Patients prefer sedation for fibreoptic bronchoscopy

Abstract This study was carried out in order to determine if intravenous (i.v.) sedation with diazepam, at the time of procedure, made fibreoptic bronchoscopy more tolerable and if these perceptions persisted on later questioning. Methodology consisted of a sequential, parallel group design comparing sedation with no sedation for bronchoscopy in a tertiary referral hospital. Patient comfort and sedation desired for hypothetical repeat bronchoscopy were assessed both immediately and after at least 1 month. Patients who received sedation rated bronchoscopy as more comfortable ( P =0.01). Those who received sedation were also more likely to want no change in sedation if the bronchoscopy were repeated ( P <0.01). These differences were more evident at later questioning. Sedation was not associated with an increased complication rate but was associated with a prolonged recovery room stay (no sedation, 19.2 min (SEM 3.8) compared with sedation, 76.1 min (5.4), P <0.001). In contrast to previous studies, our patients found bronchoscopy more comfortable with i.v. diazepam sedation. This was supported by patients who received sedation being less likely to want any change in future sedation if a repeat bronchoscopy were required. The benefit seen with sedation was more marked at later questioning supporting a previously postulated amnesic effect. However, sedation was associated with a prolonged room stay and potentially greater attendant cost.     

Slow-wave photic stimulation relieves patient discomfort during esophagogastroduodenoscopy

Background and Aim: Although pretreatment with a sedative drug is effective in relieving pain during esophagogastroduodenoscopy (EGD), such drugs can cause significant side‐effects. The aim of this study was to examine the effect of slow‐wave photic stimulation on discomfort and/or pain felt during EGD. Methods: Forty consecutive patients (25 men and 15 women) who underwent diagnostic EGD in our hospital were included in the study. Twenty patients received photic stimulation for 25 min, and underwent electroencephalographic recording, in addition to the usual premedications. Twenty control patients received the same treatment but without photic stimulation. All patients evaluated the discomfort/pain felt during endoscopy against a five‐grade scale in comparison with what they had experienced in their previous examination. Results: Patients with an improved discomfort/pain score were 18/20 and 3/20 in the treated and control groups, respectively. Overall comparison of pain scores between both groups was significant (P < 0.0001). The proportion of slow‐wave activity recorded in patients’ electroencephalograms significantly increased in the treated group compared to control values (36.6 ± 6.8% vs 29.1 ± 3.4%, P < 0.001). There was a close correlation between the degree of discomfort/pain felt during endoscopy and the proportion of slow‐wave activity (P < 0.001). Conclusion: Slow‐wave photic stimulation shows promise as a treatment for relieving the discomfort and/or pain felt by patients undergoing EGD.     

两种麻醉途径对纤维支气管镜检查的临床观察

目的观察两种麻醉途径对纤维支气管镜检查的影响。方法将160例患者随机分为实验组和对照组各80例。两组均用2%利多卡因,分别经鼻腔和咽喉部麻醉,比较两组患者在经不同途径麻醉后,在有效麻醉时间、麻醉药物使用量、麻醉效果、出现不良反应程度及各时点(麻醉后检查前(T0)、支气管镜进入声门时(T1)检察时(T2)及检查后0.5 h(T3)的HR、MAP、Sp O2的比对。结果 1实验组患者在有效麻醉时间、麻醉药物使用量明显优于对照组(P0.05),差异有统计学意义。2实验组麻醉效果优良率达82.5%,显著优于对照组(60%)(P0.05),差异有统计学意义。3实验组不良反应率达19%,对照组为57.6%,差异有统计学意义。4实验组各时点各项生命体征均比B组平稳,两组在T1时点HR及MAP差异均具有统计学意义(P0.05),且在T2时点MAP差异也具有统计学意义(P0.05)。结论纤维支气管镜检查经鼻腔喷射麻醉优于咽喉部喷雾麻醉。     

