Randomized single-blind comparative study of the midazolam/pethidine combination and midazolam alone during bronchoscopy

Midazolam with fentanyl for endobronchial ultrasound-guided transbronchial needle aspiration: a randomized, double-blind, phase III study

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a common technique for sampling mediastinal and hilar lymph nodes. However, the optimal sedation for EBUS-TBNA remains unclear. We aimed to evaluate the efficacy of adding fentanyl to midazolam.

MATERIALS AND METHODS

We conducted a single-center, randomized, double-blind, phase III study. Patients who received midazolam with fentanyl (fentanyl group) were compared with those who received midazolam with placebo (placebo group) during EBUS-TBNA. The primary outcome was the proportion of patients meeting all three criteria: 1) adequate sedation (Modified Observer's Assessment of Alertness and Sedation scale ≤4 or bispectral index values ≤80), 2) minimal additional sedation requirement (no more than two additional sedative administrations within the first 30 min), and 3) successful procedure completion (at least three EBUS-TBNA punctures).

RESULTS

A total of 84 patients (fentanyl group, 41; placebo group, 43) were enrolled. There were no significant differences in patient characteristics between the two groups. The primary outcome was significantly better in the fentanyl group than in the placebo group (46.3 % vs. 23.3 %, p = 0.038). A significantly lower rate of sedative-induced delirium, a lower number of additional sedative administrations, and a higher rate of ≥3 punctures were observed in the fentanyl group. There were no significant differences in complications. The operator visual analog scale questionnaire on cough, sputum, cooperation, and sedative effects was significantly better in the fentanyl group.

CONCLUSION

Adding fentanyl to midazolam provided better sedation. Midazolam combined with fentanyl should be considered during EBUS-TBNA.

Impact of Cough Severity on the Diagnostic Yield of Endobronchial Ultrasonography Transbronchial Biopsy with Guide Sheath: A Retrospective Observational Study

Bronchoscopy is an invasive procedure, and patient coughing during examination has been reported to cause patient distress. This study aimed to clarify the relationship between cough severity and diagnostic yield of endobronchial ultrasonography with guide sheath transbronchial biopsy (EBUS-GS-TBB). Data of patients who underwent bronchoscopy at Kyorin University Hospital between April 2019 and March 2022 were retrospectively evaluated. Bronchoscopists assessed the cough severity upon completion of the procedure using a four-point cough scale. Cough severity was included as a predictive factor along with those reportedly involved in bronchoscopic diagnosis, and their impact on diagnostic yield was evaluated. Predictors of cough severity were also examined. A total of 275 patients were enrolled in this study. In the multivariate analysis, the diagnostic group (n = 213) had significantly more 'within' radial endobronchial ultrasound findings (odds ratio [OR] 5.900, p < 0.001), a lower cough score (cough score per point; OR 0.455, p < 0.001), and fewer bronchial generations to target lesion(s) (OR 0.686, p < 0.001) than the non-diagnostic group (n = 62). The predictive factors for severe cough include the absence of virtual bronchoscopic navigation (VBN) and prolonged examination time. Decreased cough severity was a positive predictive factor for successful EBUS-GS-TBB, which may be controlled using VBN and awareness of the procedural duration.

Impact of adding pethidine on disinhibition during bronchoscopy with midazolam: a propensity score matching analysis

BACKGROUND

We sometimes experience disinhibition during bronchoscopy with sedation. However, the impact of adding pethidine on disinhibition has not yet been investigated. This study aimed to examine the additive impact of pethidine on disinhibition during bronchoscopy with midazolam.

METHODS

This retrospective study involved consecutive patients who underwent bronchoscopy between November 2019 and December 2020 (sedated with midazolam: Midazolam group) and between December 2020 and December 2021 (sedated with midazolam plus pethidine: Combination group). The severity of disinhibition was defined as follows: moderate, disinhibition that always needed restraints by assistants; and severe, disinhibition that needed antagonization of sedation by flumazenil to continue bronchoscopy. One-to-one propensity score matching was used to match baseline characteristics between both groups.

RESULTS

After propensity score matching with depression, the type of bronchoscopic procedure, and the dose of midazolam, 142 patients matched in each group. The prevalence of moderate-to-severe disinhibition significantly decreased from 16.2% to 7.8% (P = 0.028) in the Combination group. The Combination group had significantly better scores for sensation after bronchoscopy and feelings toward bronchoscopy duration than did the Midazolam group. Although the minimum SpO₂ during bronchoscopy was significantly lower (88.0 ± 6.2 mmHg vs. 86.7 ± 5.0 mmHg, P = 0.047) and the percentage of oxygen supplementation significantly increased (71.1% vs. 86.6%, P = 0.001) in the Combination group, no fatal complications were observed.

