Indications For Flexible Bronchoscopy Research Articles

Clinical utility of elective paediatric flexible bronchoscopy and impact on the quality of life: protocol for a single-centre, single-blind, randomised controlled trial

IntroductionElective flexible bronchoscopy (FB) is now widely available and standard practice for a variety of indications in children with respiratory conditions. However, there are no randomised controlled trials (RCTs) that...

Hypercapnia in COPD Patients Undergoing Endobronchial Ultrasound under Local Anaesthesia and Analgosedation: A Prospective Controlled Study Using Continuous Transcutaneous Capnometry

Background: Flexible bronchoscopy (FB) in analgosedation causes alveolar hypoventilation and hypercapnia, the more so if patients suffer from COPD. Nonetheless, neither is capnometry part of standard monitoring nor is there evidence on how long patients should be monitored after sedation. Objectives: We investigated the impact of COPD on hypercapnia during FB with endobronchial ultrasound (EBUS) in sedation and how the periprocedural monitoring should be adapted. Methods: Two cohorts of consecutive patients – with advanced and without COPD – with the indication for FB with EBUS-guided transbronchial needle aspiration in analgosedation received continuous transcutaneous capnometry (p_tcCO₂) before, during, and for 60 min after the sedation with midazolam and alfentanil. Main Results: Forty-six patients with advanced COPD and 44 without COPD were included. The mean examination time was 26 ± 9 min. Patients with advanced COPD had a higher peak p_tcCO₂ (53.7 ± 7.1 vs. 46.8 ± 4.8 mm Hg, p < 0.001) and mean p_tcCO₂ (49.5 ± 6.8 vs. 44.0 ± 4.4 mm Hg, p < 0.001). Thirty-six percent of all patients reached the maximum hypercapnia after FB in the recovery room (8 ± 11 min). Patients with COPD needed more time to recover to normocapnia (22 ± 24 vs. 7 ± 11 min, p < 0.001). They needed a nasopharyngeal tube more often (28 vs. 11%, p < 0.001). All patients recovered from hypercapnia within 60 min after FB. No intermittent ventilation manoeuvres were needed. Conclusion: A relevant proportion of patients reached their peak-pCO₂ after the end of intervention. We recommend using capnometry at least for patients with known COPD. Flexible EBUS in analgosedation can be safely performed in patients with advanced COPD. For patients with advanced COPD, a postprocedural observation time of 60 min was sufficient.

Non-anesthesiologist-administered Propofol is not Related to an Increase in Transcutaneous CO2 Pressure During Flexible Bronchoscopy Compared to Guideline-based Sedation: A Randomized Controlled Trial

IntroductionEvidence for the use of non-anesthesiologist-administered propofol for sedation during flexible bronchoscopy is scarce. The main objective of this study was to determine whether non-anesthesiologist-administered propofol balanced sedation was related to higher transcutaneous CO2 pressure compared with current guideline-based sedation (combination midazolam and opioid). Secondary outcomes were post-procedural recuperation time, patient satisfaction and frequency of adverse events. MethodsIn this randomized controlled trial we included data from outpatients aged 18 years or older with an indication for flexible bronchoscopy in a university hospital in northern Mexico. ResultsNinety-one patients were included: 42 in the midazolam group and 49 in the propofol group. During 60min of transcutaneous capnometry monitoring, mean transcutaneous CO2 pressure values did not differ significantly between groups (43.6 [7.5] vs. 45.6 [9.6]mmHg, P=.281). Propofol was related with a high Aldrete score at 5, 10, and 15min after flexible bronchoscopy (9 [IQR 6-10] vs. 10 [9,10], P=.006; 9 [8•10] vs. 10 [IQR 10•10], P<.001 and 10 [IQR 9•10] vs. 10 [10], respectively) and with high patient satisfaction on a visual analogue scale of 1 (not satisfied) to 10 (very satisfied) (8.41 [1.25] vs. 8.97 [0.98], P=.03). Frequency of adverse events was similar among groups (30.9% vs. 22.4%, P=.47). ConclusionCompared with guideline-recommended sedation, non-anesthesiologist-administered propofol balanced sedation is not associated with higher transcutaneous CO2 pressure or with more frequent adverse effects. Propofol use is associated with faster sedation recovery and with high patient satisfaction. Clinical trial RegistrationNCT02820051.

