American Journal of Environmental Protection
2018; 7(4): 55-62
http://www.sciencepublishinggroup.com/j/ajep
doi: 10.11648/j.ajep.20180704.11
ISSN: 2328-5680 (Print); ISSN: 2328-5699 (Online)

Comparative Study on Environmental Impacts of Reusable
and Single-Use Bronchoscopes
Birgitte Lilholt Sørensen, Henrik Grüttner
Centre for Life Cycle Engineering, University of Southern Denmark, Odense, Denmark

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To cite this article:
Birgitte Lilholt Sørensen, Henrik Grüttner. Comparative Study on Environmental Impacts of Reusable and Single-Use Bronchoscopes.
American Journal of Environmental Protection. Vol. 7, No. 4, 2018, pp. 55-62. doi: 10.11648/j.ajep.20180704.11
Received: August 17, 2018; Accepted: October 19, 2018; Published: November 15, 2018

Abstract: The introduction of single-use alternatives has stressed the need for environmental comparisons between reusable
and single-use devises in the healthcare sector. Discarding of single-use devices intuitively causes concern among staff in
hospitals, other users and people with environmental concerns as to whether the single use is environmentally friendly. This
study aims to compare carbon dioxide (CO2)-equivalent emissions and resource consumption from a single-use bronchoscope(Ambu® aScopeTM 4) to a reusable flexible bronchoscope. The comparison is made using a simplified life-cycle-assessment
methodology. The analysis shows that the materials used for the cleaning operations of the reusable scopes are a key factor
affecting the impact factors assessed; energy consumption, emission of CO2-equivalent and consumption of scarce resources.
Initially, it is assumed that each reusable scope is cleaned using one set of personal protective equipment (PPE) per cleaning
operation, but since cleaning practice may vary the consequence of cleaning more scopes with one set of PPE is also assessed.
Using one set of protective wear per operation and the materials for cleaning and disinfection determine that reusable scopes
have comparable or higher material and energy consumption as well as higher emissions of CO2-equivalents and values ofresource consumption. Cleaning two or more reusable scopes per set of PPE makes the impacts fairly comparable. Other
aspects that may impact the results are also assessed, including energy consumption for washing and drying units, differencesin use of PPE and differences in the disposal of PPE or single-use scopes. As the three assessed parameters are highly
dependent on cleaning procedures and the use of protective equipment, it cannot be concluded from these results which type of
bronchoscope affects the environmental factors investigated here the most.

Keywords: Flexible Bronchoscopy, Single-Use Versus Reusable, Energy, Carbon Footprint, Scarce Resources

1. Introduction
The United Nations Sustainable Development Goals [1]aim to provide a framework for the challenges that needcollaborative and joint focus from governments, the private
sector, civil society and people. These challenges include
some important global environmental factors. One challenge
is to take urgent action to combat climate change and its
impacts, partly as a result of emissions of carbon dioxide(CO2) and other greenhouse gases resulting from the use offossil fuels [2]. Another challenge is ensuring responsible
consumption and production due to the increasing scarcity ofresources because of the exploitation of known reserves in
the production of, for example, electronics and othercommodities [3].
The consumption of miscellaneous devices causes various

environmental impacts originating from the use of resources,
energy use from production and the use of devices. Impacts
originating from the use of devices may apply to different
sectors, for example, the medical sector [4]. The
consumption of scarce resources is usually related to
manufacturing of devices, while CO2 emissions usually relate
to the use of fossil fuels for production, transport and use of
the product [5].
Fortunately, concern for the environment has also entered
the healthcare sector. Hence, there is a need to be able tounderstand the contributors and map the impacts, whencomparing diverse ways to perform the same operation.
Recent studies have compared greenhouse gas emissions
calculated as CO2-equivalent emissions for reusable andsingle-use ureteroscopes [6], environmental impacts ofsingle-use versus reusable scissors [7] and single-use versus

