Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Oral insertion of a flexible bronchoscope is associated with less discomfort than nasal insertion for Korean patients. Conscious sedation reduces patient discomfort and improves satisfaction in flexible bronchoscopy. Prospective Randomized Trial of Bispectral Index Monitoring of Sedation Depth during Flexible Bronchoscopy Evaluation of the efficacy of nebulised lignocaine as adjunctive local anaesthesia for fibreoptic bronchoscopy: a randomised, placebo-controlled study. Aspirin does not increase bleeding complications after transbronchial biopsy. A Randomized Trial of 1% vs 2% Lignocaine by the Spray-as-You-Go Technique for Topical Anesthesia During Flexible Bronchoscopy. Dextromethorphan Premedication Reduces Midazolam Requirement: Objective and Subjective Parameters in Peribronchoscopy Local anaesthesia for fibreoptic bronchoscopy: transcricoid injection or the "spray as you go" technique? A phase 3, randomized, double-blind study to assess the efficacy and safety of fospropofol disodium injection for moderate sedation in patients undergoing flexible bronchoscopy. Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Cryobiopsy increases the diagnostic yield of endobronchial biopsy: a multicentre trial A new BAL fluid instillation and aspiration technique: a multicenter randomized study. Comparison of endobronchial needle aspiration with forceps and brush biopsies in the diagnosis of endobronchial lung cancer. Predictors of oxygen desaturation in patients undergoing diagnostic bronchoscopy. Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy: a complementary approach to routine analgesia. Prospective analysis of efficacy and safety of an individualized-midazolam-dosing protocol for sedation during prolonged bronchoscopy. Nebulized lidocaine for flexible bronchoscopy: a randomized, double-blind, placebo-controlled trial. Feasibility and safety of propofol sedation in flexible bronchoscopy. Comparison of nebulized and sprayed topical anaesthesia for fibreoptic bronchoscopy. Propofol sedation for flexible bronchoscopy: a randomised, noninferiority trial Feasibility of Bispectral Index-Guided Propofol Infusion for Flexible Bronchoscopy Sedation: A Randomized Controlled Trial Safety of fibreoptic bronchoscopy in asthmatic and control subjects and effect on asthma control over two weeks. A Randomized Controlled Trial of Electrocoagulation-Enabled Biopsy versus Conventional Biopsy in the Diagnosis of Endobronchial Lesions Local anaesthesia for fibreoptic bronchoscopy: comparison between intratracheal cocaine and lignocaine. Cough suppression during flexible bronchoscopy using combined sedation with midazolam and hydrocodone: a randomised, double blind, placebo controlled trial Safety of Diagnostic Bronchoscopy in Patients with Pulmonary Hypertension Investigative bronchoscopy and endobronchial biopsy is well tolerated in hyperreactive asthma patients. Premedication for bronchoscopy in older patients: a double-blind comparison of two regimens. Bilateral bronchoalveolar lavage in the diagnosis of opportunistic pulmonary infections. Absorption of lidocaine during aspiration anesthesia of the airway. Topical nasal anaesthesia for fibreoptic bronchoscopy: lignocaine spray or gel? Randomized double-blind study of remifentanil and dexmedetomidine for flexible bronchoscopy. The safety of flexible fibre-optic bronchoscopy and proceduralist-administered sedation: a tertiary referral centre experience. Prospective study of fever and pneumonia after flexible fiberoptic bronchoscopy in older people. Propofol versus propofol plus hydrocodone for flexible bronchoscopy: a randomised study Sedation for fibre optic bronchoscopy. Patient satisfaction with conscious sedation for bronchoscopy. The role of atropine premedication in fiberoptic bronchoscopy using intravenous midazolam sedation. Oxygen desaturation during fiberoptic bronchoscopy. Surveillance bronchoscopy in lung transplant recipients: risk versus benefit. Topical nasal anesthesia for flexible bronchoscopy. A comparison of four methods in normal subjects and in patients undergoing transnasal bronchoscopy. Fever and pneumonia after flexible fiberoptic bronchoscopy. The higher risk of bleeding in lung transplant recipients from bronchoscopy is independent of traditional bleeding risks: results of a prospective cohort study. Utility of flexible bronchoscopy in the evaluation of pulmonary infiltrates in the hematopoietic stem cell transplant population -- a single center fourteen year experience. Bronchoscope insertion route and patient comfort during flexible bronchoscopy. Comparison of propofol and the combination of propofol and alfentanil during bronchoscopy: a randomized study
IMPORTANCE Tissue verification of noncaseating granulomas is recommended for the diagnosis of sarcoidosis . Bronchoscopy with transbronchial lung biopsies , the current diagnostic st and ard , has moderate sensitivity in assessing granulomas . Endosonography with intrathoracic nodal aspiration appears to be a promising diagnostic technique . OBJECTIVE To evaluate the diagnostic yield of bronchoscopy vs endosonography in the diagnosis of stage I/II sarcoidosis . DESIGN , SETTING , AND PATIENTS R and omized clinical multicenter trial ( 14 centers in 6 countries ) between March 2009 and November 2011 of 304 consecutive patients with suspected pulmonary sarcoidosis ( stage I/II ) in whom tissue confirmation of noncaseating granulomas was indicated . INTERVENTIONS Either bronchoscopy with transbronchial and endobronchial lung biopsies or endosonography ( esophageal or endobronchial ultrasonography ) with aspiration of intrathoracic lymph nodes . All patients also underwent bronchoalveolar lavage . MAIN OUTCOMES AND MEASURES The primary outcome was the diagnostic yield for detecting noncaseating granulomas in patients with a final diagnosis of sarcoidosis . The diagnosis was based on final clinical judgment by the treating physician , according to all available information ( including findings from initial bronchoscopy or endosonography ) . Secondary outcomes were the complication rate in both groups and sensitivity and specificity of bronchoalveolar lavage in the diagnosis of sarcoidosis . RESULTS A total of 149 patients were r and omized to bronchoscopy and 155 to endosonography . Significantly more granulomas were detected at endosonography vs bronchoscopy ( 114 vs 72 patients ; 74 % vs 48 % ; P < .001 ) . Diagnostic yield to detect granulomas for endosonography was 80 % ( 95 % CI , 73%-86 % ) ; for bronchoscopy , 53 % ( 95 % CI , 45%-61 % ) ( P < .001 ) . Two serious adverse events occurred in the bronchoscopy group and 1 in the endosonography group ; all patients recovered completely . Sensitivity of the bronchoalveolar lavage for sarcoidosis based on CD4/CD8 ratio was 54 % ( 95 % CI , 46%-62 % ) for flow cytometry and 24 % ( 95 % CI , 16%-34 % ) for cytospin analysis . CONCLUSION AND RELEVANCE Among patients with suspected stage I/II pulmonary sarcoidosis undergoing tissue confirmation , the use of endosonographic nodal aspiration compared with bronchoscopic biopsy result ed in greater diagnostic yield . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00872612 A patient 's tolerance of fiberoptic bronchoscopy depends on the effectiveness of local anesthesia . This study compares the three different methods of local anesthesia in common use After sedation , patients ( n = 53 ) received either 4 ml of 2.5 percent cocaine by intratracheal injection ( TI ) ( n = 18 ) , by bronchoscopic injection ( BI ) ( n = 19 ) , or had 4 ml of 4 percent lidocaine delivered by nebulizer 20 min before the procedure ( NEB ) ( n = 16 ) . Patients and bronchoscopists scored the procedure using visual analog ( VAS ) and severity scales . Objective measurements of cough counts and episodes of stridor were recorded by phonopneumography . Patients ' VAS scores showed a clear preference for the transtracheal method compared with either bronchoscopically injected cocaine ( p less than 0.001 ) or nebulized lidocaine ( p less than 0.001 ) . Patients also reported that the TI method produced less cough during intubation of the larynx and inspection of the airways ( BI and NEB , p less than 0.01 ) . The TI method was also preferred by the bronchoscopists ( BI and NEB , p less than 0.001 ) ; they reported less cough and easier tracheal intubation . The mean cough count was significantly lower for the TI group , 49 ( 43 ) compared with 95 ( 52 ) for BI ( p less than 0.01 ) , and 81 ( 43 ) for the NEB group ( p less than 0.05 ) . Patients ' and bronchoscopists ' VAS showed significant correlation with cough ( r = 0.63 - 69 , p less than 0.01 ) . Stridor occurred in only two patients after TI , compared with 15 in the other two groups . Extra local anesthesia was required by 16 patients after BI , by all the NEB group , but by only one patient after TI . Subjective and objective measurement shows that 4 ml of 2.5 percent cocaine injected into the trachea produced excellent local anesthesia for fiberoptic bronchoscopy , there were no extra complications , and it was the method preferred by both patients and bronchoscopists OBJECTIVE The route of bronchoscope insertion varies between centres , without a firm rationale based on well- design ed studies . We therefore compared nasal and oral insertion of a flexible bronchoscope and evaluated efficacy and patient satisfaction . DESIGN Prospect i ve r and omised study of patients who underwent flexible bronchoscopy from May to September 2003 and who were r and omly assigned to nasal and oral insertion approaches .  