Sedation for fibreoptic bronchoscopy

Safety and efficacy of remimazolam compared with midazolam during bronchoscopy: a single-center, randomized controlled study

Although remimazolam is an ultra-short-acting benzodiazepine with a shorter elimination half-life and faster recovery time than midazolam, studies evaluating its safety and efficacy during bronchoscopy are limited. This study aimed to compare the safety and efficacy of remimazolam with those of midazolam for bronchoscopy. This prospective randomized parallel-group study was conducted at a single institution. The primary outcome was the time from the end of the procedure to full alertness. Other procedural time parameters, satisfaction profiles, and adverse effects were thoroughly evaluated. The time taken to reach peak sedation and the time from the end of the procedure to full alertness was significantly shorter in the remimazolam group than in the midazolam group (median [interquartile range], 2 min [1-4] vs. 3 min [2-5], P = 0.006; and median, 2 min [1-5] vs. 5 min [1-12], P = 0.035, respectively). In patients with non-biopsy procedures (n = 79), participant satisfaction was significantly higher in the remimazolam group than in the midazolam group (median rated scale, 10 vs. 7, P = 0.042). Physician satisfaction and willingness to repeat the procedure were similar between groups. Although the incidence of adverse effects was similar between the groups and there was no significant difference, the midazolam group had a higher antidote administration rate than the remimazolam group (15.7% vs. 4.1%, P = 0.092). Remimazolam is effective and safe for achieving adequate sedation, with a shorter onset time and faster neuropsychiatric recovery than midazolam. It may be a new option for sedation during bronchoscopy.Trial registration: The trial registration number is NCT05994547, and the date of first registration is 16/08/2023.

Diagnostic Yield and Safety of Bronchoscopist-directed Moderate Sedation With a Bolus Dose Administration of Propofol During Endobronchial Ultrasound Bronchoscopy

BACKGROUND

The propofol use for moderate sedation (MS) during endobronchial ultrasound (EBUS) bronchoscopy is primarily restricted for use by an anesthesiologist because of safety concerns. The goals of this study were to demonstrate the safety and the diagnostic yield of the use of propofol by bronchoscopists and trained endoscopy nurses during EBUS bronchoscopy without intubation.

METHODS

We tested a bolus propofol administration protocol targeting MS for EBUS bronchoscopy. A fixed initial dose of 40 mg of propofol along with a fixed 50 mcg fentanyl dose were administered. Sedation assessment was performed every 2 minutes, and repeated bolus doses of propofol were given to maintain MS under the direction of the bronchoscopist.

RESULTS

A total of 122 subjects underwent EBUS bronchoscopy with a goal of MS from August 2015 to April 2017. In total, 110 subjects who underwent convex EBUS bronchoscopy under MS with propofol were included in the analysis. Median procedure duration was 57 minutes (range, 15 to 97 min). Deep sedation and agitation-related delay were occurred in 14 and 21 subjects, respectively. Hemodynamic instability and hypoxemia occurred in 23 subjects. However, there was no need for vasopressors or artificial airway placement. Median of total propofol dose per case was 560 mg. Diagnostic yield for malignancy and granuloma was 68%, and a median of 4 lymph node stations were sampled per subject. All specimens with adenocarcinoma were sufficient for genetic marker analysis. There were no major sedation-related complications.

CONCLUSION

A bolus administration of propofol during EBUS bronchoscopy provided excellent adequacy of sedation and well tolerance safety profile.

Comparison of moderate versus deep sedation for endobronchial ultrasound transbronchial needle aspiration

RATIONALE

Most bronchoscopic procedures are performed using moderate sedation achieved by combining a short-acting benzodiazepine with an opioid agent. Propofol (2.6-diisopropylphenol), a short-acting hypnotic agent, has been increasingly used to provide deep sedation in the endoscopy community with an acceptable safety profile.

OBJECTIVES

To compare the impact of moderate versus deep sedation on the adequacy and diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

METHODS

A retrospective review of prospectively collected data was performed at two academic institutions with interventional pulmonary fellowships using two methods of sedation during EBUS (deep vs. moderate sedation). Rapid on-site cytologic evaluation was used on all procedures in both groups. EBUS-TBNA nodal sampling was considered adequate if the aspirate yielded a specific diagnosis or lymphocytes. EBUS-TBNA was considered diagnostic if a lymph node aspirate yielded a specific diagnosis or if subsequent surgical sampling or prolonged radiographic surveillance revealed no nodal pathology.