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Birgitte Lilholt Sørensen and Henrik Grüttner: Comparative Study on Environmental
Impacts of Reusable and Single-Use Bronchoscopes

reusable anaesthetic equipment [8].
The introduction of single-use alternatives has stressed theneed for such environmental comparisons [9]. Discarding of
single-use devices intuitively causes concern among staff in
hospitals, other users and people with environmental
concerns as to whether the single use is environmentallyfriendly [4]. Disposable products were originally intended for
exceptional circumstances or conditions where proper
disinfection cannot be guaranteed, for example, during wars,
disasters and epidemics [10, 11].
Furthermore, concerns over patient safety have led to theintroduction of high disinfection standards and procedures
replacing simple sterilisation. Specialised functions in
hospitals clean and disinfect reusable devices [12-14]. Suchdevelopments have naturally led to an increase in the use of
personal protective equipment (PPE) and specialised cleaningand disinfection equipment, which have increased theenvironmental burden [8].
Consequently, and due to increasing labour costs, capitalcosts, repair costs and energy requirements, single-use
devices have become the preferred choice for many choicesof equipment use, e. g. anaesthetic equipment [8, 10, 12-14].
It is necessary to consider the cleaning and disinfection of
reusable devices, and the impacts of disposal of single-use
devices, to give a complete comparison of single-use devices
and reusable devices. In this context, it seems that theapplication of a life-cycle-assessment (LCA) approach –sometimes called the cradle to grave approach – is gaining
popularity within the healthcare sector [6, 9, 11].

In this study, the motivation to perform an environmental
comparison originates from the fact that a Danish medical
company Ambu A/S has developed a single-use flexible
device for bronchoscopy: the Ambu® aScopeTM 4 broncho. A
challenge is an intuitive reaction from users that it is wrong
to discard a functional device.
FORCE Technology performed during 2017 end-of-life
profiles for an Ambu ® aScopeTM 4 broncho depending on the
different disposal procedures around the world [15]. Used
bronchoscopes may be landfilled, incinerated or sent formaterial recycling. Countries that incinerate waste andinclude energy recovery have the lowest impact. The second
most crucial factor to reduce impacts is the amount ofrecycled paper and cardboard packaging used and the option
for recycling these. The present study builds on this but aims
for comparison with reusable bronchoscopes (RBs).

2. Goal and Scope
The present study aims to evaluate the CO2-equivalentemissions and resource consumption from using a single-use
bronchoscope such as the Ambu® aScopeTM 4 broncho
compared to those for the materials used to clean flexible
RBs. The assessment compares:(1) the use and disposal of one Ambu® aScopeTM 4
broncho with
(2) the cleaning and sterilisation of one conventional RB,
including the miscellaneous consumables needed for
personal protection.

Figure 1. The reference system for RBs compared to the system for the Ambu ® aScopeTM 4 broncho.

American Journal of Environmental Protection 2018; 7(4): 55-62

Figure 1 illustrates the compared systems. The reference
system includes the use of RBs until discarding them. Aftercleaning, an RB must be brought from a washer to adryer/storage cabinet [16] in a clean environment with theoperator wearing one set of protective equipment such as anapron, protective shoes, gloves, etc. (see table 1). After using
the RBs many times (number of times unknown) they are
discarded. The materials contributions and their end-of life
fate is not considered in this assessment.
Single-use bronchoscopes are assumed to be used similarly
to the RBs, then discarded afterwards. The analysis does notinclude manufacturing of the screen needed to use theAmbu® aScopeTM 4 broncho, nor the materials andmanufacturing of the RB.
The approach here is similar to that using the ISO
14040/44 standards for LCA. It is, however, not fullycompliant with the standards as the LCA technique has beenused to produce information on only part of the lifecycle for
the RBs. It is outside the scope of this study to conduct a fullanalysis, the scope here is to compare the use and end of life
for possible learnings.

