Sedation for fibreoptic bronchoscopy: comparison of alfentanil with papaveretum and diazepam

doi:10.1016/S0954-6111(89)80034-4

Respiratory Medicine

Volume 83, Issue 3, May 1989, Pages 213-217

https://doi.org/10.1016/S0954-6111(89)80034-4 Get rights and content

Sedation for fibreoptic bronchoscopy should produce optimal conditions for the operator, patient comfort and rapid recovery allowing early discharge home. We have compared a regimen producing ‘light’ sedation with a more traditional regimen producing ‘deep’ sedation. Seventy-six patients undergoing fibreoptic bronchoscopy under topical anaesthesia were randomized to receive either light sedation with the short acting opiate, alfentanil (median dose 1·1 mg, range 0·5–2·6 mg) or deep sedation with a combination of papaveretum (median dose 10 mg, range 5–15 mg) and diazepam (median dose 8 mg, range 0–20 mg).

Both techniques gave equally good operating conditions, although patients given alfentanil coughed less than those given papaveretum and diazepam (U = 2·814 P < 0·01).

Patients recorded their degree of apprehension on a visual analogue scale prior to sedation and the actual degree of comfort experienced after recovery. There was no significant difference between apprehension or comfort between the groups. This was despite a higher degree of amnesia for an irrelevant object shown during the bronchoscopy in the deeply sedated group (χ² = 21·084 P < 0·001).

Patients given alfentanil performed significantly better in a modified Romberg test (χ² = 4·357 P < 0·05) and a visualisation test (t = 3·035 P < 0·01) two hours after the bronchoscopy.

Alfentanil produced good operating conditions, patient comfort, less cough and a more rapid recovery, compared to the deep sedation regimen, and is an ideal sedative for fibreoptic bronchoscopy.

References (11)

KorttilaK et al.
Effects of age on amnesia and sedation induced by flunitrazepam during local anaesthesia for bronchoscopy
Br J Anaesth
(1978)
GoroszeeniukT et al.
Premedication for fibreoptic bronchoscopy: fentanyl, diazepam, and atropine compared with papaveretum and hyoscine
Br Med J
(1980)
ReesPJ et al.
Premedication for fibreoptic bronchoscopy
Thorax
(1983)
PearceSJ
Fibreoptic bronchoscopy: Is sedation really necessary?
Br Med J
(1986)
GoldmanJM et al.
Effect of biofeedback on patients' tolerance of fibreoptic bronchoscopy
Br Med J
(1986)

There are more references available in the full text version of this article.

Cited by (29)

