Flexible bronchoscopy is a common diagnostic procedure, which is usually well tolerated. However, it can cause some distressing side effects such as cough, choking, and anxiety. Sedatives are commonly used to improve patient comfort and tolerance. Current British Thoracic Society (BTS) guidelines recommend that sedation is offered to all unless there is a contraindication.1 The American College of Chest Physicians has recently published its consensus statement on the use of local anesthetic, analgesia, and sedation; this recommends the use of sedation when feasible.2 Midazolam is one of the most common agents used, having a rapid onset (2 min), short duration of action (30 min), and amnesic properties.3 A combination of a benzodiazepine and narcotic can be used, although this regime may be associated with increased risk of hypoxemia and carbon dioxide retention.1 The guidelines emphasize that sedatives should be given in incremental doses to achieve a light sleep; if this is achieved, then the patient acceptance of the procedure is high.1 However, the data from a number of randomized control trials would suggest that adequate sedation is often not achieved.4,5
There have been a number of previous studies looking at ways in which patient discomfort and anxiety can be reduced and these have concluded that midazolam is beneficial.6 Playing music has also been shown to improve comfort.7 Cough has been found to be a good surrogate marker of patient discomfort during the procedure.8
Patient satisfaction is an important outcome measure and may determine whether a patient is willing to undergo a repeat procedure. However, the ideal time to assess patient satisfaction has not yet been established. A previous study concluded that if patients were asked 1 month or longer after the procedure they were more likely to report beneficial effects of sedation with diazepam.9 Two studies have shown that patients are awake and have recovered from the effects of sedation only after 35 to 60 minutes.10,11 However, the effects of sedation may take somewhat longer period to resolve in certain patients, reflecting the individual metabolism of the sedative used. Indeed, the BTS guidelines state that patients who have been sedated should be advised not to drive, sign legally binding documents, or operate machinery for 24 hours after the procedure.1
The primary aim of this study was to compare patient comfort scores obtained immediately after the procedure with those obtained at a follow-up clinic, 7 to 14 days later. In addition, we aimed to compare the comfort score as reported by the patients with the comfort score assessed by the endoscopy nursing staff. The secondary aim was to identify any factors that influenced patient comfort such as the dose of midazolam used, the experience of the bronchoscopist, and the type of samples taken at bronchoscopy.
PATIENTS AND METHODS
The study was based in a city teaching hospital covering a population of 500,000. All patients undergoing bronchoscopy between August 2010 and January 2012 (16 mo) were included. All patients were aged 18 years and above. The local Research and Development office gave their agreement to this service survey. All patients were included unless they were unable to answer the questionnaire (English not being their first language). All bronchoscopists in the hospital were involved (4 consultants and 7 specialist registrars) and each carried out the procedure in their usual manner. All patients were provided with standard written information about the bronchoscopic procedure and any questions were answered before carrying out the procedure. Midazolam was the only sedative used in the unit. An initial dose of 1 or 2 mg was administered, followed by incremental doses of 1 mg until the required sedative effect was obtained.
Data collected included age, sex, indication for bronchoscopy, route of local anesthetic (cricoid injection/to scope), position of the patient during the procedure (lying/sitting), dose of midazolam given for sedation, type of specimen taken [washings, brushings, biopsy, transbronchial biopsy, or transbronchial needle aspiration (TBNA)], and experience of the bronchoscopist (specialist registrar or consultant). Endobronchial ultrasound was not available in our institution at the time of the study. Endoscopy nursing staff recorded the patients level of sedation (1—awake and 2—sedated) and comfort (0—no discomfort and 4—severe discomfort) during the procedure and these data were also analyzed.
Approximately 30 minutes after the procedure (once “awake” and in the recovery area), patients were asked to score the discomfort they experienced during the procedure on a scale from 0 (no discomfort) to 4 (severe discomfort) using a self-administered questionnaire. They were also asked to choose the type of discomfort from the following options: pain, choking sensation, fear of being unable to breathe, or others. Endoscopy nursing staff prompted patients to complete the questionnaire. The bronchoscopist was not involved to avoid any reporting bias. At a follow-up outpatient appointment (7 to 14 d later), patients again completed the same questionnaire. Any patients who did not have an outpatient clinic visit scheduled in the following 2 weeks had a questionnaire sent to them by post.
Data analyses were performed using a Statistical Package for Social Sciences, version 16.0 (SPSS Inc, Chicago, IL), and a P value of <0.05 was considered statistically significant. Parametric data were expressed as mean±SD. Nonparametric data were expressed as the median (interquartile range). Correlation was assessed using the Spearman rank correlation coefficient and the χ2 test was used. The Wilcoxon rank test was used to assess any differences between the comfort scores.
