Nurse administered propofol sedation for pulmonary endoscopies requires a specific protocol

INTRODUCTION

This study provides an evaluation and risk analysis of propofol sedation for endoscopic pulmonary procedures according to our unit's "gastroenterologic nurse-administered propofol sedation (NAPS) guideline".

MATERIAL AND METHODS

The present study is a prospective descriptive study performed at the Endoscopy Unit, Gentofte Hospital, Copenhagen, from May to July 2009. The study comprised at total of 51 consecutive patients who underwent 77 endoscopic procedures. Only patients above the age of 16 years were eligible for treatment. The exclusion criteria were as follows: American Society of Anesthesiologists (ASA) class > 3, history of sedation-related complications, severe chronic obstructive pulmonary disease. Excluded were patients with a potentially difficult airway and ventricular retention. Data on the number and type of procedure, baseline characteristics, sedation time, propofol dose administered and adverse events were obtained from medical histories.

RESULTS

A total of 23 cases of adverse events were recorded, including one event of hypotension and 22 events of hypoxaemia. Five patients needed assisted ventilation. The frequency of hypoxaemia in sessions involving bronchoscopy was 17 of 26 (65%) compared with transoesophageal endoscopic ultrasound (EUS) (17 of 45, 35%) and endoscopic bronchial ultrasound (EBUS) (three of six, 50%). Endoscopist assessment of working conditions was good and patient assessment of discomfort was low. No patients required endotracheal intubation and there was no mortality.

CONCLUSION

This study supports the conclusion that propofol administered by nurses provides for good working conditions and satisfied patients. But our "NAPS for endoscopic gastroenterologic procedures" guideline was unsuited for endoscopic pulmonary procedures including EUS.

FUNDING

This work was supported by the START research foundation at Gentofte Hospital.

TRIAL REGISTRATION

not relevant.

The development of the first nurse-led bronchoscopy post in the United Kingdom

Nurses routinely practice Gastrointestinal endoscopy in the United Kingdom (UK) but, to our knowledge, bronchoscopy has never been introduced as a nursing discipline. The need for a nurse bronchoscopist was identified within our respiratory unit and the post was developed. This process involved: (1) seeking a precedent for the role of nurse bronchoscopist, (2) designing an appropriate teaching programme, (3) obtaining hospital accreditation for the programme, (4) supervising and completing the training, and (5) implementing a nurse-led bronchoscopy service. The development phase took approximately 1 year. No precedent was found for nurse-led bronchoscopy in the UK or elsewhere. The training programme defined minimum entry requirements and was modelled on UK nurse GI endoscopy training and the British Thoracic Society bronchoscopy guidelines. The role of nurse bronchoscopist was deemed to comply with professional codes of nursing practice by the chief nurse and the hospital management board authorised a service framework for the post. The first trainee completed the programme in January 2003 and has now examined 125 patients independently [endobronchial tumour biopsy hit-rate = 95% (95% CI 76-99%)]. The post of nurse bronchoscopist has been successfully developed and accredited within our hospital.

Developing and implementing the role of the nurse bronchoscopist

Recent years have seen a growing range of new roles being created for nurses, often in areas previously considered to be part of the medical domain. This paper discusses the development of the nurse bronchoscopist role and a training programme and service framework to support it in order to develop a nurse-led service for patients requiring this procedure.

The role of the nurse bronchoscopist

Fibre-optic bronchoscopy has traditionally been performed by respiratory physicians and registrars. It is an invaluable investigation for diagnosing lung cancer and other respiratory diseases. Modern bronchoscopy techniques make the procedure safe for most patients, apart from those who are gravely ill, or who have a gross reduction in respiratory reserve (Stradling, 1991).

Preparing and supporting patients undergoing a bronchoscopy

A bronchoscopy is an endoscopic examination of the upper respiratory tract, trachea and bronchial tree. The technique was developed in the 1960s and introduced into clinical practice a decade later (Stradling, 1991). The use of a flexible, fibreoptic instrument that incorporates a light source, biopsy and suction channel is inserted via the mouth or nose. This enables the bronchoscopist to inspect the airways visually, identify any abnormalities and obtain samples of secretions, cells or tissue biopsies (Lesser, 2003).

Pediatric flexible bronchoscopy under conscious sedation: nursing considerations for preparation and monitoring

Flexible bronchoscopy provides a powerful tool to evaluate pulmonary abnormalities in the pediatric population. Nursing involvement may range from age-appropriate preparation of the patient and family to administration of conscious sedation agents. Meticulous nursing assessment of the child, family, and environment facilitates identifying and meeting client needs related to flexible bronchoscopy. Preparation of the physical environment as well as physiological and psychological preparation of the child increase the likelihood of a positive experience. By increasing their familiarity with the procedure, sedation strategies, and monitoring standards, nurses increase the probability of safe and successful flexible bronchoscopic evaluations.

Medical investigations. 4: Bronchoscopy

Flexible fibreoptic bronchoscopy has largely superseded rigid bronchoscopy. It allows direct visualization of the respiratory mucosa and detailed examination of the upper airways and tracheobronchial tree (Figure 1). By passing instruments through the endoscope local and transbronchi al biopsies and mucus/sputum samples can be taken for histological, cytological and microbiological examination.

Endobronchial brachytherapy

Endobronchial brachytherapy is a palliative treatment primarily used for individuals with lung cancer. This article describes the brachytherapy and presents the nurse's role before, during, and after the procedure. Coordination between hospital staff--endoscopy department, pulmonologist, radiation oncologist, and radiology department--is important to assure the success of this procedure.

Inpatient education for fiberoptic/videoptic diagnostic and therapeutic procedures for gastroenterology

The purpose of this study was to evaluate the educational needs of the inpatient undergoing gastroenterology or pulmonary diagnostics or therapeutics using fiberoptic or videoptic technology. This study provided a mechanism to increase nursing, patient and family understanding of fiberoptic/videoptics diagnostics and treatment modalities. Interviews and surveys were used to evaluate the educational preparation of inpatients. These data revealed a significant difference in the educational preparation of inpatients compared to outpatients, which was a concern for quality standards in the preparation of gastroenterology/bronchoscopy patients. Teaching methods and tools were implemented in the inpatient environment with a measurable increase in patient preparation for gastroenterology/bronchoscopy procedures. This article will outline the findings, implementation methods and outcomes reported in a procedural gastroenterology laboratory performing approximately 2,000 procedures per year.

Creating a new nurse specialist post

Studies have shown the improvement in the quality of care which is achievable when clinical nurse specialists are introduced in the management of patient care. The field of respiratory care appears to be an appropriate setting for specialist nursing roles. The previous paper (Carswell et al) adds weight to the notion that there is room for improvement in the care of patients with respiratory problems. This paper provides the background to the development of a clinical nurse specialist role in respiratory care.