Sedation in Bronchoscopy

Comparing Patient Comfort During Bronchoscopy Under Conscious Sedation and Monitored Anesthesia Care: A Prospective, Observational, Controlled Study

BACKGROUND

Flexible bronchoscopy (FB) often involves sedation, with the choice left to the bronchoscopist's discretion. Prior research on sedation in gastroscopic endoscopies yields conflicting information regarding the preferred method for FB. This study compares patient comfort levels during bronchoscopy with mindful sedation using fentanyl, nalbuphine, and midazolam versus monitored anesthesia care (MAC) using propofol, midazolam, and ketamine.

METHODS

This prospective observational study assessed 83 patients undergoing bronchoscopy under either conscious sedation (CS) (n=40) or MAC (n=43). Patient comfort, sedation levels, emotional state, recovery time, safety, and the impact of smoking history and comorbidities were evaluated. Data collection included direct patient questioning and observation using the Modified Observed Assessment of Alertness and Sedation (MOAA/S) form.

RESULTS

Comfort levels were similar between groups, with mean scores of 3.6±0.89 for CS and 3.3±0.54 for MAC. MAC induced deeper sedation (mean scores: 4.37±0.66 vs. 3.8±0.98). Recovery time and complications were comparable. Emotional states and medical history did not significantly differ between groups.

CONCLUSION

CS is not inferior to MAC for bronchoscopy, providing comparable comfort and safety with less intense sedation and lower cost. These findings support the use of CS for bronchoscopy procedures, offering a cost-effective alternative without compromising patient comfort or safety.

A study of hemodynamic effects, postoperative recovery, and safety of esketamine (right handed) during flexible bronchoscopy under general anesthesia

OBJECTIVE

Flexible bronchoscopy during general anesthesia has become an indispensable tool. Anesthetics are widely utilized in flexible bronchoscopy (FB). This study delved into the application value of a subanesthetic dose of esketamine (ES) (right handed) in flexible bronchoscopy during general anesthesia.

METHODS

A sample of 160 patients who underwent flexible bronchoscopy during general anesthesia were selected as study subjects and were equally divided into the control and ES groups, with clinical baseline data (age, sex, body mass index, American Society of Anesthesiologists grading) collected. Hemodynamic parameters (mean artery pressure, heart rate, pulse blood oxygen saturation) at different time points, the onset time of anesthesia, surgery time, analgesia maintenance time, anesthesia awakening time, and perioperative adverse reactions were recorded. Visual analogue scale (VAS), Mini-Mental State Examination (MMSE), and quality of recovery-40 (QoR-40) scales were utilized for assessing post-surgery satisfaction, cognitive function, and post-surgery early recovery quality.

RESULTS

The hemodynamics were stable at each time point, but patients in the ES group were more stable than those in the control group. Patients in the ES group exhibited faster onset and awakening time of anesthesia, longer duration of analgesia, and lower total incidence of adverse reactions versus the control group. The patients' QoR-40 total scores in the ES group were improved versus the control group at 1 day after surgery.

CONCLUSION

Compared with fentanyl, the use of ES (right handed) in flexible bronchoscopy during general anesthesia produces more stable hemodynamics, faster onset and recovery time of anesthesia, longer duration of analgesia, lower incidence of adverse reactions, and improved early postoperative recovery quality in patients.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Efficacy and safety of remimazolam in bronchoscopic sedation: A meta-analysis

BACKGROUND

Remimazolam is a new benzodiazepine used for procedural sedation and general anesthesia. Several studies have used remimazolam for bendable bronchoscopy.

AIM

To assess the safety and efficacy of remimazolam for sedation in patients undergoing bendable bronchoscopy by performing a meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched the EMBASE, PubMed, Cochrane Library, and Web of Science databases for RCTs on bendable bronchoscopic procedural sedation with remimazolam vs conventional sedatives (CS).