Non-anesthesiologist-administered Propofol is not Related to an Increase in Transcutaneous CO2 Pressure During Flexible Bronchoscopy Compared to Guideline-based Sedation: A Randomized Controlled Trial

IntroductionEvidence for the use of non-anesthesiologist-administered propofol for sedation during flexible bronchoscopy is scarce. The main objective of this study was to determine whether non-anesthesiologist-administered propofol balanced sedation was related to higher transcutaneous CO2 pressure compared with current guideline-based sedation (combination midazolam and opioid). Secondary outcomes were post-procedural recuperation time, patient satisfaction and frequency of adverse events. MethodsIn this randomized controlled trial we included data from outpatients aged 18 years or older with an indication for flexible bronchoscopy in a university hospital in northern Mexico. ResultsNinety-one patients were included: 42 in the midazolam group and 49 in the propofol group. During 60min of transcutaneous capnometry monitoring, mean transcutaneous CO2 pressure values did not differ significantly between groups (43.6 [7.5] vs. 45.6 [9.6]mmHg, P=.281). Propofol was related with a high Aldrete score at 5, 10, and 15min after flexible bronchoscopy (9 [IQR 6-10] vs. 10 [9,10], P=.006; 9 [8–10] vs. 10 [IQR 10–10], P<.001 and 10 [IQR 9–10] vs. 10 [10], respectively) and with high patient satisfaction on a visual analogue scale of 1 (not satisfied) to 10 (very satisfied) (8.41 [1.25] vs. 8.97 [0.98], P=.03). Frequency of adverse events was similar among groups (30.9% vs. 22.4%, P=.47). ConclusionCompared with guideline-recommended sedation, non-anesthesiologist-administered propofol balanced sedation is not associated with higher transcutaneous CO2 pressure or with more frequent adverse effects. Propofol use is associated with faster sedation recovery and with high patient satisfaction. Clinical trial RegistrationNCT02820051.

Bronchoscope insertion route and patient comfort during flexible bronchoscopy.

Diagnostic flexible bronchoscopy performed in hospitalised and ambulatory patients in a tertiary care academic hospital in Monterrey, Mexico. To determine the effect of the route of insertion of the bronchoscope (oral or nasal) on patient comfort, vocal cord visualisation, local anaesthetic and sedation requirements and possible complications. Prospective study carried out in patients aged ⩾ 18 years with an indication for flexible bronchoscopy. The route of insertion was randomly assigned. Symptoms related to the procedure were evaluated using a questionnaire. Sixty-three patients were included: 32 in the oral insertion group and 31 in the nasal insertion group. There was no statistically significant difference in patient discomfort (1.91 ± 2.95 vs. 2.39 ± 3.56 points on a scale of 1 to 10, P = 0.74) or procedural complications (4 vs. 0 events, P = 0.12) between study groups. Oral insertion was associated with less time to vocal cord visualisation (25.5 ± 156 s vs. 56 ± 61 s, P < 0.01), lower requirement for lidocaine (15 ± 7.50 vs. 16 ± 4 ml, P = 0.01) and fewer insertion failures (0 vs. 6 cases, P < 0.01). With intravenous sedoanalgesia, route of insertion did not affect patient comfort. However, the oral route was associated with faster vocal cord visualisation, less use of lidocaine and no insertion failure.

The Clinical Experience of Pediatric Flexible Bronchoscopy at a Single Institution

lavage (BAL) was performed if need, and the BAL fluid was cultured for bacteria and fungi. We performed an acid-fast bacilli (AFB) smear and culture. Result : The most common indication for flexible bronchoscopy was suspected pulmonary tuber- culosis (37 cases, 35.2%). The most common abnormal finding was excessive secretion, which was found in 53 cases (50.4%). BAL bacterial cultures were performed in 10 of 38 cases, and Hemophilus influenza was the most common organism and was found in three cases (7.8%). There were 17 AFB culture-positive cases (49.3%) among the 37 suspected pulmonary tuberculosis cases. Among these 17, the Tb-polymerase chain reaction (Tb-PCR) was conducted for four cases (23.5 %) but only two cases (50%) were positive. TB-specific antigen-induced interferon-gamma was performed in four cases (23.5%), and all four cases (100%) were positive. Conclusion : Pediatric flexible bronchoscopy has made it possible to vary the indication and subjects. It was also safe and effective if used carefully. Further study should be conducted to develop safe and useful technology to overcome the limitations. (Pediatr Allergy Respir Dis(Korea) 2011;21:226-233)