RESULTS Clinical characteristics , factors related to the procedure and patient satisfaction were analysed . In total , 307 patients were r and omly assigned to the nasal ( n = 158 ) or oral insertion groups ( n = 149 ) . No difference in baseline characteristics was identified between the groups . Insertion by the oral route was associated with a smaller amount of lidocaine use during the procedure ( P = 0.04 ) and less frequent insertion site bleeding ( P = 0.005 ) . Patients assigned to oral insertion reported less discomfort during anaesthesia ( P = 0.01 ) and scope insertion ( P < 0.001 ) , as well as less dyspnoea ( P = 0.04 ) and coughing ( P = 0.03 ) . CONCLUSION Oral insertion of a flexible bronchoscope was associated with less discomfort for patients than nasal insertion , although the route of insertion had no significant effect on outcome BACKGROUND Conscious sedation for patients undergoing flexible bronchoscopy ( FB ) is suggested to alleviate discomfort and improve satisfaction despite controversy regarding its benefits . In Taiwan , the general FB practice involves local anesthesia only . This study aim ed to assess the benefits and risks of conscious sedation in diagnostic FB . METHODS This prospect i ve case control study enrolled 44 non-se date d and 44 se date d patients who underwent diagnostic FB .  All received the st and ard upper airway preparation , while se date d patients received clinical ly judged increments of midazolam and alfentanil for conscious sedation .  Patient discomforts and the operator 's opinions during FB were assessed using the verbal analogue score ( VAS , 0 - 10 scale ) . Willingness to return was assessed as five scales to monitor patient satisfaction . Safety profiles throughout the procedures were also assessed . RESULTS Compared to non-se date d patients , se date d ones expressed less discomfort , with lower VAS scores regarding scope insertion ( 3.5 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , cough ( 5 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , dyspnea ( 3 [ 0 - 10 ] vs. 0 [ 0 - 8 ] , p < 0.001 ) , pain ( 3 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , and global tolerance of the procedures ( 5 [ 1 - 10 ] vs. 0 [ 0 - 9 ] , p < 0.001 ) . More se date d patients expressed willingness to return ( 70.5 % vs. 36.4 % , p = 0.001 ) . The bronchoscopist also rated lower VAS scores on cough and dyspnea in se date d patients . Se date d patients had less hypertension but more hypoxemic episodes during the procedure , which were all transient and not life-threatening . CONCLUSIONS Conscious sedation with clinical ly judged midazolam and alfentanil reduces discomforts , improves satisfaction , and carries slight , but manageable , hypoxemia risks in patients undergoing FB Background : The clinical benefits associated with the use of the bispectral index ( BIS ) to monitor the depth of sedation during flexible fiberoptic bronchoscopy ( FFB ) are question able . Objectives : To evaluate the added value in terms of procedural safety and patients ' awareness of monitoring sedation depth using the BIS compared to conventional clinical judgment alone in patients undergoing FFB under propofol sedation . Methods : The cohort included 81 patients undergoing diagnostic or therapeutic bronchoscopy under propofol sedation that were prospect ively r and omized to guide the depth of sedation by BIS monitoring ( BIS group ; n = 40 ) or conventional monitoring ( control group ; n = 41 ) . Results : The mean duration s of the procedure were 18 and 19 min in the BIS and control groups , respectively . No significant difference was noted in the dosage of propofol used between the BIS and control groups ( 168.7 vs. 167.3 mg , respectively ) . Average sedation-related oxygen saturation drop and transcutaneous CO2 rise were not significantly different between groups . There was also no significant difference in the percentage of patients that required either hemodynamic support ( 5 vs. 7.5 % , respectively ) , oxygen supplementation by 100 % O2 mask ( 67.5 vs. 82.5 % , respectively ) or Ambu face mask manual ventilation ( 2.5 vs. 5 % , respectively ) between the groups . No significant difference was noted in terms of patients ' awareness during the procedure , which was assessed following recovery by a structured Brice interview . Conclusion : Using BIS to guide the depth of sedation during propofol sedation in patients undergoing FFB of relatively short duration offers no clinical ly significant advantages over conventional monitoring Optimisation of topical anaesthesia for flexible fibreoptic bronchoscopy ( FOB ) is becoming increasingly important as a wider range of more complex , and thereby more prolonged , interventional endoscopic procedures are becoming available . Lignocaine is the most commonly used topical anaesthetic agent for bronchoscopy , but there is variability in current practice as to its optimum mode of administration . In this prospect i ve , r and omised , placebo-controlled , blinded study , we examine whether there was enhanced effectiveness of additional nebulised lignocaine as compared to our current regime utilising two visual analogue scales as markers of efficacy . Treatment groups were matched in terms of age ( p = 0.39 ) , gender , concomitant sedation ( p = 0.51 midazolam ; p = 0.12  fentanyl )  and dose of background administered lignocaine  ( 290 mg ) . We found no significant additional differences between any of the treatment groups in terms of general ease of procedure ( p = 0.09 ) or in cough severity ( p = 0.12 ) . We conclude that this study does not support the hypothesis that additional nebulised lignocaine confers any additional benefit to the ease of procedure or cough severity in patients undergoing fibreoptic bronchoscopy . We suggest that preparation regimes for bronchoscopic examinations need optimization STUDY OBJECTIVES The present study was performed to determine whether the risk of bleeding after transbronchial lung biopsy is increased in patients taking aspirin .  DESIGN Prospect i ve cohort study . PATIENTS AND INTERVENTIONS After excluding patients with other coagulation problems , 1,217 patients who had undergone transbronchial lung biopsy during a prospect i ve 1.5-year study period were included in this study . The use of aspirin was not discontinued before the procedure . Two hundred eighty-five patients ( 23 % ) had consumed aspirin within 24 h of the procedure , and most of them ( 82 % ) used aspirin on a daily basis . Transbronchial biopsies were performed , and the bleeding incidence was compared between the groups . RESULTS A total of 57 patients ( 4.7 % ) experienced procedure-related bleeding . Minor bleeding occurred in 5 of 285 patients ( 1.8 % ) taking aspirin and in 27 of 932 control patients ( 2.9 % ; not significant ) . Moderate bleeding was seen in 3 of 285 patients ( 1.1 % ) in the aspirin group and in 13 of 932 patients ( 1.4 % ) in the control group ( not significant ) . Major bleeding occurred in only 9 patients , 2 of 285 ( 0.9 % ) in the aspirin group and 7 of 932 ( 0.8 % ) in the control group ( not significant ) . All bleeding was controlled by endoscopic means , and there were no fatalities and no need for blood transfusions . CONCLUSIONS We conclude that the risk of severe bleeding after transbronchial lung biopsy is small ( ie , < 1 % ) and that the use of aspirin is not associated with any increased risk of bleeding BACKGROUND The optimal concentration of lignocaine to be used during flexible bronchoscopy ( FB ) remains unknown . This r and omized controlled trial compared the efficacy and safety of 1 % and 2 % lignocaine solution for topical anesthesia during FB . METHODS Consecutive patients were r and omized to receive either 1 % or 2 % lignocaine solution through the bronchoscope by the " spray-as-you-go " technique . The primary outcome of the study was the assessment of cough by the operator and the patient using the visual analog scale ( VAS ) and pain assessment using the faces pain rating scale . The secondary outcomes included total lignocaine dose , oxygenation status , adverse reactions related to lignocaine  , and others . RESULTS Five hundred patients were r and omized ( median age , 51 years ; 71 % men ) 1:1 to either group . The median operator VAS score for cough was significantly higher ( 25 vs 21 , P = .015 ) in the 1 % group ; however , the patient VAS score was not significantly different ( 32 vs 27 , P = .065 ) . The pain rating was similar between the two groups . The median cumulative dose of lignocaine  was significantly higher in the 2 % group ( 397 mg vs 312 mg , P = .0001 ; 7.1 mg/kg vs 5.7 mg/kg , P = .0001 ) . About 28 % of patients in the 2 % group exceeded the maximum recommended dose ( > 8.2 mg/kg ) of lignocaine . No adverse event related to  lignocaine  overdose was seen in either group . CONCLUSIONS One percent lignocaine was found to be as effective as 2 % solution for topical anesthesia during FB , albeit at a significantly lower dose as the latter . Thus , 1 % lignocaine should be the preferred concentration for topical anesthesia during FB . TRIAL REGISTRY Clinical Trials.gov ; No. : NCT01955824 ; URL : www . clinical trials.gov Background : Coughing is increased during bronchoscopy and may last for several hours after the procedure . Also prior to the procedure patients show high levels of anxiety due to fear of the pain and breathing difficulties that they might experience during the procedure . Objectives : To evaluate the antitussive , anxiolytic and sedative effect of dextromethorphan ( DM ) premedication on the amount of intravenous midazolam during bronchoscopic procedures . Methods : Sixty consecutive patients undergoing scheduled bronchoscopy were r and omly allocated in a double-blind , placebo-controlled study . Half received 90 mg DM and half placebo . Local anesthesia with 2 ml of repeated intratracheal instillation of 1 % lidocaine as needed during bronchoscopy was applied . Midazolam 1 mg ( maximum of 5 mg ) was administered intravenously until a satisfactory sedation was achieved . Results : Heart rate , systolic and diastolic pressure and SpO2 were assessed before and during bronchoscopy . A visual analog score ( VAS ) for pain , cough , communication , cooperation , emotional state , complaints , expectoration , level of information about the procedure , feeling of unpleasantness and stress level assessed before and after the examination by the patient and the physician