Dexmedetomidine sedation for endobronchial ultrasound-guided transbronchial needle aspiration, a randomised controlled trial

Ting-Yu Lin, Yu-Chen Huang, Chih-Hsi Kuo, Fu-Tsai Chung, Yu-Ting Lin, Tsai-Yu Wang, Shu-Min Lin, Yu-Lun Lo, Ting-Yu Lin, Yu-Chen Huang, Chih-Hsi Kuo, Fu-Tsai Chung, Yu-Ting Lin, Tsai-Yu Wang, Shu-Min Lin, Yu-Lun Lo

Abstract

Background and aim: Appropriate sedation is important to the success of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Dexmedetomidine is a sedative agent that operates via the α2 adrenergic agonist, which provides sleep-like sedation with little respiratory suppression. This study compared the efficacy and safety of dexmedetomidine sedation with propofol in cases of EBUS-TBNA.

Methods: Patients requiring EBUS-TBNA were randomly assigned dexmedetomidine sedation (D, n=25) or propofol sedation (P, n=25). Vital signs, diagnostic yield and the bispectral index (BIS) were recorded throughout the bronchoscopic procedure and recovery period. The tolerance and cooperation of the patients were evaluated using questionnaires.

Measurements and results: The lowest mean arterial blood pressure in group D (79.2±9.9 versus 72.5±12.9 mmHg, p=0.049) exceeded that in group P, the lowest heart rate was lower (60.9±10.2 versus 71.4±11.8 beats·min-1, p=0.006) and the mean BIS during sedation was significantly higher (84.1±8.3 versus 73.6±5.7, p<0.001). Patients in group D were more likely to report perceiving procedure-related symptoms and express an unwillingness to undergo the bronchoscopy again, if indicated (41.1 versus 83.3%, p=0.007). One subject in group D aborted EBUS-TBNA due to intolerance. Many of the variables in the two groups were similar, including the proportion of hypoxaemic events, recovery times, patient cooperation and diagnostic yield.

Conclusions: The effects of dexmedetomidine on haemodynamics were in line with its pharmacodynamic features. Patients who received dexmedetomidine were more likely than those who received propofol to perceive the procedures. Overall, dexmedetomidine did not prove inferior to propofol sedation in terms of patient cooperation or diagnostic yield.

Conflict of interest statement

Conflict of interest: T-Y. Lin has nothing to disclose. Conflict of interest: Y-C. Huang has nothing to disclose. Conflict of interest: C-H. Kuo has nothing to disclose. Conflict of interest: F-T. Chung has nothing to disclose. Conflict of interest: Y-T. Lin has nothing to disclose. Conflict of interest: T-Y. Wang has nothing to disclose. Conflict of interest: S-M. Lin has nothing to disclose. Conflict of interest: Y-L. Lo has nothing to disclose.

Copyright ©ERS 2020.

Figures

FIGURE 1
FIGURE 1
Wakefulness during sedation. Following recovery, patients were asked if they had seen or heard anything during the bronchoscopic procedure. One subject in each group refused to answer the questionnaire.
FIGURE 2
FIGURE 2
a) Patient tolerance for procedure-related symptoms. Following recovery, subjects answered a questionnaire on procedure-related symptoms, including reactions to nebulised xylocaine inhalation, stimulation caused by scope insertion through the mouth, coughing, dyspnoea, pain and global tolerance to the entire procedure. Note that one subject in each group refused to answer the questionnaire. b) Patient cooperation during the bronchoscopic procedure. Bronchoscopist answered a questionnaire on the ease of scope insertion and biopsy, coughing by the patient and global cooperation during the procedure. The design of the questionnaire was based on a 100-mm visual analogue scale (VAS, 0: no bother, 100: worst intolerable/uncooperative).
FIGURE 3
FIGURE 3
Willingness to undergo repeated bronchoscopic procedure. Following recovery, patients were queried about their willingness to undergo the procedure again if indicated clinically (definitely not, possibly not, not sure, possibly yes and definitely yes). One subject in each group refused to answer the questionnaire.