3. Methods
The comparison has been made using the simplified LCA
methodology prepared for the Danish Ministry ofEnvironment [17]. This methodology assesses the ‘embodied
energy’ of the materials included in a product or cleaning
operation, and the additional energy used to manufacture anduse the product. Additionally, the methodology assesses thepotential embodied energy recovered by recycling of thematerials at end-of-life or the energy recovered byincineration of the product at end-of-life.
Analogously, the methodology assesses the emission ofgreenhouse gases as CO2-equivalents and the number ofscarce resources expressed as the commercial value of the
scarce resources (expressed in DKK ~ 0.15$). A resource isscarce when the supply horizon is less than 100 years [18].
The assessment approach is simplified, compared to‘conventional’ LCA, in the sense that the results are limited
to focus on only two impact categories. Here, we only
include greenhouse gas emissions (as CO2-equivalents) andthe loss of scarce resources.
The described setup corresponds to the European market
scenarios described by [15]. The end-of-life fate included inthis analysis assumes recycling of all recyclable materials
and incineration with energy recovery of auxiliary materials.
In section 6.4 the consequence of handling the end-of-lifematerials in a system without incineration.

57

4. Data
Ambu A/S collected the data used for the analysis ofcleaning and disinfection of RBs. The monitoring ofmaterials included in the analysis for cleaning a RB was
based on current practice at Rigshospitalet, the University
Hospital of Copenhagen, Denmark. The procedure here iscomparable to that of the American National Standards
ST91: 2015 Flexible and semirigid endoscope processing in
health care facilities prepared by the Association for the
Advancement of Medical Instrumentation [16].
Rigshospitalet collected samples of the materials used forprotective wear. We tracked the reprocessing procedure of a RB
and materials collected versus the above-mentioned standard.
The procedure, as well as the material used for the process,complied with [16] and current practice at Rigshospitalet.
Weighing of the materials was done on a Mettler Toledo
PG5002-S Delta Range with a resolution of 10 mg.
Section 4.6.1 of [16] describes the requirements related toattire when minimising the risk of cross-contamination
between RBs and contamination from the environment.
Section 4.6.2 describes the PPE intended to protect personnel
from pathogens and detergents. Attire and PPE are assumed
changed between each reprocessing cycle and when movingfrom the decontaminated area to the clean area, thus implying
one change of attire and PPE per RB complies with current
practice at Rigshospitalet.
Sections 5.5 and 5.6 of [16] describe the equipment
utilised during manual cleaning and manual rinsing,respectively.
In this analysis, the use of three disinfectant wipes was
included, in agreement with current practices at
Rigshospitalet and those of [19].
The selection of detergents depends on the manufacturer
instructions for use; included here is 40 ml of Sekusept forpre-cleaning and as an intercept detergent (Rapicide A and B)
for use in the automated bronchoscope reprocessor.
The use of isopropyl alcohol 70% is included in current
practice at Rigshospitalet for disinfection and isrecommended by the Standards of Infection Control in
Reprocessing of Flexible Gastrointestinal Endoscopes [19].
The materials used and the composition of the protective
gear used for reprocessing the RB are shown in table 1. SDU
Life Cycle Engineering determined the material compositionof the brushes used for cleaning. The metal compounds were
determined using X-ray fluorescence, and the polymers were
measured using Fourier transform infrared/attenuated totalreflectance spectroscopy.

Table 1. Material composition and amounts of protective gear and washing agents for RBs. The main components giving the basis of the simplified calculationof impacts are shown in bold.
Material

AmountWeight perunit(g)Total weight(g)

The fate of materials after
end-of-life

Polypropylene, latex-free elastic

2

2.99

5.98

Incinerated – heat value credited

PPE:
Bouffant hair covers

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Birgitte Lilholt Sørensen and Henrik Grüttner: Comparative Study on Environmental
Impacts of Reusable and Single-Use Bronchoscopes

2

Weight perunit(g)7.98

Total weight
(g)
15.96

The fate of materials after
end-of-life
Incinerated – heat value credited

2

70.74

141.48

Incinerated – heat value credited

3

10.95

32.85

Incinerated – heat value credited

2

7.74

15.48

Incinerated – heat value credited

2

6.27

12.54

Incinerated – heat value credited

3

4.23

12.69

Same

Transport container liner

Polyether
Low-Density Polyethylen, Polyethylene,
fluff, non-woven
Polypropylene, polyethylene, cellulose

