Dextromethorphan premedication reduces midazolam requirement: objective and subjective parameters in peribronchoscopy

Dextromethorphan premedication in the alleviation of cough during flexible bronchoscopy in adults: A randomized double-blind placebo-controlled trial

BACKGROUND AND OBJECTIVE

Cough is invariably encountered during flexible bronchoscopy despite sedation and topical anaesthetics. The ideal cough suppressant during flexible bronchoscopy is not known. We assessed the role of dextromethorphan premedication in relieving the cough during flexible bronchoscopy in adults.

METHODS

In this single-centre study, we randomized patients aged ≥18 years to receive dextromethorphan syrup 30 ml (90 mg) or an equal volume of placebo 1 h before the procedure. Patients rated their cough severity and discomfort on a visual analogue scale at the end of the procedure. Bronchoscopists also rated cough severity at the end of the procedure.

RESULTS

Out of 112 patients screened, 94 patients (median (interquartile range [IQR]) age 51 (36.25-60.75) years, male: female 2.13:1) were randomized to either the dextromethorphan (n = 47) or placebo (n = 47) groups. The patients-rated median (IQR) cough scores at the end of the procedure were 15 (10-23) mm in dextromethorphan versus 20 (12-45.5) mm in placebo groups (p = 0.03). Patients-rated median cough scores at 1 h (5 mm vs. 6 mm, p = 0.21), discomfort scores (12.5 mm vs. 12.5 mm, p = 0.49), and midazolam and lignocaine usage were similar between the two groups. The bronchoscopist-rated median cough score was non-significantly lower in the intervention compared to the placebo (26 mm vs. 35 mm, p = 0.09) groups.

CONCLUSION

Dextromethorphan premedication 1 h before flexible bronchoscopy may have an additive effect on cough suppression under conscious sedation and topical lignocaine. Further trials are needed to reiterate our findings with certainty.

Conventional flexible bronchoscopy during the COVID pandemic: A consensus statement from the Indian Association for Bronchology

During the times of the ongoing COVID pandemic, aerosol-generating procedures such as bronchoscopy have the potential of transmission of severe acute respiratory syndrome coronavirus 2 to the healthcare workers. The decision to perform bronchoscopy during the COVID pandemic should be taken judiciously. Over the years, the indications for bronchoscopy in the clinical practice have expanded. Experts at the Indian Association for Bronchology perceived the need to develop a concise statement that would assist a bronchoscopist in performing bronchoscopy during the COVID pandemic safely. The current Indian Association for Bronchology Consensus Statement provides specific guidelines including triaging, indications, bronchoscopy area, use of personal protective equipment, patient preparation, sedation and anesthesia, patient monitoring, bronchoscopy technique, sample collection and handling, bronchoscope disinfection, and environmental disinfection concerning the coronavirus disease-2019 situation. The suggestions provided herewith should be adopted in addition to the national bronchoscopy guidelines that were published recently. This statement summarizes the essential aspects to be considered for the performance of bronchoscopy in COVID pandemic, to ensure safety for both for patients and healthcare personnel.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

The Effect of Dextromethorphan Premedication on Cough and Patient Tolerance During Flexible Bronchoscopy: A Randomized, Double-blind, Placebo-controlled Trial

BACKGROUND

Patients undergoing bronchoscopy can experience problems such as anxiety and cough, requiring various doses of sedatives and analgesics. The purposes of this study were to investigate the effect of premedication with dextromethorphan on patients' cough and anxiety, and the use of analgesics/sedatives during flexible bronchoscopy (FB).

METHODS

A randomized, double-blind, placebo-controlled, prospective study was performed to assess the effect of dextromethorphan premedication on patients who underwent diagnostic bronchoscopy. Seventy patients included in this study were randomly allocated into 2 groups: group A consisted of 35 patients who received dextromethorphan before FB; and group B consisted of 35 patients who received a placebo. A questionnaire was given to the patients and bronchoscopist about perception of cough, anxiety, and discomfort. The amount of sedative medication and lidocaine use during the procedure and the procedure time were recorded.

RESULTS

The group that was premedicated with dextromethorphan had lower complaint scores, significantly less coughing, significantly less stress assessed by the patient and the physician evaluation, shorter total procedure time, and fewer midazolam requirements during FB (P-value <0.05).

CONCLUSION

Considering its safety profile, dextromethorphan premedication is an effective approach to facilitate the performance of FB for the physician, and could improve patient comfort.

Complications and discomfort of bronchoscopy: a systematic review

Objective

To identify bronchoscopy-related complications and discomfort, meaningful complication rates, and predictors.

Method

We conducted a systematic literature search in PubMed on 8 February 2016, using a search strategy including the PICO model, on complications and discomfort related to bronchoscopy and related sampling techniques.

Results

The search yielded 1,707 hits, of which 45 publications were eligible for full review. Rates of mortality and severe complications were low. Other complications, for instance, hypoxaemia, bleeding, pneumothorax, and fever, were usually not related to patient characteristics or aspects of the procedure, and complication rates showed considerable ranges. Measures of patient discomfort differed considerably, and results were difficult to compare between different study populations.

Conclusion

More research on safety aspects of bronchoscopy is needed to conclude on complication rates and patient- and procedure-related predictors of complications and discomfort.

The effect of remifentanil on the emergence characteristics of children undergoing FBO for bronchoalveolar lavage with sevoflurane anaesthesia

BACKGROUND AND OBJECTIVE

The aim of this study was to compare the effects of sevoflurane vs. sevoflurane and remifentanil on cough and agitation during emergence and recovery after fiberoptic bronchoscopy.

METHODS

Children between 2 and 6 years of age undergoing fiberoptic bronchoscopy were enrolled. All patients were premedicated with oral midazolam. Patients were randomly assigned to either group S (sevoflurane alone, n = 25) or group SR (sevoflurane with remifetanil, n = 25). Anaesthesia was induced and maintained with sevoflurane in all patients. Group SR received remifentanil at a bolus dose of 1 microg/kg over 2 min followed by a maintenance infusion of 0.15 microg/kg/min. In addition to routine anaesthesia documentation, agitation scores and cough scores were recorded every 5 min during emergence and recovery.

RESULTS

Duration of the procedure, anaesthesia and emergence phases was similar in both groups (P > 0.05). Time until recovery was significantly shorter in group SR than in group S (7.0 +/- 5.5 min and 13.0 +/- 3.5 min, respectively; P = 0.001). Cough scores were not significantly different between the two groups during emergence and recovery (Kruskal-Wallis ANOVA test, P > 0.05). However, the mean agitation score at 5 min in group SR was significantly higher than that in group S (Kruskal-Wallis ANOVA test, P < 0.01). One case of hypoxaemia from thoracic rigidity occurred in a patient in group SR.

CONCLUSION

The addition of remifentanil significantly shortened recovery time in children undergoing fiberoptic bronchoscopy under sevoflurane anaesthesia. In the recovery period, remifentanil did not decrease cough, and increased agitation.