两种术前麻醉给药方法在纤支镜检查应用中的比较

目的探讨术前麻醉给药方法在纤维支气管检查中的麻醉效果及不良反应。方法208例纤维支气管镜检查的患者采用不同麻醉给药的方法,1组为氧气雾化吸入利多卡因＋地西泮;2组为氧气雾化吸人利多卡因＋可待因。结果2组麻醉效果好,不良反应小,两组比较有显著性差异（P〈O．05）。结论利多卡因＋可待因麻醉方法效果好,用药量少,是一种实用的局麻方法,值得临床推广。     

Successful removal of a 12 year long intrabronchial fishbone through fibreoptic bronchoscopy

Abstract We report a 54 year old male with an intrabronchial fishbone that had been impacted for 12 years and presented as recurrent pneumonia of the right lower lobe. The fishbone was successfully removed by fibreoptic bronchoscopy.     

白光气管镜与自发荧光气管镜在肺癌中的诊断价值

目的 探讨肺癌不同病理类型在白光气管镜(white light bronchoscopy,WLB)与自发荧光气管镜(autofluorescence bronchoscopy,AFB)下的病变特点以及WLB与AFB对肺癌的诊断价值.方法 收集2010年1月至2013年12在我院同时行AFB和WLB检查,并经病理明确诊断患者708例,比较肺癌不同病理类型在WLB和AFB下的病变特点以及WLB与AFB对肺癌的诊断价值.结果 分别有63.7％、59.3％、75.0％、56.4％的鳞癌、腺癌、大细胞肺癌、小细胞肺癌在WLB下表现为增生组,100.0％、87.0％、100.0％、97.4％的鳞癌、腺癌、大细胞肺癌、小细胞肺癌在AFB下表现为Ⅲ级.AFB与WLB诊断肺癌的敏感度分别为95.6％和63.2％,特异度分别为89.4％和75.5％,差异均有统计学意义(P＜0.05).结论 肺癌各种病理类型在WLB主要表现为增生组,在AFB下主要表现为Ⅲ级.AFB对肺癌的诊断价值优于WLB.     

利多卡因联合丙泊酚行无痛支气管镜检查的临床观察

目的观察利多卡因联合丙泊酚行无痛支气管镜检查对患者呼吸与循环的影响。方法60例支气管镜检查患者分两组:常规支气管镜组(Ⅰ组30例)和无痛支气管镜组(Ⅱ组30例),Ⅰ组为单用利多卡因局部表面麻醉组,Ⅱ组为用利多卡因局部表面麻醉联合丙泊酚静脉麻醉组,采用多功能监护仪监测患者术前、术中及术后心率、血压、血氧饱和度、呼吸的变化。用SPSS13.0进行t检验。结果Ⅱ组麻醉后患者能在无知觉和无痛苦中接受检查,两组在术中心率、血压、血氧饱和度、呼吸的变化差异有统计学意义(P0.05);两组在术后心率、呼吸的变化差异有统计学意义(P0.05),而血压、血氧饱和度的变化差异无统计学意义(P0.05)。结论采用利多卡因联合丙泊酚麻醉下行支气管镜检查,麻醉效果好,是一种相对安全的麻醉方法。     

Current status of diagnostic and therapeutic bronchoscopy in Japan: 2016 national survey of bronchoscopy

