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14

Chapter 1

Chapter 8

provides a description of pharmacodynamics, systemic effects, and possible

applications of dexmedetomidine.

24

In

chapter 9

we compared in a randomised controlled

study the satisfaction and safety of a group of patients receiving moderate sedation with

dexmedetomidine with a second group sedated with propofol.

25

Our study focussed

on elective endoscopic oesophageal procedures for treatment of Barrett’s oesophagus.

These procedures require patients who are sedated, but easily arousable to provide an

excellent endoscopic view of the oesophagus. Thus, we tended to a level of sedation -

using the observer’s assessment of alertness/sedation scale (OAA/S) - between 2 and 4,

meaning that patients show maximal lethargic response to their name spoken in normal

tone.

26

Patients were constantly monitored for HR, SpO

2

, ECG, etCO

2

, NIBP, and non-invasive

cardiac output (NICO). After the procedure, patients rated their satisfaction level using a

validated questionnaire modified from the patient satisfaction with sedation instrument

(PSSI).

27

Endoscopists were asked about their experience using the corresponding clinician

satisfaction with sedation instrument (CSSI) score.

27

Chapter 10

focuses on another promising drug for moderate sedation: remifentanil, an

opioid with a rapid begin within 30-60 s, peak effect within 2.5 min, and half-life of 8-10

min. Remifentanil is metabolised by non-specific esterases resulting in a rapid systemic

elimination. This is useful especially in situations making a predictable termination of its

effect necessary. Lim et al. showed that remifentanil slowly titrated with a target controlled

infusion (TCI) system successfully suppressed the coughing reflex during intubation.

28

Intubation is a procedure that provokes irritation of the complete airway system in almost

the same manner as bronchoscopy. Therefore, we used these findings to develop a concept

for moderate sedation during bronchoscopy and bronchial thermoplasty (BT) consisting of

remifentanil TCI combined with propofol TCI.

29

BT is a novel bronchoscopic treatment for patients with moderate-to-severe asthma; it has

been shown to improve quality of life and to reduce asthma symptoms and exacerbation

rates.

30

A complete BT treatment consists of 3 consecutive bronchoscopic procedures

during which airways of the left lower lobe, right lower lobe, and finally both upper lobes

are treated with radiofrequency.

We performed a prospective observational cohort study including 32 BT procedures in

severe asthma patients. After each procedure, patients were requested to rate their overall

satisfaction with sedation on a visual analogue scale (VAS). Similarly, bronchoscopists were

asked to rate patients` cooperation and tolerance. All sedation-related events and the

number of performed radiofrequency activations on the airway were registered.