Safe sedation during diagnostic and therapeutic flexible bronchoscopy in Japan: A review of the literature

Minami, Daisuke; Takigawa, Nagio

doi:10.1016/j.resinv.2022.09.003

Cited by 6 publications

(7 citation statements)

References 28 publications

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“…It is widely acknowledged that the typical sedation regimens for FB is difficult to solve cough and stress problems in the absence of opioids. [3,13,15] As a short-acting opioid with mild respiratory depression, alfentanil possesses notable antistress and anti-coughing effects, but only at high doses can the desired effect be achieved, which has been confirmed in our previous research and other literatures. [12,20,21] In this study, the combined application of high doses of alfentanil proved effective in achieving deep sedation and contributed to ideal anti-stress effect and hemodynamic stabilization.…”

Section: Discussionsupporting

confidence: 77%

“…Most guidelines and expert consensus recommend mild to moderate sedation (RSS between 2 and 3 points) for bronchoscopy. [ 2 , 4 , 13 , 15 ] The rationale behind this recommendation is the concern that deep sedation or oversedation may lead to significant respiratory and circulatory depression. Moreover, desaturation risk with moderate sedation is particularly prone to occur in elderly patients and those with an ASA III score.…”

Section: Discussionmentioning

confidence: 99%

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Bolus administration of remimazolam was superior to midazolam for deep sedation in elderly patients undergoing diagnostic bronchoscopy: A randomized, double-blind, controlled trial

Wu,

Xu,

Zhou

et al. 2024

Medicine

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Background: To date, there is no standardized practice for the use of pharmacological sedatives during flexible bronchoscopy, particularly for elderly patients. This exploratory study aimed to assess the efficacy and safety of remimazolam at a single induced dose for deep sedation in elderly patients undergoing diagnostic flexible bronchoscopy (DFB), and compare with midazolam, a commonly used sedative. Methods: A total of 100 elderly patients (age range 65–80 yr; American Society of Anesthesiologists Physical Status I–III) undergoing DFB were randomly allocated into 2 groups according to the sedatives used for induction: the remimazolam group and the midazolam group. Sedation induction was initiated by an intravenous bolus of remimazolam (0.135 mg/kg) or midazolam (0.045 mg/kg), respectively, both groups were combined with a high-dose of alfentanil (18 µg/kg), and supplemented with high-flow nasal cannula (HFNC) oxygen supply at a flow rate of 45 L/min. If the target depth of sedation was not achieved, propofol would be titrated as a rescue. The primary outcome was the success rate of sedation at a single induced dose to achieve target depth (Ramsay sedation score [RSS] = 4) during induction, intraoperative changes in vital signs, postoperative follow-up situation and incidence of post-bronchoscopy adverse events were evaluated as secondary outcomes. Results: The success rate of sedation in the remimazolam group was significantly higher than that in the midazolam group (65.2% vs 39.6%, P = .013), while the incidence of extra sleep within 6 hours after procedure was lower in the remimazolam group as compared to the midazolam group (10.9% vs 31.3%, P = .016). No statistically significant differences were observed between the 2 groups regarding hemodynamic fluctuations, incidence of hypoxemia, and cough response during the procedure, as well as postoperative recall, willingness to undergo reexamination, and other post-bronchoscopy adverse events. Conclusions: Bolus administration of remimazolam offers advantages over midazolam for deep sedation in elderly patients undergoing DFB, in terms of a higher success rate of sedation and a lower incidence of extra sleep within 6 hours after procedure, though the safety profiles of both groups were favorable.

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 99%

Bolus administration of remimazolam was superior to midazolam for deep sedation in elderly patients undergoing diagnostic bronchoscopy: A randomized, double-blind, controlled trial

Wu,

Xu,

Zhou

et al. 2024

Medicine

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“…Time taken for the procedure was also similar in the three groups which increases the applicability of the modalities, more so in outpatient procedures like FB 24 30. All the procedures in our study were performed with the use of conscious sedation and analgesia to improve patient acceptance and comfort 31–35. Even though the dose of sedative agents used was higher in the HFOT group, the comfort levels did not differ among the three arms 24 36…”

Section: Discussionmentioning

confidence: 67%

Efficacy of different respiratory supports to prevent hypoxia during flexible bronchoscopy in patients of COPD: a triple-arm, randomised controlled trial

