End Of Bronchoscopy Research Articles

Randomized single-blind comparative study of the midazolam/pethidine combination and midazolam alone during bronchoscopy

BackgroundBronchoscopy can be a distress for the patient. There have been few studies on the combination of sedatives and opioids. The aim of this study was to demonstrate the usefulness and safety of administration of the combination of midazolam and pethidine during bronchoscopy.MethodsIn this prospective randomized single (patient)-blind study, we randomly assigned 100 patients who were scheduled to undergo bronchoscopy biopsy to receive treatment with either the midazolam/pethidine combination (combination group) or midazolam alone (midazolam group) during examinations. After the end of bronchoscopy, patients completed a questionnaire and the visual analogue scale was measured. The primary outcome was the patients’ acceptance of re-examination assessed by visual analogue scale. We also assessed pain levels, vital signs, midazolam use, xylocaine use, and adverse events. Univariate analyses were performed using Fisher’s exact test for categorical data, and the t-test or Mann-Whitney test was carried out for analysis of numeric data. All P-values were two-sided, and values < 0.05 were considered statistically significant.ResultsWe analyzed 47 patients in the combination group and 49 patients in the midazolam group. The primary outcome was a good trend in the combination group, but not significantly different (3.82 ± 2.3 in combination group versus 4.17 ± 2.75 in midazolam alone, P = 0.400). In the combination group, the visual analog scale score for pain during bronchoscopy was significantly lower (1.10 ± 1.88 versus 2.13 ± 2.42, P = 0.022), and the sedation level score per the modified observer’s assessment of alertness/sedation scale was significantly deeper (3.49 ± 0.98 versus 3.94 ± 1.03, P = 0.031). Maximal systolic blood pressure during testing was significantly lower (162.39 ± 23.45 mmHg versus 178.24 ± 30.24 mmHg, P = 0.005), and the number of additional administrations of midazolam was significantly lower (2.06 ± 1.45 versus 2.63 ± 1.35, P = 0.049). There were also significantly fewer adverse events (30 versus 41, P = 0.036).ConclusionsThe combination uses of midazolam and pethidine for sedation resulted in significant improvements in the pain, blood pressure, additional use of midazolam, and safety during bronchoscopy among patients.Trial registrationThis study was registered in the University Medical Hospital Information Network in Japan (UMINCTR Registration number: UMIN000032230, Registered: 13/April/2018).

High-flow nasal cannula for reducing hypoxemic events in patients undergoing bronchoscopy: A systematic review and meta-analysis of randomized trials.

Patients undergoing bronchoscopic procedures may develop hypoxemia and severe complications. High-flow nasal cannula (HFNC) may prevent hypoxemic events during bronchoscopy. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the effectiveness of HFNC in these patients. We conducted a search in PubMed, Embase, and the Cochrane Library for RCTs published before November 2021. Individual effect sizes were standardized, and a meta-analysis was performed to calculate the pooled effect size using random-effects models. The primary outcome was the incidence of hypoxemic events (oxygen saturation [SpO2] < 90%) during bronchoscopy. Secondary outcomes included the incidence of interrupted bronchoscopy due to desaturation, lowest SpO2 during bronchoscopy, partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), end-tidal CO2 (EtCO2) at the end of bronchoscopy, and the incidence of intubation after the procedure. Five trials involving 257 patients were reviewed. The incidence of hypoxemic events was lower in the HFNC group than in the conventional oxygen therapy group (risk ratio, 0.25; 95% confidence interval [CI], 0.14-0.42). The lowest SpO2 during the procedure was significantly higher in the HFNC group than in the conventional oxygen therapy group (weighted mean difference [WMD], 7.12; 95% CI, 5.39-8.84). PaO2 at the end of the procedure was significantly higher in the HFNC group than in the conventional oxygen therapy group (WMD, 20.36; 95% CI, 0.30-40.42). The incidence of interrupted bronchoscopy due to desaturation, PaCO2 and EtCO2 at the end of the procedure, and the incidence of intubation after the procedure were not significantly different between groups. HFNC may reduce the incidence of hypoxemic events and improve oxygenation in patients undergoing bronchoscopy.