MEASUREMENTS AND MAIN RESULTS

No difference was observed in the indication for EBUS-TBNA between the two groups. More lymph nodes were sampled per patient in the deep sedation group (314 nodes from 163 patients; 2.2 nodes per patient) than in the moderate sedation group (181 lymph nodes from 146 patients; 1.4 nodes per patient; P < 0.01). The EBUS-TBNA diagnostic yield was higher for the deep sedation group (80% of patients) than for the moderate sedation group (66% of patients; P < 0.01).

CONCLUSIONS

Diagnostic yield and number of lymph nodes sampled using deep sedation is superior to moderate sedation in patients undergoing EBUS-TBNA. Prospective studies accounting for other factors including patient selection and cost are needed.

Sedation With Meperidine for Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

BACKGROUND

Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become increasingly available and more widely used for the diagnosis of mediastinal lymph node lesions, there are few reports regarding methods of anesthesia. We conducted a retrospective study assessing the efficacy of meperidine (MP) for EBUS-TBNA.

METHODS

Sixty cases that underwent EBUS-TBNA between January 2006 and December 2009 at the Kameda Medical Center were retrospectively analyzed. We classified them into 2 groups: cases that were performed under sedation with intravenous MP cases (n=31) and cases with general anesthesia (GA cases: n=29). Furthermore, we also classified the MP cases into 2 groups: patients above 65 years of age (elderly patients) and the others (young patients) to assess the safety of MP for the elderly.

RESULTS

MP of 35 mg was administered just before EBUS-TBNA. Mean age, weight, physical status (American Society of Anesthesiologists grade), the size of the lesions, and examination time were not different between the MP and GA cases. Although the mean number of centesis for the MP cases was less than that of the GA cases (2.7 vs. 3.2 times; P<0.05), accurate diagnostic rates and sensitivity and specificity of each disorder were not different. Although the lowest saturation of peripheral oxygen during examination of the MP cases was lower than that of the GA cases (93.6% vs. 97.6%; P<0.05), GA cases required more vasopressor for a decline in the blood pressure than MP cases. Finally, none of the cases had any complications during or after the examination. In comparison between the elderly and young patients, the physical status, examination time, and the frequency or degree of complications were not different either.

CONCLUSIONS

EBUS-TBNA under the intravenous sedation by MP was as feasible and safe as that under GA. It has a possibility to be one of the effective drugs for sedation during EBUS-TBNA regardless of age, and we should analyze its safety and efficacy in prospective studies henceforth.

Fospropofol Disodium for Sedation in Elderly Patients Undergoing Flexible Bronchoscopy

BACKGROUND: Fospropofol disodium is a water-soluble prodrug of propofol. A subset analysis was undertaken of elderly patients (≥65 y) undergoing flexible bronchoscopy, who were part of a larger multicenter, randomized, double-blind study. METHODS: Patients received fentanyl citrate (50 mcg) followed by fospropofol at initial (4.88mg/kg) and supplemental (1.63mg/kg) doses. The primary end point was sedation success (3 consecutive Modified Observer's Assessment of Alertness/Sedation scores of ≤4 and procedure completion without alternative sedative or assisted ventilation). Treatment success, time to fully alert, patient and physician satisfaction, and safety/tolerability were also evaluated. RESULTS: In the elderly patients subset (n=61), sedation success was 92%, the mean time to fully alert was 8.0±10.9 min, and memory retention was 72% during recovery, and these were comparable with the younger patients subgroup (age, <65 y). Sedation-related adverse events occurred in 23% of the elderly and 18% of the younger patients (age, <65 y) group. Hypoxemia occurred in 26% of the elderly and 18% of the younger patients group, but no escalation of care was required. CONCLUSIONS: Fospropofol provided safe and effective sedation, rapid time to fully alert, and high satisfaction in this elderly subset undergoing flexible bronchoscopy, which was comparable with outcomes in younger patients.

