Photoplethysmography respiratory rate monitoring in patients receiving procedural sedation and analgesia for upper gastrointestinal endoscopy

The value of capnography during procedural sedation and analgesia (PSA) for the detection of hypoxaemia during upper gastrointestinal (UGI) endoscopic procedures is limited. Photoplethysmography respiratory rate (RRp) monitoring may provide a useful alternative, but the level of agreement with capnography during PSA is unknown. We therefore investigated the level of agreement between the RRp and capnography-based RR (RRc) during PSA for UGI endoscopy. This study included patients undergoing PSA for UGI endoscopy procedures. Pulse oximetry (SpO₂) and RRc were recorded in combination with Nellcor 2.0 (RRp) monitoring (Covidien, USA). Bland–Altman analysis was used to evaluate the level of agreement between RRc and RRp. Episodes of apnoea, defined as no detection of exhaled CO₂ for minimal 36 s, and hypoxaemia, defined as an SpO₂ < 92 %, were registered. A total of 1054 min of data from 26 patients were analysed. Bland–Altman analysis between the RRc and RRp revealed a bias of 2.25 ± 5.41 breath rate per minute (brpm), with limits of agreement from ?8.35 to 12.84 brpm for an RR ≥ 4 brpm. A total of 67 apnoea events were detected. In 21 % of all apnoea events, the patient became hypoxaemic. Hypoxaemia occurred 42 times with a median length of 34 (19–141) s, and was preceded in 34 % of the cases by apnoea and in 64 % by an RRc ≥ 8 brpm. In 81 % of all apnoea events, photoplethysmography registered an RRp ≥ 4 brpm. We found a low level of agreement between capnography and the plethysmography respiratory rate during procedural sedation for UGI endoscopy. Moreover, respiratory rate derived from both the capnogram and photoplethysmogram showed a limited ability to provide warning signs for a hypoxaemic event during the sedation procedure.     

Pulmonary aspiration during emergency endoscopy in patients with upper gastrointestinal hemorrhage

OBJECTIVE: To evaluate the frequency and significance of aspiration and its clinical importance in patients with upper GI bleeding undergoing esophagogastroduodenoscopy in the ICU. DESIGN: Thirty consecutive patients with active and severe upper GI bleeding were studied. SETTING: ICU. PATIENTS: Ranged in age from 20 to 78 yr with an equal number of males and females. INTERVENTIONS: All patients had continuous pulse oximetry monitoring and had chest radiographs obtained less than 12 hr before endoscopy and less than 4 hr after endoscopy. MEASUREMENTS: Six (20%) of 30 patients developed new lung infiltrates after esophagogastroduodenoscopy. In this group of patients, preendoscopy chest radiographs were obtained after less than 4 hr. In five of these patients, infiltrates were accompanied by fever and/or leukocytosis and oxygen desaturation to less than 90% during the esophagogastroduodenoscopy. CONCLUSION: Clinically significant aspiration pneumonia frequently complicates esophagogastroduodenoscopy in upper GI bleeding patients and is an important mechanism of esophagogastroduodenoscopy-induced hypoxia.     

A new technique in endoscopic ultrasonography of the upper gastrointestinal tract

Endoscopic ultrasonography (EUS) of the upper GI tract was unsuccessful in 42 out of 274 patients (15%) due to inaccurate guidance of the probe to small, shallow lesions, or to difficulty in clearly demonstrating the surrounding layer structure and boundary of the lesion. We applied the saline injection technique in these 42 patients. Saline was injected into the submucosal layer of the esophagogastric wall. The ultrasonographic image of adjacent saline accurately guided the probe to the lesion. Injected saline enabled the mucosal layer to be distinguished from the muscularis propria surrounding the lesion and provided clear ultrasonographic imaging of the boundary between the lesion and the surrounding layer structure. This new method was found to be effective in 38 out of 42 patients in whom EUS was unsuccessful. A study comparing the depth of tumor invasion diagnosed by the saline injection technique with histological findings obtained in 12 cases showed good correlation. These results indicate that the saline injection technique would seem to be very useful as an adjuvant to conventional EUS.     

