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The decision to use a sedative should be based on the patient's ability to cooperate and

tolerate the procedure. A variety of anesthetic agents have been used during bronchoscopy.
The goal is patient comfort, safety, and cooperation. Specifically, general and topical
anesthesia is used to provide anxiolysis, antegrade amnesia, and analgesia. Suppression of
cough and gag reflex is also an important goal of anesthesia. A combination of drugs
generally is used because no single class of agents provides anxiolysis, amnesia, and
analgesia. Most commonly, a combination of opiates and benzodiazepines is used. Among
benzodiazepines, midazolam has become the drug of choice because of its short elimination
halflife (2 hours) and rapid onset of action. Dose adjustment is not required in renal failure
but may be required in liver failure. The recommended dose of midazolam for conscious
sedation is 0.07 mg/kg. Because of its long half-life, sedative effects are prolonged in elderly
patients and in those with liver failure, a common finding in the ICU population.
Respiratory depression is the major adverse effect of benzodiazepines. Opiates are
useful during bronchoscopy for their analgesic and antitussive properties. Meperidine is the
most commonly used opiate for sedation along with ben~odiazepine. It has a half-life of 3.2
hours. Clearance is decreased in hepatic and renal failure. Propofol also can be used and has
an advantage of rapid onset of action and recovery time?

Adequate local anesthesia allows the clinician to perform


flexible, fiber-optic bronchoscopy without the addition of
sedatives or anxiolytics, and the concomitant administration
ofmoderate (conscious) sedation during this procedure is
controversial. Conflicting data exist as to whether sedation
improves patient tolerance of the procedure. In addition, many
of the complications associated with bronchoscopy, and up to
1/2 of the lifethreatening events can be attributed to the
sedation. Others have suggested that sedation should be
routine for bronchoscopy. Irrespective of this controversy, a
large majority of physicians routinely administer sedation
during bronchoscopy. Thus, it is incumbent on the
bronchoscopist to understand the regulatory requirements,
risks, benefits, medication dosages, monitoring requirements,
and impact of patient disease states to safely administer
moderate sedation.

In comparison to other benzodiazepine and non-benzodiazepine drugs,


midazolam is equally or more effective for premedication/preoperative sedation.
No evidence exists that premedication with midazolam prolongs discharge time

from hospital. Its efficacy and safety have been extensively studied in both
adults and children. This contrasts its comparator drug, diazepam for which data
in children and elderly are scarce or lacking. Midazolam is also effective for
procedural sedation as a single drug or in combination with an opioid. As a
single drug, adequate sedation for procedures in the emergency room, is
achieved in over 90% of all procedures. Comparative efficacy was shown for
propofol. Data are insufficient to determine comparative efficacy for procedural
sedation for other drugs.

Studies of benzodiazepines for sedation during bronchoscopy generally


show these agents to be associated with improved patient satisfaction and to be
well tolerated. In a study of sedation with diazepam vs no sedation, patient
comfort was greater with diazepam, although recovery time was 76 min in the
diazepam group compared to 19 min in the nonsedation group. In a randomized
study4 of sedation with diazepam compared to no sedation, tolerance of the
procedure as assessed by the patient was better in the sedation group. A
randomized trial of sedation with lorazepam vs placebo found no difference
immediately postprocedure, but a day later the lorazepam cohort was less likely
to report the procedure as being difficult and was less reluctant to undergo a
repeat bronchoscopy. Not all studies of benzodiazepines for sedation during
bronchoscopy have noted a benefit however.
Studies comparing opioids with benzodiazepines as single-agent sedative
regimens for bronchoscopy demonstrate relatively similar efficacy. A
nonrandomized study of sedation with fentanyl plus droperidol vs midazolam
observed no difference in bronchoscopist-rated scores of patient discomfort,
while patient rated scores favored midazolam. In a randomized trial comparing
midazolam and alfentanil, there was no difference in the ease of the procedure
or patient discomfort immediately postprocedure, although less coughing was
noted in the alfentanil group and patient discomfort scores assessed 24 h later
were lower with midazolam.

Sedation in flexible bronchoscopy (FOB) is widely used by pulmonary physicians in