Comparison of Inhaled Anesthesia with Sevoflurane and Intravenous Anesthetics with Propofol in Children under Flexible Bronchoscopy

Objective : Bronchoscopy is a diagnostic procedure. Due to lack of cooperation of children, pediatric bronchoscopy is necessarily accompanied by anesthesia. The most prevailing method of anesthesia in children is inhaled anesthesia, but since duration of anesthesia is long and there is involuntary respiration in this method, the amount of dispersed gas is high. The objective of this review is comparing inhaled anesthesia with sevoflurane and intravenous anesthetics with propofol in children under flexible bronchoscopy, in order to do a more appropriate and safe bronchoscopy and also to improve recovery after general anesthesia in children. Methodology : 80 children under the age of 10 who were going under flexible bronchoscopy, were randomly divided into two groups of 40 individuals. For anesthesia of one group inhaled sevoflurane was given, and for the second group intravenous propofol was given; then in both groups changes in blood pressure, heart rate, O2 saturation t, and recovery time were recorded and compared. Findings : There is no significant difference in three times measurement of both anesthetics. In other words the average blood pressure shows no difference after anesthesia, start of bronchoscopy, and end of bronchoscopy in both anesthetics (P-value=0.771). Moreover, no significant difference was observed in three times measurement of both anesthetics. This means that the average heart rate shows no difference after anesthesia, start of bronchoscopy, and end of bronchoscopy in both anesthetics. Furthermore, the average o2sat is different after anesthesia, start of bronchoscopy, and end of bronchoscopy in both anesthetics (P-value>0.001).

Safety and Efficacy of Remimazolam Compared With Placebo and Midazolam for Moderate Sedation During Bronchoscopy

While the complexity of flexible bronchoscopy has increased, standard options for moderate sedation medications have not changed in three decades. There is a need to improve moderate sedation while maintaining safety. Remimazolam was developed to address shortcomings of current sedation strategies. A prospective, double-blind, randomized, multicenter, parallel group trial was performed at 30 US sites. The efficacy and safety of remimazolam for sedation during flexible bronchoscopy were compared with placebo and open-label midazolam. The success rates were 80.6%in the remimazolam arm, 4.8%in the placebo arm (P< .0001), and 32.9%in the midazolam arm. Bronchoscopy was started sooner in the remimazolam arm (mean, 6.4 ± 5.82 min) compared with placebo (17.2 ± 4.15 min; P< .0001) and midazolam (16.3 ± 8.60 min). Time to full alertness after the end of bronchoscopy was significantly shorter in patients treated with remimazolam (median, 6.0 min; 95%CI, 5.2-7.1) compared with those treated with placebo (13.6 min; 95%CI, 8.1-24.0; P= .0001) and midazolam (12.0 min; 95%CI, 5.0-15.0). Remimazolam registered superior restoration of neuropsychiatric function compared with placebo and midazolam. Safety was comparable among all three arms, and 5.6%of the patients in the remimazolam group had serious treatment-emergent adverse events as compared with 6.8%in the placebo group. Remimazolam administered under the supervision of a pulmonologist was effective and safe for moderate sedation during flexible bronchoscopy. In an exploratory analysis, it demonstrated a shorter onset of action and faster neuropsychiatric recovery than midazolam.

Efficacy of dexmedetomidine combined with target-controlled infusion of propofol and remifentanil for fiberoptic bronchoscopy in elderly patients

