Dexmedetomidine-ketamine combination versus fentanyl-midazolam for patient sedation during flexible bronchoscopy: a prospective, single-blind, randomized controlled trial

BACKGROUND

Sedation during flexible bronchoscopy (FB) should maintain an adequate respiratory drive, ensure maximum comfort for the patient, and warrant that the objectives of the procedure are achieved. Nevertheless, the optimal sedation method for FB has yet to be established. This study aimed to compare the standard recommended combination of midazolam-fentanyl (MF) with that of dexmedetomidine-ketamine (DK) for patient sedation during FB.

METHODS

Patients subjected to FB were randomly assigned to a DK (n = 25) and an MF group (n = 25). The primary outcome was the rate of critical desaturation events (arterial oxygen saturation < 80% with nasal oxygen supply 2 L/min). Secondary outcomes included sedation depth, hemodynamic complications, adverse events, and patient and bronchoscopist satisfaction.

RESULTS

The incidence rates of critical desaturation events were similar between the two groups (DK: 12% vs. MF: 28%, p = 0.289). DK achieved deeper maximum sedation levels (higher Ramsay - lower Riker scale; p < 0.001) and was associated with longer recovery times (p < 0.001). Both groups had comparable rates of hemodynamic and other complications. Patient satisfaction was similar between the two groups, but bronchoscopist satisfaction was higher with the DK combination (p = 0.033).

CONCLUSION

DK demonstrated a good safety profile in patients subjected to FB and achieved more profound sedation and better bronchoscopist satisfaction than the standard MF combination without increasing the rate of adverse events.

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.

Effects of dexmedetomidine in non-operating room anesthesia in adults: a systematic review with meta-analysis

BACKGROUND

Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist used for its sedative, analgesic, and anxiolytic effects. Non-Operating Room Anesthesia (NORA) is a modality of anesthesia that can be done under general anesthesia or procedural sedation or/and analgesia. In this particular setting, a level-2 sedation, such as the one provided by DEX, is beneficial. We aimed to study the effects and safety of DEX in the different NORA settings in the adult population.

METHODS

A systematic review with meta-analysis of randomized controlled trials was conducted. Interventions using DEX only or DEX associated with other sedative agents, in adults (18 years old or more), were included. Procedures outside the NORA setting and/or without a control group without DEX were excluded. MEDLINE, ClinicalTrials.gov, Scopus, LILACS, and SciELO were searched. The primary outcome was time until full recovery. Secondary outcomes included hemodynamic and respiratory complications and other adverse events, among others.

RESULTS

A total of 97 studies were included with a total of 6,706 participants. The meta-analysis demonstrated that DEX had a higher time until full recovery (95% CI = [0.34, 3.13] minutes, a higher incidence of hypotension (OR = 1.95 [1.25, 3.05], p = 0.003, I2 = 39%) and bradycardia (OR = 3.60 [2.29, 5.67], p < 0.00001, I2 = 0%), and a lower incidence of desaturation (OR = 0.40 [0.25, 0.66], p = 0.0003, I² = 60%).

CONCLUSION

DEX in NORA procedures in adults was associated with a lower incidence of amnesia and respiratory effects but had a long time to recovery and more hemodynamic complications.

Tracheal stenting by rigid bronchoscopy in right lateral decubitus position in an awake patient

Rigid bronchoscopy is a common procedure for central airway obstructions (CAO). Many patients with advanced lesions causing CAO have tenuous, positionally dependent respiratory status which requires additional procedural considerations. This case report describes a 57-year-old man with high grade epithelioid angiosarcoma of the right lung and pleura who underwent placement of a tracheal stent by rigid bronchoscopy in the novel procedural conditions of right lateral decubitus, semi-sitting position with dexmedetomidine, midazolam, and propofol for moderate sedation. Dexmedetomidine, which is currently in use for flexible bronchoscopy due to its analgesic, anxiolytic, and antisialogogue properties performed ideally and should be further evaluated for this indication.

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.

Dexmedetomidine Versus Midazolam for Sedation During Medical Thoracoscopy: A Pilot Randomized-Controlled Trial (RCT)

BACKGROUND

Studies comparing the utility of dexmedetomidine with other drugs for sedation during medical thoracoscopy are lacking. In this pilot study, we compared dexmedetomidine with midazolam for sedation in thoracoscopy.

METHODS

Consecutive subjects were randomized to receive either dexmedetomidine (n=30) (group D) or midazolam (n=30) (group M). All received fentanyl for procedural analgesia. The primary endpoint was pulmonologist-rated overall procedure satisfaction on the visual analog scale (satisfaction VAS). Key secondary outcomes were pulmonologist-rated cough on VAS (cough VAS), patient-rated faces pain scale scores, change in hemodynamic variables, total additional fentanyl dose, and adverse events during procedure.