References

    1. Silvestri GA, Gonzalez AV, Jantz MA, et al. . Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143: Suppl. 5, e211S–e250S. doi:10.1378/chest.12-2355
    1. Canneto B, Ferraroli G, Falezza G, et al. . Ideal conditions to perform EBUS-TBNA. J Thorac Dis 2017; 9: Suppl. 5, S414–S417. doi:10.21037/jtd.2017.04.64
    1. Aswanetmanee P, Limsuwat C, Kabach M, et al. . The role of sedation in endobronchial ultrasound-guided transbronchial needle aspiration: systematic review. Endosc Ultrasound 2016; 5: 300–306. doi:10.4103/2303-9027.191608
    1. Wahidi MM, Sterman DH. Bringing comfort to endobronchial ultrasound bronchoscopy. Am J Respir Crit Care Med 2015; 191: 727–728. doi:10.1164/rccm.201502-0291ED
    1. Stolz D, Kurer G, Meyer A, et al. . Propofol versus combined sedation in flexible bronchoscopy: a randomised non-inferiority trial. Eur Respir J 2009; 34: 1024–1030. doi:10.1183/09031936.00180808
    1. Clarkson K, Power CK, O'Connell F, et al. . A comparative evaluation of propofol and midazolam as sedative agents in fiberoptic bronchoscopy. Chest 1993; 104: 1029–1031. doi:10.1378/chest.104.4.1029
    1. Crawford M, Pollock J, Anderson K, et al. . Comparison of midazolam with propofol for sedation in outpatient bronchoscopy. Br J Anaesth 1993; 70: 419–422. doi:10.1093/bja/70.4.419
    1. Murphy M, Bruno MA, Riedner BA, et al. . Propofol anesthesia and sleep: a high-density EEG study. Sleep 2011; 34: 283–291A. doi:10.1093/sleep/34.3.283
    1. Hillman DR, Walsh JH, Maddison KJ, et al. . Evolution of changes in upper airway collapsibility during slow induction of anesthesia with propofol. Anesthesiology 2009; 111: 63–71. doi:10.1097/ALN.0b013e3181a7ec68
    1. Eastwood PR, Platt PR, Shepherd K, et al. . Collapsibility of the upper airway at different concentrations of propofol anesthesia. Anesthesiology 2005; 103: 470–477. doi:10.1097/00000542-200509000-00007
    1. Lin T-Y, Fang Y-F, Huang S-H, et al. . Capnography monitoring the hypoventilation during the induction of bronchoscopic sedation: a randomized controlled trial. Sci Rep 2017; 7: 8685. doi:10.1038/s41598-017-09082-8
    1. Lo YL, Lin TY, Fang YF, et al. . Feasibility of bispectral index-guided propofol infusion for flexible bronchoscopy sedation: a randomized controlled trial. PLoS One 2011; 6: e27769. doi:10.1371/journal.pone.0027769
    1. Lin TY, Lo YL, Hsieh CH, et al. . The potential regimen of target-controlled infusion of propofol in flexible bronchoscopy sedation: a randomized controlled trial. PLoS One 2013; 8: e62744. doi:10.1371/journal.pone.0062744
    1. Clark G, Licker M, Younossian AB, et al. . Titrated sedation with propofol or midazolam for flexible bronchoscopy: a randomised trial. Eur Respir J 2009; 34: 1277–1283. doi:10.1183/09031936.00142108
    1. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96: 1004–1017. doi:10.1097/00000542-200204000-00031
    1. Wahidi MM, 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. doi:10.1378/chest.10-3361
    1. Perel A. Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: a Consensus Statement of 21 European National Societies of Anaesthesia. Eur J Anaesthesiol 2011; 28: 580–584. doi:10.1097/EJA.0b013e328348a977
    1. Yuan F, Fu H, Yang P, et al. . Dexmedetomidine-fentanyl versus propofol-fentanyl in flexible bronchoscopy: a randomized study. Exp Ther Med 2016; 12: 506–512. doi:10.3892/etm.2016.3274
    1. Goneppanavar U, Magazine R, Periyadka Janardhana B, et al. . Intravenous dexmedetomidine provides superior patient comfort and tolerance compared to intravenous midazolam in patients undergoing flexible bronchoscopy. Pulm Med 2015; 2015: 727530. doi:10.1155/2015/727530
    1. Ehsan Z, Mahmoud M, Shott SR, et al. . The effects of anesthesia and opioids on the upper airway: a systematic review. Laryngoscope 2016; 126: 270–284. doi:10.1002/lary.25399
    1. Venn RM, Hell J, Grounds RM. Respiratory effects of dexmedetomidine in the surgical patient requiring intensive care. Crit Care 2000; 4: 302–308. doi:10.1186/cc712
    1. Ryu JH, Lee SW, Lee JH, et al. . Randomized double-blind study of remifentanil and dexmedetomidine for flexible bronchoscopy. Br J Anaesth 2012; 108: 503–511. doi:10.1093/bja/aer400
