Bronchoscopist-directed infusion with propofol can be administered in procedures that require moderate sedation such as endobronchial ultrasound (EBUS), according to results of a retrospective analysis presented at the 2017 Annual Meeting of the American College of CHEST Physicians.
“We have demonstrated the safety of propofol infusion,” explained presenting author Ara A. Chrissian MD, FCCP, Loma Linda University Medical Centre, Loma Linda, California, speaking here at a poster session on November 1. “Concerns about sedation should not dissuade bronchoscopists from using propofol infusion without an anaesthesiologist for EBUS bronchoscopy.”
Traditionally, propofol has been viewed as a deep sedation or general anaesthesia drug. “Our usual drug…is midazolam, which works well for procedures of shorter duration,” noted Dr. Chrissian. “[But] as a procedure gets longer, the cumulative effect [of increasing the amount of midazolam] could lead to adverse events such as cardiorespiratory depression,” she cautioned.
Dr. Chrissian and colleagues examined data from a total of 171 bronchoscopies performed via the transoral route without an anesthesiologist present. The patients were consecutive and all received curvilinear and/or radial EBUS-guided sampling under moderate sedation with propofol.
The data included levels of sedation and vital signs. Complications owing to oversedation, cardiovascular and respiratory compromise, and undersedation (hypertension and agitation-related procedure delay) also were recorded and duration documented.
The mean total propofol dose was 4.3 mg/kg/hr. The sedation level during the bronchoscopies was monitored on average close to every 5 minutes. Deep sedation was achieved in 100 patients (58%), and represented 20% of total bronchoscopy time.
Dr. Chrissian noted that cardiorespiratory compromise occurred in 19% of patients overall and in 23% of patients who reached deep sedation at least once (P = .20). The episodes lasted about 4 minutes, and were treated with routine interventions, such as saline bolus for hypotension, jaw-thrust maneuver for upper-airway obstruction, and brief bag-mask ventilation to manage hypoventilation.
Vasopressor support or advanced artificial airways were not required to treat oversedation. Hypertension was managed with blood pressure-lowering medication. Procedure delays owing to agitation represented 1.4% of total bronchoscopy time.
For complex procedures that require moderate sedation such as EBUS, propofol might be an appropriate choice, Dr. Chrissian concluded. The authors noted that this study should dissuade reluctance to use propofol because of safety concerns, or because it may be thought that an anaesthesiologist needs to be present when it is administered.