Europe and in the USA. However, to our knowledge, in Portugal its use is not a daily routine
practice. FOB is usually stressful and patients often present fear and anxiety. Discomfort
during and after FOB, with persis-tent cough, pain and shortness of breath, is also common.
Several authors have shown that use of sedation ensures greater comfort for the patient and
strengthens the will-ingness to repeat the exam, if necessary. Moreover, it may shorten the
duration of the examination, with fewer interruptions, providing more satisfactory conditions
for complex techniques (e.g., bronchial brushing and biopsy, trans-bronchial needle
aspiration), and therefore better diagnostic results. The choice of a drug with sedative

properties and its dose varies according to the patients age, associated morbidities,
medication and bronchoscopists personal preference. The most commonly used drugs are
midazo-lam and propofol. The former has optimal properties for ambulatory invasive
procedures ---with rapid onset action, short half-life and few side effects. Some studies have
shown that midazolam is well tolerated and associated to greater patient satisfaction,
compared to other sedatives.6,7 Others have not reported significant differences, in terms of
efficiency and tolerance, between midazolam and opi-oids, as a single sedative drug during
FOB. The risk for cardio-respiratory depression should always be considered, although the
usually low dosage (<5 mg), the continuous cardiac and respiratory monitoring and the
existence of an effective antagonist (flumazenil), make it a rare and well-manageable side
effect. Sedation during FOB is, therefore, a common prac-tice worldwide. The potential
cardiorespiratory depressor effect, especially when used in double or triple com-bination,
warrants adequate safety measures including continuous monitoring and immediate
availability of antagonist drugs.

All the patients were given a questionnaire to complete about different aspects of their
perception of the test. It consisted of 13 questions with multiple-choice answers which were
awarded points on a Likert type response scale (1 = a lot; 2 = quite a lot; 3 = somewhat; 4 = a
little and 5 = very little). There was also one yes/ no question and 2 questions with other
alternative responses. Patients had to complete this questionnaire 30 min after the test, as long
as they were no longer under the effects of sedation. The bronchoscopist also completed a
questionnaire, consisting of 4 questions, immediately after the test was performed. Two
questions had multiple-choice scale responses (1 = a lot, 2 = somewhat and 3 = null) and 2
questions had different response alternatives (annex 1). The visual scale for sedation
consisted of a scale scoring 010, in which 0 corresponded to no sedation, 2 to minimal
sedation (defined as the presence of normal responses to verbal stimuli), 5 to moderate
sedation (defined as rapid and deliberate responses to repeated verbal or tactile stimulation), 8
to deep sedation (defined as deliberate responses to repeated painful or verbal and tactile
stimulation) and 10 to general anaesthesia (defined as the inability to wake the patient, even
using painful stimulation).

Both groups started off with a similar assessment of fear and nervousness. Group A gave a
much higher score than Group B referring to variables related to symptoms and feeling.
Patient cooperation assessed by the bronchoscopist was similar in both groups, although the
length of the procedure and difficulty was higher in group B.
Conclusion: Our results show that patients sedated with midazolam tolerate FB better,
remember less of the procedure itself and have a better predisposition to repeat the procedure.
The bronchoscopist has less difficulties during the procedure and shortens the time using the
same techniques during the bronchoscopy. The lack of severe complications and these results
suggest the use of sedation with midazolam as routine during FB.

Access to the airways in the living patient was tried already by Hippocrates (460370 bc),
who advised the introduction of a pipe into the larynx of a suffocating patient. Avicenna of
Bukhara (about ad 1000) used a silver pipe for the same purpose. Vesalius observation
around 1542 that the heartbeat and pulsation of the great vessels stopped when he opened the
chest of an experimental animal but returned again after he introduced a reed into the airway
and inflated the lungs by use of bellows, which mistakenly made him assume that the trachea
was part of the circulating system, from which it carried the name ______ (rough in Greek
language) or arteria aspera (the rough artery in Latin)

Gustav Killian of Freiburg, Germany, performed the first bronchoscopy in 1887. During the
early years of the development of bronchoscopy, the indications for the procedure were
primarily therapeutic: removal of foreign bodies and dilation of strictures from tuberculosis
and diphtheria. In the early part of the twentieth century, Chevalier Jackson, the father of
American bronchoesophagology, further advanced bronchoscopic techniques and designed
modern rigid bronchoscopes. Again, the primary indication was often therapeutic. In 1963,
Dr. Shigeto Ikeda introduced the flexible fiberoptic bronchoscope primarily as a diagnostic
instrument. Bronchoscopy soon shifted from being a therapeutic procedure performed by
thoracic surgeons and otolaryngologists to a primarily diagnostic procedure performed by
pulmonologists. Currently, next to thoracentesis and pulmonary function testing
interpretation, bronchoscopy is the most commonly performed procedure by pulmonologists.
As pulmonologists have gained expertise within the field of bronchology, the diagnostic use
of the flexible bronchoscope has expanded and there has been a growing interest in the use of
the instrument for therapeutic purposes. The worldwide epidemic of lung cancer, which has
produced many cases of airway obstruction by malignant neoplasm and benign stenosis, has
replaced foreign body removal as the main indications for therapeutic bronchoscopy.
Technology has presented bronchoscopists with numerous adjunctive therapies in addition to
the classic forceps used by Killian and Jackson. These newer therapies include laser, stents,
electrocautery, cryotherapy, and others and can be applied through either rigid or flexible
bronchoscopes. In the United States, because of familiarity and ease of application with
topical anesthesia, most pulmonologists attempt therapeutic interventions with a flexible
bronchoscope. In selected U.S. centers and in some European countries where expertise in
rigid bronchoscopy is more prevalent, the rigid bronchoscope remains the instrument of
choice for therapeutic interventions