    1. Shehabi Y, Ruettimann U, Adamson H, et al. . Dexmedetomidine infusion for more than 24 hours in critically ill patients: sedative and cardiovascular effects. Intensive Care Med 2004; 30: 2188–2196. doi:10.1007/s00134-004-2417-z
    1. Venn RM, Grounds RM. Comparison between dexmedetomidine and propofol for sedation in the intensive care unit: patient and clinician perceptions. Br J Anaesth 2001; 87: 684–690. doi:10.1093/bja/87.5.684
    1. Nelson LE, Lu J, Guo T, et al. . The alpha2-adrenoceptor agonist dexmedetomidine converges on an endogenous sleep-promoting pathway to exert its sedative effects. Anesthesiology 2003; 98: 428–436. doi:10.1097/00000542-200302000-00024
    1. Lin T-Y, Kuo C-H, Chung F-T, et al. . Comparison of dexmedetomidine to propofol for sedation of endobronchial ultrasound-guided transbronchial needle aspiration. Eur Respir J 2019; 54: Suppl. 63, PA320.
    1. Jose RJ, Shaefi S, Navani N. Sedation for flexible bronchoscopy: current and emerging evidence. Eur Respir Rev 2013; 22: 106–116. doi:10.1183/09059180.00006412
    1. Ni YL, Lo YL, Lin TY, et al. . Conscious sedation reduces patient discomfort and improves satisfaction in flexible bronchoscopy. Chang Gung Med J 2010; 33: 443–452.
    1. Fanning RM. Monitoring during sedation given by non-anaesthetic doctors. Anaesthesia 2008; 63: 370–374. doi:10.1111/j.1365-2044.2007.05378.x
    1. Conti G, Ranieri VM, Costa R, et al. . Effects of dexmedetomidine and propofol on patient-ventilator interaction in difficult-to-wean, mechanically ventilated patients: a prospective, open-label, randomised, multicentre study. Crit Care 2016; 20: 206. doi:10.1186/s13054-016-1386-2
    1. Casal RF, Lazarus DR, Kuhl K, et al. . Randomized trial of endobronchial ultrasound-guided transbronchial needle aspiration under general anesthesia versus moderate sedation. Am J Respir Crit Care Med 2015; 191: 796–803. doi:10.1164/rccm.201409-1615OC
    1. Li H, Zhang N, Zhang K, et al. . Observation of the clinical efficacy of dexmedetomidine in flexible bronchoscopy under general anesthesia: clinical case experience exchange. J Int Med Res 2019; 47: 6215–6222. doi:10.1177/0300060519880763
    1. Ingersoll-Weng E, Manecke GR, Jr., Thistlethwaite PA. Dexmedetomidine and cardiac arrest. Anesthesiology 2004; 100: 738–739. doi:10.1097/00000542-200403000-00040
    1. Gerlach AT, Murphy CV. Dexmedetomidine-associated bradycardia progressing to pulseless electrical activity: case report and review of the literature. Pharmacotherapy 2009; 29: 1492. doi:10.1592/phco.29.12.1492
    1. Radek L, Kallionpaa RE, Karvonen M, et al. . Dreaming and awareness during dexmedetomidine- and propofol-induced unresponsiveness. Br J Anaesth 2018; 121: 260–269. doi:10.1016/j.bja.2018.03.014
    1. Houghton CM, Raghuram A, Sullivan PJ, et al. . Pre-medication for bronchoscopy: a randomised double blind trial comparing alfentanil with midazolam. Respir Med 2004; 98: 1102–1107. doi:10.1016/j.rmed.2004.03.023
    1. Oztas S, Aka Akturk U, Alpay LA, et al. . A comparison of propofol-midazolam and midazolam alone for sedation in endobronchial ultrasound-guided transbronchial needle aspiration: a retrospective cohort study. Clin Respir J 2017; 11: 935–941. doi:10.1111/crj.12442
    1. Franzen D, Schneiter D, Weder W, et al. . Impact of sedation technique on the diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration. Endosc Ultrasound 2017; 6: 257–263. doi:10.4103/2303-9027.190925
    1. Conte SC, Spagnol G, Confalonieri M, et al. . Deep sedation versus minimal sedation during endobronchial ultrasound transbronchial needle aspiration. Monaldi Arch Chest Dis 2018; 88: 967. doi:10.4081/monaldi.2018.967
    1. Yarmus LB, Akulian JA, Gilbert C, et al. . Comparison of moderate versus deep sedation for endobronchial ultrasound transbronchial needle aspiration. Ann Am Thorac Soc 2013; 10: 121–126. doi:10.1513/AnnalsATS.201209-074OC
    1. Fernandes MGO, Santos VF, Martins N, et al. . Endobronchial ultrasound under moderate sedation versus general anesthesia. J Clin Med 2018; 7: 421. doi:10.3390/jcm7110421

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다