Comparison of midazolam and low-dose dexmedetomidine in flexible bronchoscopy: A prospective, randomized, double-blinded study

Efficacy and safety of remimazolam versus dexmedetomidine for patients undergoing flexible fiberoptic bronchoscopy: A randomized, clinical trial

STUDY OBJECTIVE

Remimazolam's benefits for patients undergoing painless flexible fiberoptic bronchoscopy remain uncertain. We aimed to compare the efficacy and safety of remimazolam and dexmedetomidine in flexible fiberoptic bronchoscopy (FFB).

DESIGN

Randomized controlled trial.

SETTING

University hospital.

PATIENTS

Between April 2021 and September 2022, patients undergoing painless flexible fiberoptic bronchoscopy were recruited.

INTERVENTIONS

The patients were randomly assigned with a 1:1 ratio to remimazolam-remifentanil group (RR group) or dexmedetomidine-remifentanil group (DR group).

MEASUREMENTS

The primary outcome was the procedure interruption rate during bronchoscopy. Secondary outcomes were hemodynamic changes, resuscitation time, rescue medication usage rate and dose, satisfaction scores of patients and bronchoscopists, operation-related complications, and adverse events.

MAIN RESULTS

A total of 363 patients were included for final analysis. The interruption rates of bronchoscopy were 8.2 % in the RR group and 39.2 % in the DR group (P < 0.05). The rescue medication usage rate (4.4 % vs. 38.7 %, P < 0.05) and dose (1.51 ± 8.15 mg vs. 13.17 ± 18.86 mg, P < 0.05) were lower in the RR group compared with the DR group. The incidence of oxygen desaturation was significantly lower in the RR group than in the DR group (14.3 % vs. 44.2 %, P < 0.05). Hemodynamic changes in patients in the DR group were significant, with longer recovery time and lower satisfaction scores for both inpatients and bronchoscopists (P < 0.05), compared with the RR group. However, there were no significant differences between groups in terms of operation-related complications (P > 0.05) except for postoperative dizziness, which was more common in the DR group (P < 0.05).

CONCLUSIONS

Remimazolam is effective and safe in painless flexible fiberoptic bronchoscopy. It allows a lower procedure interruption rate and incidence of oxygen desaturation, providing better hemodynamic stability compared to dexmedetomidine.

Comparison Between Dexmedetomidine and Midazolam-Fentanyl Combination in Flexible Bronchoscopy: A Prospective, Randomized, Double-blinded Study

BACKGROUND

Dexmedetomidine has acceptable clinical utility for inducing sedation during flexible bronchoscopy. Reducing its dose may not only ameliorate its cardiovascular side effects, but also maintain its clinical usefulness.

METHODS

Patients between 18 and 65 years were randomized to either dexmedetomidine (0.75 µg/kg) or the midazolam-fentanyl group (0.035 mg/kg midazolam and 25 mcg fentanyl). The primary outcome measure was the composite score. Other parameters noted were: oxygen saturation, hemodynamic variables, Modified Ramsay Sedation Score, Numerical Rating Scale (NRS) for pain intensity and distress, Visual Analog Scale score for cough, rescue medication doses, ease of doing bronchoscopy, and patient response 24 hours after bronchoscopy.

RESULTS

In each arm, 31 patients were enrolled. The composite score at the nasopharynx was in the ideal category in 26 patients in dexmedetomidine and 21 in the midazolam-fentanyl group (P=0.007). At the tracheal level, the corresponding values were 24 and 16 (P=0.056). There was no significant difference between the 2 groups regarding the secondary outcome measures except hemodynamic parameters. The mean heart rate in the dexmedetomidine and midazolam-fentanyl groups, respectively, was as follows: at 10 minutes after start of FB (90.10±14.575, 104.35±18.48; P=0.001), at the end of FB (98.39±18.70, 105.94±17.45; P=0.016), and at 10 minutes after end of FB (89.84±12.02, 93.90±13.74; P=0.022). No patient developed bradycardia. Two patients (P=0.491) in the dexmedetomidine group developed hypotension.

CONCLUSION

Low-dose dexmedetomidine (0.75 μg/kg single dose) appears to lead to a better composite score compared with the midazolam-fentanyl combination.

Clinical usefulness of nebulized dexmedetomidine for conscious sedation in daycare flexible bronchoscopy in Southern India

BACKGROUND

Sedative agents used in bronchoscopy require trained personnel to administer and monitor the patient. This increases the procedure cost, duration, and inpatient stay. Inhalational administration of sedative agents can be a practical solution to the issue. Dexmedetomidine in the inhalational form could give results similar to the intravenous form without significant adverse events.

MATERIALS AND METHODS

The study is prospective, randomized, and double-blinded study. Patients needing bronchoscopy were randomized to receive the nebulized form of either dexmedetomidine or saline (0.9%) before bronchoscopy. The study parameters are assessed and recorded before, during, and after bronchoscopy. Data collected are analyzed using the SPSS software.

