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PROPOFOL AND REMIFENTANIL SEDATION FOR BRONCHIAL THERMOPLASTY
10
BT treatment consists of 3 separate BT procedures, and to fulfil the complete treatment, it is
extremely important that the patient tolerates the procedure well.
We performed moderate sedation with propofol and remifentanil TCI combined with
topical anaesthesia facilitating a stable spontaneous breathing situation and obviating the
need for intubation as well as muscle relaxant use and ventilator support. The feasibility of
this sedation strategy was proven by high satisfaction levels combined with the fact that
all BT procedures succeeded, with a total amount of activations that did not differ from the
largest randomised controlled trial, where a range of sedation types were used.
22
Previous
studies have shown that VAS scores can be successfully applied to measure the level of
satisfaction and its separate components.
19,23
No serious adverse events occurred. The single patient in whom the investigated sedation
strategy was converted to general anaesthesia was the first patient receiving this specific
sedation protocol with propofol and remifentanil. In this first case, in retrospect, the initial
dose of remifentanil chosen was too high, and insufficient time was taken for sedation
induction, which resulted in apnea and rigidity of the thorax with desaturation. To avoid
this problem in subsequent cases, sedation was started with a lower targeted plasma level
of remifentanil (1.5 μg/ml), and sufficient time was taken to reach the optimal sedation
level. Propofol and remifentanil have the advantage of a rapid onset and termination of
action, which make this combination easily titrable. Remifentanil reduces cough and
airway reactivity, resulting in a lower dose of propofol needed, and therefore reduces the
risk of respiratory events.
24,25
Therefore, the sedation strategy used allows a rapid time to
full recovery (in this study, a median time of 6 min) allowing quick discharge from the
hospital. Administration of propofol and remifentanil TCI requires skilled specialised
sedation anaesthesia nurses or anaesthesiologists experienced in the close monitoring of
haemodynamic and respiratory parameters, such as SpO
2
, respiratory rate, and expiratory
CO
2
, since small dose modifications – especially of remifentanil – can highly impact the level
of sedation with a shift from moderate to deep sedation or even general anaesthesia with
the need to ventilate the patient. Currently, such sedation regimes are increasingly provided
by specialised sedation anaesthesia nurses, since this is a recognised option according to
the guidelines from the American Society of Anesthesiologists.
26–28
However, propofol and
remifentanil administration by specialised sedation anaesthesia nurses is still not common
and/or available in many countries in Europe. Special educational programs combined with
an optimal infrastructure, including an anaesthesiologist on call, are required.
The strong point of the current study is the prospective design and the careful assessment of
valid and important outcomes for both patients and bronchoscopists. Beside the moderate
number of patients investigated, a limitation is the fact that 3 of the 35 procedures were
performed under general anaesthesia. We judge this potential selection bias to be small
and regard it to be highly unlikely to affect the observed outcomes. Furthermore, no cost-