Sedation for flexible bronchoscopy: current and emerging evidence

Abstract

Flexible bronchoscopy is commonly performed by respiratory physicians and is the gold standard for directly visualising the airways, allowing for numerous diagnostic and therapeutic interventions. With the widespread use of flexible bronchoscopy and the evolution of interventional bronchoscopy with more complex and longer procedures, physicians are placing increasing importance on the use of sedation as a necessary adjunct to topical anaesthesia. There is no standardised practice for the use of sedation in bronchoscopy with a good deal of variation among physicians regarding the use of pre-procedure medication and pharmacological sedatives. In addition, there is ongoing debate and controversy about proceduralist-administered versus anaesthetist-administered sedation whilst at the same time there is a growing body of evidence that nonanaesthetist administered sedation is safe and cost-effective. In this review we summarise the evidence for the use of sedation as an adjunct to topical anaesthesia in bronchoscopy and provide the clinician with up-todate concise guidance for the use of pharmacological sedatives in bronchoscopy and future directions for sedation in the bronchoscopy suite.

Flexible bronchoscopy under conscious sedation with midazolam and fentanyl can be safely performed by nonanesthesiologists

“…Some researchers have also suggested that the use of propofol instead of benzodiazepines is preferable because of a more rapid patient's recovery. 9 These drugs proved to be safe in several studies used by nonanesthesiologists, [5][6][7] and are recommended by most gastroenterology and respiratory societies to use for moderate sedation in various endoscopic procedures. 4,10,11 Despite this, anesthesiology societies have raised several safety concerns, especially regarding the use of propofol 12 by nonanesthesiologists, and the use of moderate sedation has not been legally approved in many countries (including Poland), being restricted solely to anesthesiologists.…”

“…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 this brief communication, we would like to present data on the safety of moderate sedation applied by nonanesthesiologists.Patients and methods After obtaining written consent to participate in the study, we enrolled 463 consecutive patients undergoing FB at the Department of Pulmonology of the University Hospital in Krakow, Poland. The exclusion criteria were as follows: respiratory failure (defined as hemoglobin oxygen saturation [SpO 2 ] below 90% despite oxygen therapy or need for more than 50% of oxygen in a respiratory mixture),…”

“…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 this brief communication, we would like to present data on the safety of moderate sedation applied by nonanesthesiologists.…”

“…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 ).…”

Evaluation of discomfort and tolerability to bronchoscopy according to different sedation procedures with midazolam

“…A number of large surveys on bronchoscopic procedures have been performed (2)(3)(4) and numerous guidelines for bronchoscopy have been published worldwide (1,5,6). In 2009, the Japan Society for Respiratory Endoscopy performed a questionnaire survey on bronchoscopy in clinical practice to establish a guideline for painless bronchoscopy (7).…”