Attempts to gain access to the airways in the living patient were initially tried by Hippocrates
(460-370 Be), who advised the introduction of a pipe into the larynx in a suffocating patient.
In 1542, Vesalius observed that when he opened the chest of an experimental animal, the
heartbeat and pulsation of the great vessels stopped, but returned again after he introduced a
reed into the airway and inflated the lungs with a bellows

It was the rhinolaryngologist Gustav Killian of Freiburg University who on June 4th, 1895,
attended Kirsteins lecture in Heidelberg at the 2nd Congress of the Southern German
Laryngologists, who immediately recognized the importance of Kirsteins observation for the
diagnosis and treatment of laryngotracheal diseases and began his experiments with the new
method.

Gustav Killian was the first to look into the lower airways using a rigid bronchoscope
in 1897, used for the removal of a foreign body from the airway. Until this point, patients
would fall chronically ill after aspirating a foreign body, resulting in a high mortality rate for
this condition. The only option for the patient would be to undergo an invasive surgical
procedure to remove the foreign body, but only in the case that extensive scar tissue had
developed. For the next 70 years, the rigid bronchoscope became the sole instrument
available for diagnostic and therapeutic procedures in the airway. The first flexible
bronchoscope was developed and introduced nearly 35 years ago by Shigeto Ikeda,
revolutionizing the field of bronchoscopy and becoming the standard instrument used for
diagnostics. Flexible bronchoscopy is now used in nearly all diagnostic airway procedures
and has proven useful for many therapeutic uses as well.
Bronchoscopy has changed significantly since its first use with the rigid
bronchoscope, to the advancements of flexible bronchoscopy, to new technologies which
have been developed in the recent past, enabling physicians to diagnose lung cancer and other
diseases earlier and treat their patients more effectively in a minimally invasive manner.
These advancements include, but are not limited to, needle aspiration, fluorescence, narrow
band imaging, endobronchial ultrasound, virtual bronchoscopy, laser treatment,
brachytherapy, airway dilation, airway prostheses (stenting), phototherapy, and
electrocautery. In addition, bronchoscopy has played an indispensable role in the diagnosis
and treatment of pediatric lung diseases.

Rigid Bronchoscopy
The initial bronchoscope, developed by Killian in Europe and further perfected by
Chevalier Jackson in the United States, was a rigid metal tube that permitted either
spontaneous or mechanical ventilation. Over the decades, rigid bronchoscopes of various
lengths and sizes, which are adaptable for diverse applications in childrenandadults,have
becomeavailable. With development of fiberoptic and advanced electronic technology, the
flexible bronchoscope has, to a large extent, replaced the rigid bronchoscope for most
diagnostic and some therapeutic indications.

Both rigid and flexible modern systems are equipped with optic capabilities for
airway observation alone. With the rigid bronchoscope, various types of telescopic rods,
equipped with circumferential illumination, permit direct and magnified visualization.
Specially designed telescopes allow viewing not only directly forward but also at oblique and
lateral angles. Various diagnostic and therapeutic accessories can be inserted through the rigid
bronchoscope while the patient remains ventilated.
In recent years, development of small cameras based on charge coupled device (CCD)
technology has facilitated transmission of bronchoscopic images to television monitors,
enhancing the education of trainees and permitting improved documentation of
bronchoscopic findings.

Flexible Fiberoptic and Videobronchoscopy


Although the optical resolution of early fiberoptic bronchoscopes was inferior to that
of rigid devices, their flexibility, ease of manipulation, and simplicity of use, which permit
rapid examination under topical anesthesia, have made flexible bronchoscopy the primary
endoscopic procedure in pulmonary diseases.
Unlike the larger-bore rigid bronchoscope, the flexible bronchoscope varies from
ultra-thinallowing for neonatal endoscopyto larger, adult-size therapeutic devices. The
diameter of the working channel permits aspiration of secretions or introduction of
accessories required for diagnostic or therapeutic purposes (see below). With flexible
bronchoscopy, the patients ventilation is assured by airflow around the bronchoscope,
between the external wall of the device and the tracheobronchial tree. Thus, the appropriate
selection of bronchoscope size is crucial.
Recent technological advances have permitted the replacement of fiberoptic systems
by a miniaturized CCD camera at the tip of the scope that provides electronic transmission of
images to a television monitor. Flexible bronchoscopes are more fragile and more prone to
damage than are rigid metal instruments. Appropriate care and adherence to safety techniques
during procedures, as well as during routine cleaning and maintenance of the instruments,
help assure extended instrument life and reduce repair costs.