was used . There were no significant differences in the reported degrees of difficulty in undergoing bronchoscopic procedures . DM patients needed significantly fewer  lidocaine instillations and lower  midazolam dosage , achieved better analgesia , had lower emotion and complaint scores , significantly less coughing , significantly less stress , were significantly more cooperative , found that the procedure was much less unpleasant than they had expected , and produced less sputum at end of the procedure . Conclusions : DM is an effective bronchoscopic premedication in combination with midazolam and improves the overall well-being of the patients Local anaesthesia for fibreoptic bronchoscopy should be given by a safe technique that is not unpleasant to the patient and should provide acceptable conditions for the bronchoscopist . Single injection transcricoid local anaesthesia was compared with the " spray as you go " technique in patients having day case fibreoptic bronchoscopy . Patients were r and omised to receive either 100 mg lignocaine by a single cricothyroid puncture or 240 mg lignocaine instilled through the bronchoscope under direct vision . Further doses were given by the operator to both groups as required . The 30 patients receiving transcricoid lignocaine  coughed less ( 3.56 ( SD 3.1 ) coughs/min ) than the 32 patients receiving lignocaine through the bronchoscope ( 5.89 (4.8)/min ) despite receiving a lower total dose of lignocaine ( 322 ( 25.9 ) v 451 ( 20.9 ) mg ) . Cricothyroid puncture was not associated with any complications and was not unpleasant for the patients BACKGROUND Fospropofol disodium is a water-soluble prodrug of propofol with unique pharmacokinetic/pharmacodynamic properties . This r and omized , double-blind , multicenter study evaluated the use of fospropofol in patients undergoing flexible bronchoscopy . METHODS Patients > or= 18 years of age were r and omized ( 2:3 ) to receive fospropofol , 2 mg/kg or 6.5 mg/kg , after pretreatment with fentanyl , 50 microg . Supplemental doses of each were given per protocol . The primary end point was sedation success , which was defined as follows : three consecutive Modified Observer 's Assessment of Alertness/Sedation scores of < or= 4 plus procedure completion without alternative sedative medication and /or mechanical ventilation . Other end points included treatment success , patient/physician satisfaction , and safety . RESULTS Of 252 patients , 150 were r and omized to receive 6.5 mg/kg fospropofol ; 102 were r and omized to receive 2 mg/kg  fospropofol .  Sedation success rates were 88.7 % and 27.5 % , respectively ( p < 0.0001 ) . Treatment successes ( 91.3 % vs 41.2 % , respectively ; p < 0.001 ) , willingness to be treated again ( 94.6 % vs 78.2 % , respectively ; p < 0.001 ) , and absence of procedural recall ( 83.3 % vs 55.4 % , respectively ; p < 0.001 ) were significantly better with the administration of 6.5 mg/kg fospropofol . The median time to full alertness was slightly longer for the 6.5 mg/kg dose ( 5.5 vs 3.0 min , respectively ) . The proportion of patients requiring supplemental therapy with analgesics ( 16.7 % vs 37.3 % , respectively ) and the use of alternative sedative medications ( 8.0 % vs 58.8 % , respectively ) were lower for patients in the 6.5 mg/kg dose group ( all comparisons , p < 0.001 ) . The most frequent adverse events ( AEs ) were transient and self-limited paresthesias and pruritus of mild-to-moderate severity . Hypoxemia ( predominantly mild-to-moderate ) was the most common sedation-related AE , and occurred in 15.4 % and 12.6 % of patients , respectively , in the 6.5 and 2 mg/kg fospropofol dose groups . CONCLUSIONS Fospropofol provided safe and effective sedation for patients undergoing flexible bronchoscopy . TRIAL REGISTRATION Clinical Trials.gov Identifier : NCT00306722 STUDY OBJECTIVE To study the diagnostic role of flexible bronchoscopy ( FB ) in immunocompromised patients with pulmonary infiltrates . DESIGN Prospect i ve , observational study . SETTING Tertiary care hospital . PATIENTS A total of 104 consecutive non-HIV-infected immunocompromised patients with lung infiltrates in whom FB was performed . METHODS The primary outcome measure was the diagnostic yield of FB  , which was derived as the number of the diagnoses made using FB results divided by all final diagnoses . Final diagnoses were established using data from FB , surgical lung biopsy ( SLB ) , and microbiology and serology testing , and by the clinical response to empiric therapy . We also studied the diagnostic yields of individual sampling procedures such as BAL , transbronchial biopsy ( TBB ) , and protected-specimen brush ( PSB ) sampling . RESULTS Overall , 128 diagnoses were made in 104 patients . The overall diagnostic yield of FB was 56.2 % ( 95 % confidence interval [ CI ] , 47 to 64 % ) . FB provided at least one diagnosis in 53 of 104 patients ( 51 % ; 95 % CI , 40 to 62 % ) . FB was more likely to establish the diagnosis when the lung infiltrate was due to an infectious agent ( 81 % ; 95 % CI , 67 to 90 % ) than to a noninfectious process ( 56 % ; 95 % CI , 43 to 67 % ; p = 0.011 ) . The diagnostic yields of BAL ( 38 % ; 95 % CI , 30 to 47 % ) and TBB ( 38 % ; 95 % CI , 27 to 51 % ) were similar ( p = 0.94 ) . The diagnostic yield of PSB sampling was lower ( 13 % ; 95 % CI 6 to 24 % ; p = 0.001 ) than that of BAL . The combined diagnostic yield of BAL and TBB ( 70 % ; 95 % CI , 57 to 80 % ) was higher than that of BAL alone ( p < 0.001 ) . Finally , the diagnostic yield of  FB  with PSB sampling , BAL , and TBB was similar to that of FB with BAL and TBB . The complication rate from FB was 21 % ( 95 % CI , 15 to 31 % ) . Minor bleeding ( 13 % ) and pneumothorax ( 4 % ) were the most common complications . CONCLUSIONS FB has a high diagnostic yield in immunocompromised patients with pulmonary infiltrates . Based on our results , we recommend performing TBB in these patients , whenever possible Forceps , brushes or needles are currently the st and ard tools used during flexible bronchoscopy when diagnosing endobronchial malignancies . The new biopsy technique of cryobiopsy appears to provide better diagnostic sample s. The aim of this study was to evaluate cryobiopsy over conventional endobronchial sampling .  A total of 600 patients in eight centres with suspected endobronchial tumours were included in a prospect i ve , r and omised , single-blinded multicentre study . Patients were r and omised to either sampling using forceps or the cryoprobe . After obtaining biopsy sample s , a blinded histological evaluation was performed . According to the definitive clinical diagnosis , the diagnostic yield for malignancy was evaluated by a Chi-squared test . A total of 593 patients were r and omised , of whom 563 had a final diagnosis of cancer . 281 patients were r and omised to receive endobronchial biopsies using forceps and 282 had biopsies performed using a flexible cryoprobe . A definitive diagnosis was achieved in 85.1 % of patients r and omised to conventional forceps biopsy and 95.0 % of patients who underwent cryobiopsy ( p<0.001 ) . Importantly , there was no difference in the incidence of significant bleeding .  Endobronchial cryobiopsy is a safe technique with superior diagnostic yield in comparison with conventional forceps biopsy Bronchoalveolar lavage ( BAL ) is a widely used clinical and research tool even though certain steps in the procedure have not been st and arized . One step that is subject to variation is the technique used to instill and recover BAL fluid . Our aim was to assess whether attaching a plastic tube between the syringe and the working channel of the flexible bronchoscope allowed recovery of more fluid in comparison with recovery using only a syringe , and whether tubing had a favorable impact on diagnostic yield and complications . A r and omized multicenter study was performed in eleven public hospitals in Catalonia ( Spain ) . Patients scheduled for BAL  were r and omly assigned to  tubing ( n=140 ) or no-tubing groups ( n=155 ) . Flexible bronchoscopy and a 150 mL BAL in three 50 mL aliquots with or without tubing attached to the syringe . In the group with tubing , 8 % more fluid was recovered . The difference was both statistically significant and clinical ly relevant given that 17.4 % more diagnoses , 6.9 % fewer complications , and 8.8 % fewer technical failures were recorded . Based on these results , we recommend performing BAL using plastic tubing between the 50 mL syringe and the working channel of the flexible bronchoscope when carrying out manual instillation and suction Endobronchial forceps biopsy ( FB ) specimens of lung carcinoma are not uncommonly interpreted as nondiagnostic owing to extensive crush artefact , necrosis , or insufficient tissue . FB can not be performed in some endobronchial lung cancers ( EBLCs ) with massive bleeding tendency due to fragility and friability . Cytological studies from the brushings and washings may also be unproductive , increasing the bronchoscopist 's frustration . The aim of this study was to compare the diagnostic yield and complications of endobronchial needle aspiration ( EBNA ) with those of FB and brush biopsy ( BB ) in EBLCs examined by fibreoptic bronchoscopy .  A prospect i ve sequential study was carried out on 151 in- patients with EBLC .  