Changes in cardiopulmonary parameters during upper gastrointestinal endoscopy in patients with heart disease: towards safer endoscopy

BACKGROUND AND STUDY AIMS: Gastrointestinal endoscopy is an invasive examination. The aims of this study were to elucidate the effects and risks of upper gastrointestinal endoscopy with regard to cardiopulmonary functions in patients with heart disease, and to establish safety guidelines for use during endoscopy in this particular group of patients. PATIENTS AND METHODS: The patients involved were 53 inpatients in whom upper gastrointestinal endoscopy was carried out before cardiac surgery. Their cardiac functions had been evaluated previously. Electrocardiography with two leads (II, V5) was used, and blood pressure and peripheral oxygen saturation (SpO2) were monitored throughout the procedure. The relationship between the changes in cardiopulmonary parameters during endoscopy and the cardiac functions was analyzed. RESULTS: Heart rate increased immediately after insertion of the endoscope (P < 0.01). There was a significantly higher incidence of ventricular and supraventricular extrasystoles during observation of the second portion of the duodenum (P < 0.05). A lower cardiac index (P < 0.05) and a higher New York Heart Association (NYHA) functional classification (P < 0.05) were found in patients with oxygen desaturation than in patients without it. Two patients with severe coronary artery lesions showed marked ST-T depression, and these ischemic changes were thought to be due to increase in cardiac work during endoscopy. CONCLUSIONS: Upper gastrointestinal endoscopy has many adverse effects on cardiopulmonary functions in patients with heart disease. In our study, the clinical value of very close monitoring and administration of oxygen for patients with heart disease was confirmed by objective data.     

A new device for abrasive cytology sampling during upper gastrointestinal endoscopy: experience in infectious and neoplastic diseases.

BACKGROUND AND STUDY AIMS: The increase in infectious diseases of the gastrointestinal tract related to immunosuppression is becoming an important topic for the endoscopist. To improve the diagnostic efficacy of tissue acquisition while at the same time restricting costs, we have developed a new device for obtaining material from the upper gastrointestinal tract that can also be used in the diagnosis of neoplastic disease. PATIENTS AND METHODS: A total of 90 patients were examined and assigned to two groups according to indications. Group A consisted of 53 symptomatic patients with positive human immunodeficiency virus (HIV) serology with a suspicion of gastrointestinal infection. Group B included 37 patients in whom there was an endoscopic suspicion of neoplasia in the upper gastrointestinal tract. Cell fragments for cytological study were obtained using a device introduced through the endoscopic instrumentation channel (abrasive cytology). Different staining methods were used to isolate bacteria or diagnose tumors from cell fragments. The findings were compared with those obtained from conventional bioptic histology. RESULTS: Potentially responsible pathogens were isolated in 48 of the 53 patients in Group A, while bioptic histology provided a diagnosis in only 32 patients. In the 37 patients in group B, the cytological diagnosis matched the histological results. The costs of this new technique are similar to those for conventional cytological staining, and the time from sampling to obtaining a final diagnosis is less than one hour. CONCLUSIONS: This new device provides a fast and low-cost method of isolating pathogens and obtaining cell fragments from the gastrointestinal mucosa during routine upper gastrointestinal endoscopy.     

腹腔镜胆囊切除术中CO_2气腹对心率变异性的影响

目的:探讨腹腔镜胆囊切除术中CO2气腹对心率变异性的影响。方法:选择ASA分级Ⅰ～Ⅱ级择期行腹腔镜胆囊切除手术病人40例,利用心率变异功率谱分析技术(HRV-PSA)和脑电(electroencephalogram,EEG)双频谱指数技术(bispectralindex,BIS)对40例病人CO2人工气腹后心率变异性(HRV)指标低频功率(LF)、高频功率(HF)、低频高频比(LF/HF)、总功率(TP)的变化进行分析。结果:CO2人工气腹后LF、LF/HF、TP均明显升高,HF未见明显改变。结论:腹腔镜胆囊切除术中CO2人工气腹使交感神经系统活性显著升高。     