DISCUSSION

The side effects limit using commonly administered sedation agents in bronchoscopy, such as midazolam, fentanyl, and dexmedetomidine. The nebulized dexmedetomidine is safe with proven efficacy when compared to the placebo. Proceduralist-administered conscious sedation reduces the overall cost and shortens inpatient stays. Attenuation of hemodynamic parameters by dexmedetomidine could be an advantage for the physician in reducing an untoward cardiac event.

CONCLUSION

Dexmedetomidine in the nebulized form improves the comfort of patients during the procedure. It blunts the pressure response during bronchoscopy and could be a safer and cost-effective agent in its nebulized form for conscious sedation in bronchoscopy. The study is approved by the institutional ethics committee (IEC KMC MLR 10-2021-310).

Effects of dexmedetomidine in non-operating room anesthesia in adults: a systematic review with meta-analysis

BACKGROUND

Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist used for its sedative, analgesic, and anxiolytic effects. Non-Operating Room Anesthesia (NORA) is a modality of anesthesia that can be done under general anesthesia or procedural sedation or/and analgesia. In this particular setting, a level-2 sedation, such as the one provided by DEX, is beneficial. We aimed to study the effects and safety of DEX in the different NORA settings in the adult population.

METHODS

A systematic review with meta-analysis of randomized controlled trials was conducted. Interventions using DEX only or DEX associated with other sedative agents, in adults (18 years old or more), were included. Procedures outside the NORA setting and/or without a control group without DEX were excluded. MEDLINE, ClinicalTrials.gov, Scopus, LILACS, and SciELO were searched. The primary outcome was time until full recovery. Secondary outcomes included hemodynamic and respiratory complications and other adverse events, among others.

RESULTS

A total of 97 studies were included with a total of 6,706 participants. The meta-analysis demonstrated that DEX had a higher time until full recovery (95% CI = [0.34, 3.13] minutes, a higher incidence of hypotension (OR = 1.95 [1.25, 3.05], p = 0.003, I2 = 39%) and bradycardia (OR = 3.60 [2.29, 5.67], p < 0.00001, I2 = 0%), and a lower incidence of desaturation (OR = 0.40 [0.25, 0.66], p = 0.0003, I² = 60%).

CONCLUSION

DEX in NORA procedures in adults was associated with a lower incidence of amnesia and respiratory effects but had a long time to recovery and more hemodynamic complications.

Safety and Efficacy of Dexmedetomidine for Bronchoscopy: A Systematic Review and Meta-Analysis

(1) Background: Anesthetic sedatives are widely used for bronchoscopy, and controversy surrounds the safety and efficacy of dexmedetomidine compared to other sedatives. The aim of this study is to evaluate the safety and efficacy of dexmedetomidine in bronchoscopy through a systematic review. (2) Methods: PubMed, Embase, Google Scholar, and Cochrane Library electronic databases were searched for a randomized controlled study of dexmedetomidine (Group D) or other sedative drugs (Group C) for bronchoscopy. Data extraction, quality assessment, and risk of bias analysis were performed in accordance with the preferred reporting items for systematic review and meta-analysis requirements. Meta-analysis was performed using RevMan 5.2. (3) Results: Nine studies were included, with a total of 765 cases. Compared to Group C, the incidence of hypoxemia (OR = 0.40, 95% CI (0.25, 0.64) p = 0.0001, I² = 8%) and tachycardia (OR = 0.44, 95% CI (0.26,0.74), p = 0.002, I² = 14%) were lower, but bradycardia (OR = 3.71, 95% CI (1.84, 7.47), p = 0.0002, I² = 0%) was higher in Group D; no significant difference was observed in other outcome indicators. (4) Conclusions: Dexmedetomidine reduces the incidence of hypoxemia and tachycardia during bronchoscopy but is more likely to provoke bradycardia.

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.

Dexmedetomidine versus propofol sedation in flexible bronchoscopy: a randomized controlled trial

Background

Dexmedetomidine (DEX), is a highly selective alpha2 adrenoceptor (α2-AR) agonist, successfully used in various procedures including flexible bronchoscopy. Randomized controlled trials (RCTs) evaluating DEX sedation during bronchoscopy report equivocal results regarding respiratory and hemodynamic outcomes.

Methods

We conducted an RCT to evaluate the efficacy and safety of dexmedetomidine compared to propofol for sedation during bronchoscopy. The primary outcome was the number of desaturation events, secondary outcomes were transcutaneous Pco2 level, hemodynamic adverse events and physician and patient satisfaction.

Results

Overall, 63 patients were included, 30 and 33 in the DEX and propofol groups, respectively. The number of desaturation events was similar between groups, median (IQR) 1 (0–1) and 1 (0–2) in the DEX and control groups, respectively (P = 0.29). Median desaturation time was 1 (0–2) and 1 (0–3) minutes in the DEX and control groups, respectively (P = 0.48). Adverse events included hypotension, 33% vs 21.1% in intervention and control groups, respectively (P = 0.04), bradycardia, cough, and delayed recovery from sedation. Total adverse events were 22 and 7 in DEX and propofol groups, respectively (P = 0.009).

