Studies indicate that sedation during bronchoscopy makes the procedure more comfortable for patients and provides better working conditions for physicians when compared with no sedation. Sedation can be used during most bronchoscopies with minimal risk. However, research suggests that use varies widely between geographic areas of the country and within institutions. Survey results from 1991 showed that sedation was administered to more than half (51%) of bronchoscopy patients, but data from more than a decade later revealed that this figure jumped to nearly three-fourths of patients (73%). It’s not known if the use of sedation during bronchoscopy is continuing to rise.
Optimizing Use of Sedation During Bronchoscopy
In the November 2011 issue of Chest, my colleagues at the American College of Chest Physicians and I had a consensus statement published on the optimal use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adults. The statement recommends that every bronchoscopy be performed with sedation if feasible because it improves patient satisfaction and procedural tolerance significantly. It should be noted, however, that patient circumstances and access to resources may prevent use of sedation during these procedures. Patients with numerous comorbidities or severe, restricting respiratory or cardiac issues may not be appropriate because of potential complications.
Although it’s acceptable to fulfill the wishes of patients who don’t want to be sedated, research suggests that topical anesthetics should be used for everyone receiving bronchoscopy. If patients have allergies to lidocaine—the preferred topical anesthetic for bronchoscopy—use of other topical anesthetics may be explored. Anticholinergic agents, however, are discouraged for pre-bronchoscopy use because data have shown that they fail to produce a clinically meaningful effect.
When bronchoscopy is started, sedation is provided with intravenous medications. One of the most frequently used and most effective regimens is a combination of a benzodiazepine and an opioid. Depending on the characteristics of patients, the preferred combination should have a quick onset of action, rapid peak effect, and relatively short duration of effect. Propofol is an acceptable and effective alternative to the combination of a benzodiazepine and an opioid, but this agent can only be administered by anesthesiologists in the hospital in most states.
Sedation for Bronchoscopy: Proceed With Caution
Evidence-based guidelines are the strongest type of recommendations, but it’s important to note that our consensus statement—as with all consensus statements—was born out of a lack of strong literature in this area. Our suggestions resulted from a review of the limited literature available and the consensus of an expert panel. That said the body of literature that’s available now appears to support the use of topical anesthesia, analgesia, and sedation for patients undergoing bronchoscopy. Use of these agents is likely to enhance patient satisfaction and optimize procedural conditions for physicians performing bronchoscopy.
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Wahidi M, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest. 2011;140:1342-1350.
Du Rand I, Barber P, Goldring J, et al. British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax. 2011;66(Suppl 3):iii1-iii21.
Grendelmeier P, Kurer G, Pflimlin E, et al. Feasibility and safety of propofol sedation in flexible bronchoscopy. Swiss Med Wkly. 2011;141:w13248.
Sherren P. Topical anaesthesia of the upper airway following deliberate sulphuric acid ingestion. Anaesthesia. 2011;66:1058-1059.
Farley P. Should topical opioid analgesics be regarded as effective and safe when applied to chronic cutaneous lesions? J Pharm Pharmacol. 2011;63:747-756.