A study on the Effect of Perfume Inhalation in Preventing gag reflex during Fiberoptic Bronchoscopy.

Mubarack sani T.P1, Sajeev S2, Kasim kolakkadan3. 1- Faculty of Medicine, Jizan , KSA. 2,3 - Academy of Medical Sciences, Pariyaram, Kannur, Kerala, India.

Abstract.
Background.
Fibroptic Bronchoscopy ( FOB) is done usually under local anaesthesia to minimise gag reflex and coughing during the procedure. Lignocaine, the commonest local anaesthetic , used is absorbed in to the circulation and known to cause systemic toxic effects. To reduce the dose of the lignocaine used without increasing the gag reflex rate during bronchoscopy, we used a novel technique, viz, inhalation of pleasant smell ( Jasmine odour) during the procedure.

Objective.
The objective of the study was to compare the gags/minute produced during the bronchoscopy when lignocaine viscous was used as local anaesthetic in the upper respiratory tract, when perfume inhalation was used instead of lignocaine and when no lignocaine or perfume inhalation was used.

Methods.
Type of study – Randomised Controlled double blind clinical study. 83 patients who underwent bronchoscopy for various lung lesions were grouped into three. 1. Lignocaine group - who received usual dose of lignocaine. 2. Perfume group - who did not receive lignocaine in the upper respiratory tract instead they were given a gauze piece with perfume ( Jasmine odour) sprayed in to it and was asked to inhale it during the procedure. 3. Placebo group – who did not receive lignocaine or perfume inhalation.

1

But mean gags/ minute in the placebo group (0.001 respectively). Time for which the bronchoscope in the lower respiratory tract (below the vocal cords).1845) and perfume group (0. number of gags during this time. 2 . Sniffing a strong pleasant smell is a household remedy for suppressing nausea. number of the time the patient gagged during this time and the total dose of the lignocaine used were measured. The mean lignocaine dose used in the lignocaine group (340 mg) was higher than the perfume group(244 mg) and placebo group (256 mg). in preventing gag reflex associated with the passage of bronchoscope through the respiratory tract. Inhalation of pleasant smell during FOB is as effective as applying lignocaine in the upper respiratory tract. Fiberoptic bronchoscopy (FOB) is a widely used procedure for the diagnosis of various pulmonary pathologies.001 and P<0. Perfume inhalation. The results showed that mean gags / minute in the respiratory tract in lignocaine group (0. During the FOB approximately 600 mg of lignocaine is introduced in to the respiratory tract and serum lignocaine level may reach upto3mg/L4. And lignocaine 4%solution as trans-tracheal injection for anaesthetizing the LRT 3. Key Words: Fiberoptic bronchoscopy. Conclusion. 2% viscous.Measurements. A commonly used local anaesthetic is lignocaine. Results.4% solution.1714) did not show significant difference ( p value 0. Serum lignocaine level more than 5 mg/L is associated with systemic toxic effects 6.758).5.value <0. Lignocaine is used to prevent gag reflex while the bronchoscope is in the upper respiratory tract(URT) and to minimise coughing while the FOB in the lower respiratory tract(LRT).4125) was higher than in the lignocaine group and perfume group( p. Lignocaine. Our study was to find out how far inhalation of a pleasant smell (Jasmine odour) is useful in suppressing the gag reflex associated with passage of bronchoscope the respiratory tract. Introduction . 2% gel. for anaesthetizing the URT 1. Gag reflex. The time taken for the bronchoscope to traverse the upper respiratory tract (nostril to the vocal cords). The advantage of FOB is that it can be done under local anaesthesia with minimal discomfort to the patient. Various preparations of the lignocaine used for achieving local anaesthesia during FOB are Lignocaine spray.2.