Clinical application of magnification endoscopy and narrow-band imaging in the upper gastrointestinal tract: new imaging techniques for detecting and characterizing gastrointestinal neoplasia

This article introduces one of the most advanced endoscopy imaging techniques, magnification endoscopy with narrow-band imaging. This technique can clearly visualize the microvascular (MV) architecture and microsurface (MS) structure. The application of this technique is quite useful for characterizing the mucosal neoplasia in the hypopharynx, oropharynx, esophagus, and stomach. The key characteristic findings for early carcinomatous lesions are an irregular MV pattern or irregular MS pattern as visualized by this technique. Such a diagnostic system could be applied to the early detection of mucosal neoplasia throughout the upper gastrointestinal tract.     

泮托拉唑治疗老年急性上消化道出血的临床观察

目的观察泮托拉唑治疗老年急性上消化道出血的临床疗效和安全性。方法168例大于60岁以上急性上消化道出血患者，用泮托拉唑针剂40mg静滴bid，对照组用奥美拉唑针剂40mg静注bid治疗对比，观察两组的止血时间、心、肝、肾功能生化指标。结果泮托拉唑组和奥美拉唑组的治疗总有效率分别为98．73％和71．82％，两组比较有显著性差异（P〈0．05）。呕血、黑便停止时间两组无显著差异（P〉0．05）。两组生化指标均无异常改变，均无明显不良反应。结论泮托拉唑治疗老年急性上消化道出血疗效显著，无明显毒副作用。     

Blood pressure and heart rate changes during apnoea testing with or without CO2 insufflation

Objective: To determine changes of blood pressure and heart rate during apnoea testing for brain death without (A) and with (B) artificial CO₂ augmentation. Design: Prospective, consecutive study. Setting: 12 intensive care units in six towns in Northern Bavaria. Patients and participants: A total of 55 apnoea tests were performed on 55 consecutive patients as part of the determination of brain death, 27 without and 28 with CO₂ augmentation. Interventions: Apnoea tests following oxygenation with 100 % O₂ either after reduction of ventilatory volume (A) or after insufflation of CO₂ during normoventilation (B). In each case, an arterial partial CO₂ pressure of at least 8 kPa was documented. Results: All apnoea tests were without serious adverse effects (hypoxia, newly induced cardiac arrhythmia, cardiac asystole). An increased dopamine infusion rate was deemed necessary in only one case of group (A) because of marked systolic hypotension ( < 8 kPa). Individual variation of systolic and diastolic blood pressure (BP) did not exceed + 62 to –46 % and + 49 to –52 % respectively, in group (A) and + 35 to –57 % and + 40 to –48 % respectively, in group (B). Variation of heart rate (HR) remained within the range + 24 to –31 % in group (A) and + 37 to –22 % in group (B). Conclusions: HR varied less than BP. The possibility of a marked relative rise or fall of BP in group (A) was equal; in group (B) there was a lower chance of rising BP. The chances for a rise or fall in HR were equal for the two groups. There was a tendency for less variation of cardiovascular parameters in group (B). Received: 22 November 1996 Accepted: 16 June 1997     

A defoaming agent should be used with pronase premedication to improve visibility in upper gastrointestinal endoscopy

BACKGROUND AND STUDY AIMS: The study tested whether pronase can improve endoscopic visibility and alter the accuracy of the CLO test for H. pylori detection. PATIENTS AND METHODS: A total of 160 patients were randomly assigned to receive one of five premedications for endoscopy: group A: dimethylpolysiloxane (DMPS) alone; group B: DMPS plus water (up to 100 ml); group C: pronase only, with 100 ml water; group D: pronase and sodium bicarbonate plus water up to 100 ml; group E: pronase, sodium bicarbonate, and DMPS, plus water up to 100 ml. Endoscopists, who were unaware of the premedication method administered, assessed visibility scores (range 1 - 4) for the antrum, lower gastric body, upper gastric body, and fundus. The higher the score, the less clear the visibility. The sum of scores from the four locations was defined as the total visibility score. A CLO test was also done during the endoscopy. One week after their endoscopy, patients in groups C, D, and E were scheduled for a (13)C-urea breath test (UBT). RESULTS: Group E patients had a significantly lower total visibility score than those in the other four groups ( P < 0.05). Groups C and D had higher total visibility scores than the other three groups ( P < 0.05). The scores did not significantly differ between groups A and B. Based on the UBT results, the sensitivity and specificity of the CLO test were 92.6 % and 96.2 %, respectively. CONCLUSIONS: Premedication as in group E provided the clearest endoscopic visibility. Without the application of DMPS, pronase alone cannot improve endoscopic visibility. Pronase does not influence H. pylori identification using the CLO test.     

