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Sedation for flexible bronchoscopy: current and emerging evidence

Ricardo J. José, Shahzad Shaefi, Neal Navani
European Respiratory Review 2013 22: 106-116; DOI: 10.1183/09059180.00006412
Ricardo J. José
*Dept of Thoracic Medicine, University College Hospital, London, #Centre for Inflammation and Tissue Repair, University College London, London, +Lungs for the Living Research Centre, University College London, London, UK. ¶Dept of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
*Dept of Thoracic Medicine, University College Hospital, London, #Centre for Inflammation and Tissue Repair, University College London, London, +Lungs for the Living Research Centre, University College London, London, UK. ¶Dept of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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  • For correspondence: r.jose@ucl.ac.uk
Shahzad Shaefi
*Dept of Thoracic Medicine, University College Hospital, London, #Centre for Inflammation and Tissue Repair, University College London, London, +Lungs for the Living Research Centre, University College London, London, UK. ¶Dept of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Neal Navani
*Dept of Thoracic Medicine, University College Hospital, London, #Centre for Inflammation and Tissue Repair, University College London, London, +Lungs for the Living Research Centre, University College London, London, UK. ¶Dept of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
*Dept of Thoracic Medicine, University College Hospital, London, #Centre for Inflammation and Tissue Repair, University College London, London, +Lungs for the Living Research Centre, University College London, London, UK. ¶Dept of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Tables

  • Table 1. Ramsay sedation scale
    1Patient is anxious and agitated or restless, or both
    2Patient is cooperative, oriented and tranquil
    3Patient responds to commands only
    4Patient exhibits brisk response to light glabellar tap or loud auditory stimulus
    5Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus
    6Patient exhibits no response
  • Table 2. Pre-sedation flexible bronchoscopy checklist
    Patient identifier (name, date of birth)
    Consent form signed
    Responsible adult available to escort the patient post-procedure
    Adequate fasting period
    Allergies
    Hepatic and renal function (if the clinical history suggests these could be abnormal)
    Observations (vital signs)
    Continuous pulse oximetry available
    Intravenous access functioning
    Medications checked
    Resuscitation trolley available with emergency drugs
    Reversal drugs available (flumazenil and naloxone)
    Oxygen available (including variety of oxygen delivery devices)
    All staff ready for the procedure to commence
    • Data from [22].

  • Table 3. Pharmacological properties of common sedatives used in bronchoscopy
    DrugFentanylAlfentanilMorphineMidazolamLorazepamDiazepamPropofol 1%Fospropofol
    Dose i.v.Initial: 25–50 μgInitial: 250 μgInitial: 2.5 mgInitial: 2–2.5 mg
    (0.5–1 mg in the elderly)
    Initial dose: 1.5–2 mgInitial dose: 5–10 mgInitial: 10–50 mg titrated to effectInitial: 6.5 mg·kg−1
    Supplemental: 25 μgSupplemental: 250 μgSupplemental: 2.5 mgSupplemental: 1 mg (0.5–1 mg in the elderly) at 2–5 min intervalsSupplemental: usually not required
    Wait at least 10 min
    Supplemental: usually not required
    Wait at least 10 min
    Supplemental: 25% of initial doseSupplemental: 1.6 mg·kg−1
    Infusion: 25–100 μg·kg−1·min−1
    Onset of action3–5 minImmediate5–10 min30–60 s8–15 min1 min30–60 s6.5 min
    Peak effect5 minImmediate15–30 min5–10 min15–30 min2–3 min2 min12 min
    Duration of action1–2 h1–2 h1–6 h30–120 min8 h1–3 h4–8 min17 min
    MetabolismHepaticHepaticHepaticHepaticHepaticHepaticHepaticHepatic
    Renal excretion<5%<1%90%<1%<1%<1%70%70%
    Elimination half-life3–4 h1–2 h2 h1.5–2.5 h11–22 h20–50 h3–12 h45 min
    Major/common adverse evensRespiratory depression, nausea and vomitingSee fentanylSee fentanylRespiratory depression, hypotensionSee midazolamSee midazolamRespiratory depression, bradycardia, hypotension, pain at the injection siteRespiratory depression, hypotension, paraesthesiae, pruritus
    AntagonistsNaloxone 100–200 μg (1.5-3 μg·kg−1) with supplemental doses of 100 μg every 2 min until reversal occursFlumazenil 0.2 mg, repeated every 60 s up to 1 mg; if a continuous infusion is required the dose is 0.1–0.4 mg·h−1No antagonist available
    CommentsCombination with benzodiazepines may enhance respiratory depression
    Administer prior to the benzodiazepines, as a lower dose of benzodiazepine will be required to achieve the desired degree of sedation
    See fentanylSee fentanylCombination with opiates may enhance respiratory depressionSee midazolamSee midazolamCombination with opiates may enhance respiratory depression
    Dose and rate of administration should be adjusted according to desired level of sedation and response
    For patients >65 years or with severe systemic disease reduce the dose by 25%
    See propofol
    • Adapted from [10, 18, 36].

