Table 1

Commonly used drugs in bronchoscopy

DrugDoseSpeed of Onset / Duration of Action / Half-lifeCommon / Serious Side EffectsComments
MidazolamSlow IV injection - maximum rate 2 mg/min
▸ Initial dose: 2 mg-2.5 mg (0.5-1 mg in the frail or elderly) given 5-10 mins before procedure
▸ Supplemental doses, if required: 1 mg (0.5-1 mg in frail or elderly), at 2-10 mins intervals
▸ Usual maximum total dose: 3.5-7 mg (3.5 mg in frail or elderly) for standard bronchoscopic procedures. May be higher in longer procedures (e.g. EBUS)
Onset of Sedation
▸ Within 2 mins, with maximum effect at 5-10 mins. (May be longer in frail or elderly or those with chronic illnesses)
Duration of Action
▸ Variable, but typical range is 30-120 mins
Approximate half-life
▸ 1.5-2.5 hours
Respiratory depression, apnoea, bronchospasm, laryngospasm,
hypotension, heart rate alterations, cardiac arrest.

Life-threatening side effects and prolonged sedation are more likely in the elderly and those with impaired respiratory or cardiovascular status, hepatic impairment, renal impairment, myasthenia gravis, and with rapid IV injection.
Enhanced sedation and increased risk of respiratory depression when combined with opioids. When combined sedation is used, opioids should always be administered prior to midazolam.

To prevent risk of accidental overdose, only 1 mg/mL vials should be available in bronchoscopy suites. 2 mg/mL or 5 mg/mL vials should not be available unless a formal risk assessment has been undertaken.
FentanylSlow IV injection - usually over 1-3 mins
▸ Initial dose: 25 micrograms
▸ Supplemental doses, if required: 25 micrograms
▸ Usual maximum total dose: 50 micrograms
Onset of Sedation
▸ Almost immediate, with maximum effect at 5 mins
Duration of Action
▸ Variable, but typical range is 30-60 mins
Approximate half-life
▸ 2-7 hours
Nausea, vomiting and other GI upset, myoclonic movements, respiratory depression, apnoea, bronchospasm, laryngospasm, hypo/hypertension, arrhythmia, cardiac arrest.
Caution in elderly patients and those with impaired respiratory or cardiovascular status, hepatic impairment and myasthenia gravis.
Enhanced sedation and respiratory depression when given with benzodiazepines. When combined sedation is used, opioids should always be administered prior to midazolam.
AlfentanilSlow IV injection - usually over 30 secs
▸ Initial dose: 250 micrograms
▸ Supplemental doses, if required: 250 micrograms
▸ Usual maximum total dose: 500 micrograms
Onset of Sedation
▸ Almost immediate onset and maximum effect
Duration of Action
▸ Variable, but usually shorter than fentanyl
Approximate half-life
▸ 1-2 hours
See FentanylSee Fentanyl
LidocaineIntranasal
▸ Lidocaine 2% gel: 6 mL (120 mg)
Oropharnyx
▸ Lidocaine 10% spray: 3 actuations (30 mg)
Vocal cords, tracheobronchial tree
▸ Lidocaine 1% solution: 2 mL boluses applied topically, as required
Maximum total dose (see Table 3)
▸ Use minimum dose to achieve effective cough suppression and patient comfort. Subjective symptoms of Lidocaine toxicity are common when >9.6 mg/kg is used; much lower doses are usually sufficient.
Onset of Action
▸ 3 to 5 mins
Duration of Action
▸ Variable, but typical range is 60-90 mins
Approximate half-life
▸ 1.5-2 hours
CNS effects (confusion, blurred vision, dizziness, drowsiness, lightheadedness, myoclonus, nausea, nystagmus, paraesthesia, restlessness, tremulousness, coma, convulsions, respiratory failure)
CVS effects (hypotension, bradycardia, arrhythmia, cardiac arrest).
Methaemoglobinaemia (rare).
Caution in those with hepatic and cardiac dysfunction, and with significant renal impairment.
AdrenalineTopical
▸ Adrenaline 1:10,000: 2 to 10 mL
Hypertension, tachycardia, arrhythmia, tremor.