1

58.14

58.14

Same

Port/valve brush**

Stainless steel

1

0.3

0.3

Incinerated – lost as ash

Polypropylene

1

2.71

2.71

Incinerated – heat value credited

Stainless steel

1

3

3

Incinerated – lost as ash

Polypropylene

1

3

3

Incinerated – heat value credited

Polyethylene, polypropylene

2

16.64

33.28

Same
Discharged to wastewater
treatment – only impacts ofproduction considered
Same

Material

AmountExamination gloves

Polypropylene, cellulosic fibre, polyester
Polypropylene non-woven, laminated with
polyethylene, Nylon
Latex

Shoe covers

LDPE

Pop-up face shields
Gown, long sleeves

Materials for cleaning:
Lint-free cloth
Disinfectant wipes

Channel brush**
Syringe
Isopropyl alcohol 70%

10*

Sekusept

40 ml

40*

*) Estimated by SDU Life Cycle Engineering. **) Composition measured by SDU Life Cycle Engineering.

Date for consumptions for washing and drying of RBs originates from data sheets for the cleaning systems from threedifferent suppliers [20-22]. The resulting average consumptions used can be found in table 2.
Table 2. Average energy consumption for washing and drying of RB.
Duration of operation (min)Energy use of equipment (W)Total energy consumption per operation (kWh)Washing

20

400

0.13

Drying

120

130

0.26

Ambu A/s provided the data on material composition and amounts for the Ambu ® aScopeTM 4 broncho [15] summarised intable 3. Around 96% of the product is plastic. The remainder comprises different metals. The packaging consists of plastic,
paper and cardboard.
Table 3. The overall composition of an Ambu ® aScopeTM 4 broncho.
Materials

Weight (g)Fate of materials at end-of-life

Plastic in product

146.0

Incinerated – heat value credited

Metal in product

5.6

Incinerated – lost as ash

Plastic in the inner packaging

43.8

Incinerated – heat value credited

Paper and cardboard in inner packaging

0.1

Incinerated – heat value credited

Plastic in the outer packaging

2.4

Recycled – credited as such

Paper and cardboard in outer packaging

148.7

Recycled – credited as such

Total

346.6

The current assessment assumes that the typical disposal
pattern for disposal of the single-use bronchoscopes isincineration together with the inner packaging due to hygiene
requirements. The consequence is that the heat value of theplastic and paper/cardboard will be credited in theassessment. The metals will be lost in the ash.

5. Results
Figure 2 presents the results for the two options assessed.
The results for RBs base on only one bronchoscope being
cleaned per cleaning operation and thereby using one set of
PPE per RB.

American Journal of Environmental Protection 2018; 7(4): 55-62

59

Figure 2. Contributions from the different life-cycle-stages to the three
impact categories. Please note that the graphs compare one single-use scopewith one cleaning operation. See text for further explanation.

6. Discussion
Several assumptions and specific factors may affect theresults and comparisons presented in figures 3, 4 and 5.
Below the most important factors are discussed.
It is important to note that the boundary conditions statedlimit the focus of the assessment to the use and disposal
stages. The exclusion of the manufacturing and disposal of
the RBs means that the assessment of this option is fairly
conservative.
6.1. Different Standards for Cleaning and Disinfection
There are several standards for cleaning and disinfection ofRBs. The basic assumption in this study is that the staff doing
the cleaning and disinfection follow the procedure strictly
stated in [16].
There might also be several practical adaptations andmodifications of the recommended procedures. An obvious
modification may be not to change the PPE for each RB
cleaned but keep it on for a small number of RBs. Using a
different approach to that described by the standard andused as a basic assumption in this assessment will affect the
net consumption/emission/loss, as illustrated in figures 3
and 4.