BackgroundThe safety management committee of the Japan Society for Respiratory Endoscopy (JSRE) conducted national surveys to clarify the state of diagnostic and therapeutic bronchoscopy in 2016.MethodsQuestionnaire forms were mailed to 532 JSRE-accredited facilities throughout Japan. We surveyed the actual condition of clinical practice and cases of bronchoscopy during 2016.ResultsFour hundred and thirty-three facilities responded giving a response rate of 81.4%; 67.6% held more than 400 beds. The average number of board accredited senior Fellows and Fellows per facility was 1.9 and 3.2, respectively. Diagnostic bronchoscopy was performed in a hospitalized setting in 74.6% of all facilities. The radial type ultrasound probe was operated in 51.7% of all facilities. The number of facilities has markedly increased compared with that reported in the 2010 survey (19.6%). The bronchoscopic navigation system had been in operation in 41.7% of all facilities. Antithrombotic drugs were adjusted before biopsy in 96.8% of all facilities. For intravenous sedation, midazolam was the first choice in 76.9% of all facilities. Endobronchial ultrasound guided transbronchial lymph node needle aspiration (EBUS-TBNA) has become popular over the decade (19.6% in 2010 to 68.1% in 2016).The mean number of the board accredited senior Fellows and board accredited Fellows increased in comparison with that in 2010. As a new technique, radial type ultrasound-guided peripheral approach has become popular.ConclusionsThrough this survey, the advanced safety of bronchoscopic examination has been secured in many facilities. A continuous monitoring of bronchoscopic practices with respect to safety management is recommended.     

Topical lidocaine through the bronchoscope reduces cough rate during bronchoscopy

Background and objective:   Topical lidocaine is often administered through the flexible bronchoscope in an attempt to reduce excessive coughing and patient discomfort. With the increasing use of sedation, including opiates that possess central cough suppressant effects, and the potential for serious clinical toxicity, the need for evidence regarding the efficacy of topical lidocaine is important. This study assessed whether topical lidocaine through the bronchoscope could reduce cough and stridor rate.
Methods:   A randomized controlled trial of 49 patients undergoing flexible bronchoscopy was conducted. Following sedation and topical anaesthesia to the upper airway, patients were randomized to receive either lidocaine 2% or placebo (N-saline) through the bronchoscope to the vocal cords and tracheobronchial tree. Cough and stridor rates were recorded by audiotape. Bronchoscopists and nurses assessed coughing with visual analogue scales.
Results:   There were no significant differences in baseline demographics and level of sedation between the two groups. The cough rate per minute (mean (SD)) was lower ( P  < 0.001) in the lidocaine group, 12.20 (7.99), n  = 18, than in the placebo group, 27.50 (10.74), n  = 31. The stridor rate was lower with lidocaine, 0.22 (0.60) per minute than with placebo 0.80 (1.35), but the difference was non-significant at P  = 0.095. Both doctors' and nurses' scores for cough were significantly lower in the lidocaine group ( P  < 0.001 for both). Less midazolam 2.1 mg (1.1) was used with lidocaine than with placebo 3.4 mg (1.9), P  = 0.02 and less fentanyl 81.9 mg (34.1) versus 98.4 mg (20.4), P  = 0.04.
Conclusions:   Topical lidocaine through the bronchoscope significantly decreased cough frequency and the total dose of sedation required during flexible bronchoscopy.     

The relationship between age and process of care and patient tolerance of bronchoscopy

OBJECTIVES: To determine whether patient age is associated with differences in flexible bronchoscopy technique and tolerance. DESIGN: Prospective cohort study. SETTING: University hospital system. PARTICIPANTS: One thousand three hundred fifty-eight adults, including 219 (16.1%) aged 70 and older, undergoing bronchoscopy. MEASUREMENTS: Indications, sampling procedures, medication doses, patient reports of pain, willingness to return, and adverse events associated with bronchoscopy. RESULTS: Indications for bronchoscopy varied with age, with solitary pulmonary nodule (P <.001), mass (P <.001), or lymphadenopathy (P <.001) being more common in older patients. Invasive sampling methods were used more often with increasing age, but variation in disease processes between age groups accounted for the difference in sampling method performed. Mean doses of midazolam and fentanyl given for sedation decreased with increasing age (P <.001). There was no significant difference between older and younger patients in reported very good to excellent pain control (50% of patients >/=70 vs 64% of patients <40; P =.56) or in willingness to return for repeat bronchoscopy (98% vs 92%, respectively; P =.324). Overall risk for an adverse event increased with increasing patient age (P <.01), but adverse events were uncommon and generally not severe. Hypotension and pneumothorax were rare but occurred more often in older persons (1.9% and 3.4% in patients >/=70 vs 0.5% and 0.7% in patients <40, respectively). CONCLUSION: Despite more-invasive sampling methods and less sedation during bronchoscopy, elderly patients tolerate bronchoscopy as well as younger patients. There is increased risk for adverse events with increasing age, but the absolute frequency is low, suggesting that chronological age should not be a contraindication for bronchoscopy in older persons.     