Objective To investigate the efficacy of dexmedetomidine combined with target-controlled infusion (TCI) of propofol and remifentanil for fiberoptic bronchoscopy in the elderly patients.Methods Forty ASA Ⅱ or Ⅲ patients,aged 65-75 yr,with body mass index of 20-30 kg/m2,scheduled for elective fiberoptic bronchoscopy,were randomly divided into 2 groups (n =20 each):control group (group C) and dexmedetomidine group (group D).In group D,a loading dose of dexmedetomidine 0.5/μg/kg was injected at 10 min before induction of anesthesia,followed by infusion at 0.5 μg· kg-1 · h-1 until the end of fiberoptic bronchoscopy.While the equal volume of normal saline was given instead in group C.Anesthesia was induced with TCI of propofol and remifentanil.The target effect-site concentration (Ce) of propofol was 3 μg/ml.When the plasma concentration and Ce were balanced,TCI of remifentanil (target Ce 4 ng/ml) was started.The fiberoptic bronchoscope was placed after consciousness was lost and then the Ces of propofol and remifentanil were adjusted to 1-3 μg/ml and 2-4 ng/ml,respectively.MAP,HR and OAA/S score were recorded before induction (T0),immediately after induction (T1),when the tip of fiberoptic bronchoscope reached the glottis (T2) and carina (T3),at the end of bronchoscopy (T4)and 10 min after the end of bronchoscopy (T5).The consumption of propofol and remifentanil,duration of bron-choscopy,emergence time,adverse cardiovascular events and side effects such as hyoxemia,nausea and vomiting,regurgitation and aspiration were recorded.Results Compared with group C,OAA/S score at T5 and the consumption of propofol and remifentanil was reduced,and emergence time was shortened,and the incidence of hypotension and hyoxemia was decreased in group D (P ＜ 0.05).No patients developed side effects such as hyoxemia,nausea and vomiting,regurgitation and aspiration in both groups.Conclusion Dexmedetomidine (infusion at 0.5 μg·kg-1 ·h-1 after a loading dose of 0.5 μg/kg) combined with TCI of propofol and remifentanil can be safely and effectively used for fiberoptic bronchoscopy in the elderly patients. Key words: Dexmedetomidine ; Propofol; Piperidines ; Drug delivery systems; Bronchoscopy

High-Flow Nasal Interface Improves Oxygenation in Patients Undergoing Bronchoscopy

During bronchoscopy hypoxemia is commonly found and oxygen supply can be delivered by interfaces fed with high gas flows. Recently, the high-flow nasal cannula (HFNC) has been introduced for oxygen therapy in adults, but they have not been used so far during bronchoscopy in adults. Forty-five patients were randomly assigned to 3 groups receiving oxygen: 40 L/min through a Venturi mask (V40, N = 15), nasal cannula (N40, N = 15), and 60 L/min through a nasal cannula (N60, N = 15) during bronchoscopy. Gas exchange and circulatory variables were sampled before (FiO2 = 0.21), at the end of bronchoscopy (FiO2 = 0.5), and thereafter (V40, FiO2 = 0.35). In 8 healthy volunteers oxygen was randomly delivered according to V40, N40, and N60 settings, and airway pressure was measured. At the end of bronchoscopy, N60 presented higher PaO2, PaO2/FiO2, and SpO2 than V40 and N40 that did not differ between them. In the volunteers (N60) median airway pressure amounted to 3.6 cmH2O. Under a flow rate of 40 L/min both the Venturi mask and HFNC behaved similarly, but nasal cannula associated with a 60 L/min flow produced the better results, thus indicating its use in mild respiratory dysfunctions.

Changes on QT, Qtc and P Dispersion during Flexible Bronchoscopy under Propofol and 12121 Remifentanil Sedation. A Double-Blind Randomized Trial

Background: Serious hemodynamic alterations have been shown during flexible fiberoptic bronchoscopy (FFB). QT and P wave dispersion (QTd, Pd) may give us an significant information about cardiac status during FFB. This study aimed to compare the effect of propofol and remifentanil sedation on QTd, corrected QT dispersion (QTcd) and Pd during FFB. Method: Forty-nine ASA class I or II patients who were not pre-medicated were selected and allocated to receive either propofol 1 mg/kg (n=20) or remifentanil 1 µg/kg (n=20) and titrated to achieve Ramsey sedation score level of 5. QTd, QTcd and Pd were measured on electrocardiography baseline (T0), at the end of the infusion of drugs (T1), shortly after laryngoscopy (T2), at the end of bronchoscopy (T3) and the time of Modified Aldrete score to be achived 10 (T4) Heart rate, mean arterial pressure, respiratory rate and partial CO2 pressure in blood gas were recorded at these time points. Furthermore, recovery times (RT) were recorded Results: QTd at all measurement times, corrected QTd at T1 and T2, P dispersion at T1, T2 and T3 increased significantly in the propofol group compared to remifentanil group (p<0.05). Mean arterial pressure increased signifi cantly in the propofol group compared to the remifentanil group at T2 (p<0.05). There was a significant decrease in respiratory rate at T1 and T3 in the remifentanil group (p<0.05). There were no significant differences in heart rate and partial CO2 pressure between groups. RT was shorter in the remifentanil group (p<0.05). Conclusion: Remifentanil shortened and propofol prolonged QTd, QTcd and Pd at sedative doses during FFB. Also we obtained the short RT with remifentanil. So remifentanil may be more suitable sedative agent during FFB.

