination room, suction systems, reprocessing, and recovery, which provides a more complete picture than studies focused only on device disposal.
The national extrapolation adds policy relevance. Even if such estimates are approximate, they help bridge the gap between unit-level environmental audits and system-wide planning.
Limitations
Several limitations should temper interpretation. The study included only two tertiary care centers and 107 procedures, so representativeness may be limited. Waste profiles may differ in community hospitals, ambulatory settings, or centers with different bronchoscopy volumes, EBUS mix, or procurement systems.
The abstract does not provide confidence intervals for the main waste estimates, which limits precision assessment. It also does not detail the exact criteria used to classify materials as potentially recyclable, and these criteria may vary across jurisdictions.
In addition, the comparison with single-use endoscopes appears modeled rather than observed. Such modeling is useful, but its accuracy depends on assumptions about packaging, disposal, and workflow. Finally, waste mass is only one environmental metric. Comprehensive sustainability decisions would ideally be informed by life-cycle assessments and cost analyses.
Practice and Policy Implications
Immediate actions for bronchoscopy units
Bronchoscopy units can begin with waste mapping by procedure type, especially distinguishing routine bronchoscopy from bronchoscopy plus EBUS. Units should identify which consumables are opened but unused, which PPE items dominate trash volume, and whether waste segregation is intuitive for staff working under time pressure.
Procurement teams should consider reusable gowns where local infection-control standards and laundry capacity permit. Hospitals can also work with vendors to reduce packaging volume and improve material recyclability. Simple visual prompts at the point of disposal may increase proper sorting of paper, plastics, and residual waste.
Research priorities
Future studies should expand beyond waste weighing to full life-cycle environmental assessments comparing reusable and disposable bronchoscopy platforms in different clinical scenarios. Multicenter studies across outpatient and inpatient settings would improve generalizability. It would also be useful to examine whether sustainability interventions affect workflow, turnaround times, costs, or staff acceptance.
An especially important next step is integrating environmental metrics with value-based care. Procedures such as EBUS may generate more waste than simple bronchoscopy, but they often avert more invasive surgery or repeated diagnostic testing. The goal is not merely to minimize waste per procedure, but to optimize waste per clinically meaningful outcome.
Conclusion
This multicenter observational study provides one of the clearest quantitative estimates to date of waste generation during pulmonary endoscopy in routine German practice. The main finding is that bronchoscopy, particularly when combined with EBUS, produces substantial waste, most of it originating in the examination room rather than during reprocessing. At a national level, the cumulative burden is large enough to justify formal sustainability strategies.
The most compelling near-term intervention identified was the use of reusable gowns, which was associated with a major projected reduction in waste. Recycling also appears underused, with nearly one-third of the waste stream potentially recoverable under appropriate systems. In contrast, substituting single-use bronchoscopes for reusable instruments would likely increase per-procedure waste, reminding clinicians that convenience and infection-control simplification do not automatically translate into environmental benefit.
For respiratory medicine, the study reframes sustainability as a concrete quality-improvement domain. The practical message is straightforward: bronchoscopy services can reduce waste without compromising clinical care, but gains will require attention to the entire procedural ecosystem, from PPE and packaging to workflow design and disposal infrastructure.
Funding and ClinicalTrials.gov
The abstract and citation provided do not report funding information. A ClinicalTrials.gov registration number is not reported in the abstract.
References
Seeger A, Welsch L, Kim S, Antonow G, Zeuzem S, Hessz D, Kohlhäufl J, Rohde G, Maitra R, Baumhöfner C, Schmitt S, Heide A, Eickhoff A, Friedrich-Rust M, Michael FA. Cutting waste in bronchoscopy – a multicenter observational study in the German healthcare system. Chest. 2026-06-05. PMID: 42250587. Available at: https://pubmed.ncbi.nlm.nih.gov/42250587/
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