A total of 240 consecutive patients who underwent bronchoscopy were included. Only 180 patients (75%) returned the follow-up questionnaires, and therefore, 180 complete patient data sets were analyzed. The mean age (SD) was 64.8 (13.6) ranging from 18 to 89 years. Sixty percent of patients were male individuals.
The indications for bronchoscopy were the evidence of a mass on computed tomography image (59.4%), slowly resolving pneumonia (11.7%), hemoptysis (14.4%), cough (4.4%), or other indication (10.1%—radiologic signs of interstitial lung disease and mediastinal lymphadenopathy).
The procedures were performed by a specialist registrar in 55% of the cases and by a consultant in 45% of the cases. The dose of midazolam used varied between 0 (3 patients, 1.67%) and 8 mg (2 patients, 1.1%), most patients having received between 2 and 4 mg (84.4%). Most patients had bronchial brushings and endobronchial biopsies performed at bronchoscopy (58.3%) with 8.9% having had transbronchial biopsies or TBNA. However, 25.6% of patients underwent washings alone, although 7.2% had no samples collected.
The majority of patients had a low discomfort score when assessed in recovery and at follow-up. However, 28.9% of patients reported at least moderate discomfort (a score of 3 or 4) on immediate assessment with 33.9% reporting this at follow-up. Figure 1 shows the range of patient comfort scores obtained immediately after bronchoscopy was performed. The number of patients who reported higher discomfort (score of 3 or 4) was similar for the immediate (N=52) and follow-up (N=61) assessments (χ2=1.044, P=0.2).
The comfort score assessed by a nurse was 0 or 1 in 50% of the cases. The sedation score assessed by the nurse during the procedure was recorded as “asleep or drowsy” in 65% of the cases and “awake” in 27.2% (in 7.8% cases, no record was made).
The immediate and follow-up comfort scores recorded by patients were related (the Spearman rank correlation 0.51, P<0.01). There was no difference between the scores reported immediately and that at follow-up (Wilcoxon P=0.79).
The comfort score recorded by the nurses was related to the immediate comfort score (the Spearman rank 0.22, P<0.01) and the follow-up score (the Spearman rank 0.28, P<0.01) of the patients.
No relationship was found between the sedation score (assessed by the nursing staff) and the patient comfort score recorded in recovery or at follow-up.
Younger patients (age less than 60) recorded higher discomfort scores in recovery (χ2=7.69, P<0.05) but not at follow-up assessment (χ2=1.10, P=0.29), despite the fact that older patients received lower doses of midazolam (χ2=12.9, P<0.01). Figure 2 shows a series of box plots representing the comfort scores obtained in each age group.
The experience of the bronchoscopist, position of the patient during bronchoscopy (lying or sitting), intubation route (nasal or oral), dose of midazolam used, or route of local anesthetic (cricoid/to scope) had no influence on the immediate or follow-up comfort scores. Table 1 shows the immediate comfort scores for each of these variables. There was a trend noted that patients undergoing TBNA or transbronchial biopsy reported a higher immediate discomfort score, but this did not reach statistical significance and was not mirrored in the follow-up scores. The absolute numbers of patients undergoing TBNA or transbronchial biopsy were small; hence, this study had limited ability to detect any difference in discomfort.
Discomforts reported were a choking sensation (32%), burning from the local anesthetic spray (22%), dyspnea (15%), cough (13%), anxiety (10%), pain (5%), and inability to clear secretions (4%). Twenty-seven percent of patients reported no specific discomfort.
The overall complication rate was 16%. Complications included bleeding requiring local adrenaline (5%), significant desaturation (>10% drop in oxygen saturation by pulse oximetry) (5%), agitation leading to early termination of procedure (2%), and severe coughing (2%). The complication rate was not higher in patients older than 60 years of age or in those receiving more invasive procedures such as a transbronchial biopsy or TBNA.
The ideal time to assess patient satisfaction with bronchoscopy has not been established. Nor is it clear whether there is a relationship between the patients’ self-assessed comfort scores and those recorded by nursing staff. This is the first large study that has looked into whether patient comfort scores recorded immediately after bronchoscopy are comparable with those documented at follow-up. We found a correlation between these 2 scores and a correlation between the comfort scores assessed by patients themselves and those recorded by the nursing staff.