and direct punch biopsy from intra bronchial lesions. Kerala). Informed consent. Lignocaine group.0 mg Diazepam IM) were given half hour before the procedure. The diagnostic procedure done were transbronchial biopsy. The bronchoscope used was ‘Pentax FiberOptic Bronchoscope (EB 1830 TZ). The patients were randomly grouped in to three( by drawing lots). 2. Hypersensitivity to lignocaine. Informed consent was taken from all the patients included in the study and the ethical committee of the ACME Medical College approved the study. Asthmatics who give history of wheezing on exposure to strong smell. 2. The procedure varied from patient to patient depending upon the lung lesions. 3. 3. Perfume group. Type of study – Randomised Controlled double blind clinical study. 4. Kannur.6mg Atropine and 5. Trissur.Materials & Methods. 3 . Eighty three patients who underwent FOB for various indications in our hospital ( academy of Medical Sciences. The odour of the perfume used was Jasmine ( Manufactured by the Mughal Cosmopharma. CVS diseases. 1. The inclusion criteria for the study were 1. CNS disorders ( as the gag reflex may be impaired). Kerala) during a period of one year were included in the study. Pariyaram. brush biopsy. Placebo group.) The exclusion criteria for the study were 1. with outer diameter 6 mm and single working channel. Next day morning premedications (0. Intact gag reflex (determined by tickling the oropharynx with cotton during clinical examination. All the patients were tested for lignocaine sensitivity by skin prick test and was asked to starve after 10 pm. 2. bronchial washings and bronchioalveolar lavage.

Then it was spit out and 2 ml of 4% lignocaine solution (4% Xylocaine Topical. 1. The FOB was introduced in to the nostril after lubricating with sterile KY-Jelly. The time taken for the completion of the FOB procedure. number of gags during this time. Placebo group. Then the patient was given a gauze piece with normal saline sprayed in to it and was asked to sniff the gauze piece whenever he felt nausea or gag reflex. 1 ml of 4% lignocaine solution was instilled through the channel of the FOB. After the FOB all patients were asked to avoid oral intake for 3 hours. To avoid bias in the duration of the procedure all the bronchoscopy procedure was done by the same investigator. Perfume group. In all the groups during the FOB procedure . Then it was spit out and 2 ml of 4% lignocaine solution (4% Xylocaine Topical. Astra IDL)was given as trans tracheal injection. Then the patient was given a gauze piece with normal saline sprayed in to it and was asked to sniff the gauze piece whenever he felt nausea or gag reflex. In this group 5 ml of normal saline was poured in to the mouth of the patient and was asked to hold the solution in the throat for 5 minutes. 2. The FOB was introduced in to the nostril after lubricating with sterile KY-Jelly. In this group 5 ml of normal saline was poured in to the mouth of the patient and was asked to hold the solution in the throat for 5 minutes. Then the patient was given a gauze piece with perfume (Jasmine smell) sprayed in to it and was asked to sniff the gauze piece whenever he felt nausea or gag reflex. time of entry in to the trachea. Astra IDL)was given as trans tracheal injection. The FOB was introduced in to the nostril after lubricating with sterile KY-Jelly.IDL)was poured in to the mouth of the patient and was asked to hold the solution in the throat for 5 minutes. whenever the patient coughed while bronchoscope was in the LRT. Astra IDL)was given as trans tracheal injection. time of removal from LRT. 3. 4 . Lignocaine group In this group 5 ml of 2% lignocaine viscous solution ( Xylocaine Viscous 2% Astra. Then it was spit out and 2 ml of 4% lignocaine solution (4% Xylocaine Topical. number of times the patient gagged while the FOB was in the URT and LRT and the amount of lignocaine introduced to the respiratory tract was noted.The investigator who noted the gags and other parameters and the patient were not aware of the group in which the patient belongs. The total dose of lignocaine administered was calculated by adding the total amount of 2% viscous and 4% solution introduced in to the respiratory tract.

Statistical Analysis Relationship between the variables in the three groups were analysed using paired student’s t-test with 2 tailed distribution. for Perfume group was 6.6785 and the Placebo group it was 2. Mean time taken for bronchoscope to traverse the URT For the Lignocaine group the mean time taken was 1.276 and for the Placebo group it was 1. Mean number of gags in the URT for the Lignocaine group was 0. 5 .9642.08%)were females (Table 1).The commonest type was squamous cell carcinoma( n=22). Mean gags/minute in the URT For the Lignocaine group it was 0. Mean time spend by the bronchoscope in the LRT.6204 min and there was no statistically significant difference between these 3 groups regarding the time spend by the bronchoscope in the LRT ( Table3). for Perfume group was 0. Perfume group was 244 mg and Placebo group was 256mg.343 min.92%) were males and 15(18.482 minutes. There was no statistical difference between these 3 groups. for the Perfume group was 0. suggesting that the time in the URT for all the three groups is almost equal (table3). For the Lignocaine group it was 6.39%) had lung cancer.6128.5982 min and the Placebo group it was 7.7321 min. Disease-wise distribution of cases.Out of 83 patients 41 (49. for the Perfume group it was 1.5277 and the Placebo group it was 1. Gender Distribution of the cases Out of 83 patients 68(81. Age distribution of cases – Maximum number of the patients in the older age group (>60) and least was in the age group 21 – 30 (Table 2). Mean number of gags while the bronchoscope was in the URT. Results.1481 which was higher than the other 2 groups and was statistically significant ( Table3). The mean dose of lignocaine used in Lignocaine group was 340 mg.5891 which was higher than the other 2 groups ( Table3).