RESULTS

Five studies with 1080 cases were included. Remimazolam had the same sedation success rate compared with CS [relative risk (RR): 1.35, 95%CI: 0.60-3.05, P = 0.474, I2 = 99.6%]. However, remimazolam was associated with a lower incidence of hypotension (RR: 0.61; 95%CI: 0.40-0.95, P = 0.027; I2 = 65.1%) and a lower incidence of respiratory depression (RR: 0.50, 95%CI: 0.33-0.77, P = 0.002, I2 = 42.3%). A subgroup analysis showed a higher success rate of sedation with remimazolam than midazolam (RR: 2.45, 95%CI: 1.76-3.42, P < 0.001). Compared with propofol, the incidence of hypotension (RR: 0.45, 95%CI: 0.32-0.64, P < 0.001, I2 = 0.0%), respiratory depression (RR: 0.48, 95%CI: 0.30-0.76, P = 0.002, I2 = 78.4%), hypoxemia (RR: 0.36, 95%CI: 0.15-0.87, P = 0.023), and injection pain (RR: 0.04, 95%CI: 0.01-0.28, P = 0.001) were lower.

CONCLUSION

Remimazolam is safe and effective during bronchoscopy. The sedation success rate was similar to that in the CS group. However, remimazolam has a higher safety profile, with fewer inhibitory effects on respiration and circulation.

Efficacy and Safety of Chinese Medicine Resuscitation Pack for Enhanced Recovery after Bronchoscopy: A Randomized, Single-Blind, Placebo-Controlled Clinical Trial

OBJECTIVE

To evaluate the efficacy and safety of a hospital-made resuscitation pack, a Chinese medicinal herbal compound formula designed to enhance recovery in post-bronchoscopy patients.

METHODS

In this randomized, single-blind, placebo-controlled clinical trial, eligible patients were randomly assigned 1:1 to either the treatment or control groups. The patients in the treatment group applied the resuscitation pack, which contained aromatic compounded Chinese herbs. The patients in the control group applied a hospital-made, single herb placebo pack. Packs were placed on the Tiantu (CV 22) acupuncture point for 4 h as soon as the bronchoscopy finished. Efficacy indicators, such as recovery time, patients' symptoms including nausea and dizziness, and adverse events (AEs) were observed and compared. The outcome indices were evaluated at baseline, 1 and 24 h after the bronchoscopy. Subgroup analysis was further performed by patients' age and depth of sedation.

RESULTS

When applying generalized estimating equations (GEE) to evaluate the intensity of post-bronchoscopy nausea and vomiting, the intensity was lower in the treatment group (163 cases) compared with the control group (162 cases; 95% CI: 0.004, 0.099, P=0.03]. Also, significantly lower intensity of nausea was observed in the 60-70 years of age subgroup (95% CI: 0.029, 0.169, P=0.006) and deep sedation subgroup (95% CI: 0.002, 0.124; P=0.04). There was no significant difference in dizziness between two groups by GEE (95% CI: -0.134, 0.297; P=0.459). In addition, no serious AEs were observed in either group.

CONCLUSIONS

Our study found that the resuscitation pack markedly improved patients' symptoms by reducing nausea and vomiting after bronchoscopy without AEs, compared with placebo in the perioperative period. (Trial registration No. ChiCTR2000038299).

Transcutaneous gas monitoring is a useful tool to detect respiratory depression during bronchoscopy performed under propofol sedation

BACKGROUND

Bronchoscopy is a relatively invasive procedure where patients are often sedated. However, adequate sedation is not always achieved. Propofol is often used for difficult-to-sedate patients undergoing bronchoscopy despite a potential risk of respiratory depression. Transcutaneous carbon dioxide (tcpCO2) monitoring, introduced recently, is recognized as a convenient surrogate method for continuous monitoring of the partial pressure of arterial carbon dioxide (PaCO2). This study examined the safety of switching to propofol during bronchoscopy by using transcutaneous carbon dioxide monitoring.

METHODS

Patients in whom transcutaneous gas monitoring had been performed during bronchoscopy were included in this study. The participants were divided into two groups: 1) the midazolam + fentanyl group (MF group), and 2) the group in which midazolam was switched to propofol owing to inadequate sedation obtained with midazolam + fentanyl (MFP group). We retrospectively analyzed the transcutaneous gas measurement data collected in patients under propofol sedation for bronchoscopy.

RESULTS

This study included 61 (MF, n = 41; MFP, n = 20) patients. The duration of elevated tcpCO2 (>50 mm Hg) was greater in the MFP group (MF 8.5 min vs. MFP 22.1 min, p = 0.042).