There are many potential indications for both diagnostic and therapeutic bronchoscopy, many
of which are listed in Boxes 12-2 and 12-3. The most common reason for bronchoscopy
remains the evaluation of a lung mass or nodule. Other major indications include the
evaluation of pulmonary infiltrates, evaluation of opportunistic infections in
immunocompromised hosts, hemoptysis, suspected foreign body, and treatment of airway
complications related to neoplasms in the tracheobronchial tree. Some of these indications are
discussed in the following sections.

Hasegawa et all reported the frequency of performing bronchoscopy in ICU patients with
different medical conditions (Table 1). Olapade et al reported the frequency of use of the FB
for different indications in critically ill patients with various medical disorders. Of a total of
198 bronchoscopies, 45% were performed for removal of retained secretions, 35% for
obtaining specimens for culture, 7% for airway evaluation, 2% for hemoptysis, and 0.5%
each for facilitation of endotracheal intubation and removal of foreign bodies. In another
study, 27% of emergency bronchoscopies were performed for atelectasis and airway mucous
retention, 17% for acute respiratory distress syndrome (ARDS) and pulmonary edema, 13%
for airway stenosis or tracheobronchomalacia, 13% for pneumonia or empyema, and 8%
each for airway bleeding and aspiration of foreign bodies. Two percent of the total numbers
of bronchoscopies were required for bronchial asthma. The two major indications for use of
bronchoscopy are diagnosticg3 and therapeutic as listed subsequently.
Indications for diagnostic bronchoscopy include
Cough
Wheeze, stridor
Abnormal chest roentgenogram
Hemoptysis
Persistent pneumothorax
Vocal cord paralysis and hoarseness
Chemical or thermal burns of tracheobronchial tree
Refractory lung abscess
Thoracic trauma
Bronchography
Abnormal or atypical sputum cytology
Diagnostic bronchoalveolar lavage
Suspected pulmonary infections
Suspected bronchopleural fistula or tracheoesophageal fistula
Follow-up of bronchogenic carcinoma
Carcinoma of the lung
Mediastinal neoplasm
Esophageal carcinoma

Foreign body in the tracheobronchial tree


Obstructing neoplasm
Tracheobronchial strictures and stenosis
Bronchopleural fistula
Assessment of endobronchial tube placement
Assessment of potential tracheobronchial tube-related injury
Postoperative assessment of tracheal, tracheobronchial, or bronchial anastomosis

For nearly seven decades, the rigid bronchoscope was the sole instrument available for
diagnostic and therapeutic procedures on the airway. In the last 30 years, the flexible
bronchoscope has become the instrument of choice for nearly all diagnostic airway
procedures and also has proven useful for many therapeutic uses. However, the rigid
bronchoscope remains an important instrument primarily for therapeutic procedures including
laser bronchoscopy, cryotherapy, electrocautery, foreign body removal, stent insertion and
dilatation of stenosis. Table 1 lists current indications for rigid bronchoscopy. Many of these
procedures are discussed in detail in other chapters of this monograph. In general terms, the
main indications for rigid bronchoscopy involve foreign body removal, relief of malignant
airway obstruction, management of massive hemoptysis and pediatric bronchoscopy. The
need for deep bronchial biopsy with the rigid bronchoscope has been obviated with the wider
application of transbronchial needle aspiration for diagnosis of submucosal and mucosal
lesions.

To date there have not been any trials to assess those factors that may increase the risk
for patients undergoing flexible bronchoscopy. The decision to perform flexible
bronchoscopy, like that for any procedure, must be made after weighing the potential
benefits of the procedure against the potential risk to the patient. In general, most
contraindications to flexible bronchoscopy are relative rather than absolute and are based on
common sense. There should be available to the bronchoscopist adequate facilities and
personnel to handle emergencies that could occur during the procedure, including
cardiopulmonary arrest, pneumothorax, or bleeding.
An inability to adequately oxygenate the patient during the procedure based on his or
her clinical presentation is a clear contraindication to performing bronchoscopy, particularly
in a nonintubated patient.When assessing a patient before the procedure, special attention
must be paid to his or her respiratory status and potential for clinical decline as a result of the
procedure, including patients with severe obstructive airway disease, patients with severe
refractory hypoxemia, or patients with an unstable hemodynamic status. Likewise,
assessment of a patients bleeding status is critical, especially when biopsies are being

considered. The procedure may need to be postponed for a patient whose coagulopathy or
bleeding diathesis cannot be corrected.
Relative contraindications to this, or any procedure, might include lack of patient
cooperation, a recent myocardial infarction or unstableangina, a partial tracheal obstruction,
moderateto-severe hypoxemia, or hypercarbia. Depending on available facilities and
comorbidities, additional relative contraindications might include morbid obesity or severe
sleep apnea. It is preferable that patients do not undergo elective conscious sedation until 8
hours after a solid meal or 24 hours after clear liquids or medications given orally.