Bronchial aspiration ( BA ) , EBNA and BB were performed in the patients with respiratory distress and with accompanying tumours of high bleeding tendency , completely obstructing main bronchi ( Group 1 : 68 patients ) . BA , EBNA and FB were performed in those with either central or peripheral EBLCs but without respiratory distress and /or significant bleeding tendency ( Group 2 : 83 patients ) . In Group 1 , the diagnostic yield of EBNA was found to be 90 % , whereas that of BB was 66 % ( p < 0.05 ) . In the same group , EBNA provided cell types in 95 % , compared with 88 % by BB ( p > 0.05 ) . EBNA was diagnostic in 92 % of Group 2 patients , while FB established diagnosis in 78 % of patients ( p > 0.05 ) . In determining cell type , no significant difference was found between EBNA ( 95 % ) and FB ( 97 % ) ( p > 0.05 ) . Regarding complications ( only bleeding ) , there was no significant difference ( p > 0.05 ) between EBNA ( 7 % ) and BB ( 13 % ) , or between EBNA ( 4 % ) and FB ( 17 % ) . We conclude that in endobronchial lung cancers : 1 ) the diagnostic yield of endobronchial needle aspiration is higher than brush biopsy ; 2 ) endobronchial needle aspiration increases the yield of brush biopsy when forceps biopsy can not be performed owing to significant bleeding ; 3 ) endobronchial needle aspiration increases the diagnostic yield when a forceps biopsy specimen is inadequate because of crush artefact , necrosis , or tissue resistance ; and 4 ) endobronchial needle aspiration is as safe as brush biopsy and forceps biopsy BACKGROUND Oxygen desaturation is not uncommon during bronchoscopy . We sought to identify factors predictive of desaturation during flexible bronchoscopy . METHODS Over eight months , we enrolled 137 r and omly selected patients who were undergoing fiberoptic bronchoscopy at our medical center . The patients ' oxygen saturation was monitored on their arrival and during the procedure by finger pulse oximetry . Desaturation was defined as an overall saturation nadir of < 90 % or an episode of decreased saturation of 5 % from the baseline regardless of whether the patient was receiving supplemental oxygen . RESULTS The need for oxygen supplementation before the procedure was predictive of a higher rate of desaturation episodes ( 73.9 % vs. 50 % , p = 0.036 ) . Although all interventional procedures or their complications can cause desaturation , the specific type of procedure was the most important predictor of desaturation ( lavage , 88.9 % ; washing , 43.8 % ; brushing , 15.2 % ; biopsy , 10 % ) . A low peak expiratory flow rate before the procedure seemed to be predictive of a high desaturation rate in patients undergoing lavage or washing during bronchoscopy . CONCLUSION Our study suggested that age , sex and baseline oxygen saturation were not predictors of desaturation . We should be reminded of the possibility of desaturation during every procedure , especially in patients who need supplemental oxygen before bronchoscopy STUDY OBJECTIVES To determine whether distraction therapy with nature sights and sounds during flexible bronchoscopy ( FB ) reduces pain and anxiety . DESIGN R and omized controlled trial . SETTING Teaching hospital in Baltimore , MD . PATIENTS Consecutive adult patients ( n = 80 ) undergoing FB with conscious sedation . INTERVENTION Nature scene murals were placed at the bedside , and patients were provided a tape of nature sounds to listen to before , during , and after the procedure . Patients assigned to the control group were not offered either the nature scene or the sounds . MEASUREMENTS AND RESULTS The primary outcomes were patient ratings of pain control ( a 5-point scale ranging from poor to excellent ) and anxiety . In a multivariate ordinal logistic regression model , the odds of better pain control were greater in the intervention patients than in the control patients ( odds ratio [ OR ] , 4.76 ; 95 % confidence interval [ CI ] , 1.35 to 16.7 ) , after adjustment for age , gender , race , education , health status , and dose of narcotic medication . Older patients and patients with better health status reported significantly less pain . There was no difference in patient-reported anxiety between the two groups ( OR , 0.87 ; 95 % CI , 0.39 to 1.96 ) . CONCLUSIONS Distraction therapy with nature sights and sounds significantly reduces pain in patients undergoing FB . Although the precise mechanism of this beneficial effect requires further investigation , clinicians should consider this nonintrusive strategy in addition to st and ard analgesic medications in patients undergoing painful , invasive procedures BACKGROUND Newer more advanced techniques in bronchoscopy may require longer procedure times , although a st and ard protocol for sedation during prolonged bronchoscopy has not yet been defined . METHODS We design ed a prospect i ve , non-r and omized , single-arm study ( UMIN trial number 000003971 ) using patient question naires and vital sign monitoring to assess the efficacy and safety of a st and ardized midazolam dosing protocol based on gender and age for use during bronchoscopy . The loading dose of midazolam was 0.075mg/kg for men ≤65 years old and women ≤70 and 0.05mg/kg for men ≥66 years and women ≥71 years , with subsequent doses of one-half the loading dose to be administered every 20min . The primary endpoint was tolerability and secondary endpoints included anxiety and recall of procedure , willingness to undergo repeat procedure , and complications . Safety was evaluated in terms of monitored changes in blood pressures , ECG , oxygen saturation , and CO2 content in expiration during the procedure . RESULTS A total of 204 patients were included in the study . Overall , 163 patients ( 79.9 % ) reported " no distress " during the procedure , 185 patients ( 90.7 % ) reported " no anxiety , " and 175 ( 85.8 % ) replied that they would accept a repeat procedure , if necessary . The mean minimum oxygen saturation was 90.2 % and the mean maximum expiratory CO2 level was 37.7mmHg . There were no serious complications related to the protocol . CONCLUSIONS The midazolam dosing protocol examined in this study was safe and effective . It is simple , and it could easily be translated to routine clinical practice OBJECTIVE Topical anesthesia for flexible bronchoscopy can be administered via transcricoid injection , nebulizer , or directly through the bronchoscope in a " spray as you go " fashion . We performed a prospect i ve , r and omized , double-blind , placebo-controlled trial to evaluate whether nebulized lidocaine provides additional benefit and reduces the total anesthetic dose required during bronchoscopy . SETTING Tertiary care university hospital . METHODS One hundred fifty patients ( 93 men ; age , 20 to 89 years ) undergoing diagnostic flexible bronchoscopy were r and omized to receive either 4 mL of 4 % lidocaine ( 160 mg ) or 4 mL of saline solution as placebo via nebulization . Combined sedation was achieved using 5 mg of IV hydrocodone and midazolam boluses . Supplemental lidocaine doses and total midazolam required as judged by the bronchoscopist were recorded for each patient . After the procedure , both bronchoscopists and patients charted their perception of cough on a 10-cm visual analog scale ( VAS ) . Similarly , patients recorded their discomfort related to the procedure on a 10-cm VAS . RESULTS The most common procedures were BAL in 77 cases ( 51 % ) , transbronchial biopsy in 40 cases ( 27 % ) , and transbronchial needle aspiration in 34 cases ( 23 % ) . Outcome parameters , including hemodynamic findings , duration of the procedure , cough scores for physicians and patients , discomfort score for patients , midazolam doses , and supplemental lidocaine doses , were similar in both groups . Mean total lidocaine dose required in the lidocaine group was 318 + /- 41 mg and was significantly higher than the total dose required in the placebo group ( 157 + /- 44 mg [ + /- SD ] ) [ p < 0.001 ] . CONCLUSION Additional nebulized lidocaine can not be recommended for flexible bronchoscopy performed under combined sedation BACKGROUND Propofol is a sedative-hypnotic with a rapid onset of action . There are only limited data evaluating propofol for flexible bronchoscopy . We analysed the feasibility and safety of propofol for bronchoscopy in a high output tertiary care centre . METHODS Prospect i ve data on patients undergoing flexible bronchoscopy at the University Hospital Basel , Switzerl and , were analysed . Patient demographics , ASA class , Mallampati class , indication for bronchoscopy , bronchoscopic procedures , duration of examination , medication requirements , minor and major adverse events , haemodynamic parameters , as well as cough scores during the procedure were documented . Patients were followed up to discharge from the bronchoscopy suite . RESULTS Data from 440 patients with a mean age 60 years ( ±15.5 , 260 male ) were analysed . The main indication for bronchoscopy was a suspicion of malignancy . The most common diagnostic procedures were bronchoalveolar lavage in 253 cases ( 31.5 % ) and bronchial washing in 174 cases ( 21.7 % ) . The mean duration of the procedure was 19.6 min ( ±12.08 ) . The mean propofol dose was 200 mg ( ±107.5 ) corresponding to 2.89 mg/kg ( ±1.70 ) . Minor adverse events included oxygen desaturation in 72 ( 16.4 % ) , hypotension in 68 ( 15.4 % ) and minor bleeding in 11 ( 2.5 % ) patients . No major adverse events were recorded . The median decline in systolic blood pressure after initiation of sedation was 14 mm Hg ( 3 - 28 ) . A drop in systolic blood pressure greater than 20 mm Hg was observed in 166 of the 440 patients ( 37 % ) . CONCLUSION Propofol sedation for flexible bronchoscopy is feasible and safe We compared the efficacy of nebulized ( N ) and sprayed ( S ) topical anaesthesia prior to fibreoptic bronchoscopy in a blinded study involving 54 patients aged 57 + /- 26 yrs ( mean + /- SD ) .  Cough frequency , recorded on cassette tape , was the index of efficacy . All patients received 100 mg lignocaine sprayed into the pharynx , or nebulized in r and om order prior to bronchoscopy , and all received intravenous diazepam sedation . Each patient received a further 100 mg of lignocaine solution through the bronchoscope onto the vocal cords and major airways during the procedure . No significant difference was found in overall cough frequency between N and S groups ( 8.7 + /- 6.9 coughs.min-1 N vs 10.5 + /- 6.0 S ) , and cough frequency was also similar between N and S during the periods above and below the vocal cords . Furthermore , no differences were found in cough frequency between N and S among smokers , patients with asthma and COPD , and patients who had a biopsy procedure , although a trend was seen in all comparisons towards a lower cough frequency with the nebulized route . Most patients in the S group found the spray unpleasant , whereas only one in the N group complained . We conclude that nebulized and sprayed lignocaine have similar efficacy as topical anaesthetics in fibreoptic bronchoscopy , but patient preference favours the nebulized route Propofol has been established as a reliable method for sedation in flexible bronchoscopy . There are no data comparing propofol administered as intravenous boluses versus continuous infusion . 