Sedation During Bronchoscopy:Dexmedetomidine vs Alfentanil

BACKGROUND:

• Problem:

The endoscopy of the tracheobronchial tree by endoscopy is an act very common in the daily activity of pulmonologists. The indications for bronchoscopy are multiple and include infectious causes, tumor, systemic disease, foreign bodies and other indications. It can be diagnostic or therapeutic purposes. Bronchoscopy is an invasive but rarely, however, induced severe complications (respiratory failure, hemodynamic collapse, massive bleeding ...). However, tolerance to the examination varies significantly between patients [1-3]. Different signs and symptoms include desaturation, chest pain, choking sensation and cough. These effects are likely to alter patient comfort during the procedure and the quality of it. To further improve the tolerance operators have resorted to various techniques. A first step in improving the comfort is a good local anesthesia using spray or swab intra nasal base and lidocaine anesthesia of the airway (trachea, carina and bronchi) during the examination. The second step involves the use of intravenous sedation [1, 3-14].

• Background:

Until now, there is no standardized protocol for the best product and the best dose to use for sedation of patients. Several studies have been done comparing different drug or drug combination in the benzodiazepine family, ketamine or morphine with varying results and not leading in most cases to allow conclusions to establish clear guidelines regarding the use or no sedation plus local anesthesia and sedation dose of this [1, 3, 5, 8, 15]. Especially, for fear of adverse effects of sedation on respiratory function, many pulmonologists far are a little hesitant about the administration of sedatives during bronchoscopy. Dexmedetomidine is a new molecule sedation which is approved for its sedative effect while holding a revival meeting described as "awake sedation." [12, 16-22]

DESCRIPTION:

The aim of this randomized controlled trial was to evaluate the feasibility and safety of three different regimes of sedation during bronchoscopy:

• Group standard / control (local anesthesia only): (C)
• Group alfentanil (+ local anesthesia): (A)
• Group dexmedetomidine (+ local anesthesia): (D)

The primary endpoint is:

• / Feasibility / tolerance of bronchoscopy by the "score bronchoscopy" which includes:

• The movement of the vocal cords (4 levels)
• Cough (4 levels)
• Movement members (4 levels)

Secondary objectives:

• / level sedation for bronchoscopy:

• Level of sedation achieved according to the objective using: Nursing Instrument for the Communication of Sedation (NICS) (7 levels).
• Dose of midazolam necessary complementary in each group. Midazolam to give to the judgment of the operator (if necessary) is predetermined speed (1 mg each minute) to the level of sedation (-1) "Level of sedation achieved according to the objective using: Nursing Instrument for the communication of Sedation (NICS)".
• / Tolerance examination:

• During the procedure
• At the end of the procedure
• After 1 hour of the end of the examination

Inclusion criteria

• All patients admitted for diagnostic flexible bronchoscopy in the endoscopy department

Exclusion criteria

• Bronchoscopy outside the endoscopy unit
• Tracheal stenosis
• SpO2 <90% in the open air
• Bradycardia <55 per minute
• Atrioventricular block
• Heart failure known (EF <40%)
• Alcoholism (> 5 drinks per week)