Comparison of alfetanil and ketamine in combination with propofol for patient-controlled sedation during fiberoptic bronchoscopy

BACKGROUND

During fiberoptic bronchoscopy, propofol, ketamine, benzodiazepines, and opiates are most commonly used, alone or in combination for sedation. The aim of this study was to compare the clinical efficacy of propofol/ketamine with propofol/alfentanil for patient-controlled sedation (PCS) during fiberoptic bronchoscopy.

METHOD

Patients undergoing fiberoptic bronchoscopy were randomly assigned to receive either propofol/alfentanil (PA group; n = 138) or propofol/ketamine (PK group; n = 138) via a patient-controlled analgesia (PCA) device for sedation and analgesia. Changes in blood pressure, heart rate (HR), and oxygen saturation were monitored. Degree of patient and bronchoscopist satisfaction was evaluated using a 10-cm visual analog scale (VAS) (0 = extremely uncomfortable to 10 = extremely comfortable).

RESULTS

After sedation, systolic arterial pressure (SAP) decreased in the PA group, but SAP was stable in the PK group. Compared with values immediately before starting bronchoscopy, SAP and HR increased during the procedure in both groups (P < 0.05). Patients in the PK group showed more satisfaction [(9.5 (6-10) vs. 9.0 (6-10)), P < 0.05] and amnesia (82% vs. 61%, P < 0.01). Despite these differences, the majority (greater than 90%) of the patients in both groups stated that they were comfortable during the procedure.

CONCLUSION

Our results show that although both techniques proved effective for sedation in patients undergoing fiberoptic bronchoscopy, ketamine is superior to alfentanil when used in combination with propofol because of the high patient satisfaction and amnesia.

Should patients undergoing a bronchoscopy be sedated?

BACKGROUND

The techniques, drugs and depth of sedation for flexible fiberoptic bronchoscopy is controversial, and several reports consider that the routine use of sedation is not a prerequisite. We evaluate whether the addition of sedation with propofol improves patient tolerance, compared to local anesthesic of the airway only.

METHODS

Eighteen patients with pneumonia undergoing flexible fiberoptic bronchoscopy were included in a randomized, single blind, prospective controlled study. The non-sedation group received airway topical anesthesia, whereas the sedation group received topical anesthesia and intravenous sedation with propofol. The degree of pain, cough, sensation of asphyxiation, degree of amnesia, global tolerance and acceptance of another bronchoscopy in the future were noted. Changes in blood pressure, heart rate and saturation of oxygen by pulse oximetry were also evaluated.

RESULTS

The patients in sedation group had less cough (P < 0.05), pain (P < 0.01) and sensation of asphyxiation (P < 0.001). Global tolerance to the procedure was significantly better in the group under sedation (P < 0.01). These patients had total amnesia to the procedure (P < 0.0001), thus is more probable that will accept another bronchoscopy in the future (P < 0.01). There was a significant rise in heart rate and blood pressure in the patients without sedation. There were no differences in oxygen saturation (P = 0.75).

CONCLUSIONS

Our results show that if we administer propofol for sedation, in addition to local anesthesia of the airway, the tolerance to the procedure is much better. Also it appears that sedation with propofol is safe if we carefully select and monitor the patient.

Fibre-optic bronchoscopy in adults: a position paper of The Thoracic Society of Australia and New Zealand

Fibre-optic bronchoscopy in adults is a common procedure in clinical respiratory practice. Under controlled conditions it is safe, resulting in relatively few significant adverse events. The present position paper updates guidelines previously published by The Thoracic Society of Australia and New Zealand and is based on evidence obtained by searching the Medline and Embase databases. The level of evidence to support recommendations is indicated in the text. Where no evidence has been found, the guidelines reflect the opinions of the authors. Specific recommendations are made regarding sedation and anaesthesia, the cleaning of bronchoscopes and the training of bronchoscopists.

Role of bronchoscopy in modern medical intensive care unit

This article gives a broad overview of the increasingly important applications of bronchoscopy, flexible (FOB) and rigid (RB), in a modern medical intensive care unit. Special emphasis is made to bronchoscopy use in mechanically ventilated patients. Therapies such as endobronchial stenting and Nd:YAG laser are being used to improve respiratory failure and facilitate weaning from mechanical ventilation. Practical applications of recent advancements in technology (endobronchial stenting, laser therapy, and so forth), the increasing use of rigid bronchoscopy, and the new generation of flexible bronchoscopes like battery bronchoscopes, and ultra-thin bronchoscopes, are also discussed. The risks, potential benefits, complications, and suggested technique of performing bronchoscopy in mechanically ventilated patients are reviewed.