CONCLUSION

Switching midazolam to propofol during bronchoscopy was significantly associated with a higher risk of elevated tcpCO2, which is indicative of respiratory depression. Therefore, continuous tcpCO2 monitoring is required to ensure the safety of patients under propofol sedation for bronchoscopy.

Safety and Efficacy of Dexmedetomidine for Bronchoscopy: A Systematic Review and Meta-Analysis

(1) Background: Anesthetic sedatives are widely used for bronchoscopy, and controversy surrounds the safety and efficacy of dexmedetomidine compared to other sedatives. The aim of this study is to evaluate the safety and efficacy of dexmedetomidine in bronchoscopy through a systematic review. (2) Methods: PubMed, Embase, Google Scholar, and Cochrane Library electronic databases were searched for a randomized controlled study of dexmedetomidine (Group D) or other sedative drugs (Group C) for bronchoscopy. Data extraction, quality assessment, and risk of bias analysis were performed in accordance with the preferred reporting items for systematic review and meta-analysis requirements. Meta-analysis was performed using RevMan 5.2. (3) Results: Nine studies were included, with a total of 765 cases. Compared to Group C, the incidence of hypoxemia (OR = 0.40, 95% CI (0.25, 0.64) p = 0.0001, I² = 8%) and tachycardia (OR = 0.44, 95% CI (0.26,0.74), p = 0.002, I² = 14%) were lower, but bradycardia (OR = 3.71, 95% CI (1.84, 7.47), p = 0.0002, I² = 0%) was higher in Group D; no significant difference was observed in other outcome indicators. (4) Conclusions: Dexmedetomidine reduces the incidence of hypoxemia and tachycardia during bronchoscopy but is more likely to provoke bradycardia.

Clinical effects of remimazolam alone or in combination with dexmedetomidine in patients receiving bronchoscopy and influences on postoperative cognitive function: a randomized-controlled trial

BACKGROUND

Remimazolam and dexmedetomidine are commonly used as sedatives. However, the effects and safety of remimazolam alone or in combination with dexmedetomidine have not been investigated.

AIM

We sought to investigate the clinical effects of remimazolam alone or in combination with dexmedetomidine in bronchoscopy, and their influence on cognitive function.

METHOD

Ninety eligible patients who underwent bronchoscopy under intravenous anesthesia were randomly divided into three groups: propofol control, remimazolam, and remimazolam plus dexmedetomidine. The primary outcome was the incidence of perioperative hypoxemia. Secondary outcomes included induction and maintenance doses of remimazolam, hemodynamic variables, scores for modified Observer's Assessment of Alertness/Sedation (MOAA/S), coughing, limb movement, incidence of adverse events, patient satisfaction, bronchoscopist satisfaction, incidence of post-operative cognitive dysfunction (POCD), time to loss of consciousness (LoC), and time to awake.

RESULTS

The incidence of hypoxemia, hypotension, and bronchoscopist satisfaction score were significantly decreased, and time to LoC and time to awake were markedly longer in the remimazolam and remimazolam plus dexmedetomidine groups than in the propofol control group (p < 0.05). The remimazolam group had significantly decreased induction and maintenance doses of remimazolam and a shorter time to LoC than the remimazolam plus dexmedetomidine group (p < 0.05). Scores for coughing, limb movement, MOAA/S, and post-operative patient satisfaction were comparable among the three groups. POCD was not induced in any of the groups.

CONCLUSION

Remimazolam is safe and effective for painless bronchoscopy, with a low incidence of adverse reactions, and exhibits a good synergistic effect with dexmedetomidine.

TRIAL REGISTRATION

This trial protocol had been registered on Chinese Clinical Trial Registry (ChiCTR2000041435, date: 2020 12 26.

Safe sedation during diagnostic and therapeutic flexible bronchoscopy in Japan: A review of the literature