  • Table 4. Summary of clinical studies of propofol in flexible bronchoscopy
    ArticleStudy typeDrugMain results
    Clarkson [54]Randomised, double-blind, prospective-controlled studyPropofol (n=21) versus midazolam (n=20)More rapid onset and recovery from sedation seen in the propofol group
    No significant difference in the amount of topical anaesthetic required or in oxygen desaturation
    Crawford [55]Randomised, double-blind, prospective-controlled studyPropofol (n=21) versus midazolam–alfentanil (n=21)In three patients in the midazolam–alfentanil and five in the propofol group the depth of sedation exceeded the moderate level
    Recovery to an appropriate level was more rapid in the latter group
    Oxygen saturations decreased in both groups and there were no significant differences in blood pressure
    Those in the midazolam group had more amnesia and longer recovery time
    Gonzalez [5]Randomised, single-blind, prospective-controlled studyPropofol (n=9) versus no sedation (n=9)Less cough, pain, sensation of asphyxiation, total amnesia and improved tolerance of the procedure in the propofol group
    No differences in oxygen saturations between the groups
    Hwang [47]Randomised, double-blind, prospective-controlled studyPropofol–alfentanil (n=138) versus propofol–ketamine (n=138) for patient-controlled sedationPatients in the propofol–ketamine group reported greater amnesia and satisfaction
    Haemodynamic stability and adequate oxygenation during the procedure in both groups; however, a significant drop in oxygen saturations below 90% was seen in both groups immediately before the procedure
    This was transient and with no sequelae
    Clark [20]Randomised, double-blind, prospective-controlled studyPropofol (n=43) versus midazolam (n=39)Propofol resulted in faster recovery from sedation and patient tolerance and satisfaction were improved
    There were no differences in operator satisfaction
    Safely administered by non-anaesthetis
    Stoltz [56]Randomised, non-blinded, prospective-controlled studyPropofol (n=100) versus midazolam–hydrocodone (n=100)Mean oxygen saturation and desaturation below 90% were similar in both groups
    Patients receiving propofol had less tachycardia during the procedure and faster recovery from sedation
    Grendelmeier [12]Prospective case seriesPropofol (n=440)Systolic blood pressure dropped below 90 mmHg in 15.4% and oxygen saturation dropped below 90% in 16.4% of patients but some of these had higher American Society of Anesthesiology scores and were already hypotensive or hypoxaemic prior to the sedation
    None of the patients required intubation
    Lo [21]Randomised, non-blinded, prospective-controlled studyPropofol (n=243) versus midazolam (n=249)Bispectral index-guided propofol infusion is as safe as clinically judged midazolam sedation
    The proportion of patients with hypoxemia or hypotensive events were not different in the two groups but those in propofol group had the lowest mean arterial blood pressure and oxygen saturation readings
    Those in the propofol group had less cough, improved procedure tolerance and faster recovery from sedation
    Yoon [57]Randomised, double-blind, prospective-controlled studyPropofol (n=32) versus propofol–alfentanil (n=32)They did not find differences in patient or bronchoscopist satisfaction or in degree of coughing but those in the alfentanil group had significantly lower oxygen saturation levels. However, the lower levels of oxygen saturation reported in the alfentanil are most likely not clinically significant
    Schlatter [58]Randomised, double-blind, prospective-controlled studyPropofol (n=154) versus propofol–hydrocodone (n=146)This combination suppressed coughing and reduced patient discomfort during flexible bronchoscopy compared to placebo alone with no differences in complication rates
    Carmi [59]Randomised, non-blinded, prospective-controlled studyPropofol (n=56) versus midazolam–alfentanil (n=59)Those in the midazolam–alfentanil group rather than the propofol group had higher carbon dioxide tension values and required more oxygen supplementation or airway support; however, both were considered equally safe and effective
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Sedation for flexible bronchoscopy: current and emerging evidence
Ricardo J. José, Shahzad Shaefi, Neal Navani
European Respiratory Review Jun 2013, 22 (128) 106-116; DOI: 10.1183/09059180.00006412

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Sedation for flexible bronchoscopy: current and emerging evidence
Ricardo J. José, Shahzad Shaefi, Neal Navani
European Respiratory Review Jun 2013, 22 (128) 106-116; DOI: 10.1183/09059180.00006412
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  • Article
    • Abstract
    • MODERATE SEDATION
    • SAFE DELIVERY OF MODERATE SEDATION
    • PRE-MEDICATION DRUGS IN BRONCHOSCOPY
    • PHARMACOLOGICAL SEDATIVES USED FOR SEDATION DURING BRONCHOSCOPY
    • EMERGING PHARMACOLOGICAL SEDATIVES IN BRONCHOSCOPY
    • DRUG INTERACTIONS
    • CONCLUSION
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