自发荧光实时成像技术与普通光支气管镜在诊断肺癌及癌前病变方面效果的比较

目的 比较自发荧光实时成像技术(AFI)与普通光支气管镜(WLB)诊断肺癌及癌前病变的灵敏度及特异度,并探讨在临床支气管镜检查中常规应用AFI技术的可行性.方法 在MEDLINE和EMBASE上检索近10年的相关文献,再手工检索纳入文献.由2位研究人员独立筛选文献,评估其质量并提取数据.用Review Manager 5.0运算AFI与WLB在诊断肺癌及癌前病变方面总的灵敏度、特异度、相对危险度(RR).结果 检索得到2339篇文献,最终7项研究可用于汇总数据分析.AFI组512例病理阳性,其中464例镜下阳性;WLB组517例病理阳性,其中371例镜下阳性.AFI、WLB的汇总灵敏度分别为90.6％(464/512)、71.8％(371/517),P=0.0004,RR=1.28,95％可信区间(95％CI)为1.11～1.46.即AFI在诊断肺癌及癌前病变方面灵敏度较WLB高.AFI组725例病理阴性,其中567例镜下阴性;WLB组720例病理阴性,其中590例镜下阴性.AFI、WLB的汇总特异度分别为78.2％(567/725)、81.9％(590/720),P=0.53,RR=0.93,95％CI为0.74～1.17.即AFI在诊断肺癌及癌前病变方面特异度不比WLB低.结论 AFI在诊断肺癌及癌前病变方面灵敏度较WLB高,而且其特异度并不比WLB低.加之其切换自由,使用方便,安全可靠,可常规用于临床支气管镜检查.     

A randomized controlled trial evaluating airway inspection effectiveness during endobronchial ultrasound bronchoscopy

Background

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) has revolutionized the evaluation of patients with mediastinal and hilar adenopathy. Limitations of conventional endobronchial ultrasound (C-EBUS) bronchoscopes include the inability to perform a complete airway inspection, low definition optics, and limited maneuverability. These limitations require the use of a standard bronchoscope to perform an airway examination prior to the EBUS procedure. Recently, a hybrid endobronchial ultrasound (H-EBUS) bronchoscope with high definition optics and increased maneuverability has been introduced. Our objective was to assess the ability of H-EBUS to perform a full airway inspection and TBNA.

Methods

Patients referred for EBUS-TBNA were prospectively randomized to either form of EBUS from November 2013 to January 2014. The primary outcome was the airway segment visualization in each lobe using an EBUS bronchoscope. Secondary outcomes included the number of bronchoscopes used per procedure, procedure length, diagnostic yield and specimen adequacy.

Results

Sixty-two consecutive patients undergoing EBUS-TBNA were randomized to H-EBUS (n=30) or C-EBUS (n=32). In cases in which EBUS-TBNA was the only procedure performed (n=32), use of a second bronchoscope to perform an adequate airway inspection was significantly higher in C-EBUS compared to H-EBUS (5 vs. 0, P=0.046). There was better segmental visualization achieved in multiple lobes when using H-EBUS (P<0.01). No differences in TBNA sample diagnostic yield, specimen adequacy or procedure time were noted when comparing bronchoscopes (P= NS).

Conclusions

Use of an H-EBUS may improve the ability to perform an adequate airway inspection potentially obviating the need for a conventional bronchoscope.     