American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients
2011, Chest
Citation Excerpt :
Fentanyl is the most commonly used drug in the setting of bronchoscopy because of its lipophilic properties resulting in a rapid onset of action and short half-life. Data on the use of opioids as single agents for bronchoscopy are limited; three randomized studies found opioids to be inferior to benzodiazepines in terms of procedure recall and amnesia40,54 and patient comfort.41 The main additive advantage of the use of opioids over benzodiazepines during bronchoscopy is better suppression of cough.41–43,55
Optimal performance of bronchoscopy requires patient's comfort, physician's ease of execution, and minimal risk. There is currently a wide variation in the use of topical anesthesia, analgesia, and sedation during bronchoscopy.
A panel of experts was convened by the American College of Chest Physicians Interventional/Chest Diagnostic Network. A literature search was conducted on MEDLINE from 1969 to 2009, and consensus was reached by the panel members after a comprehensive review of the data. Randomized controlled trials and prospective studies were given highest priority in building the consensus.
In the absence of contraindications, topical anesthesia, analgesia, and sedation are suggested in all patients undergoing bronchoscopy because of enhanced patient tolerance and satisfaction. Robust data suggest that anticholinergic agents, when administered prebronchoscopy, do not produce a clinically meaningful effect, and their use is discouraged. Lidocaine is the preferred topical anesthetic for bronchoscopy, given its short half life and wide margin of safety. The use of a combination of benzodiazepines and opiates is suggested because of their synergistic effects on patient tolerance during the procedure and the added antitussive properties of opioids. Propofol is an effective agent for sedation in bronchoscopy and can achieve similar sedation, amnesia, and patient tolerance when compared with the combined administration of benzodiazepines and opiates.
We suggest that all physicians performing bronchoscopy consider using topical anesthesia, analgesic and sedative agents, when feasible. The existing body of literature supports the safety and effectiveness of this approach when the proper agents are used in an appropriately selected patient population.
A randomized, placebo-controlled trial of bronchodilators for bronchoscopy in patients with COPD
2007, Chest
Citation Excerpt :
In addition, the patient's cough perception may have been influenced 2 h after the procedure because of the amnesic effect of midazolam. However, according to several previous studies, wake up time for combined sedation with an opiate and benzodiazepine seems to be between 35 to 60 min and discharge time 75 to 120 min after the procedure.34–36 Thus, we believe that it is fair to assume that patients were able to estimate their cough related to the procedure after 2 h.
Background:In contrast to asthma, the indication for bronchodilators prior to bronchoscopy in patients with COPD has not been properly investigated. We therefore performed a randomized, double-blind, placebo-controlled trial to determine whether use of a short-acting bronchodilator provides a protective effect in patients with COPD undergoing bronchoscopy.
Methods:One hundred twenty patients undergoing bronchoscopy were included. Patients with COPD were randomized to receive either 200 μg of salbutamol (n = 40) or placebo (n = 40) before bronchoscopy. Control patients (n = 40) did not receive any inhaled medication. Spirometry was performed before and 2 h after bronchoscopy in all patients. Sedative drug requirements and hemodynamic parameters were recorded.
Results:Hemodynamic findings before, during, and after bronchoscopy were similar in patients with COPD randomized to either salbutamol or placebo (p = not significant for all). Compared to prebronchoscopy values, postbronchoscopy percentage of predicted FEV₁decreased significantly in all three groups: salbutamol (median, − 4.7%; interquartile range [IQR], − 13.3 to 6.6); placebo (median, − 4.8%; IQR, − 19.9 to 8.4); and control subjects (median, − 10.0%; IQR, − 20.2 to − 3.3) [p = 0.023]. The decrease in FEV₁was similar in all three patient groups (p = 0.432). The relative change in FEV₁was inversely correlated to the increasing severity of COPD as expressed by Global Initiative for Chronic Obstructive Lung Disease stages (p = 0.01).
Conclusions:Premedication with an inhaled short-acting β-agonist cannot be recommended in patients with COPD undergoing bronchoscopy.
Nebulized lidocaine for flexible bronchoscopy: A randomized, double-blind, placebo-controlled trial
2005, Chest
Citation Excerpt :
One possible limitation of this study is that tolerability may have been overestimated 2 h after the procedure because of the amnesic effect of midazolam. According to several previous studies,23, 24, 25 wake-up time for combined sedation with an opiate and benzodiazepine is 35 to 60 min and discharge time is 75 to 120 min after the procedure. We therefore believe that it is fair to assume that patients were able to estimate their discomfort during flexible bronchoscopy 2 h after the procedure.
Topical anesthesia for flexible bronchoscopy can be administered via transcricoid injection, nebulizer, or directly through the bronchoscope in a “spray as you go” fashion. We performed a prospective, randomized, double-blind, placebo-controlled trial to evaluate whether nebulized lidocaine provides additional benefit and reduces the total anesthetic dose required during bronchoscopy.
Tertiary care university hospital.
One hundred fifty patients (93 men; age, 20 to 89 years) undergoing diagnostic flexible bronchoscopy were randomized to receive either 4 mL of 4% lidocaine (160 mg) or 4 mL of saline solution as placebo via nebulization. Combined sedation was achieved using 5 mg of IV hydrocodone and midazolam boluses. Supplemental lidocaine doses and total midazolam required as judged by the bronchoscopist were recorded for each patient. After the procedure, both bronchoscopists and patients charted their perception of cough on a 10-cm visual analog scale (VAS). Similarly, patients recorded their discomfort related to the procedure on a 10-cm VAS.
The most common procedures were BAL in 77 cases (51%), transbronchial biopsy in 40 cases (27%), and transbronchial needle aspiration in 34 cases (23%). Outcome parameters, including hemodynamic findings, duration of the procedure, cough scores for physicians and patients, discomfort score for patients, midazolam doses, and supplemental lidocaine doses, were similar in both groups. Mean total lidocaine dose required in the lidocaine group was 318 ± 41 mg and was significantly higher than the total dose required in the placebo group (157 ± 44 mg [± SD]) [p < 0.001].
Additional nebulized lidocaine cannot be recommended for flexible bronchoscopy performed under combined sedation.
Pre-medication for bronchoscopy: A randomised double blind trial comparing alfentanil with midazolam
2004, Respiratory Medicine
This study was designed to compare the effects of alfentanil and midazolam pre-medication on patient comfort during and after flexible bronchoscopy.
A randomised, double-blind study was performed; 40 patients received alfentanil and 29 midazolam. Subjects completed questionnaires about discomfort and adverse effects immediately post-procedure and 24 h later. The bronchoscopist also completed a questionnaire.
No difference in patient discomfort was found immediately post-procedure and no differences were found for amount of topical lignocaine used or minimum oxygen saturation. Operators reported no overall difference between the agents for ease of procedure but about 20% less cough was reported in the alfentanil group (P=0.02). Patient discomfort scores in the 24 h questionnaire were significantly lower in patients given midazolam (P=0.01 for nasal discomfort, P=0.003 for throat discomfort) but drowsiness was commoner in this group (P=0.04). There was no significant difference in patients’ reports of cough, nausea or vomiting or their willingness to have a repeat procedure.
In conclusion, cough during bronchoscopy was slightly less marked with alfentanil than midazolam pre-medication but this made no difference to the ease of procedure or to overall patient discomfort. Patients given midazolam reported less discomfort when asked about the test 24 h later.
Patient satisfaction with conscious sedation for bronchoscopy
1999, Chest
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 IM (nonsedation group; 50 patients) or lidocaine spray, atropine IM and diazepam IV (sedation group; 50 patients).
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.
In our study, sedation had a beneficial effect on patient tolerance and rarely induced significant alterations in cardiorespiratory monitoring parameters.
Analgesia and sedation in fibre optic bronchoscopy
1995, Respiratory Medicine

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Sedation for fibreoptic bronchoscopy: comparison of alfentanil with papaveretum and diazepam

Effects of age on amnesia and sedation induced by flunitrazepam during local anaesthesia for bronchoscopy

Br J Anaesth

Premedication for fibreoptic bronchoscopy: fentanyl, diazepam, and atropine compared with papaveretum and hyoscine

Br Med J

Premedication for fibreoptic bronchoscopy

Thorax

Fibreoptic bronchoscopy: Is sedation really necessary?

Br Med J

Effect of biofeedback on patients' tolerance of fibreoptic bronchoscopy

Br Med J