702 consecutive patients undergoing flexible bronchoscopy were r and omly allocated to receive intravenous propofol using either an intermittent bolus technique or a continuous infusion . The primary end-point was the number of adverse events assessed at the end of flexible bronchoscopy and at 24 h. The number of any adverse event was similar in both r and omised groups ( 219 versus 211 , p=0.810 ) . There were complications in eight cases ( seven major bleedings , one respiratory failure ) . As compared with the bolus group , the amount of propofol required was significantly higher in the infusion group ( 226 ±147 mg versus 308±204.8 mg , p<0.0001 ) . In a multivariate regression model , this difference remained significant independent of the duration and the interventions performed during the procedure . The duration of bronchoscopy was significantly longer in the infusion group ( median 14 ( interquartile range 9–24 ) versus 17 ( 12–27 ) min , p<0.0001 ) . Propofol continuous infusion is as safe as bolus administration ; however , it is associated with higher propofol requirements and a longer duration of the bronchoscopy  . Propofol continuous infusion is as safe as bolus administration , but has higher requirements and longer bronchoscopy Objectives There are safety issues associated with propofol use for flexible bronchoscopy ( FB ) . The bispectral index ( BIS ) correlates well with the level of consciousness . The aim of this study was to show that BIS-guided propofol infusion is safe and may provide better sedation , benefiting the patients and bronchoscopists . Methods After administering alfentanil bolus , 500 patients were r and omized to either propofol infusion titrated to a BIS level of 65 - 75 ( study group ) or incremental midazolam bolus based on clinical judgment to achieve moderate sedation . The primary endpoint was safety , while the secondary endpoints were recovery time , patient tolerance , and cooperation . Results The proportion of  patients with hypoxemia or hypotensive events were not different in the 2 groups ( study vs. control groups : 39.9 % vs. 35.7 % , p = 0.340 ; 7.4 % vs. 4.4 % , p = 0.159 , respectively ) . The mean lowest blood pressure was lower in the study group . Logistic regression revealed male gender , higher American Society of Anesthesiologists physical status , and electrocautery were associated with hypoxemia , whereas lower propofol dose for induction was associated with hypotension in the study group . The study group had better global tolerance ( p<0.001 ) , less procedural interference by movement or cough ( 13.6 % vs. 36.1 % , p<0.001 ; 30.0 % vs. 44.2 % , p = 0.001 , respectively ) , and shorter time to orientation and ambulation ( 11.7±10.2 min vs. 29.7±26.8 min , p<0.001 ; 30.0±18.2 min vs. 55.7±40.6 min , p<0.001 , respectively ) compared to the control group . Conclusions BIS-guided propofol infusion combined with alfentanil for FB sedation provides excellent patient tolerance , with fast recovery and less procedure interference . Trial Registration Clinical Trials . gov BACKGROUND : Concerns remain about the safety of bronchoscopy in asthma and there are few data on the effect of this procedure on asthma control in the days or weeks following bronchoscopy . METHODS : In an initial study of bronchoalveolar lavage and bronchial biopsies in asthmatic and control subjects , data on peak expiratory flow rates ( PEFR ) collected prospect ively before and after the procedure were available from 21 of the 29 asthmatic subjects studied . These showed a median 23 % fall in PEFR from baseline after bronchoscopy ( range 3 - 58 % ) . To determine whether this fall in PEFR following bronchoscopy reflected bronchospasm or the effect of sedation , PEFR and spirometric tests were performed during the two hours following bronchoscopy in a further study of 15 symptomatic asthmatic subjects and 20 non-asthmatic controls . To examine the effect on asthma control , asthmatic patients recorded PEFR , symptom scores , and medication use for two weeks before and after bronchoscopy . RESULTS : After bronchoscopy with bronchial biopsies there was no difference between the median maximal fall in either PEFR or arterial oxygen saturation between the 15 asthmatic patients ( 10.4 % and 4 % , respectively ) and 20 controls ( 12 % and 3 % ) . Moreover , there were no significant changes in PEFR , symptom score , or medication use by the asthmatic subjects in the two weeks after bronchoscopy when compared with the two weeks before bronchoscopy . CONCLUSIONS : Fibreoptic bronchoscopy is well tolerated in asthmatic subjects . Falls in PEFR in both asthmatic and non-asthmatic subjects after bronchial biopsy may reflect the effects of sedation rather than bronchospasm . Additional bronchoalveolar lavage may cause bronchoconstriction . Careful monitoring is therefore essential . Peak flow monitoring up to two weeks after bronchoscopy with bronchial biopsy revealed no delayed effects on asthma control Background : Although electrocoagulation at time of endobronchial biopsy can potentially reduce procedure-related bleeding during fiberoptic bronchoscopy ( FOB ) , it can also impair quality of tissue specimen ; credible data for either are lacking . Objective : To evaluate the impact of hot biopsy on the quality of tissue sample s and to quantify the amount of procedure-related bleeding during endobronchial biopsy . Methods : In this single-center , prospect i ve , single-blind , r and omized controlled study we included adult patients referred for FOB and having endobronchial lesions . Patients were r and omized to bronchial biopsy using an electrocoagulation-enabled biopsy forceps , with ( EC+ group ) or without ( EC– group ) application of electrocoagulation current ( 40 W for 10 s in a monopolar mode ) . Procedure-related bleeding was semi-quantified by observer description , as well as through a visual analogue scale . Overall quality of biopsy specimen and tissue damage were assessed and grade d by a pulmonary pathologist blinded to FOB details . Result : 160 patients were r and omized to endobronchial biopsy with ( n = 81 ) or without ( n = 79 ) the application of electrocoagulation . There were no severe bleeding episodes in either group , and severity of bleeding in the EC+ and EC– groups was similar ( median visual analogue scale scores of 14 and 16 , respectively ) . Histopathological diagnosis was similar in the EC+ and EC– groups ( 77.8 % and 82.3 % , respectively ) . There was no significant difference in tissue quality between the two groups . Conclusion : Use of electrocoagulation-enabled endobronchial biopsy does not alter specimen quality and does not result in any significant reduction in procedure-related bleeding In a double-blind study of 60 patients undergoing fibreoptic bronchoscopy  we have compared the local anaesthetic effects of intratracheal injections of cocaine ( 4 ml , 2.5 % ) and lignocaine ( 4 ml , 4 % ) . The two local anaesthetics were equally effective in terms of cough suppression , requirement for extra local anaesthetic , patient discomfort and operator acceptability Background : Current British Thoracic Society guidelines do not recommend routinely the combined use of a benzodiazepine and opiate during flexible bronchoscopy ( FB ) . A r and omised , placebo controlled , double blind study was undertaken to determine whether hydrocodone in combination with midazolan  improves cough suppression during FB without increasing the risk of desaturation . Methods : 120 patients were r and omised to receive midazolam and 5 mg IV hydrocodone or midazolam and placebo with topical anaesthesia . Pulse oximetry  was recorded continuously during FB . Bronchoscopists and nurses charted their perception of cough and the patients rated their discomfort during the procedure on a 10 cm visual analogue scale ( VAS ) . Results : There was no significant difference between the two groups with regard to the indication for FB , duration of procedure ( 21 ( 11 ) min v 22 ( 10 ) min , p = 0.570 ) , doses of supplemental lignocaine ( 171 ( 60 ) mg v 173 ( 66 ) mg , p = 0.766 ) and midazolam ( 4.5 ( 2.3 ) mg v 4.9 ( 2.7 ) mg , p = 0.309 ) , lowest oxygen saturation ( 94.8 ( 2.7 ) v 94.9 ( 2.7 ) , p = 0.433 ) , and desaturations ⩽90 % . Perception of cough by both the bronchoscopist and the nurse was significantly lower in the hydrocodone group ( 3 ( 0–10 ) and 3 ( 0–10 ) ) than in the placebo group ( 6 ( 0–10 ) and 6 ( 0–10 ) ) , respectively ( p = 0.001 ) . According to the VAS scale , patients ’ tolerance was also significantly better with hydrocodone than with placebo ( 2 ( 0–8 ) v 3 ( 0–9 ) , p = 0.043 ) . Conclusion : The combination of midazolam and hydrocodone markedly reduces cough during FB without causing significant desaturation , especially when invasive diagnostic procedures are performed Background : Patients with pulmonary hypertension ( PH ) are considered to be at risk for complications associated with flexible bronchoscopy ( FB ) . Although previous reports suggest that transbronchial biopsies increase the risk for hemorrhage in this population , data are limited to survey analyses and isolated reports . Objectives : It was the aim of this study to describe our experience with FB and to determine if bronchoscopic procedures are associated with adverse events in this population . Methods : We conducted a retrospective review of patients with diagnosis of PH who underwent FB at the Clevel and Clinic between 2002 and 2005 . Patients without PH who underwent FB by the same pulmonary physician were used as controls . Results : A total of 90 patients , PH ( n = 45 ) versus controls ( n = 45 ) , were included . The mean systolic pulmonary artery pressure in patients with PH was 58 ± 7 mm Hg . Patients with PH had higher oxygen requirements at baseline ( FiO2 0.42 vs. 0.3 % ; p = 0.01 ) . The total number of procedures was similar between the groups ( 95 vs. 102 ) . Procedures performed were bronchoalveolar lavage ( 21 vs. 13 ) , transbronchial biopsies ( 24 vs. 32 ) and transbronchial needle aspiration ( 7 vs. 6 ) . There were no hemodynamic complications or episodes of respiratory failure associated with the procedures . None of the patients had significant hemorrhage and only 2 developed mild bleeding which resolved spontaneously . Similarly , none required hospitalization or transfer to an intensive care unit . Conclusions : FB can be performed safely in patients with mild to moderate PH . Transbronchial biopsies are not associated with worsening hypoxemia or an increased risk of hemorrhage . Prospect i ve studies with hemodynamic measurements are necessary to confirm these findings The tolerability of 57 non-smoking asthma patients inhaling salbutamol as needed ( ATS , 18 - -60 years , 60 % < or = FEV1 < or = 100 % , PD15FEV1 < 0.4 mg histamine ) to fibreoptic bronchoscopy ( FOB ) and endobronchial biopsy was studied . The FOB was done in local Lignocaine anaesthesia , and from five to eight biopsy specimens were taken from the bronchial mucosa of the right lung . The tolerability was measured as cough/bronchospasm during the procedure ( from 0 = normal to 3 = interrupted procedure ) , success of the procedure , and untoward occurrences . Twenty-seven of the 57 patients ( 48 % ) had no cough or bronchospasm during the FOB ( score 0 ) . Few coughs of no importance ( score 1 ) were documented in 23 patients ( 40 % ) . Seven patients ( 12 % ) had cough and /or bronchospasm interfering with the FOB procedure ( score 2 ) . The FOB procedure was not interrupted because of cough and /or bronchospasm ( score 3 ) in any patient . Scores of cough and /or bronchospasm diminished progressively with the increase of PD15FEV1 histamine . The success of the procedure was 100 % . Two patients had untoward medical occurrences requiring additional rescue medication ( 3.5 % ) . In conclusion , we found that hyperreactivity predicts cough and /or bronchospasm during the FOB . Cough and /or bronchospasm are frequently observed during the bronchial procedure , but they are mild and of minor clinical importance . An investigational endobronchial procedure can be successfully performed in mildly or moderately obstructive asthmatic patients , even in cases with severe bronchial hyperreactivity INTRODUCTION Older patients are the most prevalent age cohort requiring bronchoscopy .  Prior sedation should be offered to improve patient comfort and operator technical ease .  Older patients have increased sensitivity to central ly acting drugs increasing the procedural risk . This perceived risk may limit access to bronchoscopy in older patients . There have been no systematic prospect i ve placebo-controlled studies in older patients . We compared a novel premedication regimen-oral temazepam plus nebulised Lignocaine ( new treatment ) to an established regimen of intravenous alfentanyl ( control ) . METHODS Consecutive patients 75 years and older referred for bronchoscopy were considered . Twenty-five patients were r and omly assigned to each group . The primary outcome measure was the lowest oxygen saturation recorded from the administration of IV drugs and for 30 min post-bronchoscopy . RESULTS The lowest mean oxygen saturation in the new treatment group was 92.2 % ( 90.3 - 94.2 ) and in the control group 91.1 % ( 89.2 - 93.1 ) . This was not statistically different ( P = 0.370 ) . There were no adverse events . CONCLUSION This is the largest prospect i ve study to date on an older population undergoing bronchoscopy supporting previous retrospective findings regarding the safety of this procedure . Determined by oxygen saturations there is no difference in safety between premedication regimens comprising oral temazepam/nebulised lignocaine or intravenous alfentanyl To further improve the diagnostic value of bronchoscopy in the immunosuppressed population presenting with diffuse pulmonary infiltrates , we prospect ively investigated the utility of bilateral bronchoalveolar lavage ( BAL ) . We performed 62 bronchoscopies on 52 immunosuppressed patients . Of the 52 patients , 33 had pulmonary infections . The yield for Pneumocystis carinii pneumonia on bilateral BAL was 94 percent ( 31/33 ) , compared to the 84 percent ( 51/61 ) previously obtained with unilateral BAL in our institution . The recovery of P carinii was unilateral in four of five patients without AIDS and in four of 26 patients with AIDS . Transbronchial biopsy gave a yield of 85 percent ( 11/13 ) . In ten patients with definitive cytomegalovirus ( CMV ) pneumonia , recovery of CMV by combined culture and cytology was 100 percent . Of nine bronchoscopies with positive cytology for CMV , five showed cytopathologic changes in the BAL from both sides and four in the BAL from one side only . No complications were seen in the 14 patients with thrombocytopenia or the five patients receiving mechanical ventilation . Our findings indicate that bilateral BAL significantly increases the yield for recovery of P carinii ( p less than 0.02 ) and CMV ( p less than 0.001 ) in immunosuppressed patients STUDY OBJECTIVE To determine the optimal solution to use when anesthetizing the airway by aspiration of lidocaine . DESIGN R and omized , double-blind clinical study . SETTING University hospital . PATIENTS 96 adult ASA physical status 1,II , and III patients , scheduled for diagnostic flexible bronchoscopy . INTERVENTIONS Patients were r and omized to receive one of 5 solutions of lidocaine : Group A ( n = 16 ) : 1 % lidocaine , 0.2 mL. kg(-1 ) ; Group B ( n = 16 ) : 1.5 % 0.2 mL. kg(-1 ) ; Group C ( n = 32 ) : 2 % 0.2 mL. kg(-1 ) ; Group D ( n = 16 ) : 1 % 0.3 mL. kg(-1 ) , and Group E ( n = 16 ) : 2 % 0.3 mL. kg(-1 ) . Fiberoptic bronchoscopy was performed after the airway was anesthetized with this aspiration technique , using the assigned lidocaine solution . The scope was manipulated in the trachea to test for anesthesia . MEASUREMENTS AND MAIN RESULTS Successful airway anesthesia was determined by tolerance to bronchoscopy without sustained coughing , and also by the number of lidocaine supplements , if any , that were given via the bronchoscope . Arterial plasma concentrations of lidocaine  were measured in 33 patients from Groups C , D , and E. All solutions provided equally effective anesthesia of the airway . All patients tolerated endoscopy through the vocal cords , and 94 patients required no supplementary anesthesia , or only one dose of lidocaine , during bronchoscopy to the carina . The highest peak plasma concentrations of  lidocaine  were 5.02 and 6.28 microg . mL. No patient had signs of toxicity . CONCLUSIONS This technique produced anesthesia of the airway to the carina , safely , suitable for awake intubation , in 94 of 95 patients . The use of 1 % lidocaine , 0.2 to 0.3 mL. kg(-1 ) , so that the volume is 10 to 20 mL , is recommended Lignocaine spray for anaesthetising the nasal mucosa for fibreoptic bronchoscopy often causes discomfort to the patient . We compared two techniques of applying nasal topical anaesthesia using either lignocaine spray  ( group A : 25 patients ) or gel  ( group B : 30 patients ) to assess patients ' tolerance to the procedure . Both groups received 100 mg of lignocaine in the nostril , 40 - 50 mg to oropharynx , 120 mg to vocal cords and 40 - 100 mg to trachea and bronchi . Throat anaesthesia was the most common unpleasant part experienced by both groups of patients ( 34.5 % ) , followed by examination of bronchi ( 30.6 % ) and nasal anaesthesia ( 21.8 % ) . Significantly more patients in group A experienced discomfort or pain during nasal anaesthesia as compared to group B ( p < 0.001 ) .  Patients ' tolerance to the bronchoscopy  was similar in both groups and the examination was performed satisfactorily in all patients . Thus , lignocaine gel is a simple technique , effective and less irritating as compared to lignocaine spray for topical nasal anaesthesia BACKGROUND The safety profiles and efficacies of remifentanil and dexmedetomidine ( a sedative-analgesic without respiratory depression ) for sedation during flexible bronchoscopy were investigated . METHODS Seventy-two patients undergoing elective flexible bronchoscopy were r and omly assigned to a propofol-remifentanil group ( Group PR , n=36 ) or a propofol-dexmedetomidine group ( Group PD , n=36 ) . The primary outcome was the incidence of oxygen desaturation . Haemodynamic variables , adverse events , need of oral cavity suction , cough scores , satisfaction scores of patients and bronchoscopists , levels of sedation , and recovery times were also compared . RESULTS The incidence of oxygen desaturation was significantly lower in the PD group than in the PR group ( P=0.01 ) . There were no significant differences between groups in terms of level of sedation , oxygen saturation , mean arterial pressure , heart rate over time , cough scores , or patient satisfaction scores ( P>0.05 ) . However , cough scores and bronchoscopist satisfaction scores ( P<0.01 ) were lower in the PD group . In addition , topical anaesthesia ( P<0.01 ) was required more frequently and recovery time ( P=0.00 ) was significantly longer in the PD group . However , oral suction ( P=0.03 ) was required less frequently in the PD group . CONCLUSIONS Dexmedetomidine was associated with fewer incidents of oxygen desaturation and a reduced need for oral cavity suction than remifentanil during flexible bronchoscopy . However , dexmedetomidine was associated with a longer recovery time and poorer bronchoscopist satisfaction score BACKGROUND Flexible fibre-optic