RESULTS

The satisfaction VAS score (mean±SD) was significantly greater in group D versus group M (7.5±1.4 and 6.5±1.1, respectively) ( P =0.003). The cough VAS scores (mean±SD) were 2.1±1.5 (group D) and 3.1±1.3 (group M) ( P =0.014). The scores (mean±SD) for patient-rated faces pain scale were 2.9±1.8 and 4.2±2.3 ( P =0.019) in group D and group M, respectively. The additional dose of fentanyl administered in group M was significantly greater than in group D ( P =0.001). The responses at the local anesthesia infiltration, skin incision, thoracoscope insertion, and biopsy between both groups were similar. The hemodynamic parameters were comparable in both groups. Also, more patients were willing for repeat thoracoscopy if needed; in the dexmedetomidine group.

CONCLUSION

The findings of this pilot RCT indicate that dexmedetomidine may be more efficacious than midazolam for sedation in patients undergoing medical thoracoscopy. These observations need to be confirmed in an adequately powered RCT.

Dexmedetomidine versus propofol sedation in flexible bronchoscopy: a randomized controlled trial

Background

Dexmedetomidine (DEX), is a highly selective alpha2 adrenoceptor (α2-AR) agonist, successfully used in various procedures including flexible bronchoscopy. Randomized controlled trials (RCTs) evaluating DEX sedation during bronchoscopy report equivocal results regarding respiratory and hemodynamic outcomes.

Methods

We conducted an RCT to evaluate the efficacy and safety of dexmedetomidine compared to propofol for sedation during bronchoscopy. The primary outcome was the number of desaturation events, secondary outcomes were transcutaneous Pco2 level, hemodynamic adverse events and physician and patient satisfaction.

Results

Overall, 63 patients were included, 30 and 33 in the DEX and propofol groups, respectively. The number of desaturation events was similar between groups, median (IQR) 1 (0–1) and 1 (0–2) in the DEX and control groups, respectively (P = 0.29). Median desaturation time was 1 (0–2) and 1 (0–3) minutes in the DEX and control groups, respectively (P = 0.48). Adverse events included hypotension, 33% vs 21.1% in intervention and control groups, respectively (P = 0.04), bradycardia, cough, and delayed recovery from sedation. Total adverse events were 22 and 7 in DEX and propofol groups, respectively (P = 0.009).

Conclusion

Dexmedetomidine sedation during bronchoscopy did not show differences in oxygen saturation and transcutaneous CO2 level in comparison to propofol. Moreover, DEX sedation required a significantly higher number of rescue boluses, due to inadequate sedation and was associated with a higher rate of adverse events.

Trial registration NCT04211298, registration date: 26.12.2019.

Clinical usefulness of intermediate-dose dexmedetomidine (0.75 μg/kg) in flexible bronchoscopy - A prospective, randomized, double-blinded study

BACKGROUND:

Dexmedetomidine, although an effective drug for conscious sedation during flexible bronchoscopy, has occasional side effects on the cardiovascular system which need to be addressed.

MATERIALS AND METHODS:

Patients between 18 and 65 years, requiring diagnostic flexible bronchoscopy, found eligible, after screening, were randomized to either receive 0.75 μg/kg intravenous dexmedetomidine over 10 min or intravenous midazolam 0.035 mg/kg over 1 min. Composite score was used as the primary outcome measure. Additional parameters recorded were: Hemodynamic variables, oxygen saturation, Ramsay sedation score, for pain intensity and distress Numerical Rating Scale, number of rescue medication doses, ease of doing bronchoscopy, Visual Analog Scale score for cough and response of the patient 24 h after bronchoscopy.

RESULTS:

In each group, 24 patients were enrolled. The composite score was in the ideal category in 24 patients in dexmedetomidine group and 21 in midazolam group, at nasopharynx (P = 0.234). The corresponding values at the level of trachea were 23 and 16 (P = 0.023). In dexmedetomidine group, patient response after 24 h of bronchoscopy showed quality of sedation to be excellent in 0 subjects, good in 13, fair in 9 and poor in 2 and discomfort to be nil in 7, mild 10, moderate in 7 and severe in 0. The corresponding values in midazolam group for quality of sedation were 0, 4, 14, 6, and for discomfort 0, 10, 14, 0. The Visual Analog Scale (VAS) for cough revealed a mean score of 0.800 and 1.812 (P = 0.011) during and 2.092 and 3.542 (P = 0.016) 24 h after bronchoscopy in the respective study groups.

CONCLUSION:

Low-dose dexmedetomidine (0.75 μg/kg single dose) appears to provide better patient comfort and equivalent safety profile when compared with midazolam.

Review of the Physiology and Anesthetic Considerations for Pleuroscopy/Medical Thoracoscopy

Pleuroscopy or medical thoracoscopy is the second most common utilized procedure after bronchoscopy in the promising field of interventional pulmonology. Its main application is for the diagnosis and management of benign or malignant pleural effusions. Entry into the hemithorax is associated with pain and patient discomfort, whereas concurrently, notable pathophysiologic alterations occur. Therefore, frequently procedural sedation and analgesia is needed, not only to alleviate the patient's emotional stress and discomfort by mitigating the anxiety and minimizing the pain but also for yielding better procedural conditions for the operator. The scope of this review is to present the physiologic derangements occurring in pleuroscopy and compare the various anesthetic techniques and sedative agents that are currently being used in this context.