We explored whether a combination of an opioid (fentanyl or pethidine) and midazolam could safely sedate Japanese patients undergoing bronchoscopic procedures. We searched the PubMed Medline and Igaku Chuo Zasshi (ICHUSHI) databases from 1980 to 2022 for papers on sedatives used during bronchoscopy, especially opioids (fentanyl and pethidine) and midazolam. The keywords were "bronchoscopy" and "sedation" ("kikanshikyo" and "chinsei", respectively, in Japanese). The results showed that midazolam was the preferred sedation agent during flexible bronchoscopy; with midazolam sedation is rapid, and the drug is associated with anterograde amnesia and decreased discomfort. A combination of an opioid (fentanyl or pethidine) and midazolam improved the patient tolerance and willingness to undergo a repeat procedure and also improved the working conditions for the physician. The British Thoracic Society guideline of 2013 suggested that a combination of an opioid (fentanyl or alfentanil) and midazolam should be considered to improve bronchoscopic tolerance. The American College of Chest Physicians Consensus Statement of 2011 suggested that fentanyl should be preferred; the onset of action and peak effect are rapid, and the effects are of relatively short duration. Emphasis has been placed on safety aspects, such as patient monitoring, the precautions that should be taken in patients with certain conditions, prevention and management of complications, adequate staffing, and optimal sedation and disinfection. In conclusion a combined opioid (fentanyl or pethidine) and midazolam sedation is optimal for diagnostic and therapeutic flexible bronchoscopy in Japanese patients.

Moderate sedation with dexmedetomidine-remifentanil is safer than deep sedation with propofol-remifentanil for endobronchial ultrasound while providing comparable quality: a randomized double-blind trial

OBJECTIVE

We compared dexmedetomidine-remifentanil vs. propofol-remifentanil in terms of safety and quality during sedation for Endobronchial ultrasonography (EBUS).

METHODS

A randomized, double-blind trial. Outpatients undergoing EBUS randomly received 1 μg/kg/hour dexmedetomidine or a target concentration of 2.5 μg/mL propofol, both combined with remifentanil initially targeted at 1.5 ng/mL and subsequently titrated. Additional sedatives were restricted. The primary outcome was the need for airway rescue interventions to treat oxygen desaturation.

RESULTS

Twenty-eight patients received dexmedetomidine-remifentanil and 27 received propofol-remifentanil. Airway rescue interventions were fewer in the dexmedetomidine group vs. the propofol one (23 vs. 76% patients, relative risk 3.21 (95% CI 1.55-6.64, P < 0.002)). Desaturation in the dexmedetomidine group was always resolved by increasing nasal oxygen flow, whereas additional interventions were needed in 60% of patients receiving propofol. Hypotension was more frequent in the propofol group, while hypertension, bradycardia and coughing were similar in both. Bronchoscopists' and patients' satisfaction were similar, although in the dexmedetomidine group two patients needed additional sedatives and two patients would not repeat the sedation technique.

CONCLUSION

Moderate sedation with dexmedetomidine-remifentanil for EBUS is safer than deep sedation with propofol-remifentanil but it would occasionally need additional sedatives to ensure patient satisfaction.

Inhibition of stress and spontaneous respiration: Efficacy and safety of monitored anesthesia care by target-controlled infusion remifentanil in combination with dexmedetomidine in fibreoptic bronchoscopy for patients with severe tracheal stenosis

Objective

This study aimed to determine the effective concentration of target-controlled infusion (TCI) of remifentanil used to inhibit stress during the treatment of severe tracheal stenosis with fibreoptic bronchoscopy and to evaluate the monitored anesthesia care (MAC) by remifentanil.

Materials and methods

60 patients with severe tracheal stenosis who underwent fibreoptic bronchoscopy was performed. Dexmedetomidine was initially administered at a bolus dose (0.8 mcg/kg), followed by a 0.5 mcg/(kg⋅h) continuous infusion. Remifentanil was administered by TCI. The effective concentration (EC) of remifentanil was titrated by the improved sequential method, and 30 patients were included. The EC95 of remifentanil was set as the plasma target concentration to evaluate the safety of the MAC, and another 30 patients were included.

Results

The half effective effect-chamber concentration of remifentanil (EC50) was 2.243 ng/ml, and the EC95 was 2.710 ng/ml. Among the 30 patients who received an EC95 of remifentanil as the target concentration, one patient was remedied by injecting propofol, the score of Ramsay sedation was three. The incidence of subclinical hypoxemia (SPO2 of 90-95%) was 30%, the incidence of moderate hypoxemia (SPO2 of 75-89%, ≤60 s) was 20 and 86.7% of patients with oxygen saturation was less than 95% returned to normal by awakening. The satisfaction score of the operator was nine, the satisfaction score of the anesthesiologist was eight, the satisfaction score of the patients was 10, the rate of patient willingness to re-accept the procedure was 93.3% and the circulation was stable during the operation.