Conclusion

Dexmedetomidine sedation during bronchoscopy did not show differences in oxygen saturation and transcutaneous CO2 level in comparison to propofol. Moreover, DEX sedation required a significantly higher number of rescue boluses, due to inadequate sedation and was associated with a higher rate of adverse events.

Trial registration NCT04211298, registration date: 26.12.2019.

Effect of Bronchoscopist-Directed Sedation and Other Factors on Patient Comfort during Diagnostic Flexible Bronchoscopy

BACKGROUND

The factors affecting patient comfort during flexible bronchoscopy are not sufficiently addressed in resource-limited countries, and a need to devise strategies to improve patient experience is felt. The present study was undertaken to assess the effect of sedation and other factors on patient comfort during flexible bronchoscopy.

METHODS

A total of 374 patients, aged ≥18 years undergoing flexible bronchoscopy, were enrolled in this prospective, single-center, cross-sectional study. The baseline clinical data of sedation and nonsedation groups were recorded. Anxiety level was assessed using Visual Analog Scale (VAS). Postprocedure VAS score (primary outcome measure) assessed the discomfort related to flexible bronchoscopy. Patient-reported willingness for a repeat procedure and occurrence of adverse events were used as secondary outcome measures. Based on the median of VAS score, the study population was divided into low discomfort and high discomfort groups, and the factors affecting comfort levels in these two groups were noted.

RESULTS

Postprocedural VAS score (median (Q1, Q3)) for sedation and nonsedation groups was 20 (15, 30) and 25 (20, 40), respectively (<0.001). Willingness for a repeat procedure was significantly more in the sedation group (p=0.002). In the low and high discomfort groups, the preprocedural anxiety level (median (Q1, Q3)) was 20 (10, 25) and 30 (20, 40), respectively (p < 0.001).

CONCLUSION

Bronchoscopist-directed sedation significantly reduces patient discomfort and increases their willingness for a repeat procedure. Midazolam-fentanyl combination and lower prebronchoscopy anxiety are associated with lower discomfort levels during flexible bronchoscopy. This study is registered with the Clinical Trial Registry of India (CTRI/2018/11/016328).

Use of high-flow nasal cannula and intravenous propofol sedation while performing flexible video bronchoscopy in the intensive care unit: Case reports

Flexible video bronchoscopy is a procedure that plays an important role in diagnosing various types of pulmonary lesions and abnormalities. Case 1 is a 68-year-old male patient with a lesion in the right lung apex of approximately 4 mm × 28 mm with atelectasis bands due to a crash injury. High-flow system with 35 L/min and fraction of inspired oxygen (FiO₂) 0.45 and temperature of 34 °C was installed prior to the video bronchoscopy. SpO₂ was maintained at 98%-100%. The total dose of sedative was 50 mg of propofol. In Case 2, a 64-year-old male patient with bronchiectasis, cystic lesions and pulmonary fibrosis of the left lung field was placed on a high-flow system with 45 L/min and 0.35 FiO₂ at a temperature of 34 °C. SpO₂ was maintained at 100%. The total duration of the procedure was 25 min; SpO₂ of 100% was sustained with oxygenation during maintenance time with the flexible bronchoscope within the airway. The total dose of propofol to reach the degree of desired sedation was 0.5-1 mg/kg. Both patients presented hypotension. For the patient of case 1, a vasopressor (norepinephrine at doses of 0.04 µg/kg/min) was given, and for the patient of case 2, only saline volume expansion was used. The video bronchoscopy with propofol sedation and high-flow nasal cannula allows adequate oxygenation during procedure in the intensive care unit.

Bronchoscopy during COVID-19 pandemic, ventilatory strategies and procedure measures

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has changed bronchoscopy practices worldwide. Bronchoscopy is a high-risk aerosol-generating procedure with a potential for direct SARS-CoV-2 exposure and hospital-acquired infection. Current guidelines about personal protective equipment and environment considerations represent key competencies to minimize droplets dispersion and reduce the risk of transmission. Different measures should be put in field based on setting, patient's clinical characteristics, urgency and indications of bronchoscopy. The use of this technique in SARS-CoV-2 patients is reported primarily for removal of airway plugs and for obtaining microbiological culture samples. In mechanically ventilated patients with SARS-CoV-2, bronchoscopy is commonly used to manage complications such as hemoptysis, atelectasis or lung collapse when prone positioning, physiotherapy or recruitment maneuvers have failed. Further indications are represented by assistance during percutaneous tracheostomy. Continuous positive airway pressure, non-invasive ventilation support and high flow nasal cannula oxygen are frequently used in patient affected by Coronavirus Disease-2019 (COVID-19): management of patients' airways and ventilation strategies differs from bronchoscopy indications, patient's clinical status and in course or required ventilatory support. Sedation is usually administered by the pulmonologist (performing the bronchoscopy) or by the anesthetist depending on the complexity of the procedure and the level of sedation required. Finally, elective bronchoscopy for diagnostic indications during COVID-19 pandemic should be carried on respecting rigid standards which allow to minimize potential viral transmission, independently from patient's COVID-19 status. This narrative review aims to evaluate the indications, procedural measures and ventilatory strategies of bronchoscopy performed in different settings during COVID-19 pandemic.