Monitored Anesthesia Care with Dexmedetomidine Supplemented by Midazolam/Fentanyl versus Midazolam/Fentanyl Alone in Patients Undergoing Pleuroscopy: Effect on Oxygenation and Respiratory Function

Although pleuroscopy is considered a safe and well tolerated procedure with a low complication rate, it requires the administration of procedural sedation and analgesia. The purpose of this study was to assess the effects of dexmedetomidine administration on oxygenation and respiratory function in patients undergoing diagnostic or therapeutic pleuroscopy. Through a prospective, single center, cohort study, we studied 55 patients receiving either a dexmedetomidine intravenous infusion supplemented by midazolam/fentanyl (Group DEX + MZ/F) or a conventional sedation protocol with midazolam/fentanyl (Group MZ/F). Our primary outcome was the changes in lung gas exchange (PaO₂/FiO₂ ratio) obtained at baseline and at predetermined end points, while changes in respiratory mechanics (FEV1, FVC and the ratio FEV1/FVC) and PaCO₂ levels, drug consumption, time to recover from sedation and adverse events were our secondary endpoints (NCT03597828). We found a lower postoperative decrease in FEV1 volumes in Group DEX + MZ/F compared to Group MZ/F (p = 0.039), while FVC, FEV1/FVC and gas exchange values did not differ between groups. We also found a significant reduction in midazolam (p < 0.001) and fentanyl consumption (p < 0.001), along with a more rapid recovery of alertness postprocedure in Group DEX + MZ/F compared to Group MZ/F (p = 0.003), while pain scores during the postoperative period, favored the Group DEX + MZ/F (p = 0.020). In conclusion, the use of intravenous dexmedetomidine during pleuroscopy is associated with a smaller decrease in FEV1, reduction of the consumption of supplementary sedatives and analgesics and quicker awakening of patients postoperatively, when compared to midazolam/fentanyl. Therefore, dexmedetomidine administration may provide clinically significant benefits in terms of lung mechanics and faster recovery of patients undergoing pleuroscopy.

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.

Dexmedetomidine versus midazolam for sedation during endobronchial ultrasound-guided transbronchial needle aspiration: A randomised controlled trial

BACKGROUND

Desaturation is a common complication of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Dexmedetomidine (DEX), a commonly used sedative in intensive care, is associated with less respiratory depression compared with other sedatives.

OBJECTIVE

We compared DEX with midazolam (MDZ) when used as a sedative during EBUS-TBNA.

DESIGN

A randomised, parallel, double-blinded trial.

SETTING

A university-affiliated teaching hospital between June 2014 and July 2015.

PATIENTS

A total of 102 patients who underwent EBUS-TBNA were randomly allocated to two groups (48 DEX group, 54 MDZ group).

INTERVENTIONS

DEX group received 0.25 to 0.75 μg kg-1 h-1 (start with 0.5 μg kg-1 h-1, modulated in three steps from 0.25 to 0.75 μg kg-1 h-1) of DEX after a loading dose of 0.25 μg kg-1 h-1 for 10 min to maintain a Ramsay Sedation Scale (RSS) of 3 to 5. If the patient was agitated, 1 mg of MDZ bolus was used as a rescue drug. Patients in the MDZ group initially received 0.05 mg kg-1 of MDZ as a bolus. For maintenance and rescue, 1 mg of MDZ bolus was used.

MAIN OUTCOME MEASURES

The primary outcome was the presence of oxygen desaturation. Secondary outcomes were level of sedation (Ramsay Sedation Scale score), cough score, sedation and procedure satisfaction score.

RESULTS

The baseline characteristics of the patients, duration of EBUS-TBNA procedures and the use of rescue MDZ were not different between the groups. There was no significant difference in desaturation events between the DEX and MDZ groups (56.3 and 68.5%, respectively; P = 0.20). The level of sedation and the sedation satisfaction scores were similar between the two groups. However, cough score was significantly lower in the DEX group (41.9 vs. 53.4; P = 0.02).

CONCLUSION

The use of DEX during EBUS-TBNA was not superior to MDZ in terms of oxygen desaturation.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02157818.

Fixed dexmedetomidine infusion versus fixed-dose midazolam bolus as primary sedative for maintaining intra-procedural sedation during endobronchial ultrasound-guided transbronchial needle aspiration: a double blind randomized controlled trial

Objective: The utility and safety of fixed dexmedetomidine infusion was compared to fixed-dose midazolam bolus among patients undergoing EBUS-TBNA.Methods: In this randomized double-blind study, 197 patients were assigned to receive dexmedetomidine (Group D, 1 μg/kg before, and 0.6 μg/kg/hour during, procedure) or midazolam (Group M, 2 mg before procedure) sedation. The primary outcome was number of rescue midazolam boluses administered to achieve Ramsay Sedation Scale (RSS) score of two or more. We also studied sedation depth during procedure, adverse hemodynamic and hypoxemic events, bronchoscopist and patient satisfaction, and time-to-discharge from recovery room.Results: Rescue midazolam requirement was significantly lesser in 99 Group D (0.9 ± 1.2 boluses) than in 98 Group M (2.0 ± 2.4 boluses), subjects. Mean RSS score was significantly higher in Group D subjects (2.5 ± 0.7 vs. 2.3 ± 0.7). Significantly more subjects in Group D developed hypotension (46 vs. 27) or bradycardia (37 vs. 5), but none required specific intervention. Bronchoscopists reported significantly greater overall procedure satisfaction in Group D subjects.Conclusion: Fixed dexmedetomidine infusion reduced need for rescue sedation during EBUS-TBNA, and allowed slightly faster post-procedure recovery, as compared to fixed-dose midazolam bolus. However, it caused hypotension and bradycardia more frequently.Clinical trial registration: www.clinicaltrials.gov identifier is NCT02713191.

