Safety of Bronchoscopist-Directed Propofol Infusion During Endobronchial Ultrasound Bronchoscopy

Abstract

SESSION TITLE: Interventional Pulmonology SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Propofol is an effective option for providing moderate sedation during bronchoscopy. However, in the United States its use with procedural sedation is often restricted to anesthesiologists due to concerns for potential cardiorespiratory compromise. Our objective was to demonstrate the safety of propofol infusion when administered under the direction of the bronchoscopist for a complex bronchoscopy such as endobronchial ultrasound (EBUS). METHODS: This was a retrospective analysis of prospectively defined and collected data from 171 consecutive patients who received curvilinear and/or radial EBUS-guided sampling under moderate sedation. We used a bronchoscopist-directed propofol infusion protocol that we had previously shown to be effective for maintaining moderate sedation during EBUS. All bronchoscopies were performed in a routine procedure suite via the transoral route, and without an airway adjunct. Sedation level and vital signs were checked and recorded at regular intervals. Criteria defining complications related to oversedation (cardiovascular and respiratory compromise) and undersedation (hypertension and agitation-related procedure delay) were prospectively characterized. Their incidence and duration were recorded. RESULTS: Of the 171 bronchoscopies, 113 utilized curvilinear EBUS only, 28 radial EBUS only, and 30 both modalities. 71% were performed by a supervised trainee. Mean bronchoscopy duration was 50.0 minutes, allowing collection of an average 11.9 samples from 2.4 lesions. Mean total propofol dose was 4.3 mg/kg/hr, and fentanyl 1.44 mcg/kg/hr. Sedation level was checked on average every 4.7 minutes. Deep sedation was reached in 100 patients (58%), and represented 20% of total bronchoscopy time. Cardiorespiratory compromise occurred in 19% of patients overall, and in 23% of patients who reached deep sedation at least once (p=0.2). These episodes lasted four minutes on average, and occupied only 1.4% of total bronchoscopy time and 4.7% of deep sedation time. Fourteen patients (8%) required saline bolus for hypotension. Five patients (3%) required a jaw-thrust maneuver for upper airway obstruction, and two patients (1%) required brief bag-mask ventilation for hypoventilation. None of the patients required vasopressors or an advanced airway due to oversedation. Ten patients (6%) became hypertensive during bronchoscopy, and two (1%) required antihypertensive medication. Agitation-related procedure delays occupied only 1.4% of total bronchoscopy time. Predefined sampling goals were achieved in 95% of patients. CONCLUSIONS: Bronchoscopist-directed propofol infusion for EBUS bronchoscopy appears to be very safe in experienced hands when administered by protocol. In this setting, clinically significant cardiorespiratory compromise is infrequent, of short duration, and easily managed with routine maneuvers and infusion adjustments. The need for advanced artificial airways and vasopressor support seems to be exceptionally rare. Propofol infusion is well tolerated by patients, and agitation-related procedure delays are uncommon. CLINICAL IMPLICATIONS: Sedation-related safety concerns alone should not dissuade experienced bronchoscopists from using propofol infusion without an anesthesiologist for EBUS bronchoscopy. DISCLOSURE: The following authors have nothing to disclose: Ara Chrissian, Avi Cohen No Product/Research Disclosure Information