Remifentanil and propofol for sedation in children and young adolescents undergoing diagnostic flexible bronchoscopy

Flexible fibreoptic bronchoscopy (FOB) has become a useful diagnostic and therapeutic procedure in children. We investigated 26 patients (3-14 years) for FOB using a new sedation strategy. All patients received oral premedication and inhalation of topical anaesthetic. Sedation for bronchoscopy was achieved with a continuous infusion of remifentanil and intermittent boluses of propofol. Propofol injection was repeated if sedation was inadequate. Sedation could be successfully performed in all children without adverse effects. Endtidal CO2 concentration and arterial oxygen saturation remained stable throughout the study. All children were awake 5+/-1.3 min after stopping remifentanil infusion. Sedation with remifentanil/propofol is a new sedation strategy for diagnostic flexible paediatric bronchoscopy in children with spontaneous ventilation.

Patient satisfaction with conscious sedation for bronchoscopy

STUDY OBJECTIVE

Bronchoscopic technique is not standardized. Controversies exist with regard to premedication with sedatives before the test. To evaluate safety and efficacy of conscious sedation, we studied 100 randomized patients undergoing diagnostic bronchoscopy; patients received premedication with lidocaine spray and atropine sulfate i.m. (nonsedation group; 50 patients) or lidocaine spray, atropine i.m. and diazepam i.v. (sedation group; 50 patients).

METHODS AND RESULTS

Monitoring during flexible fiberoptic bronchoscopy included continuous ECG and pulse oximetry. The procedure could not be completed in six patients. None received premedication with diazepam; among the patients who ended the examination, tolerance to the examination (visual analogue scale, 0 to 100; 0 = excellent; 100 = unbearable) was better in the sedation group. Low anxiety, male sex, but not age were also associated with improved patient tolerance to the test. Oxygen desaturation occurred in 17% of patients, and it was not more frequent after diazepam treatment.

CONCLUSIONS

In our study, sedation had a beneficial effect on patient tolerance and rarely induced significant alterations in cardiorespiratory monitoring parameters.

[Consensus guidelines for respiratory endoscopy issued by the Argentine Society of Bronchoesophagology]

The international consensus is that guidelines for respiratory endoscopy are inadequate, regarding such issues as institutional requirements, benefits, risks and limitations of the procedure, training programs and accreditation, with the result that the way or performing endoscopy varies according to how an operator was trained. The absence of precise recommendations means that practice is highly diverse and inappropriate use of the procedure has increased. The Argentine Consensus Group for Normalization of Respiratory Endoscopy was created in 1995 to unify criteria for several aspects of endoscopic practice. The official recommendations of the Group and of the Argentine Society of Bronchoesophagology define the indications (diagnostic, therapeutic and investigative) and contraindications (absolute, relative and high risk) for bronchoscopy. Required pre-bronchoscopic studies for routine and special cases are defined, as are indications for premedication, intubation and general anesthesia. Requirements for the setting, support personal and instruments are specified. Guidelines for topical anesthesia and techniques for insertion of the endoscope are suggested. The technique, indications and limitations of bronchoalveolar lavage, bronchial brushing and biopsy and transbronchial needle biopsy are defined. The utility and limitations of the various therapeutic techniques of bronchoscopy (laser, radiotherapy and stents) are defined. Norms to safeguard the patient, instruments and operator are emphasized.

Myocardial ischemia in sedated patients undergoing fiberoptic bronchoscopy

STUDY OBJECTIVE

To study the incidence of myocardial ischemia and related hemodynamic alterations in sedated patients undergoing fiberoptic bronchoscopy (FOB).

DESIGN

Prospective study.

SETTING

Tertiary care, university hospital.

PATIENTS

Twenty-nine patients, age 50 years or older, undergoing elective FOB.

INTERVENTIONS

Myocardial ischemia was assessed by continuous ECG monitoring beginning 30 min before, and until 2 h after FOB.