Risk Factors for Predicting Hypoxia in Adult Patients Undergoing Bronchoscopy under Sedation

BACKGROUND

Flexible bronchoscopy is one of the essential procedures for the diagnosis and treatment of pulmonary diseases. The purpose of this study was to identify the risk factors associated with the occurrence of hypoxia in adults undergoing flexible bronchoscopy under sedation.

METHODS

We retrospectively analyzed 2,520 patients who underwent flexible bronchoscopy under sedation at our tertiary care university hospital in South Korea January 1, 2013-December 31, 2014. Hypoxia was defined as more than 5%-point reduction in the baseline percutaneous oxygen saturation (SpO2) or SpO2 <90% for >1 minute during the procedure.

RESULTS

The mean age was 64.7±13.5, and 565 patients developed hypoxia during the procedure. The mean sedation duration and midazolam dose for sedation were 31.1 minutes and 3.9 mg, respectively. The bivariate analysis showed that older age, a low forced expiratory volume in one second (FEV1), use of endobronchial ultrasound, the duration of sedation, and the midazolam dose were associated with the occurrence of hypoxia during the procedure, while the multivariate analysis found that age >60 (odds ratio [OR], 1.32), a low FEV1 (OR, 0.99), and a longer duration of sedation (>40 minutes; OR, 1.33) were significant risk factors.

CONCLUSION

The findings suggest that patients older than age 60 and those with a low FEV1 tend to develop hypoxia during the bronchoscopy under sedation. Also, longer duration of sedation (>40 minutes) was a significant risk factor for hypoxia.

Comparison of midazolam and low-dose dexmedetomidine in flexible bronchoscopy: A prospective, randomized, double-blinded study

BACKGROUND

Dexmedetomidine is a clinically useful drug for providing sedation, but concern regarding its cardiovascular side effect profile can limit its widespread use during routine diagnostic flexible bronchoscopy (FB).

MATERIALS AND METHODS

Patients between 18 and 65 years of age, who required diagnostic FB, were screened. Eligible patients were randomized to either receive 0.5 μg/kg intravenous dexmedetomidine over 10 min or intravenous midazolam 0.035 mg/kg over 1 min. If required, rescue medication (intravenous midazolam 0.5 mg bolus) was administered. The primary outcome measure was the composite score. Other parameters observed were numerical rating scale, hemodynamic variables, oxygen saturation, number of doses of rescue medication, visual analog scale score for cough, ease of bronchoscopy, Ramsay Sedation Score, and postprocedure patient response after 24 h of bronchoscopy.

RESULTS

A total of 54 patients were enrolled, 27 in each group. Total composite score (mean ± standard deviation) in dexmedetomidine and midazolam group at nasopharynx was 7.04 ± 2.19 and 6.59 ± 1.55 (P = 0.387), respectively. The corresponding values at the level of trachea were 9.22 ± 3.69 and 8.63 ± 2.13 (P = 0.475). In the dexmedetomidine group, patient response after 24 h of bronchoscopy showed the quality of sedation to be excellent in three patients, good in 10, fair in 11, and poor in 3 and discomfort to be nil in 14, mild 7, moderate in 3, and severe in 3. The corresponding values in the midazolam group for the quality of sedation were 0, 9, 18, 0 and for discomfort 10, 16, 1, 0. Other parameters did not reveal any statistically significant difference.

CONCLUSION

Dexmedetomidine at a dose of 0.5 μg/kg may provide clinically useful conscious sedation, comparable to midazolam.

Efficacy of premedication with intranasal dexmedetomidine for removal of inhaled foreign bodies in children by flexible fiberoptic bronchoscopy: a randomized, double-blind, placebo-controlled clinical trial

Background

Tracheobronchial foreign body aspiration in children is a life-threatening, emergent situation. Currently, the use of fiberoptic bronchoscopy for removing foreign bodies is attracting increasing attention. Oxygen desaturation, body movement, laryngospasm, bronchospasm, and breath-holding are common adverse events during foreign body removal. Dexmedetomidine, as a highly selective α₂-adrenergic agonist, produces sedative and analgesic effects, and does not induce respiratory depression. We hypothesized that intranasal dexmedetomidine at 1 μg kg − 1 administered 25 min before anesthesia induction can reduce the incidence of adverse events during fiberoptic bronchoscopy under inhalation general anesthesia with sevoflurane.