bronchoscopy has become an essential investigation and is widely regarded as safe , but wider published prospect i ve data regarding delayed complications are limited . There is continuing debate concerning the safety of proceduralist-administered sedation . We evaluated complication rates of bronchoscopy and proceduralist-administered sedation at our tertiary institution , and their clinical significance . METHODS Prospect i ve evaluation of all patients undergoing bronchoscopy over a 12-month period at a tertiary referral centre . Immediate minor and major complications were documented within 4 h of bronchoscopy , delayed complications at 48 h , case notes and bronchoscopy records were review ed 1 month later . RESULTS Five hundred and fifty-eight flexible fibre-optic bronchoscopies were performed , 216 with transbronchial biopsy or nodal aspiration , 19 had therapeutic airways intervention . The minor complication rate at 4 h was 4.12 % ( 23 ) , rising to 26 % ( 145 ) at 48 h. All 2.2 % ( 12 ) major complications occurred exclusively within 4 h of bronchoscopy . No complications could be attributed to proceduralist-administered sedation . DISCUSSION Complication rates at 4 h were comparable with previously reported data . Delayed minor complications were greater than expected , and did not require additional medical input . There were no complications from proceduralist-administered sedation . Flexible fibre-optic bronchoscopy and proceduralist-administered sedation within our institution 's guidelines are safe OBJECTIVES To assess the frequency of fever and pneumonia after  fiberoptic bronchoscopy ( FOB ) in older people and to evaluate increased risk for these two adverse events with increasing age . DESIGN Prospect i ve study . SETTING University hospital system . PARTICIPANTS Three hundred fifty-eight patients , with 165 ( 46.1 % ) patients aged 70 and older , undergoing bronchoscopy .  MEASUREMENTS Indications , abnormal bronchoscopic findings , sampling procedures , final diagnosis , and fever and pneumonia after bronchoscopy .  RESULTS With regard to the indication for bronchoscopy and abnormal bronchoscopic findings , there was no statistical difference between elderly patients ( > or = 70 ) and younger patients ( < 70 ) . Procedures such as forceps biopsy , brushing , and curetting were not performed more often in elderly patients , although final diagnosis of lung cancer was significantly more common in the elderly group ( P=.002 ) . The overall incidence of fever after FOB was 6.7 % , and that of pneumonia after FOB was 5.6 % . The patients aged 70 and older had an incidence of fever after FOB of 3.6 % and an incidence of pneumonia of 4.2 % , which were not higher than those in patients younger than 70 . CONCLUSION Increasing age is not associated with increasing fever and pneumonia after FOB , and chronological age should not be considered a limiting factor in the decision of whether to perform FOB when it is clinical ly indicated Propofol and the combination of a benzodiazepine and an opiate have been established for sedation in flexible bronchoscopy . It is as yet unknown whether propofol in combination with an opiate is superior to propofol alone to suppress cough during the procedure . 300 consecutive patients undergoing flexible bronchoscopy at a tertiary care university hospital were r and omly allocated to receive either the combination propofol and hydrocodone or propofol alone in a double-blind fashion . The primary end-point was the cough score during the procedure as estimated by the physician using a visual analogue scale . Demographics were similar in both groups . Compared with propofol alone , median ( interquartile range ) cough scores assessed by physicians , nurses and patients were significantly lower in the group r and omised to the combination propofol and hydrocodone ( 2.5 ( 1.5–4.0 ) versus 2.0 ( 1.0–3.0 ) , respectively , p=0.011 ) . Additionally , patients receiving the combination required significantly lower doses of propofol than those receiving propofol alone ( 200 mg ( 140–280 ) versus 260 mg ( 180–350 ) , p<0.0001 ) . Complex examinations , including bronchoalveolar lavage or transbronchial biopsy , benefited more from additional opiate . The duration of the procedure , time to discharge and complication rate were similar in both groups . The combination of propofol and hydrocodone is safe and superior to propofol alone for cough suppression in flexible bronchoscopy Most current sedative regimens for fibre optic bronchoscopy use an opioid , a benzodiazepine or a combination of both . This study compares midazolam ( M ) ( a benzodiazepine ) , alfentanil ( A ) ( an opioid ) and a combination of both drugs ( M+A ) . One hundred and three patients were r and omized in double-blind manner into groups M(35 ) , A(33 ) and M+A(35 ) . The number of coughs , number of additional aliquots of lignocaine and duration of the procedures were recorded along with oxygen desaturation . The patient 's level of discomfort was assessed by patient and bronchoscopist and expressed as a visual analogue score . There were significantly fewer coughs per minute in Group A compared with Group M ( P = 0.0053 ) , and significantly less  lignocaine  was required in Group A ( P = 0.005 ) and in Groups M+A ( P < 0.002 ) compared with Group M. There was no significant difference in the assessment of discomfort between the groups . There was a trend for Group M+A to desaturate more than the other two with a significant difference between desaturation in Group M+A and Group A ( P = 0.033 ) . Alfentanil is a more effective anti-tussive agent than midazolam for outpatient fibre optic bronchoscopy . The combination of alfentanil and midazolam does not provide any better anti-tussive effect and may have the risk of a greater degree of desaturation secondary to increased sedation STUDY OBJECTIVE Bronchoscopic technique is not st and ardized . Controversies exist with regard to premedication with sedatives before the test . To evaluate safety and efficacy of conscious sedation , we studied 100 r and omized patients undergoing diagnostic bronchoscopy ; patients received premedication with lidocaine spray and atropine sulfate i.m . ( nonsedation group ; 50 patients ) or lidocaine spray , atropine i.m . and diazepam i.v . ( sedation group ; 50 patients ) . METHODS AND RESULTS Monitoring during flexible fiberoptic bronchoscopy included continuous ECG and pulse oximetry . The procedure could not be completed in six patients . None received premedication with diazepam ; among the patients who ended the examination , tolerance to the examination ( visual analogue scale , 0 to 100 ; 0 = excellent ; 100 = unbearable ) was better in the sedation group . Low anxiety , male sex , but not age were also associated with improved patient tolerance to the test . Oxygen desaturation occurred in 17 % of patients , and it was not more frequent after diazepam treatment . CONCLUSIONS In our study , sedation had a beneficial effect on patient tolerance and rarely induced significant alterations in cardiorespiratory monitoring parameters OBJECTIVE Atropine premedication is widely used for fiberoptic bronchoscopy and may help by drying secretions , producing bronchodilatation , or preventing vasovagal reactions . The objective of this study was to see whether atropine premedication is really of practical benefit when patients are se date d with i.v . midazolam . DESIGN In a double-blind study , patients were r and omly allocated to receive i.m . atropine ( 0.6 mg ) or saline placebo ( 1 mL ) as premedication 30 to 60 minutes before they were se date d with progressive doses of i.v . midazolam until judged to be lightly asleep . SETTING A District General Hospital in Engl and . PARTICIPANTS One hundred consecutive patients referred for bronchoscopy . MEASUREMENTS AND RESULTS Sample s taken during the procedure were washings for microbiology and cytology and brushings for cytology and biopsy , but no transbronchial biopsies . Peak flow readings were recorded before premedication and before the start of the procedure . During the procedure an estimate was made of pharyngeal and tracheobronchial secretions , bleeding , use of saline to wash out secretions , and local anesthetic needed to control coughing . Patients were monitored for saturation and cardiac rhythm . There was no significant bronchodilatation after premedication in either group , nor were there differences in secretions , use of saline , tracheobronchial bleeding , desaturation , and arrhythmias . More local anesthetic was needed to control coughing in the placebo group ( mean 357 mg vs 331 mg in the atropine group , p=0.02 ) , but this was not of practical significance . CONCLUSION When intravenous midazolam sedation is used for bronchoscopy , atropine premedication is not of benefit A prospect i ve study was performed to detect oxygen saturation ( SaO2 ) during and following  fiberoptic bronchoscopy ( FOB ) in 50 patients . Twenty-five patients ( group 1 ) underwent the procedure  without and 25 ( group 2 )  with supplemental oxygen . The SaO2 declined from the baseline value of 96.4 % to 92.08 % in group 1 and to 94.88 % in group 2 after bronchoscopy alone . The decline was also noted when biopsy and broncho-alveolar lavage ( BAL ) were performed , the lowest values being recorded during BAL . The result showed that the fall in SaO2 in group 2 was significantly less than that in group 1 ( P < 0.05 ) . SaO2 returned to baseline values after a mean time of 4.9 minutes in group 1 and 2.4 minutes in group 2 , demonstrating the benefit of supplemental oxygen BACKGROUND Long-term survival of lung transplant ( LT ) recipients is limited by the development of the bronchiolitis obliterans syndrome ( BOS ) . A number of risk factors for BOS have been identified , which can be detected using bronchoscopy with transbronchial biopsy ( TBB ) . Many LT units perform routine surveillance bronchoscopy ( SB ) to detect problems such as : acute rejection ( AR ) ; infection , particularly with cytomegalovirus ( CMV ) ; and lymphocytic bronchiolitis . This study aim ed to assess the safety and efficacy of surveillance bronchoscopy in lung transplant recipients ( LTRs ) , including TBB and bronchoalveolar lavage ( BAL ) . METHODS All bronchoscopy procedures , including SB and clinical ly indicated ( CB ) procedures performed on LTRs in one calendar year , were audited prospect ively . Complications and clinical utility were recorded to determine the clinical utility both early ( 3 months and 3 to 12 months ) and late ( > 12 months ) post-LT . RESULTS In one calendar year , 353 procedures ( 232 SBs and 121 CBs ) were performed on 124 LTRs , with 246 performed < 1 year post-LT . The complication rates were similar to those reported previously , except for an increased rate of sedation-related complications , particularly up to 3 months post-LT . SBs showed high rates of acute rejection , particularly in the first year post-LT ( p = 0.01 ) . The rate of asymptomatic infection diagnosed on BAL remained high regardless of time post-transplant . CONCLUSIONS This study confirms that SB can frequently detect clinical ly significant infection and rejection with very low complication rates . The data support SB with TBB up to 12 months post-LT , and ongoing use of SB with BAL ( only ) to detect clinical ly silent infection beyond 1 year post-LT We evaluated nasal anesthesia regimens by comparing , in seven normal men , four drug regimens : 1 ) 1 percent phenylephrine ; 2 ) 4 percent lidocaine ; 3 ) 1 percent phenylephrine + 4 percent lidocaine ; and 4 ) 5 percent cocaine . After spraying each drug into the anterior nares , vasoconstriction , decongestion , and nasal anesthesia ( measured as transnasal depth of nasogastric ( NG ) tube insertion before discomfort ) were assessed . There were no significant differences in NG tube insertion depth between the regimens ( p = 0.54 ) . Insertion depth was significantly increased after 10 ml of 2 percent viscous lidocaine were sniffed ( p less than 0.004 ) , but again , differences between regimens were not significant ( p = 0.051 ) . One hundred bronchoscoped patients received one of the following sprayed into the nose : 1 ) placebo ( P ) ; 2 ) 1 percent phenylephrine + P ; 3 ) 1 percent phenylephrine + 4 percent lidocaine ; or 4 ) 5 percent cocaine + P. Each patient then sniffed viscous lidocaine . There were no significant differences between regimens for any of the following : 1 ) nasal resistance to bronchoscope insertion , 2 ) patient 's nasal discomfort , or 3 ) bronchoscopist 's perception of patient discomfort . We conclude that sprayed anesthetics contribute little to nasal anesthesia and any regimen appears acceptable when viscous lidocaine is used The frequencies of fever , parenchymal infiltration , and bacteremia were studied prospect ively after 100 flexible fiberoptic bronchoscopies performed transnasally under topical anesthesia .  Fever occurred after 16 per cent , and parenchymal infiltration , after 6 per cent of the procedures . Most complications were mild and transient ; however , one patient developed rapidly progressive pneumonia and died . No organisms were isolated from cultures of blood drawn at the time of the procedure or during complications . The organisms most commonly isolated from the sputum of the patients who developed pneumonia were the aerobic and anaerobic bacteria normally found in the mouth . Isolation of a significant pathogen before the procedure did not predispose to development of a complication . Advanced age ( greater than 60 years ) and the endoscopic findings of abnormalities were significant predisposing factors . Bronchial brushing , but not bronchial biopsy or bronchial washing , was associated with significantly higher complication rates in patients with bronchial carcinomas than in those without a neoplasm . The mechanism of the fever and parenchymal infiltration is thought to be related to obstructive atelectasis and infection produced by organisms present in the airways at the time of the procedures STUDY OBJECTIVE To determine whether recipients of lung transplants have a higher risk of bleeding from fiberoptic bronchoscopy ( FOB ) than other patients who undergo the procedure . DESIGN Prospect i ve cohort study . SETTING Bronchoscopy services of Johns Hopkins Hospital , a tertiary referral center and Johns Hopkins Bayview Medical Center , a community hospital . PATIENTS All adult patients ( 18 years ) who underwent FOB between July 1 , 1996 and June 30 , 1997 by the full-time pulmonary medicine staff were included . A total of 720 procedures were performed , including 38 in lung transplant recipients . MEASUREMENTS Bleeding was assessed by review ing physician reports of bloody drainage after the procedure and whether the procedure was terminated early for bleeding . Patient reports of hemoptysis were assessed using question naires administered pre- and post-FOB . Predictor variables included patient demographics , bleeding parameters ( platelets , prothrombin time , and activated partial thromboplastin time ) , immunosuppressive medications , aspirin use , use of transbronchial biopsy , and the time length of the procedure . RESULTS Lung transplant recipients were significantly more likely to have used  aspirin  prior to FOB ( 18.4 vs 7.2 % , p < 0.05 ) and to undergo transbronchial biopsy ( 64.9 vs 26.8 % , p < 0.001 ) . Lung transplant patients were more likely to have new or worsened hemoptysis ( 53.8 vs 24.6 % , p < 0.001 ) , to have > 25 mL of blood loss ( 44.5 vs 17.5 % , p < 0.001 ) and to have the procedure terminated early for bleeding ( 5.4 vs 1.0 % , p < 0.05 ) . In multivariate analysis , predictors of new or worsened hemoptysis included lung transplant , longer procedure time , and older patient age . Independent predictors of greater blood loss included lung transplant , performance of transbronchial biopsy , longer procedure time , and older patient age . CONCLUSIONS Lung transplant recipients are at higher risk of bleeding from bronchoscopy than are other patients . This propensity to bleed is independent of coagulation parameters , platelet count , immunosuppressive medication use , aspirin use , or performance of transbronchial biopsy . The higher risk of bleeding should be considered when assessing the risks and benefits of bronchoscopy in lung transplant recipients INTRODUCTION Pulmonary infiltrates are common within the hematopoietic stem cell transplant ( HSCT ) population and unfortunately portend an increased mortality . Bronchoscopy is often utilized as an initial diagnostic tool , but the literature supporting its diagnostic utility and effect on clinical management varies significantly . The aim of this study was to investigate the diagnostic ability , complication rate , and clinical impact of flexible bronchoscopy ( FB ) in evaluating pulmonary infiltrates in a large HSCT population . PATIENTS AND METHOD Retrospective review of all patients undergoing FB after HSCT in the Bone Marrow Transplant Unit from 1996 to 2009 . RESULTS FB was performed 162times in 144 patients with pulmonary infiltrates yielding positive results in 52.5 % . The most common positive results were bacterial pneumonia ( 31 % ) , fungal pneumonia ( 15 % ) , and alveolar hemorrhage ( 11 % ) . Treatment changes occurred in 44 % of patients after FB . Treatment changes included antibiotic modification ( 59 % ) , addition of corticosteroids ( 21 % ) , antifungal modification ( 12 % ) , and antiviral modification ( 7 % ) . The overall complication rate associated with FB was 30 % , although 84 % of these complications were considered minor . CONCLUSIONS FB in patients with pulmonary infiltrates after HSCT should still be considered a valuable tool in the evaluation and management of pulmonary infiltrates in the HSCT population . Future prospect i ve , multicenter r and omized studies are needed to evaluate the overall clinical impact that bronchoscopic results and management changes have in this unique population SETTING Diagnostic flexible bronchoscopy performed in hospitalised and ambulatory patients in a tertiary care academic hospital in Monterrey , Mexico . OBJECTIVE To determine the effect of the route of insertion of the bronchoscope ( oral or nasal ) on patient comfort , vocal cord visualisation , local anaesthetic and sedation requirements and possible complications . DESIGN Prospect i ve study carried out in patients aged ⩾ 18 years with an indication for flexible bronchoscopy .  The route of insertion was r and omly assigned . Symptoms related to the procedure were evaluated using a question naire . RESULTS Sixty-three patients were included : 32 in the oral insertion group and 31 in the nasal insertion group . There was no statistically significant difference in patient discomfort ( 1.91 ± 2.95 vs. 2.39 ± 3.56 points on a scale of 1 to 10 , P = 0.74 ) or procedural complications ( 4 vs. 0 events , P = 0.12 ) between study groups . Oral insertion was associated with less time to vocal cord visualisation ( 25.5 ± 156 s vs. 56 ± 61 s , P < 0.01 ) , lower requirement for lidocaine ( 15 ± 7.50 vs. 16 ± 4 ml , P = 0.01 ) and fewer insertion failures ( 0 vs. 6 cases , P < 0.01 ) . CONCLUSIONS With intravenous sedoanalgesia , route of insertion did not affect patient comfort . However , the oral route was associated with faster vocal cord visualisation , less use of lidocaine and no insertion failure Background : Propofol is an excellent sedative agent for use in patients undergoing bronchoscopy . The addition of an opioid to propofol can be advantageous because of the antitussive effect of the opioid and the possible improvement in sedation quality . However , it may increase the risk of hypoxaemia . To investigate the effect of the addition of alfentanil to propofol , we performed a prospect i ve study to compare propofol‐only sedation with propofol – alfentanil combination sedation in patients undergoing bronchoscopy
Objective To identify bronchoscopy-related complications and discomfort , meaningful complication rates , and predictors .