鱼腥草注射液治疗小儿急性上呼吸道感染的疗效观察

急性上呼吸道感染(以下简称上感)是小儿最常见的疾病,多由病毒引起.我科2003年8月-2004年9月收治的部分上感患儿(50例)用静脉输注鱼腥草注射液治疗,取得满意疗效.现介绍如下.……     

高血压患者腹腔镜手术CO2气腹过程中自主神经功能的变化

目的 探讨高血压患者在腹腔镜手术CO2气腹过程中自主神经功能的变化.方法 应用心率变异性(HRV)分析法对25例择期高血压患者腹腔镜手术(Ⅰ组)和25例无高血压腹腔镜手术患者(Ⅱ组)麻醉前、气管插管结束后15 min、腹腔内CO2充气完成后的心率变异性改变进行分析.结果 麻醉诱导及插管15min后Ⅰ组低频(LF)、高频(HF)、低频与高频的比值(LF/HF)及总功率(TP)显著降低(P＜0.05),Ⅱ组LF、LF/HF、11P亦显著降低(P＜0.05),而HF未见明显改变.腹腔CO2充气完成后两组HRV值均显著升高(P＜0.05).组间比较显示,插管15min后Ⅰ组HF和TP显著低于Ⅱ组,LF和LF/HF组间差异无统计学意义;气腹后Ⅰ组HF和TP亦显著低于Ⅱ组.而LF/HF显著高于Ⅱ组,LF组间差异仍无统计学意义.结论 高血压患者迷走神经活性厦总自主神经张力显著低于非高血压患者,迷走神经对心脏窦房结的调控作用严重受损.     

Accuracy of laryngeal examination during upper gastrointestinal endoscopy for premalignancy screening: prospective study in patients with and without reflux symptoms

BACKGROUND AND STUDY AIMS: Gastroesophageal reflux disease may be associated with laryngeal damage caused by reflux material. The aim of this study was to investigate the accuracy of laryngeal examinations during routine upper gastrointestinal endoscopy as a method of screening for major laryngeal injury in a series of patients with reflux symptoms. PATIENTS AND METHODS: A total of 100 consecutive patients with reflux symptoms and 100 control individuals underwent upper gastrointestinal endoscopy with standard or high-resolution magnifying video endoscopes. Any laryngeal abnormalities were initially identified by the gastroenterologist before the scope was inserted into the esophagus. All of the examinations were recorded on video and subsequently reevaluated by an otorhinolaryngologist. All of the patients underwent standard laryngoscopy as a reference procedure. RESULTS: All of the patients completed the study. The sensitivity, specificity, negative predictive value, and positive predictive value of the preliminary laryngeal exploration for detecting laryngeal abnormalities (such as laryngitis and vocal leukoplakia) were 90%, 90%, 92%, and 89%, respectively. High-resolution magnifying endoscopy had a higher sensitivity and specificity than standard endoscopy for detecting laryngeal pathology. Two patients were found to have laryngeal leukoplakia. CONCLUSIONS: This study shows that preliminary diagnosis of laryngeal disorders can be accurately carried out by the gastroenterologist when patients are undergoing upper endoscopy for reflux symptoms. This approach could also be helpful for the timely diagnosis of major reflux-related laryngeal disease.     