Methods

In all, 40 preschool-aged children (6–48 months) with an American Society of Anesthesiologists physical status of I or II were randomly allocated to receive either intranasal dexmedetomidine at 1 μg·kg − 1 or normal saline at 0.01 ml kg^− 1 25 min before anesthesia induction. The primary outcome was the incidence of perioperative adverse events. Heart rate, respiratory rate, parent-child separation score, tolerance of the anesthetic mask, agitation score, consumption of sevoflurane, and recovery time were also recorded.

Results

Following pre-anesthesia treatment with either intranasal dexmedetomidine or saline, the incidences of laryngospasm (15% vs. 50%), breath-holding (10% vs. 40%), and coughing (5% vs. 30%) were significantly lower in patients given dexmedetomidine than those given saline. Patients who received intranasal dexmedetomidine had a lower parent–child separation score (P = 0.017), more satisfactory tolerance of the anesthetic mask (P = 0.027), and less consumption of sevoflurane (38.18 ± 14.95 vs. 48.03 ± 14.45 ml, P = 0.041). The frequency of postoperative agitation was significantly lower in patients given intranasal dexmedetomidine (P = 0.004), and the recovery time was similar in the two groups.

Conclusions

Intranasal dexmedetomidine 1 μg·kg^− 1, with its sedative and analgesic effects, reduced the incidences of laryngospasm, breath-holding, and coughing during fiberoptic bronchoscopy for FB removal. Moreover, it reduced postoperative agitation without a prolonged recovery time.

Trail registration

The study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1800017273) on July 20, 2018.

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.

Dexmedetomidine plus sufentanil for pediatric flexible bronchoscopy: A retrospective clinical trial

Several studies have reported the use of dexmedetomidine (DEX) plus opioids for flexible bronchoscopy in both adults and children. To determine whether DEX plus sufentanil (SF) is safe for children, 142 children undergoing flexible bronchoscopy were assigned to one of three groups, each of which received the same SF loading dose and similar DEX and SF maintenance doses, but different loading doses of DEX: DS1 (DEX 0.5 μg·kg^–1), DS2 (DEX 1.0 μg·kg^–1), and DS3 (DEX 1.5 μg·kg^–1). The Ramsay sedation scale was maintained at 3 in all groups. Results showed that anesthesia onset time was shorter, and the perioperative hemodynamic profile was more stable, in the DS3 group. The number of intraoperative movements was also lowest in the DS3 group. The time to first dose of rescue midazolam and lidocaine was significantly longer, but the total corresponding accumulated doses were lower in the DS3 group. Although the time to recovery prior to discharge from the post anesthesia care unit was longer, the overall incidence of tachycardia was lower in the DS3 group, and it received the highest bronchoscopist satisfaction score among the three groups. We therefore conclude that high-dose DEX plus SF can be safely and efficaciously used in children undergoing flexible bronchoscopy.

A randomized double-blind controlled trial comparing three sedation regimens during flexible bronchoscopy: Dexmedetomidine, alfentanil and lidocaine

INTRODUCTION

No standardized sedation protocol is available for flexible bronchoscopy (FB).

OBJECTIVES

The aim of this study was to evaluate the efficacy and safety of three regimens used for sedation during FB.

METHODS

This randomized double-blind controlled trial assessed patients undergoing bronchoscopy and receiving lidocaine alone (C) or combined with dexmedetomidine (D) or alfentanil (A). Tolerance was assessed using the bronchoscopy score, and level of sedation was assessed using the Nursing Instrument for the Communication of Sedation. Safety was evaluated in terms of pulmonary function and vital signs.

RESULTS

A total of 162 patients were enrolled. The bronchoscopy score was identical in all groups. Group D subjects were the most sedated (P = .013), whereas group A subjects were the least agitated. Linear regression showed a negative association between bronchoscopy score and age in A (β = -0.06; P = .001). Positive predictors of bronchoscopy score were female gender (β = 1.96; P = .003) in D and obesity (β = 2.41; P = .012), longer procedures (β = 0.08; P = .009) and female gender (β = 1.15; P = .038) in C. Longer procedures (β = -0.12; P = .010) was a negative predictor of bronchoscopy score in D. Desaturation, hypoxia and heart rate changes were most prevalent in group A. Hypotension was mostly observed in D.

CONCLUSIONS

No consistent differences were present between the three regimens; however, each was more appropriate in certain patient profiles. We consequently proposed a protocol as a first step towards standardizing sedation practice in FB in a patient-tailored manner. A more comprehensive and detailed protocol including other sedative agents with their corresponding doses should be developed.