Even though flexible bronchoscopy is a relatively safe and well-tolerated procedure,


there are still a number of potential complications, which can include airway problems
(including those that result from irritation including laryngospasm, increased airway
resistance, exacerbation of obstructive airways disease, and physical obstruction). There can
bemechanical problems including epistaxis, hemoptysis, or pneumothorax. Complications
can be directly hemodynamically important such as cardiac arrhythmias, including
bradycardia, or other vagally mediated phenomena, tachyarrhythmias, or cardiac arrest. The
bronchoscopes themselves can pose a hazard to both the bronchoscopist and the patient
through exposure to infection. Crosscontamination of specimens or bronchoscopes has also
occurred. In general, flexible bronchoscopy is usually an extraordinarily safe procedure with
major complications, such as bleeding, respiratory depression, and pneumothorax, occurring
in less than 1%of cases [5,6] Mortality is rare, with a reported death rate of 0%0.04% in a
large number of procedures [5,6].

PATIENT ASSESSMENT

Clinical assessment
There are no published criteria regarding the utility of clinical history and
examination before bronchoscopy. It is recommended that the bronchoscopist clinically
assess each patient before bronchoscopy. Bronchoscopies can be carried out as an inpatient or
outpatient procedure and the safety of the latter has been well established. Chest radiography
is considered essential for all patients.

Respiratory function assessment

Routine lung function testing or arterial blood gas analysis is not required unless patients are
suspected of having significant impairment or respiratory failure on clinical grounds.

Coagulation assessment
Routine coagulation studies and platelet counts are not required, but it is suggested these be
carried out before transbronchial biopsy because of the increased risk of bleeding. At-risk
patients identified during clinical assessment, particularly those with renal impairment,
should be tested. Anticoagulants should be ceased and reversed before bronchoscopy
involving biopsy procedures. The risk associated with antiplatelet drugs is not known, but it
is preferable that non-steroidal anti-inflammatory drugs be withheld for at least 1 week before
bronchoscopic biopsy.

Other assessment
There are no data to support the role of routine testing, other than those detailed earlier.

High-risk procedures
The following situations are considered to represent high-risk bronchoscopies and the risk :
benefit ratio should be considered carefully before proceeding:
Cardiac: life-threatening arrhythmias, myocardial infarction within the last 4 weeks,
unstable angina.
Respiratory: refractory hypoxaemia.
Clotting abnormalities: platelet count of less than 50 000, uncorrected coagulopathy, severe
renal impairment.
Infective: patient with transmissible infection (e.g. active pulmonary tuberculosis).
Uncooperative patient.

In addition, while prophylaxis for bacterial endocarditis is not recommended for routine
flexible bronchoscopy, it is recommended for patients undergoing rigid bronchoscopy. This is
particularly so for patients with high-risk cardiac lesions; a history of previous endocarditis,
prosthetic valves, complex cyanotic congenital heart disease, left-sided major valve
abnormalities or surgically constructed systemic pulmonary shunts or conduits.

Research subjects
All volunteers undergoing bronchoscopy for research purposes should have screening tests to
ensure their safety.21 Bronchial responsiveness should be measured in asthmatic volunteers
because there is a direct correlation between the provocative concentration (PC20) of
methacholine and the percentage fall in forced expiratory volume in 1 s (FEV1) during the
procedure when compared with values measured before the procedure.22 A PC20 of less than
2 mg/mL is associated with a significant risk of a fall in FEV1 of greater than 20% (grade C).

All patients undergoing bronchoscopy should undergo a complete prebronchoscopy


evaluation, including a medical history, physical examination, and chest imaging (Box 12-1).
Although routine laboratory tests are not required, each evaluation should be individualized
on the basis of patients underlying conditions and the diagnostic and therapeutic procedures
planned.
Most fiberoptic bronchoscopies are performed after patient premedication with
sedative agents. Most frequently a combination of a short-acting benzodiazepine (e.g.,
midazolam) and a narcotic agent (e.g., fentanyl) is used. The sedatives are generally
administered along with an anticholinergic medication (e.g., atropine or glycopyrrolate) to
reduce the risk of vasovagal reactions and to minimize airway secretions. Local anesthesia of
the upper airway, larynx, and tracheobronchial tree is achieved with inhaled or
bronchoscopically instilled lidocaine. Although rigid bronchoscopy was performed initially
with minimal anesthesia and later under general anesthesia, the recent trend has been to
perform the procedure with patients either breathing spontaneously or ventilated with a jet
ventilator, often under total intravenous anesthesia (TIVA) with drugs such as propofol and
remifentanil. With appropriate monitoring, good oxygenation and adequate ventilation can be
ensured.
Success of bronchoscopy, whether diagnostic or therapeutic, depends, in large part, on
proper preparation of the patient, including relief of anxiety, muscle relaxation, cough
suppression, and adequate anesthesia. Time spent in achieving these goals will be well worth
it in reducing the risks of complications and in increasing the ease of performance of the
procedure.