Katsoulin K et al. 30 minutes after completion of the bronchoscopy 4.2mg/L.0997 and for the Placebo group it was 0.875 min and for the Placebo group it was 8. Mean total time spend by the bronchoscope in the RT There was no statistically significant difference in total time spend by the bronchoscope in the RT. A study by Langmack EL.0741.2142 min. They found that there was no significant relation between serum lignocaine concentration and subject age. 6 . For the Lignocaine group it was 8. Discussion Lignocaine is a drug which is rapidly absorbed through the mucosal surfaces. Mean number of gags in the RT for the Lignocaine group it was 1.et al.5. Martin RJ.7407 which was higher than the other 2 groups and was statistically significant ( Table3). Mean number of gags while the bronchoscope was in the RT.6429 and the Placebo group it was 1.1714 and for the Placebo group it was 0. Mean number of gags in the LRT for the Lignocaine group was 0.4127 which was higher than the other 2 groups and was statistically significant ( Table3).1845.9629 min ( Table3). for the Perfume group was 0.5 – 3. In another study by LoukiderS. for the Perfume group was 7. mean peak serum concentration was well below the critical level of toxicity (5mg/L)and produced no side effects 5. Mean gags/minute while the bronchoscope was in the RT For the Lignocaine group it was 0. Mean gags/minute while the bronchoscope was in the LRT For the Lignocaine group it was 0. showed that on an average 600 mg lignocaine is introduced to respiratory tract during the bronchoscopy and the serum lignocaine concentration ranged between 0.2009 which was higher than the other 2 groups and was statistically significant ( Table3). sex and duration of the procedure. for the Perfume group was 0.5714. Various studies have shown that during bronchoscopy the serum lignocaine significantly correlatedwith the total amount of lignocaine administered 4.3214 and the Placebo group it was 3. for Perfume group it was 1.537. for Perfume group was 0.5926 which was higher than the other 2 groups and was statistically significant ( Table3).Mean number of gags while the bronchoscope was in the LRT.

Gender Male Female Table-1 GENDER – DISTRIBUTION OF CASES Lignocaine Perfume 24 23 4 5 Placebo 21 6 7 . Out of the 83 patients 41 (49. Our study did not include asthmatics. Thus this technique may be helpful in reducing the dose of lignocaine instilled in the respiratory tract during FOB for local anaesthesia. cardiac arrhythmias. This is reflected in our study. It was lower than the Placebo-group and was statistically significant (Table3). even though not statistically significant. The number of males requiring bronchoscopy is higher than females. thereby reducing the risk of lignocaine associated systemic toxicity. so the pharyngeal anaesthesia may be less.39%) had lung cancer predominantly squamous cell carcinoma. To determine the use of this technique in other procedure like fiberoptic gastrointestinal-endoscopy or rigid bronchoscopy . The higher value of mean gags /minute in the Lignocaine-group when compared to the Perfume-group may be because.92 % male and 18.08% females. The disadvantage of perfume inhalation is that it may induce bronchospasm in asthmatic patients who gives history of wheezing on exposure to strong small. Further lignocaine has to be used with caution in cardiac. On the contrary sniffing the gauze piece is very simple and we have seen that patients readily uses it as he feels the gag. the mean gags/minute in the Perfume –group was lower than the Lignocaine-group. In spite of a low dose of lignocaine. In our study mean dose of lignocaine used in the Lignocaine-group was 340 mg while in the Perfume-group it was 244 mg and Placebo-group it was 256 mg.But lignocaine used during bronchoscopy can cause severe systemic side effects like methemoglobinemia 7. renal and hepatic disorders 6. even after repeated instructions some patients were unable to hold the viscous solution in the throat properly. and even death 8. Instead they kept in the oral cavity. upper Summary Our study shows that inhalation of pleasant odour ( Perfume) instead of topical solution of lignocaine during FOB is helpful in reducing gag reflex associated with FOB. which had 81. further studies required.