MEASUREMENTS AND RESULTS

During FOB, there was a significant rise in heart rate (89+/-3 [mean+/-SE] to 120+/-4 beats/min) and fall in oxygen saturation (95+/-1 to 90+/-1%). There was no significant rise in systolic or diastolic BP. Five patients (17%) had myocardial ischemia during FOB that lasted 20+/-8 min. Their demographic and pre-FOB characteristics were not different from the other patients. Compared to baseline values, a significant rise in heart rate, a fall in oxygen saturation, and no significant change in BP were observed during FOB in patients, both with or without ischemia. Although not statistically significant, ischemia was associated with more protracted procedures.

CONCLUSIONS

Myocardial ischemia may develop in elderly patients undergoing FOB. This observation encourages the routine use of ECG and oximetry during FOB, allowing for early intervention to prevent the dangerous combination of hypoxia, tachycardia, and myocardial ischemia. Moreover, this study suggests that methods to ensure oxygenation during FOB should be adhered to, and that the routine administration of atropine should be reconsidered.

Sedation for fibre optic bronchoscopy

Most current sedative regimens for fibre optic bronchoscopy use an opioid, a benzodiazepine or a combination of both. This study compares midazolam (M) (a benzodiazepine), alfentanil (A) (an opioid) and a combination of both drugs (M+A). One hundred and three patients were randomized in double-blind manner into groups M(35), A(33) and M+A(35). The number of coughs, number of additional aliquots of lignocaine and duration of the procedures were recorded along with oxygen desaturation. The patient's level of discomfort was assessed by patient and bronchoscopist and expressed as a visual analogue score. There were significantly fewer coughs per minute in Group A compared with Group M (P = 0.0053), and significantly less lignocaine was required in Group A (P = 0.005) and in Groups M+A (P < 0.002) compared with Group M. There was no significant difference in the assessment of discomfort between the groups. There was a trend for Group M+A to desaturate more than the other two with a significant difference between desaturation in Group M+A and Group A (P = 0.033). Alfentanil is a more effective anti-tussive agent than midazolam for outpatient fibre optic bronchoscopy. The combination of alfentanil and midazolam does not provide any better anti-tussive effect and may have the risk of a greater degree of desaturation secondary to increased sedation.

[Diprivan: sedation for difficult intubation]

No study has compared anaesthetic protocols appropriate for the sedation for fiberoptic tracheal intubation. Extrapolation of results of randomised studies comparing sedation techniques for diagnostic bronchoscopy under local anaesthesia enables the following conclusions: 1. Possible hypnotic agents for this procedure are benzodiazepines, barbiturates and propofol. Fentanyl improves the conditions for bronchoscopy. 2. Sedation using propofol is a well established technique. The induction dose, given as a bolus injection is 1 mg.kg-1, followed by continuous maintenance infusion of 1 mg.kg.h-1. 3. Irrespective of the sedation protocol used, there is always respiratory depression which justifies the need for preoxygenation, continuous oxygenation and Spo2 monitoring. Reversal of benzodiazepine and opioid effects may temporarily protect against respiratory depression.

A comparative evaluation of propofol and midazolam as sedative agents in fiberoptic bronchoscopy

Propofol, a new intravenous sedative agent, was investigated in 41 asthmatic patients undergoing day-case (outpatient) fiberoptic bronchoscopy. The study design was a randomized comparison between propofol and midazolam, which is a well-established intravenous sedative agent. The age, weight, and American Society of Anesthesiologists physical status and lung function of the two groups were not significantly different. Mean (SD) induction dose of propofol was 104.7 (30.1) mg with a maintenance dose of 121.9 (38.5) mg. Corresponding values of midazolam were 9.3 (3.1) mg and 3.7 (2.3) mg. The required level of sedation was achieved significantly faster with propofol, mean (SD) 125.4 (39.8) s, compared with midazolam, 179.4 (55.2) s (p < 0.001). Significantly faster recovery was noted with propofol compared with midazolam in terms of time to recall name and date of birth 2.3 (1.7) min vs 6.3 (8.6) min, (p < 0.045). Alertness scored with the digital symbol substitution test (DSST) returned to prebronchoscopy values in the propofol group at 30 min, DSST score = 35.9 (18.2) vs 13.4 (9.1), in the midazolam group (p < .0001) and was still significantly higher at 90 min-39.4 (17.9) and 23.1 (13.8) (p < 0.01). We conclude that propofol is a useful sedating agent in fiberoptic bronchoscopy with similar efficacy to midazolam but with a faster onset of action and a more rapid recovery. These represent significant advantages for day-case procedures.