Recommendations
Patient safety

BEFORE BRONCHOSCOPY

Verbal and written patient information improves tolerance of the procedure by the
patient and should be provided.
Patients with suspected chronic obstructive pulmonary disease (COPD) should
have spirometric parameters checked before bronchoscopy and, if the COPD is
found to be severe (FEV1 <40% predicted and/or SaO2 <93%), should also have
arterial blood gas tensions measured.
Oxygen supplementation and/or intravenous sedation may lead to an increase in
the arterial CO2 level and hence sedation should be avoided where the prebronchoscopy arterial CO2 is raised and oxygen supplementation given only with
extreme caution.
Prophylactic antibiotics should be given before bronchoscopy to patients who are
asplenic, have a heart valve prosthesis, or a previous history of endocarditis.
Bronchoscopy should be avoided if possible within 6 weeks of a myocardial
infarction.
Asthmatic subjects should be premedicated with a bronchodilator before
bronchoscopy.
Routine preoperative checks of the platelet count and/or prothrombin time are
only required in those patients with known risk factors having routine
bronchoscopy without transbronchial biopsy.
If it is anticipated that biopsy specimens may be required at bronchoscopy, oral
anticoagulants should be stopped at least 3 days before bronchoscopy or they
should be reversed with low dose vitamin K.
On the rare occasions when it is necessary to continue with anticoagulants, the
international normalised ratio (INR) should be reduced to <2.5 and heparin should
be started.
Platelet count, prothrombin time, and partial thromboplastin time should be
checked before performing transbronchial biopsies.
It is sufficient for patients to have no food by mouth for 4 hours and to allow clear
fluids by mouth up to 2 hours before bronchoscopy.
Intravenous access should be established in all patients before bronchoscopy is
commenced (and before sedation, if given) and left in place until the end of the
postoperative recovery period.
Sedation should be offered to patients where there is no contraindication.
Atropine is not required routinely before bronchoscopy.

DURING BRONCHOSCOPY

Patients should be monitored by oximetry.


Oxygen supplementation should be used to achieve an oxygen saturation of at
least 90% to reduce the risk of significant arrhythmias during the procedure and
also in the postoperative recovery period.
The total dose of lignocaine (lidocaine) should be limited to 8.2 mg/kg in adults
(approximately 29 ml of a 2% solution for a 70 kg patient) with extra care in the
elderly or those with liver or cardiac impairment.

Lignocaine gel (2%) is preferred to lignocaine spray for nasal anaesthesia.


The minimum amount of lignocaine necessary should be used when instilled
through the bronchoscope.
Sedatives should be used in incremental doses to achieve adequate sedation and
amnesia.
Fluoroscopic screening is not required routinely during transbronchial biopsy in
patients with diffuse lung disease, but should be considered in those with localised
lung lesions.
At least two endoscopy assistants should be available at bronchoscopy, and at
least one of these should be a qualified nurse.
Routine ECG monitoring during bronchoscopy is not required but should be
considered in those patients with a history of severe cardiac disease and those who
have hypoxia despite oxygen supplementation.
Resuscitation equipment should be readily available.

AFTER BRONCHOSCOPY
Postoperative oxygen supplementation may be required in some patients, particularly
those with impaired lung function and those who have been sedated.
A chest radiograph should be carried out at least 1 hour after transbronchial biopsy to
exclude a pneumothorax.
Patients who have had transbronchial biopsies should be given verbal and written advice
about the possibility of developing a pneumothorax after leaving hospital.
Patients who have been sedated should be advised verbally and in writing not to drive,
sign legally binding documents, or operate machinery for 24 hours after the procedure.
It is preferable that day case patients who have been sedated should be accompanied
home and that higher risk patients such as the elderly or those from whom transbronchial
biopsy specimens have been taken should have someone to stay with them at home
overnight.
Bronchoscope cleaning and disinfection
Compatibility of decontamination methods should be checked with the manufacturers
of bronchoscopic instruments and accessories.
Decontamination and disinfection should be carried out at the beginning and end of a
list and between patients.
Cleaning and disinfection of bronchoscopes should be undertaken by trained staff in a
dedicated room.
Thorough cleaning with detergent remains the most important initial stage of the
process.

When 2% glutaraldehyde is used for manual and automated disinfection, immersion


for 20 minutes is recommended for bronchoscopes at the beginning and end of a
session and between patients.