196 Number of gags while the bronchoscope Lignocaine 0.1845 + 0.6696 Placebo group <0.5714 + 0.6215 Placebo group <0.3407 Lignocaine group-0.567 was in the URT Perfume 0.001 Time spend by the bronchoscope in the Lignocaine 6.6341 Perfume group-0.3426 + 0.3876 Placebo group -0.5982 +2.0991 Lignocaine group<0.0741 + 0.3124 + 1.001 Number of gags while the bronchoscope Lignocaine 0.189 Number of gags while the bronchoscope Lignocaine 0.9643 + 0.6429 + 0.672 was in the RT Perfume 0.4655 Lignocaine group-0.001 Placebo 0.2033 Lignocaine group<0.001 Placebo 1.627 Perfume group-0.112 Placebo 8.284 Total gags while the bronchoscope in the Lignocaine 1.3189 Perfume group-0.480 Perfume group-0.1563 Placebo group <0.001 Placebo 0.838 LRT Perfume 6.8750 + 2.001 Total time spend by the bronchoscope in Lignocaine 8.275 Placebo group -0.5277 + 0.6746 Lignocaine group<0.4820 + 0.6785 + 0.622 the RT Perfume 7.5926 + 1.7321 + 2.493 Lignocaine group-0.2009 + 0.433 Placebo 1.953 Lignocaine group<0.5891 + 0.001 8 .001 Placebo 1.758 was in the RT Perfume 0.041 pass the URT Perfume 1.7407 + 1.1564 Placebo group <0.6128 + 0.4406 Perfume group-0.1376 Lignocaine group<0.2142 + 2.5168 Placebo group <0.2768 + 0.0812 Perfume group-0.0999 Placebo group <0.001 Placebo 3.5870 Perfume group-0.9629 + 2.001 Mean gags/min while the bronchoscope Lignocaine 0. Parameter Groups Mean + SD p-value in relation to Time taken to pass the bronchoscope to Lignocaine 1.0997 + 0.124 Placebo 7.001 Placebo 2.202 was in the URT Perfume 0.1481 + 1.484 RT Perfume 1.296 was in the LRT Perfume 0.6204 + 2.001 Mean gags/min while the bronchoscope Lignocaine 0.Age Lignocaine Perfume Placebo 21-30 0 1 0 Table -2 AGE DISTRIBUTION 31-40 41-50 51-60 1 5 6 1 3 7 0 7 8 >60 16 16 12 Table 3 – Relationship between various parameters in 3 groups.0099 Lignocaine group<0.4127 + 0.9616 Perfume group-0.1714 + 0.1617 Perfume group-0.5357 + 1.494 Placebo group -0.

Zainudin BM. Randell T. May4.References 1. Otolaryngol. Dinneen SF et al. Eris JE.1991 april. Respiration 2000. Topical Anaesthesia for Fiber Optic Bronchoscopy – Lignocaine spray or Gel. Implications for Australian Clinical Research. 9 .117(4): 1055-60. Clague J. Nisar M. 14:515-9. 7. North. 2.1998. Loukides S. Sufarlan AW. Day RO. Lindgren L. Methemoglobinemia from topically applied anaesthetic spray. 1994 . 4. Katsoulis K. 8. Langmack EL. Kalogeropoulos N. Clin. Rafia MH. Panagou P.34(2):148-9. 6. Metabolism and Toxicity. Valli H. 1981. Local Anaesthetics – Action . 168 (9): 449-51. Topical anaesthesia for nasal mucosa for fiber optic airway endoscopy. Martin RJ. Serum concentrations of lignocaine before during and after fiberoptic bronchoscopy. Hay JG. 5. Comparison of three different methods used to achieve local anaesthesia for fiberoptic bronchoscopy. Chest. Chest 1992. Singapore Med J. Graham DR. 67(1):9-10. Campbell TJ.Yli-Hankala A. 3. Tsarpalis K. Pak J.1992 Feb68(2):164-7. Mayo Clin Proc . Chalmers DR. Br J Anaesthesia. 102 930:704-7. The death of the healthy volunteer in a human research project. Kraft M. Am. Difazio CA. Williams KM. Serum lignocaine concentration in asthmatics undergoing research bronchoscopy.2000 April.69: 886-8.