In a previous study, Maguire et al9 have compared 2 groups of patients undergoing bronchoscopy: one received sedation with diazepam, the other received no sedation. A questionnaire was completed immediately after the procedure and a second questionnaire completed at least 1 month later. The study reported that the differences in comfort scores between the patients who received sedation and those who did not were greater at later questioning, which may be due to the amnestic effect of diazepam. In a study on a smaller number of patients, the authors noted that there was no difference in the immediate comfort score between the patients receiving midazolam or alfentanyl as sedation. However, patients who were given midazolam reported less discomfort when asked about the procedure 24 hours later.12 Previous studies have shown that the elderly tolerate bronchoscopy just as well as the younger patients and indeed less sedation is needed.13 Our study supports these findings with older patients reporting a lower discomfort score when assessed immediately after bronchoscopy. However, at follow-up assessment, no difference was seen in comfort score on the basis of age, and this may be due to the amnestic effect of midazolam.
The available evidence suggests that the type of bronchoscopic procedure being undertaken does not influence patient satisfaction with the procedure. Satisfaction with endobronchial ultrasound-guided TBNA has been shown to be extremely high, despite the more invasive nature of the procedure.14 Another study found no difference in satisfaction between patients having a standard bronchoscopy and those having a TBNA.15 Our findings suggest that the patients undergoing more invasive procedures (TBNA/transbronchial biopsy) had a trend toward a higher discomfort score, although this did not reach statistical significance.
It has been established by a number of studies that topical lignocaine through the scope is associated with decreased cough frequency, decreased sedation requirements, and increased patient satisfaction compared with sedation alone.16 A study comparing intratracheal cocaine with cocaine through the bronchoscope or nebulized lignocaine showed a clear patient preference for the intratracheal route.17 A more recent study showed a reduction in cough with a transcricoid injection of lignocaine compared with a “spray as you go” technique. No difference was seen in discomfort scores between the groups.18 Our study showed similar results with route of local anesthetic having no influence on comfort scores; however, only a small number of patients in our study received transcricoid injection.
A number of other studies have looked into variables affecting patient comfort. Mitsumune et al19 found that patient discomfort decreased with increasing bronchoscopist experience and increased with patient anxiety regarding bronchoscopy. The experience of operator (specialist registrar vs. consultant) did not influence comfort score in our study. A recent observational cohort study found that the semirecumbent position was associated with less cough and sedative requirement compared with the supine position.20 Position did not influence comfort score in our study.
The best intubation route for bronchoscopy has been a matter of debate for many years.21,22 The most recent evidence from a study in Korea found that the oral route was associated with less discomfort compared with that of the nasal route.23 Our study has not provided any further insight into this debate with intubation route having no influence on comfort score. However, only 20% of bronchoscopies were carried out through the nasal route, and therefore, only limited conclusions can be drawn from our data.
Some authors have reported that satisfaction with bronchoscopy is dependent upon satisfaction with the overall process of care. Quality of information given about the procedure is particularly important together with other factors, such as waiting times and the bronchoscopy suite environment.24 In our study, all patients received written information about the procedure and any questions they had were answered before the bronchoscopy.
There are several limitations to this study. First, the timing of the follow-up questionnaire was not fixed, and hence, some patients did not complete this until a few weeks after the procedure. However, the reason for a late questionnaire was to ensure that the sedative effect of midazolam had worn out; in view of its short half-life, this is likely to have occurred much sooner compared with that in our second questioning of the patients (within minutes or hours).
Our study found that 28.9% of patients experienced moderate to severe discomfort during the procedure. This is a significantly high proportion and would suggest that modest doses of midazolam together with topical anesthetic are not sufficient. Notably, 27% of patients in this study had a sedation score that was graded as “awake” by the nursing staff, indicating that suboptimal sedation was given. Despite this, no correlation was seen between the comfort score and the sedation score. This suggests that the amnestic effect of midazolam may have a greater role in the perception of discomfort during the procedure compared with the sedative effect. It would also have been useful to collect data on the duration of procedure as this may have had an impact on both the level of sedation and the patient comfort.
Previous studies have found that both bronchoscopy nurses and bronchoscopists themselves are unreliable in assessing the discomfort patients experience during the procedure. The parameter most accurately measured is cough, although in a recent study, this did not correlate with patient satisfaction with the procedure.8 We included cough when asking patients to describe their discomfort but did not objectively quantify it during the procedure.
A further tool often used in the assessment of patient satisfaction is to ask whether the patient would agree for a repeat bronchoscopy. We did not include this in our questionnaire as we believe that the answer is subject to other variables in addition to procedure-related discomfort, for example, the desire for a diagnosis.
We conclude that the patient satisfaction with bronchoscopy can be reliably assessed immediately after the sedative effect of midazolam has worn off. We found that when midazolam is used for sedation during bronchoscopy most patients report low discomfort and the type of samples taken at routine diagnostic bronchoscopy does not affect the patient comfort score.
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