Flexible bronchoscopy is a frequent procedure for diagnostic or therapeutic interventions such as bronchoalveolar lavage, biopsies or bronchial suction. The British Thoracic Society guideline recommends offering sedation, unless contraindicated, to all patients undergoing flexible bronchoscopy.1 The best anaesthetic procedure for flexible bronchoscopy remains unknown. Cough and anxiety are frequent side events that may limit both efficacy and patient satisfaction.2,3
We conducted a randomised controlled study to investigate the impact of sedation with propofol or remifentanil, in target-controlled infusion (TCI) mode, on cough episodes and patient and bronchoscopist satisfaction during flexible fibreoscopy procedures at Saint Louis Hospital (Paris, France) between July 2013 and April 2017 (Trial registration: ClinicalTrials.gov identifier: NTC01872754). The primary endpoint was the total duration of prolonged cough episodes. The secondary endpoints were number of prolonged cough episodes by patients, occurrence of at least one episode of prolonged cough, patient and bronchoscopist satisfaction, number of adverse events (oxygen desaturation, bradycardia, hypotension, nausea or/and vomiting, coma). The randomisation was stratified by both the bronchoscopist's experience and the patient's level of anxiety (a patient was considered anxious if the visual analogue scale value was above 20) (e-Table 1, https://links.lww.com/EJA/A216). Thirty-one patients were randomised to the propofol group and 39 were randomised to the remifentanil group (e-Fig. 1, https://links.lww.com/EJA/A216). Patients and bronchoscopists were blind to the drug used. The initial target concentrations were 2.5 μg ml−1 in the propofol group and 4 ng ml−1 in the remifentanil group. The TCI was adjusted, every minute, by increments or decrements of 0.5 μg ml−1 for the propofol group and 1 ng ml−1 for the remifentanil group until the desired level of sedation was reached. All adjustments to the target site-specific concentrations were standardised (e-Table 2, https://links.lww.com/EJA/A216). The vital signs and the Observer's Assessment of Alertness/Sedation Scale were collected every minute (e-Table 3, https://links.lww.com/EJA/A216).
The total median [lower quartile to upper quartile] duration of prolonged cough episodes was significantly shorter in the remifentanil group than in the propofol group (median 13 [0 to 70] vs. 50 [12 to 138] s, P = 0.049). There were no significant differences in the number of prolonged cough episodes (1 [0 to 2] vs. 2 [0 to 3], P = 0.258), nor the number of patients with at least one prolonged cough episode [24 (62%) vs. 22 (71%), P = 0.403] (e-Table 4, https://links.lww.com/EJA/A216). We did not find any difference regarding the presence of adverse events between the two groups (e-Table 5, https://links.lww.com/EJA/A216). The satisfaction score of the bronchoscopists (e-Table 6, https://links.lww.com/EJA/A216) was significantly higher for the remifentanil group (27 [23 to 30] vs. 23 [18 to 27], P = 0.002). The pulmonologist reported better procedure quality and perceived fewer patient movements and fewer cough episodes (P = 0.001). In contrast, patients in the propofol group (e-Supplementary file Table 6, https://links.lww.com/EJA/A216) had better satisfaction scores (33 [31 to 35] vs. 28 [25 to 30], P < 0.001). They reported less discomfort and less memory of the procedure (P < 0.001).
In this study, we observed a significant difference in favour of remifentanil for the total duration of prolonged coughing episodes. Bronchoscopists also perceived this difference and reported a higher quality for the procedure and decreased perception of cough with remifentanil. These findings might be related to the antitussive and analgesic effects of opioids such as remifentanil and may have improved the quality of the procedure because of a decrease in cough-related movements during the procedure, leading to better bronchoscopist satisfaction. However, the sedative effect of propofol may improve patient comfort and satisfaction. The higher incidence of recall with remifentanil is consistent with previous studies.4,5 Expected technical difficulties may indicate the use of remifentanil rather than propofol to limit episodes of cough, while the majority of patients may benefit from propofol.6,7 Further studies should investigate the impact of combining propofol and remifentanil on patient comfort and the bronchoscopist's satisfaction.
In conclusion, remifentanil reduces the total duration of prolonged cough and was associated with better bronchoscopist satisfaction. These results will guide physicians and patients when choosing the best anaesthetic for fibreoscopy procedures requiring sedation.
Acknowledgements relating to this article
Assistance with the letter: none.
Financial support and sponsorship: the study was funded by a grant from Assistance Publique-Hôpitaux de Paris.
Conflicts of interest: none.
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