Fiber optic bronchoscopy in patients with acute hypoxemic respiratory failure requiring noninvasive ventilation - a feasibility study

IntroductionNoninvasive ventilation (NIV) is a standard procedure in selected patients with acute respiratory failure. Previous studies have used noninvasive ventilation to ensure adequate gas exchange during fiberoptic bronchoscopy in spontaneously breathing hypoxemic patients, thus avoiding endotracheal intubation. However, it is unknown whether bronchoscopy can be performed safely in patients with acute hypoxemic respiratory failure already in need of NIV prior to the decision for bronchoscopy.MethodsWe prospectively investigated 40 consecutive, critically ill, adult patients with acute hypoxemic respiratory failure (14 women, 26 men, age 61 ± 15 years, partial pressure for oxygen/fraction of inspired oxygen (PaO2/FiO2) < 300 under noninvasive ventilation, Simplified Acute Physiology scores (SAPS II) 47 ± 9.9 points). All patients required noninvasive ventilation prior to the decision to perform bronchoscopy (median 10.5 h; range 2.2 to 114). Blood gases, heart rate, blood pressure and ventilation were monitored before, during and up to 120 minutes after bronchoscopy.ResultsBronchoscopy could be completed in all patients without subsequent complications. Oxygen saturation fell to < 90% in two patients (5%), and the lowest value during the procedure was 84%. The mean PaO2/FiO2 ratio improved from 176 ± 54 at baseline to 240 ± 130 (P < 0.001) at the end of bronchoscopy and 210 ± 79 after 120 minutes. The transient mean partial pressure of carbon dioxide in the arterial blood (PaCO2) increase was 9.4 ± 8.1 mm Hg. Four patients (10%) required endotracheal intubation during the first eight hours after the procedure. Bronchoalveolar lavage yielded diagnostic information in 26 of 38 (68%) patients.ConclusionsIn critically ill patients with acute hypoxemic respiratory failure requiring noninvasive ventilation, bronchoscopy can be performed with an acceptable risk. Since these patients per se have a high likelihood of subsequent endotracheal intubation due to failure of NIV, bronchoscopy should only be performed by experienced clinicians.

Measurement of combined oximetry and cutaneous capnography during flexible bronchoscopy

The aim of the present study was to assess the feasibility of measuring combined arterial oxygen saturation measured by pulse oximetry (Sp,O2) and cutaneous carbon dioxide tension (Pc,CO2) to monitor ventilation and quantify change in Pc,CO2 during bronchoscopy. Combined Sp,O2 and Pc,CO2 were measured at the ear lobe in 114 patients. In four patients, the ear-clip slipped and they were excluded. In total, 11 patients had artefacts with Sp,O2 recordings, thus, Sp,O2 was analysed in 99 patients. Spirometry data were available in 77 patients. Multivariate analysis of covariance and logistic regression were used for statistical analyses. Mean baseline Pc,CO2 was 4.78+/-1.06 kPa (36+/-8 mmHg) and mean rise in the Pc,CO2 during bronchoscopy was 1.26+/-0.70 kPa (9.5+/-5.3 mmHg), while mean Pc,CO2 at the end of bronchoscopy was 5.85+/-1.19 kPa (44+/-9 mmHg) . Baseline Pc,CO2 and the lowest Sp,O2 were significantly associated with peak Pc,CO2 and the change in Pc,CO2 during bronchoscopy. Risk of significant hypoxaemia (Sp,O2<or=90%) was lower for a higher baseline Sp,O2. Peak Pc,CO2 was directly associated with significant hypoxaemia. There was no significant association in the baseline Pc,CO2, peak Pc,CO2, baseline Sp,O2 or the lowest Sp,O2 comparing patients with and without chronic obstructive pulmonary disease. In conclusion, it is feasible to measure combined pulse oximetry and cutaneous carbon dioxide tension effectively to monitor ventilation during flexible bronchoscopy.