Persiapan yang harus dilakukan adalah :


1. Mendapatkan informasi tentang pasien seperti riwayat penyakit sebelumnya, penyakit
sekarang, kondisi fisik dan mental pasien serta riwayat reaksi alergi terhadap obat
yang akan digunakan untuk tindakan bronkoskopi.
2. Memberikan informasi kepada pasien tentang prosedur tindakan yang akan dilakukan
mulai dari persiapan bronkoskopi sampai setelah tindakan bronkoskopi, seperti puasa
sebelum bronkoskopi dilakukan dimana puasa dilakukan sekitar 8 jam dan 2 jam
setelah tindakan bronkoskopi dilakukan, serta pemberian anastesi dan yang dirasakan
pasien setelah anastesi diberikan,
3. Menandatangani pernyataan persetujuan tindakan medik untuk prosedur yang akan
dilakukan.
4. Mengevaluasi kondisi pasien sebelum bronkoskopi dilakukan dan mengelompokkan
pasien berdasarkan kondisi fisiknya. American Association of Anesthesiologists
(ASA) membuat klasifikasi sebagai berikut:
ASA I

: Pasien dengan kondisi fisik normal.

ASA II

: Pasien dengan penyakit sistemik ringan.

ASA III

: Pasien dengan penyakit sistemik yang berat


dengan keterbatasan aktifitas.

ASA IV

: Pasien dengan penyakit yang tergantung dengan

obat-obatan agar dapat bertahan.


ASA V

: Pasien dengan kondisi yang gawat dengan


prediksi tidak akan bertahan hidup dalam 24
jam dengan atau tanpa tindakan bronkoskopi.

Selain itu persiapan lain yang harus dilakukan, antara lain:7,32


Persiapan fasilitas penunjang :

Ruangan :

Broncoscopy suite

Ruangan persiapan, ruangan tindakan, ruangan pemulihan, ruangan desinfeksi


alat.

Bronkoskopi :

Kelengkapan televisi, vidio, foto.

Kelengkapan alat diagnostik dan terapi.

Sarana penunjang:

Oksigen, mesin penghisap lendir (suction).

Alat pemantau EKG, oksimeter

Nebulizer

Alat- alat Resusitasi

Jet ventilation

It is most important that the bronchoscopy procedure is carefully explained and that
the patient is reassured. A friendly and calm atmosphere is desirable. Premedication is usually
unnecessary and should be avoided if at all possible because it may potentiate decreases in
conscious state both during and following the procedure. If required for a highly anxious
hospital inpatient, an agent, such as the benzodiazepine lorazapam given orally, is useful
because it has significant amnesic and anxiolytic properties.
For patients with a history of asthma or airway hyperresponsiveness, a nebulized beta2 agonist, such as salbutamol, with or without an anticholinergic, such as ipratropium
bromide, should be given approximately 15 min before the commencement of the
bronchoscopy.

Sedative drugs provide amnesia and anxiolysis, as well as preventing coughing.


Because no single drug possesses all of these properties, a combination is used. In general,
benzodiazepines provide amnesia and anxiolysis, while opioid drugs possess analgesic and
antitussive properties. Benzodiazepine and opioid drugs act in a synergistic fashion, but their
combined use also increases the risk of cardiovascular and respiratory side-effects.
Where possible within a class of drugs, it is desirable to use agents with a shorter
duration of action, such as the benzodiazepine midazolam instead of diazepam, and the
opioids fentanyl and alfentanil instead of morphine and pethidine. Doses should be
individualized for each patient and titrated with respect to sedative effect (grade C).24 Dose
response relationships are not necessarily linear and judicious incremental dosing should
occur in order to avoid undesirable and unexpected decreases in conscious state.

Sedative antagonist drugs


When intravenous sedation is employed, specific antagonists to benzodiazepines, such
as flumazenil, and to opioids, such as naloxone, must be readily available. It is important to
recognize that the duration of action of these agents is less than that of the drugs they
antagonize. Thus it is possible for resedation to occur once their effect has ceased.24 Use of

either agent at the end of a case to allow for increased sedation during the procedure is not
recommended. Flumazenil and naloxone may precipitate withdrawal reactions in patients
who are taking benzodiazepines or opioids, respectively.

Local anaesthetic drugs


The application of topical local anaesthetic to the airways is effective in inducing
airway anaesthesia (grade C). Recent studies have shown local anaesthetic agents to have
antimicrobial properties, although not all bacteria are susceptible. Their use may therefore
result in false-negative results of microbiological tests carried out on bronchoscopic
specimens (grade C).
Lignocaine, an amide local anaesthetic agent, is the drug of choice because of its
relatively quick onset of action, short duration of action and decreased toxicity compared
with other agents. It may be administered by nebulization, via a spray to the nasal cavity,

The purpose of sedation is to improve patient comfort for what can be an unpleasant
procedure. Sedation may also make the procedure easier for the bronchoscopist to perform
and the patient more willing to accept a repeat procedure (if necessary). It is the perception of
physicians and nurses (but not always patients) that bronchoscopy is better tolerated with
sedatives than without. Two studies have compared intravenous diazepam with no sedation.
In a recent Malaysian study which examined common fears of patients undergoing
bronchoscopy the authors concluded that careful explanation of the sensations experienced
did more to allay anxiety than describing the procedure itself.83 The same study reported that
80% of patients preferred to be sedated.