Sharma,

Singh,

Govindagoudar

et al. 2023

BMJ Open Resp Res

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BackgroundPatients with chronic-obstructive-pulmonary-disease (COPD) undergo bronchoscopy for various reasons, and are at relatively higher risk of complications. This study evaluated the efficacy of non-invasive ventilation (NIV) and high-flow-oxygen-therapy (HFOT) compared with conventional-oxygen-therapy (COT) in patients with COPD undergoing bronchoscopy, to prevent hypoxia.MethodsIt was a triple-arm, open-label, randomised controlled trial. Ninety patients with COPD were randomly assigned into three intervention arms in 1:1:1 ratio. The incidence of hypoxia, lowest recorded oxygen saturation measured by plethysmography (SpO2), ECG, patient vitals and comfort levels were assessed.ResultsMean age of the study population was 61.71±7.5 years. Out of 90 cases enrolled, 51, 34 and 5 were moderate, severe and very-severe COPD, respectively, as per GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification. Rest of the baseline characteristics were similar. SpO2during flexible bronchoscopy (FB) was lowest in COT group (COT: 87.03±5.7% vs HFOT: 95.57±5.0% vs NIV: 97.40±1.6%, p<0.001). Secondary objectives were similar except respiratory-rate (breaths-per-minute) which was highest in COT group (COT: 20.23±3.1 vs HFOT: 18.57±4.1 vs NIV: 16.80±1.9, p<0.001). Whereas post FB partial of oxygen in arterial blood was highest in NIV group (NIV: 84.27±21.6 mm Hg vs HFOT: 69.03±13.6 mm Hg vs COT: 69.30±11.9 mm Hg, p<0.001). Post FB partial pressure of carbon dioxide in arterial blood was similar in the three arms. Operator’s ease-of-performing-procedure was least in the NIV group as assessed with Visual Analogue Scale (p<0.01). A higher number of NIV group participants reported nasal pain as compared with the other two arms (p<0.01).ConclusionNIV and HFOT are superior to COT in preventing hypoxia during bronchoscopy, but NIV is associated with poor patient-tolerance and inferior operator’s ease of doing procedure.Trial registration numberCTRI/2021/03/032190.

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“…Fentanyl is an opioid analgesic like pethidine ( 20 ). Midazolam is a short-acting benzodiazepine, which has the effects of anti-anxiety, sedation, hypnosis, and muscle relaxation but with side effects such as respiratory depression ( 21 , 22 ). We find that promethazine-pethidine treatment showed a tendency for milder liver injury than midazolam-fentanyl in patients 7-day after severe burns.…”

Section: Discussionmentioning

confidence: 99%

Histamine H1 receptor antagonist attenuates catecholamine surge and organ injury after severe burns

Wang

Liu

et al. 2023

Front. Endocrinol.

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Severe burns induce a catecholamine surge, causing severe damage to the organism and raising the possibility of multisystem organ failure. Few strategies are generally acceptable to reduce catecholamine surge and organ injury post-burn. We have previously shown that histamine can amplify the catecholamine surge. In addition, promethazine, a first-generation histamine H1 receptor antagonist, alleviates catecholamine surge and organ injury after severe burns in rats. However, evidence is lacking on whether promethazine benefits patients after severe burns. Currently, sedation and analgesia (such as midazolam and fentanyl) are commonly required for patients after severe burns. It remains unclear if patients after severe burns derive clinical benefit from histamine H1 receptor antagonists combined with sedation and analgesia. This study investigates the therapeutic effect of promethazine on patients after severe burns. Moreover, we test the therapeutic effect of cetirizine, a second-generation histamine H1 receptor antagonist, combined with sedation and analgesia in rats after severe burns. We find that promethazine-pethidine treatment shows a tendency for a lower level of total bilirubin than midazolam-fentanyl in patients 7-day after severe burn. Our study confirms that cetirizine combined with midazolam and fentanyl reduces catecholamine surge and liver and lung damage after severe burns in rats; the effects are better than midazolam and fentanyl treatment. In summary, for the first time, we suggest that histamine H1 receptor antagonist has the potential clinical value of reducing liver injury in patients after severe burns. In addition, we reveal that cetirizine combined with midazolam and fentanyl may be an ideal strategy for treating severe burns.

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Safe sedation during diagnostic and therapeutic flexible bronchoscopy in Japan: A review of the literature

Cited by 6 publications

References 28 publications

Bolus administration of remimazolam was superior to midazolam for deep sedation in elderly patients undergoing diagnostic bronchoscopy: A randomized, double-blind, controlled trial

Bolus administration of remimazolam was superior to midazolam for deep sedation in elderly patients undergoing diagnostic bronchoscopy: A randomized, double-blind, controlled trial

Efficacy of different respiratory supports to prevent hypoxia during flexible bronchoscopy in patients of COPD: a triple-arm, randomised controlled trial

Histamine H1 receptor antagonist attenuates catecholamine surge and organ injury after severe burns

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