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KEY WORDSchronic obstructive pulmonary disease, computed tomography, emphysema score, endobronchial ultrasound, markers of remodelling ABSTRACT INTRODUCTION Airway remodeling plays an important role in the development of chronic obstructive pulmonary disease (COPD). Imaging methods, such as computed tomography (CT) and endobronchial ultrasound (EBUS), may be useful in the assessment of structural alterations in the lungs.OBJECTIVES The aim of this study was to evaluate a relationship between the severity of emphysema assessed by chest CT, the thickness of bronchial wall layers measured by EBUS, and the markers of remodeling in bronchoalveolar lavage fluid (BALF) in patients with COPD. PATIENTS AND METHODSThe study included 33 patients with COPD who underwent pulmonary function tests, emphysema score assessment by chest CT, as well as bronchofiberoscopy with EBUS in order to measure the total bronchial wall thickness and, separately, layers L 1 , L 2 , and L 3-5 . Selected remodeling (matrix metalloproteinase 9 [MMP-9], tissue inhibitor of metalloproteinase 1, transforming growth factor β 1 [TGF-β 1 ]) and inflammatory markers (neutrophil elastase, eosinophil cationic protein) were measured in BALF samples using an enzyme-linked immunosorbent assay.RESULTS MMP-9 levels in BALF were significantly higher in patients with very severe bronchial obstruction than in those with moderate and mild bronchial obstruction (P = 0.02), and showed a negative correlation with forced expiratory volume in 1 second (r = -0.538, P = 0.002). The thickness of L 1 and L 2 , which histologically correspond to the mucosa, submucosa, and smooth muscle, demonstrated a positive correlation with TGF-β 1 levels in BALF (r = 0.366, P = 0.046 and r = 0.425, P = 0.02) and the thickness of L 1 showed a negative association with neutrophil elastase levels (r = -0.508, P = 0.004). There was no significant correlation between the analyzed markers in BALF and the emphysema score. CONCLUSIONS Significant correlations of TGF-β 1 and elastase with the thickness of bronchial wall layers, and of MMP-9 with the severity of obstruction, may suggest the involvement of these markers in airway remodeling in patients with COPD.

RESEARCH LETTER Flexible bronchoscopy under conscious sedation with midazolam and fentanyl... 869contraindications to use midazolam or fentanyl, diminished communication capacity, and cognitive disorders. The study was approved by the Ethics Committee at Jagiellonian University, Kraków, Poland.In all patients, topical anesthesia was used according to current guidelines. 4 Most patients received a bolus of midazolam (2.5 mg) and fentanyl (0.05 mg) before the examination. If necessary, both medications were titrated in incremental doses during FB to achieve adequate analgosedation. The initial dose of fentanyl was not administered in 23 patients for one of the following reasons: exacerbation of chronic obstructive pulmonary disease, respiratory failure, or advanced age with several comorbidities. A bronchofiberoscope was introduced through a mouthpiece 3 minutes after drug administration. During the whole procedure, vital parameters were monitored including oxygen saturation, blood pressure, and electrography; adverse events were also recorded. The level of patient sedation was continuously assessed according to the Ramsey sedation scale.6 The study personnel were trained in acute life support and study nurses had specialization in anesthesia and intensive care. During the whole procedure, the patient's spontaneous ventilation was sustained with oxygen administered through a nasal cannula if needed (in 282 patients, approximately 3.5 l/min of O 2 ). Monitoring was continued following FB until complete recovery from sedation was observed. If needed, patients were administered antagonists-flumazenil and naloxone-to reverse drug reaction. Immediate anesthesiologist support was available at all time during the study in case of need.A statistical analysis was performed using the Statistica software (version 10.0; StatSoft, Inc., Introduction Flexible bronchoscopy (FB) is one of the most commonly used diagnostic and therapeutic tools in current respiratory medicine.1 It is an invasive method that is unpleasant for the patient and is preferably performed under analgosedation. 2 According to several studies, relieving the patient's anxiety during the endoscopic procedure shortens the time of the procedure and prevents adverse events. 3 There are no exact guidelines on how to perform analgosedation; however, most authors agree that using only topical anesthesia is insufficient and suggest using moderate sedation, previously known as conscious sedation. 4This approach enables the medical personnel to stay in verbal contact with the patient and, at the same time, to relieve unpleasant symptoms. In several countries, mainly in Europe, moderate sedation in endoscopic procedures is restricted only to anesthetists despite several reports on the safety and cost-effectiveness of sedation applied by nonanesthesiologists. [5][6][7] Between the years 2013 and 2014, we performed a prospective observational study that aimed to assess factors that influence anxiety and satisfaction in patients undergoing FB under analgosedation.8 In thi...

Patients who had previously undergone BF were better prepared for their procedure; however, satisfaction levels after the procedure were similar in both groups. Results suggest that medical staff should target patients who have not undergone BF previously to relieve anxiety.