Conclusion

MAC using TCI of remifentanil with continuous pumping dexmedetomidine can effectively inhibit the stress response to fibreoptic bronchoscopy in patients with severe tracheal stenosis while maintaining spontaneous breathing. Under the anesthesia management of an experienced anesthesiologist, it provides a reference to tracheoscopic anesthesia of autonomous breathing.

Clinical trial registration

[http://www.chictr.org.cn/], identifier [ChiCTR 2100043380].

Sufentanil target controlled infusion (TCI) versus remifentanil TCI for monitored anaesthesia care for patients with severe tracheal stenosis undergoing fiberoptic bronchoscopy: protocol for a prospective, randomised, controlled study

INTRODUCTION

The use of monitored anaesthesia care (MAC) is necessary and ubiquitous for fiberoptic bronchoscopy. Anaesthetic management of patients with severe tracheal stenosis has always been a challenge. The efficacy and safety of the MAC with sufentanil target controlled infusion (TCI) and remifentanil TCI in patients with severe tracheal stenosis are still unknown.

METHODS ANALYSIS

This study is a prospective, investigator-initiated, two-arm, randomised control trial to compare the efficacy and safety of sufentanil TCI with remifentanil TCI in patients with severe tracheal stenosis undergoing fiberoptic bronchoscopy. 270 patients will be randomly assigned to the sufentanil TCI group or remifentanil TCI group, with a 1:1 ratio in two groups. The primary outcome is the incidence of hypoxaemia (an oxygen saturation of <90%). The secondary outcome investigates the severity of hypoxaemia, cough severity, haemodynamic variables, sedation scores and satisfaction scores.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of Shanghai Pulmonary Hospital (approval No. K19-122). The results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100043380.

Guidelines on analgosedation, monitoring, and recovery time for flexible bronchoscopy: a systematic review

BACKGROUND

Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and gas exchange. The restitution of normal respiration takes place in the recovery room. Nonetheless, there is no evidence on the necessary observation time. We systematically reviewed current guidelines on bronchoscopy regarding sedation, monitoring and recovery.

METHODS

This review was registered at the PROSPERO database (CRD42020197476). MEDLINE and awmf.org were double-searched for official guidelines, recommendation or consensus statements on bronchoscopy from 2010 to 2020. The PICO-process focussed on adults (Patients), bronchoscopy with maintained spontaneous breathing (Interventions), and recommendations regarding the intra- and postprocedural monitoring and sedation (O). The guideline quality was graded. A catalogue of 54 questions was answered. Strength of recommendation and evidence levels were recorded for each recommendation.

RESULTS

Six guidelines on general bronchoscopy and three expert statements on special bronchoscopic procedures were identified. Four guidelines were evidence-based. Most guidelines recommend sedation to improve the patient's tolerance. Midazolam combined with an opioid is preferred. The standard monitoring consists of non-invasive blood pressure, and pulse oximetry, furthermore electrocardiogram in cardiac patients. Only one guideline discusses hypercapnia and capnometry, but without consensus. Two guidelines discuss a recovery time of two hours, but a recommendation was not given because of lack of evidence.

CONCLUSION

Evidence for most issues is low to moderate. Lung-diseased patients are not represented by current guidelines. Capnometry and recovery time lack evidence. More primary research in these fields is needed so that future guidelines may address these issues, too.

A randomised study of comfort during bronchoscopy comparing conscious sedation and anaesthetist-controlled general anaesthesia, including the utility of bispectral index monitoring

Background

The difference in patient comfort with conscious sedation versus general anaesthesia for bronchoscopy has not been adequately assessed in a randomised trial. This study aimed to assess if patient comfort during bronchoscopy with conscious sedation is noninferior to general anaesthesia.

Methods

96 subjects were randomised to receive conscious sedation or general anaesthesia for bronchoscopy. The primary outcome was subject comfort. Secondary outcomes included willingness to undergo a repeat procedure if necessary and level of sedation assessed clinically and by bispectral index (BIS) monitoring.

