Supraglottic jet oxygenation and ventilation reduces desaturation during bronchoscopy under moderate to deep sedation with propofol and remifentanil

Abstract

BACKGROUND Hypoxaemia is frequently seen during flexible bronchoscopies that are done with a nasal approach under the traditional sedation with propofol. This study investigated the potential benefits of supraglottic jet oxygenation and ventilation (SJOV) using the Wei nasal jet tube (WNJ) in reducing hypoxaemia in patients undergoing bronchoscopy under moderate to deep intravenous sedation using a propofol, lidocaine and remifentanil cocktail. OBJECTIVES Our primary objective was to evaluate the efficacy and complications of SJOV via the WNJ during flexible bronchoscopy under moderate to heavy sedation with propofol and remifentanil. DESIGN A randomised controlled clinical trial. SETTING The 180th Hospital of People's Liberation Army, Quanzhou, China, from 1 June to 1 November 2019. PATIENTS A total of 280 patients aged ≥18 years with American Society of Anesthesiologists’ physical status 1 to 3 undergoing flexible bronchoscopy were studied. INTERVENTIONS Patients were assigned randomly into one of two groups, a nasal cannula oxygenation (NCO) group ( n = 140) using a nasal cannula to deliver oxygen (4 l min −1 ) or the SJOV group ( n = 140) using a WNJ connected to a manual jet ventilator to provide SJOV at a driving pressure of 103 kPa, respiratory rate 20 min −1 , F i O 2 1.0 and inspiratory:expiratory (I:E) ratio 1:2. MAIN OUTCOME MEASURES The primary outcome was an incidence of desaturation (defined as SpO 2 < 90%) during the procedure. Other adverse events related to the sedation or SJOV were also recorded. RESULTS Compared with the NCO group, the incidence of desaturation in the SJOV group was lower (NCO 37.0% vs. SJOV 13.1%) ( P < 0.001). Patients in the SJOV group had a higher incidence of a dry mouth at 1 min (13.1% vs. 1.5%, P < 0.001) than at 30 min (1.5% vs. 0%, P = 0.159) or at 24 h (0% vs. 0%). There was no significant difference between the groups in respect of sore throat, subcutaneous emphysema or nasal bleeding. CONCLUSIONS SJOV via a WNJ during flexible bronchoscopy under moderate to deep sedation with propofol and remifentanil significantly reduces the incidence of desaturation when compared with regular oxygen supplementation via a nasal cannula. Patients in the SJOV group had an increased incidence of transient dry mouth. TRIAL REGISTRATION Registered at www.chictr.org.cn (ChiCTR1900023514).

Remimazolam alone or in combination with dexmedetomidine in patients receiving bronchoscopy: a randomized-controlled trial

“…Hypoxemia frequently occurs during exible bronchoscopy and leads to termination of the bronchoscopy procedure until it is corrected. Previous studies have demonstrated that incidence of hypoxemia is 30-50% during exible bronchoscopy with propofol sedation [22,23]. Similarly, in our study hypoxemia was reported in 46.7% patients receiving propofol sedation only.…”

The Efficacy and Safety of Remimazolam Tosilate Versus Dexmedetomidine in Outpatients Undergoing Flexible Bronchoscopy: A Prospective, Randomized, Blind, Non-Inferiority Trial

“…Despite the fact that recent evidence supports the use of capnography in deep sedation, its use in moderate sedation has not been shown to improve patient safety ( Vakil et al, 2018 ). Despite various monitoring methods, the incidence of oxygen desaturation in this study was still relatively high, which may be due to inhibition of the respiratory centre in the brainstem by RF, especially when associated with benzodiazepines; hypoventilation secondary to sedation; and airway obstruction by the bronchoscope itself ( Zha et al, 2021 ).…”

“…Hypoxia was defined according to previous studies, as oxygen desaturation (SpO 2 75–89% for ≤60 s) and severe oxygen desaturation (SpO 2 < 75% at any time or <90% for >60 s) ( Zha et al, 2021 ). In the presence of hypoxia, the following maneuvers were carried out as required: oxygen delivery increased to 10 L/min, verbal and tactile stimulation, chin lift, jaw thrust, bronchoscope removal, face mask and manual ventilation, and tracheal intubation for mechanical ventilation.…”

“…However, it is characterized by significant variability in metabolic clearance, and resedation may occur due to the cumulative effects of its active metabolites and numerous drug–drug interactions, particularly in elderly patients ( Lee et al, 2019 ). Propofol is usually used in combination with benzodiazepines or opioids because of the increased risk of oversedation, airway obstruction, pain on injection, allergic reaction from egg and soybean components, and propofol infusion syndrome ( Zha et al, 2021 ). Dex is a highly selective α2 adrenergic agonist with sedative and analgesic properties that can preserve airway reflexes, expand the smooth muscle of the trachea, and inhibit the cough response without causing respiratory depression.…”

Comparison of the Effects of Esketamine/Propofol and Sufentanil/Propofol on the Incidence of Intraoperative Hypoxemia during Bronchoscopy: Protocol for a Randomized, Prospective, Parallel-Group Trial

“…The combination of propofol and an opioid is a usual anesthesia method during bronchoscopy, despite known side effects such as hypoxemia, postoperative nausea and vomiting, etc., especially for patients without airway devices [ 11 , 12 ]. Joskova et al found in animal experiments that pharmacodynamic interactions between propofol, sufentanil, and midazolam via GABA A receptor-mediated interactions negatively affect ciliary beat frequency in respiratory epithelial cells [ 13 ].…”