Anesthesia and sedation during flexible bronchoscopy

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Anesthesia and sedation during flexible
bronchoscopy
Dr. Aditya Jindal Interventional Pulmonologist
Intensivist Jindal Clinics SCO 21, Sec 20D,
Chandigarh DM Pulmonary and Critical Care
Medicine (PGI Chandigarh), FCCP
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Outline

• Introduction
• Premedication
• Topical anaesthesia
• Sedation
• Summary

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Introduction

• Flexible bronchoscopy is one of the most common
  procedures performed by pulmonary physicians
• Wide variety of procedures available
• Duration of procedure is variable
• Use of topical anaesthesia and sedation is widely
  variable throughout the world
• Not strictly necessary for the procedure

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Need for sedation/ anaesthesia

• Patient
• Better tolerance
• Better comfort and satisfaction
• Willingness to get repeat procedure if needed
• Operator
• Reduced cough
• Better physician satisfaction
• Minimum iatrogenic complications
• Outcome
• Variable
• Jose, R. J., et al. (2013). "Sedation for
  flexible bronchoscopy current and emerging
  evidence." Eur Respir Rev 22(128) 106-116.
• Wahidi, M. M., et al. (2011). "American College
  of Chest Physicians consensus statement on the
  use of topical anesthesia, analgesia, and
  sedation during flexible bronchoscopy in adult
  patients." Chest 140(5) 1342-1350.

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• Premedication

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• Anticholinergics
• Atropine and Glycopyrrolate
• Theoretical benefits
• Bronchodilation
• Drying up of secretions (nasopharynx, oropharynx
  bronchi)
• Protect against vasovagal reaction
• Shown to improve pulmonary function by iv/ im
  route
• Not shown to decrease secretions
• Neuhaus A et al, Ann Thorac Surg . 1978 25 ( 5
  ) 393 - 398
• Belen J et al, Chest . 1981 79 ( 5 ) 516 - 519
  
• Roffe C et al, Monaldi Arch Chest Dis . 1994 49
  ( 2 ) 101 - 106
• Williams T et al, Chest . 1998 113 ( 5 ) 1394
  - 1398
• Cowl CT et al, Chest . 2000 118 ( 1 ) 188 - 192

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• 1,000 patients, RCT
• IM atropine 0.01 mg/kg vs glycopyrrolate 0.005
  mg/kg vs saline
• Glycopyrrolate, but not atropine, was associated
  with reduced bronchoscopist-reported airway
  secretion
• Both drugs not associated with any significant
  reduction in cough, patient discomfort, oxygen
  desaturation, or procedure time
• Increase in heart rate and BP was significantly
  greater

Chest . 2009 136 ( 2 ) 347 - 354 .
Use discouraged as pre-bronchoscopy medications
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• Topical anaesthesia

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• Need
• To decrease cough
• To reduce the dose of sedative drugs
• Methods
• Topical Anaesthesia
• Soaked cotton pledgets
• Gel
• Dropper instillation
• Gargling
• Spray
• Nebulization
• Spray-as-you-go technique
• Transcricoid or transtracheal injection
• Nerve blocks
• Glossopharngeal nerve block
• Superior laryngeal nerve block
• Recurrent laryngeal nerve block

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• Limited data available as to preferred technique
  of administration
• Method dictated by patient comfort, physician
  comfort and training
• Commonly used methods
• Nebulization
• Gel instillation
• Spray
• Spray as you go technique (through the working
  channel of the bronchoscope)

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• Spray as you go technique
• Local anasesthetic sprayed through the working
  channel of the bronchoscope
• Sites
• Vocal cords
• Carina
• Right and left main bronchi
• Used in combination with other methods
• Recent trial
• RCT
• 1 vs 2 lignocaine
• No difference in patient VAS score for cough and
  pain
• Operator VAS score significantly higher for 1
  group
• Dose significantly lower in 1 group
• Kaur H.,
  Dhooria S, et al. (2015). "A randomized trial of
  1 vs. 2 lignocaine by the spray-as-you-go
  technique for topical anesthesia during flexible
  bronchoscopy." Chest.

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Nerve blocks
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• Knowledge of anatomy and training are required
• Equal efficacy
• 
  
  Alka Chandra et al,
  Indian J Anaesthesia 2011 55483-7
• More difficult to perform
• Higher risk of complications
• Complications
• Bleeding
• Nerve damage
• Intra-vascular injection
• discouraged as first-line techniques because of
  their invasive nature and required special
  training.
• 
  Wahidi, M. M., et al. (2011). "American College
  of Chest Physicians consensus statement on the
  use of topical anesthesia, analgesia, and
  sedation during flexible bronchoscopy in adult
  patients." Chest 140(5) 1342-1350.