Effect of dexmedetomidine and midazolam for flexible fiberoptic bronchoscopy in intensive care unit patients: A retrospective study

This study aimed to investigate the clinical effectiveness of dexmedetomidine and midazolam for sedation of intensive care unit (ICU) patients requiring flexible fiberoptic bronchoscopy (FFB).This retrospective cohort study included 148 patients from the third ICU ward of the Second Affiliated Hospital of Harbin Medical University (Harbin, China) who received simultaneous invasive mechanical ventilation and FFB between March 2012 and December 2014. Patients were divided into dexmedetomidine (n  =  72) and midazolam (n  =  76) groups according to sedative mode. The sedative effects, incidence of adverse events, and bronchoscopist satisfaction scores were compared between groups.During FFB, total sedation time and total time of FFB were significantly shorter in the midazolam group (P < .001, respectively), with a lower percentage of these patients requiring propofol for remedial sedation (P < .001). The incidence of FFB-related adverse events (including bronchospasm, cough, and decreased oxygen saturation) was significantly higher in dexmedetomidine group compared with midazolam group (P  =  .007, .014 and .008, respectively). However, the incidence of other adverse events was not significantly different between groups. In addition, bronchoscopist satisfaction scores were significantly higher in the midazolam compared with dexmedetomidine group (7.72 ± 1.65 vs 7.08 ± 1.77; P  =  .030).For sedation of ICU patients during FFB, combination of midazolam and dexmedetomidine demonstrated an enhanced sedative effect, lower incidence of adverse events, and higher bronchoscopist satisfaction score compared with dexmedetomidine alone, thus represents a suitable alternative sedative for FFB patients.

The safety and efficacy of dexmedetomidine-remifentanil in children undergoing flexible bronchoscopy: A retrospective dose-finding trial

Flexible bronchoscopy is more and more used for diagnosis and management of various pulmonary diseases in pediatrics. As poor coordination of children, the procedure is usually performed under general anesthesia with spontaneous or controlled ventilation to increase children and bronchoscopists' safety and comfort. Previous studies have reported that dexmedetomidine (DEX) could be safely and effectively used for flexible bronchoscopy in both adulate and children. However, there is no trial to evaluate the dose-finding of safety and efficacy of dexmedetomidine-remifentanil (DEX-RF) in children undergoing flexible bronchoscopy.The objective of this study is to evaluate the dose-finding of safety and efficacy of DEX-RF in children undergoing flexible bronchoscopy.One hundred thirty-five children undergoing flexible bronchoscopy with DEX-RF were divided into 3 groups: Group DR1 (n = 47, DEX infusion at 0.5 μg·kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; RF infusion at 0.5 μg kg for 2 minutes, then adjusted to 0.05-0.2 μg kg min), Group DR2 (n = 43, DEX infusion at 1 μg kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; RF infusion at 1 μg kg for 2 minutes, then adjusted to 0.05-0.2 μg kg min), Group DR3 (n = 45, DEX infusion at 1.5 μg kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; RF infusion at 1 μg kg for 2 minutes, then adjusted to 0.05-0.2 μg kg min). Ramsay sedation scale of the 3 groups was maintained 3. Anesthesia onset time, total number of intraoperative children movements, hemodynamics (heart rate, arterial pressure, pulse oxygen saturation (SpO2), respiratory rate), total cumulative dose of dexmedetomidine and remifentanil, the amount of midazolam and lidocaine, time to first dose of rescue midazolam and lidocaine, postoperative recovery time, adverse events, bronchoscopist satisfaction score were recorded.Anesthesia onset time was significantly shorter in DR3 group (14.23 ± 5.45 vs 14.45 ± 5.12 vs 11.13 ± 4.51 minutes, respectively, of DR1, DR2, DR3, P = 0.003). Additionally, the perioperative hemodynamic profile was more stable in group DR3 than that in the other 2 groups. Total number of children movements during flexible bronchoscopy was higher in DR1 group than the other 2 groups (46.81% 22/47 vs 34.88% 15/43 vs 17.78% 8/45, respectively, of DR1, DR2, DR3, P = 0.012). Total doses of rescue midazolam and lidocaine were significantly higher in DR1 and DR2 groups than that of DR3 group (P = 0.000). The time to first dose of rescue midazolam and lidocaine was significantly longer in DR3 group than DR1 and DR2 groups (P = 0.000). Total cumulative dose of dexmedetomidine was more in DR2 and DR3 groups (P = 0.000), while the amount of remifentanil was more in DR1 and DR2 groups (P = 0.000). The time to recovery for discharge from the PACU was significantly shorter in DR1 group compared with the other 2 groups (P = 0.000). Results from bronchoscopist satisfaction score showed significantly higher in DR2 and DR3 groups than that of DR1 group (P = 0.025). There were significant differences among the 3 groups in terms of the overall incidence of hypertension, tachycardia, hypoxemia, and cough (P < 0.05).Though it required longer recovery time, high dose of DEX-RF, which provided better stable hemodynamic profiles and bronchoscopist satisfaction score, less amount of rescue scheme, and children movements, could be safely and efficacy used in children undergoing flexible bronchoscopy.

Dexmedetomidine versus Midazolam in Procedural Sedation. A Systematic Review of Efficacy and Safety

Objectives

To systematically review the literature comparing the efficacy and safety of dexmedetomidine and midazolam when used for procedural sedation.

Materials and Methods

We searched MEDLINE, EMBASE and COCHRANE for clinical trials comparing dexmedetomidine and midazolam for procedural sedation up to June 20, 2016. Inclusion criteria: clinical trial, human subjects, adult subjects (≥18 years), article written in English, German, French or Dutch, use of study medication for conscious sedation and at least one group receiving dexmedetomidine and one group receiving midazolam. Exclusion criteria: patients in intensive care, pediatric subjects and per protocol use of additional sedative medication other than rescue medication. Outcome measures for efficacy comparison were patient and clinician satisfaction scores and pain scores; outcome measures for safety comparison were hypotension, hypoxia, and circulatory and respiratory complications.