Results

There was no significant difference between subject comfort scores (difference -0.01, 95% CI -0.63-0.61 on a 10-point scale; p=0.97) or willingness to undergo a repeat procedure (97.7% versus 91.8%, 95% CI -4.8-15.5%; p=0.37). Deeper levels of sedation in the general anaesthesia cohort was confirmed with both clinical and BIS monitoring. There was no significant difference in diagnostic accuracy (conscious sedation 93.9%, 95% CI 80.4-98.3% versus general anaesthesia 86.5%, 95% CI 72.0-94.1%; p=0.43). There were more complications (29.6%, 95% CI 18.2-44.2% versus 6.1%, 95% CI 2.1-16.5%; p<0.01) in the general anaesthesia group. There was no relationship between high BIS scores and subject discomfort. BIS levels <40 during a procedure were associated with increased complications.

Conclusion

Conscious sedation is not inferior to general anaesthesia in providing patient comfort during bronchoscopy, despite lighter sedation, and is associated with fewer complications and comparable diagnostic accuracy. BIS monitoring may have a role in preventing complications associated with deeper sedation.

Dexmedetomidine combined with midazolam infusion guided by bispectral index during bronchoscopy

BACKGROUND

Conscious sedation guided by bispectral index (BIS) during bronchoscopy has been proved to be a feasible approach. This study aimed to investigate the safety and efficacy of dexmedetomidine combined with midazolam for undergoing conscious sedation during bronchoscopy.

METHODS

The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry. Patients were randomized into DEX group (dexmedetomidine combined with midazolam) and FEN group (fentanyl combined with midazolam). Bronchoscopy was performed under awake sedation titrated to a BIS level of 60-80. The primary endpoint was the incidence of hypoxia, the secondary endpoint was the incidence of bradycardia and hypotension, effect of sedation including satisfaction degree (VAS) of the operators and patients and patients' willingness to undergo bronchoscopy again.

RESULTS

A total of 222 cases in DEX group and 211 cases in FEN group completed the study. The incidence of hypoxia and tachycardia in DEX group was lower than that in FEN group (8.1% vs 14.7%, 10.4% vs 19.0%, p < 0.05), and the incidence of hypotension and bradycardia in DEX group was higher than that in FEN group (6.8% vs 0, 15.3% vs 8.1%, p < 0.05). Midazolam dosage was significantly lower in the DEX group than in the FEN group, and the duration of surgery was significantly longer in the DEX group. The differences in intraoperative discomfort of VAS score, satisfaction VAS score, and willingness rate to undergo bronchoscopy again were not statistically significant between the two groups. In addition, the proportion of "procedural interference by patient movement" in DEX group was higher than that in FEN group.

CONCLUSIONS

The conscious sedation regimen of dexmedetomidine combined with midazolam monitored by BIS is considered to be safe and effective during bronchoscopy. The occurrence of hypoxia and tachycardia was less, and the fluctuation of blood pressure and heart rate was mild, but the proportion of bradycardia in dexmedetomidine group was higher than that in fentanyl combined with midazolam group.

Induction and maintenance of procedural sedation in adults: focus on remimazolam injection

Introduction: Procedural sedation (PS) is a humane way to help patients get through painful medical procedures by the administration of sedative drugs combined with analgesics. However, each of the currently used medications has certain shortcomings, urging the search for a new drug. Remimazolam, a novel benzodiazepine, is an ultra-short-acting hypnotic agent invented out of the 'soft drug' development.Areas covered: This presented review provides an overview of the drugs used in clinical practice for the induction and maintenance of procedural sedation in adults, focusing on the newly investigated benzodiazepine remimazolam. Literature search was conducted using the MEDLINE and ClinicalTrial.gov databases from January 2007 to December 2020.Expert opinion: Based on the reported clinical trials so far, remimazolam has demonstrated its effectiveness and safety with promising properties including rapid onset, short duration of action, predictable and consistent recovery profile, metabolism almost unaffected by liver or renal function, with non or minimal cardiorespiratory depression, and availability with a reversal drug. With marketing approval received recently, remimazolam is expected to have a place in the practice for procedural sedation in the near future if its efficacy and safety are further confirmed by more clinical trials and post-market analyses.