Although premedication with oral lorazepam does have a significant amnesic effect
compared with placebo, most sedation regimens are based upon a single dose or incremental
doses of an intravenous sedative agent administered at the time of bronchoscopy.

Premedication originally referred to drugs administered to facilitate the induction and


maintenance of anaesthesia (literally, preliminary medication). Nowadays, premedication
refers to the administration of any drugs in the period before induction of anaesthesia.
Consequently, a wide variety of drugs are used with a variety of aims, summarized in Table
2.1.

Anxiolysis and Sedation


Traditionally, the most widely used premedicants have been barbiturates and
benzodiazepines. These drugs produce doserelated anxiolysis, sedation, and ultimately,
unconsciousness (see Chapter 26). Barbiturates are not commonly used as premedicants in
the outpatient setting because of residual sedation, which makes them less cost beneficial
than nonbarbiturate sedative drugs (e.g., midazolam, propofol). Methohexital and ketamine
have been used for rectal premedication in children. However, side effects of ketamine (e.g.,
confusion, vivid dreams) are frequent unless this drug is combined with midazolam.
Melatonin has also been reported to produce sedation and anxiolysis comparable to oral
midazolam when administered for premedication. (MILLER 2394)

The use of premedication in the outpatient setting has been a subject of considerable
debate over the past 30 years. The primary indications for preoperative medication include
anxiolysis, sedation, analgesia, amnesia, and prophylaxis against postoperative emesis and
aspiration pneumonia. Despite these well-recognized indications, benzodiazepine
premedication is not routinely used at many ambulatory surgery facilities in the United States
because of concern that these drugs will prolong the recovery period. Interestingly,
prospective studies have not found recovery to be prolonged after the use of appropriate
doses of sedative premedication in the outpatient setting (e.g., midazolam, 1-2 mg
intravenously [IV]). Van Vlymen and associates found that premedication with a small dose
of a benzodiazepine actually improved outcome in women undergoing needle- localized
breast biopsies without delaying recovery. Midazolam premedication not only decreases
preoperative anxiety but may also be associated with a reduction in postoperative pain.
(MILLER 2393)

Midazolam secara IM dengan dosis 80 microgram/kg body weight sesuai sebagi premedikasi
untuk pasien ASA klas I dan II. Dimana midazolam dapat mengurangi rasa cemas, sebagai
obat penenang, efek anterograde amnesia dibandingkan dengan diazepam 10 mg. Midazolam
secara sistemik dan toleransi lokalnya sangat bagus. Berdasarkan dari manfaat klinis inilah
midazolam dapat digunakan sebagai obat tambahan yang berguna untuk mencapai sedasi
sebelum pra oprasi. (evaluation of midazolam and diazepam for pre-oprative sedation)

Diazepam (Valium) was synthesized by Sternbach in 1959 in a search for a new and
better compound. It was first described for use as an IV anesthetic induction in 1965.
Oxazepam (Serax), a metabolite of diazepam, was synthesized in 1961 by Bell. Lorazepam

(Ativan), a 2 chloro-substitution product of oxazepam, was synthesized in 1971 in an attempt


to produce a more potent benzodiazepine. The next major achievement was Fryer and
Walsers 1976 synthesis of midazolam (Versed), the first clinically used water-soluble
benzodiazepine. Midazolam was the first benzodiazepine that was produced primarily for use
in anesthesia.
The benzodiazepines have many of the characteristics sought by anesthesiologists.
Specific benzodiazepine receptors were described when ligands were found to interact with a
central receptor. The discovery and understanding of the mechanism of the benzodiazepine
receptor have enabled chemists to develop many agonist compounds and to produce a
specific antagonist for clinical use.

aktu paruh midazolam adalah antara l-4 jam, lebih pendek daripada
diazepam.

aktu paruh

aktu paruh ini dapat meningkat pada pasien tua dan gangguan fungsi hati. Pada

pasien dengan obesitas, klirens midazolam akan lebih lambat karena obat banyak berikatan
dengan sel lemak. Akibat eliminasi yang cepat dari midazolam, maka efek pada CNS akan
lebih pendek dibanding diazepam.

Awitan aksi : I 30 detik-l menit; IM l5 menit; PO/rektal menit; intranasal < l0 menit;
intranasal < 5 menit

Efek Puncak

l0 menit; rekta

: I

3-5 menit; IM l5-30 menit; PO 30 menit; intranasal