Inhibitory actions of procaterol, a beta-2 stimulant, on substance P-induced cough in normal subjects during upper respiratory tract infection

We studied substance P (SP)-induced cough in normal subjects without and with colds, and the effects of orally administered procaterol on SP-induced cough in normal subjects with colds. SP aerosols caused cough at a concentration of approximately 10(-15) M in subjects with colds whereas it did not cause cough at a concentration of up to 10(-5) M in subjects without colds. Procaterol (50 micrograms) completely inhibited SP-induced cough in normal subjects with colds. These results suggest that cough response to SP remarkably increases during colds and that beta-2 stimulant may be a useful tool for treatment of cough during colds in normal subjects.     

丙泊酚效应室靶控输注用于患心血管疾病老年人胃镜结肠镜联合检查的临床观察

目的 观察效应室靶控（TCI）丙泊酚用于患心血管疾病老年患者胃肠镜检查的效果和安全性.方法 合并一种以上心血管疾病的拟行择期胃镜＋结肠镜检查的患者40例（年龄60-80岁）,分为TCI组和TIVA组（n=20）,分别以效应室浓度2.5 μg/ml靶控输注和1-1.5 mg/kg初始量＋5 mg/kg/h恒速输注丙泊酚.记录术中循环情况,苏醒时间,并发症,丙泊酚用量和患者满意度.结果 两组患者均顺利完成检查,TCI组术中循环波动幅度小,用药量少,术中体动、低氧等并发症少,两组患者在苏醒时间上无差异,而均未出现术后恶心呕吐和术中知晓.TCI组的苏醒时效应室浓度为0.96±0.23μg/ml.结论 Ce=2.5 μg/ml的效应室靶控模式输注丙泊酚用于合并心血管疾病老年患者胃镜＋肠镜联合检查麻醉效果确切,维持剂量少,安全有效.     

A prospective comparison of performance of biopsy forceps used in single passage with multiple bites during upper endoscopy

BACKGROUND AND STUDY AIMS: A single biopsy is usually obtained for each passage of a biopsy forceps. It was hypothesized that multiple bites per passage might improve the quantity and quality of tissue obtained, without significant artifacts. This hypothesis was tested in a prospective, pathologist-blinded study using different forceps. PATIENTS AND METHODS: Forty consecutive patients who underwent elective upper endoscopy were included. Five different forceps were used in six different ways, varying in the number of bites taken per passage. Two pathologists, who were blinded to the type of biopsy forceps used, evaluated the specimens according to the parameters of maximum weight (mg), size of largest fragment (mm), depth, squash artifact, adequacy, and overall rating. RESULTS: A total of 240 biopsy specimens were obtained. The Microvasive Multibite and Megabite forceps obtained specimens with the maximum weight (P<0.05) and the largest size (P<0.05), respectively. Alligator forceps were able to obtain specimens significantly larger in size than the oval-shaped forceps (P<0.05). The Olympus FB-24K forceps performed best in both the adequacy score and the overall rating score (P<0.05). CONCLUSIONS: Forceps with a needle, or the Multibite forceps, allow more biopsies to be taken per passage and improve the quality of tissues obtained. "Needleless" forceps can be used to obtain two samples per passage through the endoscope that are as good as when only one sample is collected. This approach can save time, and causes no significant damage to the biopsy specimens.     

Accuracy of capnography with a 30 foot nasal cannula for monitoring respiratory rate and end-tidal CO2 in children

We tested the accuracy of a low flow (50 cc/min) sidestream capnographysystem equipped with an experimental 30-foot nasal cannula to monitor ventilatory status in children. End-tidal CO₂ and respiratory rate, both at room air and in the presence of supplemental oxygen, were recorded simultaneously from the experimental 30-foot nasal cannula and the standard, FDA approved, 10-foot nasal cannula. The 30-foot nasal cannula was as accurate as the 10-foot nasal cannula in measuring respiratory rate and end-tidal CO₂ in children. When supplemental oxygen was delivered by facemask, there was no dilutional effect on the respiratory rate or end-tidal CO₂ recorded with either the 10-foot or 30-foot nasal cannulas inplace. This revised version was published online in July 2006 with corrections to the Cover Date.