Supraglottic jet oxygenation and ventilation reduces desaturation during bronchoscopy under moderate to deep sedation with propofol and remifentanil: A randomised controlled clinical trial

BACKGROUND

Hypoxaemia is frequently seen during flexible bronchoscopies that are done with a nasal approach under the traditional sedation with propofol. This study investigated the potential benefits of supraglottic jet oxygenation and ventilation (SJOV) using the Wei nasal jet tube (WNJ) in reducing hypoxaemia in patients undergoing bronchoscopy under moderate to deep intravenous sedation using a propofol, lidocaine and remifentanil cocktail.

OBJECTIVES

Our primary objective was to evaluate the efficacy and complications of SJOV via the WNJ during flexible bronchoscopy under moderate to heavy sedation with propofol and remifentanil.

DESIGN

A randomised controlled clinical trial.

SETTING

The 180th Hospital of People's Liberation Army, Quanzhou, China, from 1 June to 1 November 2019.

PATIENTS

A total of 280 patients aged ≥18 years with American Society of Anesthesiologists' physical status 1 to 3 undergoing flexible bronchoscopy were studied.

INTERVENTIONS

Patients were assigned randomly into one of two groups, a nasal cannula oxygenation (NCO) group (n = 140) using a nasal cannula to deliver oxygen (4 l min-1) or the SJOV group (n = 140) using a WNJ connected to a manual jet ventilator to provide SJOV at a driving pressure of 103 kPa, respiratory rate 20 min-1, FiO2 1.0 and inspiratory:expiratory (I:E) ratio 1:2.

MAIN OUTCOME MEASURES

The primary outcome was an incidence of desaturation (defined as SpO2 < 90%) during the procedure. Other adverse events related to the sedation or SJOV were also recorded.

RESULTS

Compared with the NCO group, the incidence of desaturation in the SJOV group was lower (NCO 37.0% vs. SJOV 13.1%) (P < 0.001). Patients in the SJOV group had a higher incidence of a dry mouth at 1 min (13.1% vs. 1.5%, P < 0.001) than at 30 min (1.5% vs. 0%, P = 0.159) or at 24 h (0% vs. 0%). There was no significant difference between the groups in respect of sore throat, subcutaneous emphysema or nasal bleeding.

CONCLUSIONS

SJOV via a WNJ during flexible bronchoscopy under moderate to deep sedation with propofol and remifentanil significantly reduces the incidence of desaturation when compared with regular oxygen supplementation via a nasal cannula. Patients in the SJOV group had an increased incidence of transient dry mouth.

TRIAL REGISTRATION

Registered at www.chictr.org.cn (ChiCTR1900023514).

A Randomized Trial of Nebulized Lignocaine, Lignocaine Spray, or Their Combination for Topical Anesthesia During Diagnostic Flexible Bronchoscopy

BACKGROUND

The optimal mode of delivering topical anesthesia during flexible bronchoscopy remains unknown. This article compares the efficacy and safety of nebulized lignocaine, lignocaine oropharyngeal spray, or their combination.

METHODS

Consecutive subjects were randomized 1:1:1 to receive nebulized lignocaine (2.5 mL of 4% solution, group A), oropharyngeal spray (10 actuations of 10% lignocaine, group B), or nebulization (2.5 mL, 4% lignocaine) and two actuations of 10% lignocaine spray (group C). The primary outcome was the subject-rated severity of cough according to a visual analog scale. The secondary outcomes included bronchoscopist-rated severity of cough and overall procedural satisfaction on a visual analog scale, total lignocaine dose, subject's willingness to undergo a repeat procedure, adverse reactions to lignocaine, and others.

RESULTS

A total of 1,050 subjects (median age, 51 years; 64.8% men) were included. The median (interquartile range) score for subject-rated cough severity was significantly lower in group B compared to group C or group A (4 [1-10] vs 11 [4-24] vs 13 [5-30], respectively; P < .001). The bronchoscopist-rated severity of cough was also the least (P < .001), and the overall satisfaction was highest in group B (P < .001). The cumulative lignocaine dose administered was the least in group B (P < .001). A significantly higher proportion of subjects (P < .001) were willing to undergo a repeat bronchoscopy in group B (73.7%) than in groups A (49.1%) and C (59.4%). No lignocaine-related adverse events were observed.

CONCLUSIONS

Ten actuations of 10% lignocaine oropharyngeal spray were superior to nebulized lignocaine or their combination for topical anesthesia during diagnostic flexible bronchoscopy.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03109392; URL: www.clinicaltrials.gov.