Safety of High Dose Lidocaine in Flexible Bronchoscopy

Background The maximum safe dose for topical lidocaine during flexible bronchoscopy (FB) without toxicity is not established; recent guidelines advocate a dose <8.2 mg/kg. Noting our routine use of lidocaine above 12 mg/kg, we prospectively evaluated the safety of high dose topical lidocaine. Methods The standard institution FB preparation included 4% nebulized lidocaine, 2% nasal viscous lidocaine, 2% aqueous lidocaine for the vocal cords, and 1% aqueous lidocaine for the tracheobronchial tree. Procedure data were collected to include FB indication and duration, lidocaine use, and postprocedure symptoms. Serum lidocaine and blood methemoglobin levels were obtained 45 minutes postlidocaine administration. Results Consecutive data were collected for 154 patients with a mean age of 64.7 years. The most common FB indication (60%) was evaluation of a lung mass or mediastinal adenopathy. No arrhythmias or seizures were noted. Symptoms of euphoria or dizziness were reported in 84 patients (62.2%). Mean lidocaine usage was 15.4±4.5 mg/kg (1.17±0.20 gm). Lidocaine dose for females was significantly higher than males (16.9±4.9 mg/kg vs. 14.3±3.8 mg/kg, P=0.0003). There was no significant difference in dose on the basis of age, indication for FB, or presence of symptoms. Mean serum lidocaine level was 1.6±0.7 μg/mL and mean blood methemoglobin level was 0.7±0.3%. There were no significant differences shown. Conclusions Our routine use of lidocaine in FB is higher than recommended. There were not significantly elevated serum lidocaine or blood methemoglobin levels, or clinical evidence of toxicity.

Can HRCT Contribute in Decision-Making on Indication for Flexible Bronchoscopy for Solitary Pulmonary Nodules and Masses?

Can HRCT Contribute in Decision-Making on Indication for Flexible Bronchoscopy for Solitary Pulmonary Nodules and Masses?

Indications for flexible versus rigid bronchoscopy in children with suspected foreign-body aspiration

Diagnostic indications for flexible bronchoscopy in the initial investigation of children with suspected foreign-body (FB) aspiration have not been evaluated prospectively. We prospectively collected history, clinical, and radiologic findings at prebronchoscopic examination of all children referred for suspected FB aspiration between February 1993 and September 1995. Children with asphyxiating FB aspiration, requiring immediate rigid bronchoscopy, were excluded. If there was clear evidence of FB aspiration from the physical and radiographic findings, rigid bronchoscopy was directly performed. If the evidence was not convincing, children underwent diagnostic flexible bronchoscopy under local anesthesia. If an FB was found, rigid bronchoscopy was always performed for extraction. Eighty-three consecutive children (median age: 24 mo) were included. Among 28 who underwent rigid bronchoscopy first, 23 had an FB. Among the 55 children who underwent flexible bronchoscopy first, 17 had an FB. Predictive signs of a bronchial FB were a radiopaque FB, and associated unilaterally decreased breath sounds and obstructive emphysema (positive predictive value = 0.94). We propose the following management algorithm: Rigid bronchoscopy is performed first in case of asphyxia, a radiopaque FB, or association of unilaterally decreased breath sounds and obstructive emphysema. In any other case, flexible bronchoscopy is performed first for diagnostic purposes. If applied retrospectively to the 83 children in our study, this algorithm would have decreased the negative first rigid bronchoscopy rate to 4%. Flexible bronchoscopy is a safe and cost-saving diagnostic procedure in children with suspected FB aspiration.

Endoscopy of the airway in infants and children

We believe that many of our readers will appreciate having some familiarity with the procedures described in this manuscript. For those who have had difficulty in deciding whether the need for diagnosis justifies the risk of a procedure, this perspective will shed new light on the problem. It is appropriate to warn our readers that complete unanimity on several points is not yet evident. For example, the indications for flexible bronchoscopy, by whom the procedure should be done, and even more specific technical aspects are questions not completely resolved. However, this article is not an effort to instruct anyone in how to do the procedure. Rather, it is an effort to acquaint our readers with progress in the field. With that in mind, we are confident that the remaining questions will be answered on the basis of the training, experience, and, ultimately, the good judgment of all the physicians involved.