Abstract
ObjectivesThere are safety issues associated with propofol use for flexible bronchoscopy (FB). The bispectral index (BIS) correlates well with the level of consciousness. The aim of this study was to show that BIS-guided propofol infusion is safe and may provide better sedation, benefiting the patients and bronchoscopists.MethodsAfter administering alfentanil bolus, 500 patients were randomized to either propofol infusion titrated to a BIS level of 65-75 (study group) or incremental midazolam bolus based on clinical judgment to achieve moderate sedation. The primary endpoint was safety, while the secondary endpoints were recovery time, patient tolerance, and cooperation.ResultsThe proportion of patients with hypoxemia or hypotensive events were not different in the 2 groups (study vs. control groups: 39.9% vs. 35.7%, p = 0.340; 7.4% vs. 4.4%, p = 0.159, respectively). The mean lowest blood pressure was lower in the study group. Logistic regression revealed male gender, higher American Society of Anesthesiologists physical status, and electrocautery were associated with hypoxemia, whereas lower propofol dose for induction was associated with hypotension in the study group. The study group had better global tolerance (p<0.001), less procedural interference by movement or cough (13.6% vs. 36.1%, p<0.001; 30.0% vs. 44.2%, p = 0.001, respectively), and shorter time to orientation and ambulation (11.7±10.2 min vs. 29.7±26.8 min, p<0.001; 30.0±18.2 min vs. 55.7±40.6 min, p<0.001, respectively) compared to the control group.ConclusionsBIS-guided propofol infusion combined with alfentanil for FB sedation provides excellent patient tolerance, with fast recovery and less procedure interference.Trial RegistrationClinicalTrials. gov NCT00789815
Highlights
Patients undergoing flexible bronchoscopy (FB) experience procedure-related symptoms [1]
The mean duration of FB was 25 min, and the proportion of patients with hypotension or hypoxemia, as well as the lowest SpO2 value was similar in both groups (Table 1 and Figure 2)
Logistic regression revealed that male gender, higher American Society of Anesthesiologists (ASA) physical status, and electrocautery were associated with hypoxemia and lower induction doses of propofol were associated with hypotension in the study group (Table 2)
Summary
Patients undergoing flexible bronchoscopy (FB) experience procedure-related symptoms [1]. Benzodiazepines (i.e., midazolam) plus an opioid is the most common combination used to improve patient tolerance and satisfaction [2,3]. Current guidelines recommend incremental midazolam sedation to all patients undergoing FB, except when there are contraindications [4]. The required dose varies, and its prolonged effect delays patient recovery [5]. A bolus of midazolam is often administered when patients suffer from procedure related discomfort that interferes with bronchoscopic procedures. Sedation with intermittent propofol (2,6-diisopropylphenol) bolus has shown to provide good tolerance and fast recovery in patients undergoing FB [6,7,8]. Adding opioids may provide antitussive effects and modify the pharmacokinetics of propofol, which reduces the required propofol dose [9,11,12]. Controversy about combining propofol and opioids persists because of the risk of over-sedation and cardiopulmonary depression [16,17]
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