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Birgitte Lilholt Sørensen and Henrik Grüttner: Comparative Study on Environmental
Impacts of Reusable and Single-Use Bronchoscopes

Table 4. Comparison of the consumption of PPE for cleaning andsterilisation of one RB.
PPEThis study

Bouffant hair covers
Pop-up face shields
Drop down face shield
Surgical mask
Examination gloves (pairs)
Extended-cuff gloves (pairs)
Gown, long sleeves
Shoe covers

2
2

3
2
2

Ofstead (2017) [24]
Min.
Max.
2
2
2
2
2
4
7
1
1
2
2
2
2

The table clearly illustrates that some variations in thetypes and amount of PPE is to be expected. The amount of
PPE used as the basis for this study is less than [24] andhence is expected to be a conservative assumption.
According to [16] one change in attire and PPE is likely to
be conservative as pre-cleaning is carried out by cleaning
staff at the site, where the bronchoscopy procedure isconducted, suggesting an additional change of attire and PPE.
6.3. Different Equipment for Cleaning and Disinfection

Figure 3. Results for the number of RBs handled per cleaning operation.
Ambu ® aScopeTM 4 broncho red line and cleaning of scopes blue curve,
orange dotted line corresponds to [23].

Figure 4. Scarce resources in DKK related to the number of RBs handled
per cleaning operation. Ambu ® aScopeTM 4 broncho red line and RB andcleaning blue curve, orange dotted line corresponds to [23].

6.2. Different Uses of PPE
Different adaptations of the standard might also mean adifferent use of PPE during the cleaning and disinfection
procedures and thereby use of different amounts of PPE.
Table 4 compares the consumption of PPE in this study withthe findings of Ofstead [24].

Another factor relates to the different equipment applied
for cleaning and disinfection of RBs. Hence the consumptionof energy for performing operations may differ between
different equipment manufacturers.
The detailed calculations show the consumption of energy
for washing and drying of the RBs is relatively low (3.5 MJ)
compared to the total reprocessing operation (47 MJ).
Energy used for washing and drying RBs may also beaffected by the fact that the RBs are often kept in the dryers
for longer than the two hours assumed here, and sometimes
rewashing is required when the RBs have been stored longer
than accepted by the standard.

Figure 5. Energy consumption related to the number of RBs handled per
cleaning operation. Ambu ® aScopeTM 4 broncho red line and cleaning of
bronchoscopes blue curve, orange dotted line corresponds to [23]. The purple
line corresponds to low energy consumption for washing and drying, and thegreen line shows high energy consumption for washing and drying of RBs.

The impact of the energy used for washing and drying isfurther assessed as illustrated in figure 5. Figure 5 shows theenergy consumptions for two more extra scenarios. They

American Journal of Environmental Protection 2018; 7(4): 55-62

have been calculated based on either five times lower energy
consumption for washing and drying, or five times higher
energy consumption than the typical situation.
The high energy consumption might happen if the drying
cupboard runs at maximum capacity for 10 hours per scope
instead of two hours as assumed in the typical situation. If so
the total energy consumption increases to 56 MJ for RBs.
Similarly, assuming a potential saving of energy used fordrying of the scopes, the total energy consumption decreases
to 42 MJ (figure 5).
If the RBs have been stored for more than 72 hours,
washing and drying need to be repeated. If so, it will result ina higher energy consumption per bronchoscope. The ratio ofrewashing per procedure may be between 1 and 2. The extra
energy used for rewashing and drying a RB can, therefore, be
understood as already included in the interval shown infigure 5.
6.4. Different Waste Treatment Scenarios

61

The end-of-life impact assessment performed by FORCE
Technology [15] for the Ambu ® aScopeTM 4 broncho
considers different scenarios for the fate of materials from thebronchoscopes depending on where in the world the products
are used and discarded. The same segregation will be
relevant for the materials and protective wear from cleaningand disinfection of the RBs.
The tables 1 and 3 describe the fate of the materials. The
fates described in this study correspond to the European
market scenarios described by FORCE Technology 2017[15], and the results of this study are comparable to theirresults. Other studies have found optional incineration withenergy recovery and recycling to be significant, whenassessing the options for waste treatment, for example,
recycling [8].
The main differences between the end-of-life scenarios
relate to whether incineration with energy recovery isavailable in the different regions. Table 5 highlights thecrediting from incineration and recycling.