Results

We identified 89 papers, of which 12 satisfied the inclusion and exclusion criteria; 883 patients were included in these studies. Dexmedetomidine was associated with higher patient and operator satisfaction than midazolam. Patients receiving dexmedetomidine experienced less pain and had lower analgesic requirements. Respiratory and hemodynamic safety were similar.

Conclusions

Dexmedetomidine is a promising alternative to midazolam for use in procedural sedation. Dexmedetomidine provides more comfort during the procedure for the patient and clinician. If carefully titrated, the safety profiles are similar.

The efficacy of dexmedetomidine-remifentanil versus dexmedetomidine-propofol in children undergoing flexible bronchoscopy: A retrospective trial

Flexible bronchoscopy has been more and more used for diagnosis and management diseases of respiratory system in pediatrics. Previous studies have reported that remifentanil (RF) and propofol are safe and effective for flexible bronchoscopy in adults, however, there have no trials evaluate the efficacy of DEX-RF versus dexmedetomidine-propofol in children undergoing flexible bronchoscopy.We divided 123 children undergoing flexible bronchoscopy with DEX-RF or dexmedetomidine-propofol into 2 groups: Group DR (n = 63, DEX infusion at 1.0 μg kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; RF infusion at 1.0 μg kg for 5 minutes, then adjusted to 0.05-0.2 μg kg min), Group DP (n = 60, DEX infusion at 1.0 μg kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; propofol infusion at 10 μg kg for 5 minutes, then adjusted to 0.05-0.1 μg kg min). Ramsay sedation scale of the 2 groups was maintained at 3. Anesthesia onset time; total number of intraoperative patient movements; hemodynamics; total cumulative dose of DEX; amount of and time to first-dose rescue midazolam and lidocaine; postoperative recovery time; adverse events; and bronchoscopist satisfaction score were recorded.Anesthesia onset time was significantly shorter in DP (8.22 ± 2.48 vs 12.25 ± 6.43 minutes, respectively, for DP, DR, P = 0.015). The perioperative hemodynamic profile was more stable in DR than DP group. More children moved during flexible bronchoscopy in DP group (P = 0.009). Total dose of rescue midazolam and lidocaine was significantly higher in DR than in DP (P < 0.001). Similarly, the time to first dose of rescue midazolam and lidocaine was significantly longer in DP than in DR (P < 0.001). Total cumulative dose of DEX was more in DR than DP group (P < 0.001). The time to recovery for discharge from the postanesthesia care unit (PACU) was significantly shorter in DP than in DR group (P < 0.001). The bronchoscopist-satisfaction scores were higher for DR than DP (P = 0.036). There were significant differences between the 2 groups in terms of the overall incidence of hypertension, tachycardia, and hypoxemia (P < 0.05).Although underwent longer recovery time and more incidence of rescue scheme, DEX-RF resulted in more stable hemodynamic profiles and bronchoscopist-satisfaction scores, lesser patient movements, and can hence be more effectively used in children undergoing flexible bronchoscopy than dexmedetomidine-propofol.

Efficacy of Dexmedetomidine as a Sole Sedative Agent in Small Diagnostic and Therapeutic Procedures: A Systematic Review

Dexmedetomidine is an upcoming agent with sedative, anxiolytic, and analgesic properties. This review summarizes empirical evidence for the efficacy of dexmedetomidine as a sole sedative agent, and its effectiveness for small diagnostic and therapeutic procedure, in comparison with other frequently used sedatives. All randomized controlled trials on the effect of dexmedetomidine were reviewed. Pain level, patient satisfaction, operator satisfaction, procedure duration, recovery time, and hemodynamic and respiratory characteristics were examined. A total of 1993 patients (1,621 adults; 372 children) from 35 studies were included. In the adult studies, dexmedetomidine yielded significantly lower pain levels compared to the other sedatives (in 31.25% of the included studies) and significantly more patient satisfaction (68.2%). In studies on children, more favorable results concerning respiratory safety and the level of adequate sedation were found compared to the control sedatives. Implications for future studies are discussed.

Anesthetic experience of an adult male with citrullinemia type II: a case report

Background

Citrullinemia type II is an autosomal recessive urea cycle disorder and a subtype of citrin deficiency. However, the management of recurrent hyperammonemia with neurologic symptoms in patients with citrullinemia type II is quite different from the management of other types of urea cycle disorders. In pats with citrullinemia type II, regional anesthesia might be a good choice for the early detection of hyperammonemic symptoms and addressing psychic stress.

Case presentation

A 48-year-old male with adult onset citrullinemia type II was scheduled for urethral scrotal fistula repair. During the first operation, spinal anesthesia with conscious sedation using dexmedetomidine was used, a second operation was performed after confirmation of infection control and a stable neurologic condition. In this patient, dietary planning with close monitoring of serum ammonia level and close observation of neurologic conditions might lead to successful perioperative care.