Technique and use of transbronchial biopsy in children and adolescents

Since July 1988, a total of 92 transbronchial biopsies (TBB) have been performed in 18 patients (aged 3-16 years). Twelve patients (67%) were heart-lung transplant (HLT) recipients undergoing surveillance for pulmonary graft rejection and infection. The remainder included immunocompromised patients at risk of opportunistic infections (n = 4), patients with fibrosing alveolitis (n = 1) and a collagen vascular disorder with suspected lung involvement (n = 1). TBB was performed through either a fiberoptic (n = 50) or a rigid (n = 41) bronchoscope, all under general anesthesia. On one occasion a cardiac bioptome was used through an endotracheal stent. The sensitivity of TBB for diagnosing acute and chronic rejection in HLT patients was 88% and 60%, respectively (specificity, 91% and 100%). Definitive diagnoses were made in 4 (67%) of the non-HLT group. Bronchoalveolar lavage (BAL) was performed during each procedure for microbiological and cytological examination. Thirty-four pathogenic organisms including Pseudomonas aeruginosa (16/34), Staphylococcus aureus (8/34), and Candida albicans (5/34) were isolated from BAL culture. Complications included pneumothorax (8%), transient pyrexia (7%), and dyspnea (2%).

Sedation for bronchofiberoscopy: comparison between propofol infusion and intravenous boluses of fentanyl and diazepam

Two methods of sedation were evaluated in unpremedicated patients undergoing elective bronchofiberoscopy. The patients were randomly allocated to receive either propofol infusion 1 mg kg-1 h-1 preceded by a 1 mg kg-1 bolus (15 patients) (the propofol group) or intravenous fentanyl 1 micrograms kg-1 and diazepam 0.05 mg kg-1 (15 patients) (the fentanyl+diazepam group). Thirteen patients were treated twice during the study period and sedated with both methods (the first treatment according to random order and the second with the method not used on the first occasion). A topical anaesthetic was applied to the selected nostril with two cotton swabs soaked in 4% lidocaine. Epiglottis, vocal cords, trachea and bronchi were anaesthetized by spraying 4% lidocaine through the working channel of the fiberoscope as the instrument was advanced. The patients in the propofol group were more sedated than those in the fentanyl+diazepam groups (P less than 0.01). The working conditions were the same. After sedation, respiratory frequency decreased only in the fentanyl+diazepam group (P less than 0.05). Before sedation, haemoglobin saturation of oxygen was 95 +/- 2% (mean +/- s.d.) in the propofol group and 94 +/- 3% in the fentanyl+diazepam group. Immediately before the start of bronchofiberoscopy, it was 89 +/- 4% and 90 +/- 3%, respectively. The decrease was statistically significant in both groups (P less than 0.001). After sedation, systolic arterial pressures (SAP) decreased in both groups (P less than 0.01). Compared to values immediately before starting bronchofiberoscopy, SAP increased during the procedure in both groups (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of atelectasis with selective bronchial suctioning. Use of a curved-tipped catheter with a guide mark

We applied our technique of selective bronchial suctioning (SBS) for the treatment of atelectasis (AT) of middle and lower lobes; nine patients with refractory ATs were successfully treated. We considered that SBS using a curve-tipped catheter with a guide mark (CTCGM) is the technique of choice for the treatment of refractory AT when conventional respiratory therapy is not effective and a bronchoscopist is not available.

Fiberoptic bronchoscopy without premedication. A retrospective study

The objective of this study was to determine if flexible FOB could be performed safely without premedication other than topical anesthesia. A total of 281 procedures performed during a 12-month period at a VA medical center were reviewed. Ninety-one procedures performed without premedication were compared with 190 procedures performed with premedication. Complications occurred in 5 percent of patients in each group. Statistical analysis revealed no significant differences in age, spirometry, P(A-a)O2 or SaO2 between both groups. Despite the proven safety of outpatient FOB without sedation, many bronchoscopists administer complicated premedication regimens and employ ambulatory surgery beds or recovery rooms to monitor patients before and after procedures. These results support a simplified approach to routine FOB which would include no premedications and greater use of outpatient facilities resulting in decreased expenditures without compromising patient care, safety or comfort.