Ultrathin endoscope flexibility can predict discomfort associated with unsedated transnasal esophagogastroduodenoscopy

AIM: To evaluate the effects of choice of insertion route and ultrathin endoscope types.METHODS: This prospective study (January-June 2012) included 882 consecutive patients who underwent annual health checkups. Transnasal esophagogastroduodenoscopy (EGD) was performed in 503 patients and transoral EGD in 235 patients using six types of ultrathin endoscopes. Patients were given a choice of insertion route, either transoral or transnasal, prior to EGD examination. For transoral insertion, the endoscope was equipped with a thin-type mouthpiece and tongue depressor. Conscious sedation was not used for any patient. EGD-associated discomfort was assessed using a visual analog scale (VAS; no discomfort 0- maximum discomfort 10).RESULTS: Rates of preference for transnasal insertion were significantly higher in male (male/female 299/204 vs 118/117) and younger patients (56.8 ± 11.2 years vs 61.3 ± 13.0 years), although no significant difference was found in VAS scores between transoral and transnasal insertion (3.9 ± 2.3 vs 4.1 ± 2.5). Multivariate analysis revealed that gender, age, operator, and endoscope were independent significant predictors of VAS for transnasal insertion, although gender, age, and endoscope were those for transoral insertion. Further analysis revealed only the endoscopic flexibility index (EFI) as an independent significant predictor of VAS for transnasal insertion. Both EFI and tip diameter were independent significant predictors of VAS for transoral insertion.CONCLUSION: Flexibility of ultrathin endoscopes can be a predictor of EGD-associated discomfort, especially in transnasal insertion.     

Gastrointestinal discomfort and hypotension in a patient with Reutealis trisperma seeds intoxication: A case report

Rationale:Reutealis trisperma is a plant belonging to the Euphorbiaceae family and Reutealis genus and is often mistaken for a plant of the genus Aleurites. Accidental ingestion of R trisperma seeds is relatively rare in Taiwan than that of Vernicia fordii. Mostly, the clinical course of R trisperma seed poisoning is similar to that of V fordii poisoning. Recent studies have shown that the median lethal dose 50 of R trisperma seeds in mice is approximately 4954 mg/kg. R trisperma seed extract has a significant effect on the autonomic nervous system by causing ptosis and disrupting breathing, and affects the central nervous system by reducing motor activity.Patient concerns:A 51-year-old man with underlying gout and hepatitis B picked several seeds of R trisperma, which he misidentified at chestnuts, at an elementary school. He prepared soup by boiling 3 to 4 seeds and consumed it. He experienced abdominal pain, vomiting, and watery diarrhea with hypotension.Diagnosis:R trisperma seeds intoxication.Interventions:The patient was given a soft diet, input and output were recorded, and intravenous fluid supplements were administered.Outcomes:The patient was discharged after 3 days of hospitalization, once a relatively stable condition was achieved.Lessons:Human poisoning by accidental consumption of R trisperma seeds is relatively rare in Taiwan. It may cause gastrointestinal symptoms and even hypotension. Patients can recover within 2 to 3 days of receiving proper treatment and intravenous fluid infusion.     

Use of microdebrider bronchoscopy for the treatment of endobronchial leiomyoma

Aims: Pulmonary leiomyomas are rare benign tumors that may cause symptoms when they spread endobronchially. Traditionally they were managed surgically or through interventional bronchoscopy with the aid of thermal modalities to assist in debulking of tumor. We report the novel use of microdebrider bronchoscopy to debulk an endobronchial leiomyoma in a symptomatic patient. Method/Results: The microdebrider successfully débrided the endobronchial leiomyoma. Conclusion: This modality can be successfully employed when oxygenation is an issue, preventing use of thermal modalities. In addition, use of microdebrider not only reduced procedure time but also decreased the risk of airway fire and damage to adjacent normal tissue in our patient. Please cite this paper as: Wahla AS, Khan I, Bellinger C, Haponik E and Conforti JF. Use of microdebrider bronchoscopy for the treatment of endobronchial leiomyoma. Clin Respir J 2011; 5: e4–e7.