Conclusion

For anesthesia of patients with adult onset citrullinemia type II, close monitoring of neurologic signs and serum ammonia are important to reduce neurologic complications induced by hyperammonemia. Regional anesthesia with a proper dietary plan might reduce patient stress and prevent metabolic tragedy.

Dexmedetomidine-fentanyl versus propofol-fentanyl in flexible bronchoscopy: A randomized study

The aim of the present study was to evaluate the effect of a combination of dexmedetomidine and fentanyl on peripheral oxygen saturation (SpO₂) and hemodynamic stability in patients undergoing flexible bronchoscopy. One hundred patients undergoing elective flexible bronchoscopy were randomized into either a propofol-fentanyl group (PF group; n=50) or a dexmedetomidine-fentanyl group (DF group; n=50). SpO₂ values, heart rate (HR), systolic and diastolic blood pressure (SBP and DBP), patients' cough scores and discomfort scores as determined by patients and bronchoscopists, levels of sedation, number of times that additional lidocaine was required, elapsed time until recovery, and adverse events were recorded. The mean SpO₂ values in the DF group were significantly higher than those in the PF group (P<0.01), and HR, SBP and DBP were significantly lower in the DF group than in the PF group (P<0.05). There were no statistically significant differences between the two groups in terms of cough scores or discomfort scores, sedation levels, or number of times that additional lidocaine was required (P>0.05). Elapsed time until recovery in the DF group was significantly longer than in the PF group (P=0.002). The incidence of hypoxemia was significantly lower in the DF group than in the PF group (P=0.027), but the incidence of bradycardia was significantly higher in the DF group than in the PF group (P=0.037). Dexmedetomidine-fentanyl was superior to propofol-fentanyl in providing satisfactory SpO₂. Furthermore, dexmedetomidine-fentanyl attenuated hemodynamic responses during bronchoscopy and maintained hemodynamic stability in the early stage of the procedure.

Dexmedetomidine versus midazolam for sedation during endoscopy: A meta-analysis

Patients undergoing endoscopy frequently require sedation, which commonly includes the administration of midazolam or dexmedetomidine. Previous meta-analyses have mainly focused on comparing the effects of these two drugs in intensive care unit patients. In the present study, randomized controlled trials (RCTs) that compared the sedative and clinical effectiveness of these two drugs in patients undergoing endoscopy were searched in a number of databases. The meta-analysis showed that dexmedetomidine demonstrated a significantly lower rate of respiratory depression and adverse events compared with those presented upon midazolam administration. A significant difference was also observed in the sedation potency of the sedatives. The current controlled data suggest that dexmedetomidine may be an alternative to midazolam in the sedation for endoscopy. However, more high-quality and well-designed studies are required to further evaluate this conclusion.

Intravenous Dexmedetomidine Provides Superior Patient Comfort and Tolerance Compared to Intravenous Midazolam in Patients Undergoing Flexible Bronchoscopy

Dexmedetomidine, an α2 agonist, has demonstrated its effectiveness as a sedative during awake intubation, but its utility in fiberoptic bronchoscopy (FOB) is not clear. We evaluated the effects of midazolam and dexmedetomidine on patient's response to FOB. The patients received either midazolam, 0.02 mg/kg (group M, n=27), or dexmedetomidine, 1 µg/kg (group D, n=27). A composite score of five different parameters and a numerical rating scale (NRS) for pain intensity and distress were used to assess patient response during FOB. Patients rated the quality of sedation and level of discomfort 24 h after the procedure. Ease of bronchoscopy, rescue medication requirement, and haemodynamic variables were noted. Ideal or acceptable composite score was observed in 15 and 26 patients, respectively, in group M (14.48±3.65) and group D (9.41±3.13), p<0.001. NRS showed that 11 patients in group M had severe pain and discomfort as compared to one patient with severe pain and two with severe discomfort in group D during the procedure, p<0.001. Rescue midazolam requirement was significantly higher in group M (p=0.023). We conclude that during FOB, under topical airway anaesthesia, IV dexmedetomidine (1 µg/kg) provides superior patient comfort and tolerance as compared to IV midazolam (0.02 mg/kg).

Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review

The bronchoscopic procedures have seen a remarkable increase in both numbers and complexity. Although many anesthesia providers have kept pace with the challenge, the practice is varied and frequently suboptimal. Shared airway during bronchoscopy poses unique challenges. The available reviews have tried to address this lacuna; however, these have frequently dealt with the technical aspects of bronchoscopy than anesthetic challenges. The present review provides evidence-based management insights into anesthesia for bronchoscopy-both flexible and rigid. A systematic approach toward pre-procedural evaluation and risk stratification is presented. The possible anatomical and physiological factors that can influence the outcomes are discussed. Pharmacological principles guiding sedation levels and appropriate selection of sedatives form the crux of safe anesthetic management. The newer and safer drugs that can have potential role in anesthesia for bronchoscopy in the near future are discussed. Ventilatory strategies during bronchoscopy for prevention of hypoxia and hypercarbia are emphasized.