The effects of remifentanil on haemodynamic stability during rigid bronchoscopy

We examined the effect of remifentanil on the haemodynamic response to rigid bronchoscopy in 22 adult ASA 2-4 patients, randomly allocated to receive 1.0 microg.kg-1 remifentanil over 1 min followed by 0.5 microg.kg-1.min-1 (remifentanil group) or 2.0 microg.kg-1 fentanyl followed by a saline infusion (control group). Following the initial infusion, all patients received a sleep dose of propofol followed by rocuronium 0.6 mg.kg-1 and their lungs were ventilated using a Sander's injector attached to the rigid bronchoscope. Direct arterial blood pressures, heart rate and ST segment changes on the CM5 lead configuration of the electrocardiograph were measured at 1-min intervals from before induction of anaesthesia until the end of bronchoscopy. Arterial pressures and heart rate were similar in the two groups before and after induction of anaesthesia. Remifentanil attenuated the haemodynamic response to bronchoscopy (p < 0.05 for increases in arterial pressures and heart rate). Four patients in the remifentanil group had ST segment depression compared with eight patients in the control group, but this was not statistically significant.

Bronchoalveolar lavage causes decrease in PaO 2, increase in ( A-α) gradient value and bronchoconstriction in asthmatics

The aims of this study were to (1) record the changes of (arterial oxygen partial pressure) PaO 2, (arterial carbon dioxide partial pressure) PaCO 2, (percentage saturation of haemoglobin with oxygen in arterial blood) SaO 2 and alveolar-arterial ( A-α) oxygen gradiant resulting from bronchoalveolar lavage (BAL) in asthmatic and normal subjects; (2) measure changes in forced expiratory volume in 1s (FEV 1), vital capacity forced (FVC) associated with BAL; and (3) assess possible predictive factors for the degree of hypoxaemia and impairment of spirometry resulting from BAL. Bronchoscopy and BAL (150 ml) were performed in 24 asthmatics and 15 healthy subjects. Serial arterial blood samples (radial artery) were obtained in all subjects: T 1 and before T 2 after local anaesthesia; T 3 at end of bronchoscopy; T 4 after BAL and 5 min, 15 min, 1 h, 2 h, 8 h and 24 h (T 5–T 10) after the procedure, FEV 1 and FVC were measured immediately before and 5 min afer bronchoscopy. Baseline PaO 2 was lower in asthmatics (10·2 ± 0· kPa) than in healthy subjects (10·8 ± 0·8). Both groups showed a significant decrease in PaO 2, and a significant widening in ( A-a) oxygen tension gradiant at T 3–9, with respect to T 1 ( P<0·05). PaO 2 reached a significantly lower value in asthmatics (7·1 ± 0·6 kPa) than in HS (7·7 ± 0·5; P<0·05). In asthmatics, FEV 1, FVC and the ratio FEV 1 FVC decreased significantly after BAL ( P<0·001). In healthy subjects, FEV 1 and FVC decreased significantly ( P<0·001), whereas FEV 1 FVC did not. The fall in FEV 1 after BAL was significantly greater in asthmatics (32·4 ± 10·0%) than in healthy subjects (17·7 ± 4·6; P<0·001). Severity of asthma, basline FEV 1 or initial PaO 2 did not predict the degree of hypoxaemia or the fall of FEV 1. It is concluded that BAL causes more severe hypoxaemia and a greater decrease in FEV 1 in asthmatics compared to healthy subjects, strongly supporting the recommendation of special caution and careful monitoring when BAL is undertaken in asthmatics.

OROTRACHEAL ANAESTHESIA FOR BRONCHOSCOPY

SUMMARY A method of general anaesthesia using thiopentone, nitrous oxide and oxygen, with full muscular relaxation, using suxamethonium, was employed in 120 patients undergoing bronchoscopy. After orotracheal intubation the lungs were ventilated by manual compression of the reservoir bag. This method was found to provide excellent conditions for the bronchoscopist Blood gas measurements in seven patients on samples taken before and at the end of bronchoscopy indicated that satisfactory pulmonary ventilation is obtained by this method.