Table 5. Data for crediting from incineration and recycling.

Ambu ® aScopeTM 4 broncho
Energy (MJ)
CO2-equivalent emissions
Scarce resources
Reusable bronchoscope
Energy (MJ)
CO2-equivalent emissions
Scarce resources

Net impacts

Crediting from incineration%

Crediting from recycling
%

23
1.6
2.1

1.4
-0.34
0.07

6%
-21%
3%

4.3
0.014
0.000008

19%
1%
~0%

43.8
2.9
2.7

3.54
-0.76
0.17

8%
-26%
6%

0
0
0

0%
0%
0%

The table shows that the Ambu® aScopeTM 4 broncho,
gives a credit of 6% energy when incinerated but adds anextra 21% emission of CO2-equivalents. Because theincineration substitutes other fossil fuels, it also gives a creditof 3% scarce resources. The numbers are similar for the RB.
The consequence for regions where incineration with energy
recovery is not available is that the energy consumption will
be 6% higher, the CO2-equivalent emissions will be 21%
lower, and the consumption of scarce resources will be 3%
higher for the aScope. In the same way, the numbers can beinterpreted for RBs.
Recycling of the packaging materials from the Ambu ®
aScopeTM 4 broncho gives nearly 20% crediting of energy
and 1% crediting for CO2-equivalent emissions. Because thematerials come from renewable resources, the crediting ofscarce resources are insignificant. Due to the assumption, thatnone of the PPE or auxiliary materials used for the cleaningof RBs is recycled, there will be no crediting to consider.

7. Conclusion
From the above discussion, environmental assessment of
the reuse option is far more complex than an assessment of
the single-use option; furthermore, production of themultiple-use system is not included in this study. The
challenge of defining the typical or average procedure forcleaning and sterilisation is obvious. Furthermore, the use ofdiverse types of PPE may vary significantly, and the various
PPE used may have significantly different environmental
impacts due to the varying material composition.
Investigation of these hidden environmental impacts – andcosts – is an important challenge for the future, as also
pointed out by [24], if the comparison of upcoming singleuse devices to existing complex multiple-use options is to be
carried out.
The end-of-life scheme will have a significant impact on
the results, but as single-use devices and single-use PPE will
follow the same disposal route, it will have a limited impact
on the comparison.
Presented here is a case of how such a comparison
between a single-use device and multiple-use systems may
look. It will hopefully contribute to the continuous
development of such assessments.
The analysis shows that the materials used for the cleaning
operation are substantial when comparing the two types ofbronchoscopes. It is clear from this simple and limited
analysis, on embodied energy, CO2-equivalent emissions andvalue of scarce resources, that if RBs are cleaned using one
set of PPE per cleaning operation per bronchoscope, thematerial consumptions are significant. The use of cleaningmaterials and PPE determines that RBs have comparable orhigher material and energy consumption as well as emissions

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Birgitte Lilholt Sørensen and Henrik Grüttner: Comparative Study on Environmental
Impacts of Reusable and Single-Use Bronchoscopesof CO2-equivalents and value of resource consumption toAmbu® aScopeTM 4 bronchoscopes. It must be emphasisedthat the result of the assessment highly depends on the use of
PPE and the cleaning procedures applied for the RBs.
Hopefully, this study can contribute to establishing a moreneutral approach to the assessment and comparison of singleuse versus multiple-use options in the healthcare sector. Even
though it does not intuitively seem right to discard a fully
functional device, although, it may make sense if cleaningand disinfection are sufficiently complex and resource
consuming.

Competing Interests
This study has been funded and by Ambu a/s. The authors
have no competing interests.

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