CONCLUSIONS

Adding pethidine could reduce disinhibition occurrence in patients undergoing bronchoscopy with midazolam, with better subjective patient outcomes during and after bronchoscopy. However, whether more patients may need oxygen supplementation and whether hypoxia occurs during bronchoscopy should be considered.

CLINICAL TRIAL REGISTRATION

UMIN000042635.

Effect of different doses of midazolam combined with fentanyl during painless bronchoscopy in adults

OBJECTIVE

To investigate the clinical effect of different doses of midazolam combined with fentanyl during painless bronchoscopy in adult patients.

METHODS

In this retrospective study, a total of 200 patients who underwent painless bronchoscopy in The First People's Hospital of Wenling from January 2018 to January 2021 were selected as research subjects. These patients were assigned into an experimental group and a control group with 100 patients in each group. Patients from the experimental group were sedated with an intravenous infusion of 0.05 mg/kg midazolam and 0.2 μg/kg fentanyl, while patients from the control group were sedated using 0.1 mg/kg midazolam and 0.2 μg/kg fentanyl. The changes in heart rate (HR), saturation of pulse oximetry (SpO₂), systolic blood pressure (SBP), and diastolic blood pressure (DBP) before and at 10 minutes after administration were compared between the two groups. Ramsay sedation scale, RSS agitation scale, awaking time, incidence of adverse reactions, and anesthetic effects were also compared.

RESULTS

After medication, there was no significant difference in terms of HR, SBP, or DBP values between the two groups. The SpO₂ value in the experimental group was higher than that in the control group (96.93±1.10% vs. 94.78±0.83%, P<0.05). Ramsay sedation scale of patients from the experimental group after medication was (3.88±0.66), which was significantly higher than that of the control group (2.32±0.63), while RSS agitation score in the experimental group was (1.08±0.16), lower than that of the control group (2.32±0.63). The awaking time in the experimental group was shorter than that in control group (43.60±3.30 min vs. 50.19±4.45 min, P<0.05). Moreover, the incidence of mild cough or no cough in the experimental group was significantly better than in the control group (P<0.05). The overall incidence of adverse reactions in the experimental group was lower than that of the control group (5.00% vs. 13.00%, P<0.05). In addition, the anesthetic effect in the experimental group was better than that of the control group (90% vs. 80%, P<0.05).

CONCLUSION

The use of 0.05 mg/kg midazolam combined with 0.2 μg/kg fentanyl in adult painless bronchoscopy has little effect on SpO₂ levels, possesses a good sedative and anesthetic effect, and reduces the awaking time, restlessness response, and adverse reactions.

Safe sedation during diagnostic and therapeutic flexible bronchoscopy in Japan: A review of the literature

We explored whether a combination of an opioid (fentanyl or pethidine) and midazolam could safely sedate Japanese patients undergoing bronchoscopic procedures. We searched the PubMed Medline and Igaku Chuo Zasshi (ICHUSHI) databases from 1980 to 2022 for papers on sedatives used during bronchoscopy, especially opioids (fentanyl and pethidine) and midazolam. The keywords were "bronchoscopy" and "sedation" ("kikanshikyo" and "chinsei", respectively, in Japanese). The results showed that midazolam was the preferred sedation agent during flexible bronchoscopy; with midazolam sedation is rapid, and the drug is associated with anterograde amnesia and decreased discomfort. A combination of an opioid (fentanyl or pethidine) and midazolam improved the patient tolerance and willingness to undergo a repeat procedure and also improved the working conditions for the physician. The British Thoracic Society guideline of 2013 suggested that a combination of an opioid (fentanyl or alfentanil) and midazolam should be considered to improve bronchoscopic tolerance. The American College of Chest Physicians Consensus Statement of 2011 suggested that fentanyl should be preferred; the onset of action and peak effect are rapid, and the effects are of relatively short duration. Emphasis has been placed on safety aspects, such as patient monitoring, the precautions that should be taken in patients with certain conditions, prevention and management of complications, adequate staffing, and optimal sedation and disinfection. In conclusion a combined opioid (fentanyl or pethidine) and midazolam sedation is optimal for diagnostic and therapeutic flexible bronchoscopy in Japanese patients.