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• Anaesthetic agents
• Cocaine (4)
• Vasoconstriction
• Habit formation
• Adverse CVS actions myocardial infarction,
  coronary thrombosis
• Benzocaine (20) Tetracaine (1)
• Methemoglobinemia
• Lignocaine
• Efficacious at suppressing cough
• Short half-life
• Wide safety margin
• Minimal tissue toxicity

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Lignocaine

• Onset 2-5 min
• Duration 15-60 min
• Minimum tissue toxicity
• Wide safety margin
• Metabolised liver (CYP 450, CYP 1A2)
• Excretion renal
• Toxicity
• CNS CVS Dose related gt 7mg/kg (serum gt5 mg/L)
• MHb rare, idiosyncratic
• Use with caution in patients with
• Advance age
• Impaired liver function
• CHF

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Formulations

• Jelly 2 (30 g tube)
• 20 mg/g
• Spray
• 10 pump spray (50 ml, 500 sprays)
• 10 mg/ spray
• Injection
• 0.5 /- adrenaline (5mg/ml)
• 1.0 /- adrenaline (10mg/ml)
• 2.0 /- adrenaline (20mg/ml)
• Topical solution (clear 30 ml bottle)
• 4.0 (40 mg/ml)
• Viscous (2, red 200 ml bottle)
• For gargles
• 20 mg/ml

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• Sedation

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• Depends upon type and duration of procedure
• Level of sedation
• Who administers?
• Drugs

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Continuum of Depth of Sedation Definition of
General Anesthesia and Levels of Sedation and
Analgesia (ASA)
Variables Minimal sedation (anxiolysis) Moderate sedation (conscious sedation) Deep sedation General anaesthesia
Responsiveness Normal response to verbal stimulation Purposeful response to verbal or tactile stimulation Purposeful response following repeated or painful stimlulation Unarousable even with painful stimulus
Airway Unaffected No intervention required Intervention maybe required Intervention often required
Spontaneous ventilation Unaffected Adequate May be inadequate Frequently inadequate
Cardiovascular function Unaffected Usually maintained Usually maintained May be impaired

• Adapted from Cohen, N. A. and S. W. Stead
  (2008). "Moderate sedation for chest physicians."
  Chest 133(6) 1489-1494.

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Who administers?

• Proceduralist administered vs anesthetist
  administered
• Safety
• Efficacy
• Comfort
• Cost
• Dang D, Robinson PC, Winnicki S, et al. The
  safety of flexible fibreoptic bronchoscopy and
  proceduralist-administered sedation a tertiary
  referral centre experience. Int Med J 2012 42
  300305.
• Jose, R. J., et al. (2013). "Sedation for
  flexible bronchoscopy current and emerging
  evidence." Eur Respir Rev 22(128) 106-116.
• Caveat
• Experience in airway management and ventilation
• Backup

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AJRCCM. Volume 191 Number 7, April 1 2015
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• Prospective RCT
• EBUS-TBNA
• 75 patients under general anaesthesia to 74
  patients under moderate sedation
• No significant difference in
• Diagnostic yield (70.7 vs 68.9)
• Sensitivity (98.2 vs 98.1)
• Major complications (none in either group)
• Significant difference in
• Minor complication rate (29.6 vs. 5.3) (Plt0.001)

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Endobronchial Ultrasoundguided Transbronchial
Needle Aspiration and Sedation-related
Complications
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Drugs

• Ideal sedative
• easy to use
• rapid onset
• short duration of action
• rapid recovery with rapid return of cognition
• predictable pharmacokinetic and pharmacodynamic
  profile
• not altered by interactions with other drugs
• reversible with a predictable and specific
  antagonist
• use should result in improved safety, enhanced
  patient comfort and tolerance

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Pharmacokinetic Properties of Commonly Used
Analgesic and Sedative Agents

• Wahidi, M. M., et al. (2011). "American College
  of Chest Physicians consensus statement on the
  use of topical anesthesia, analgesia, and
  sedation during flexible bronchoscopy in adult
  patients." Chest 140(5) 1342-1350.

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• Midazolam
• Benzodiazipine
• Sedation, hypnosis, anxiolysis, amnesia
• No analgesia
• Rapid onset of action
• Rapid time to peak effect
• Short duration of action
• Antagonist available
• Can be combined with opioids

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Take home message

1. Use topical anesthesia and/ or sedation in all
   flexible bronchoscopies
2. Balance patient and physician comfort with post
   op recovery times/ complications
3. Lignocaine is the preferred agent for local
   anaesthesia by any method
4. Premedication with anticholinergics is
   discouraged
5. Sedation should be titrated according to the ASA
   continuum of sedation scale
6. One should be versed in emergency airway and
   ventilation management
7. Have a backup protocol ready

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THANK YOU