Bronchoscopist-directed Continuous Propofol Infusion for Targeting Moderate Sedation During Endobronchial Ultrasound Bronchoscopy: A Practical and Effective Protocol.

BACKGROUND: Propofol use for sedation during routine flexible bronchoscopy is expanding. However, there are concerns over propofol's reliability in targeting moderate sedation during more complex and lengthy procedures, such as endobronchial ultrasound (EBUS) bronchoscopy. Its delivery by continuous infusion, which provides a steady sedation effect, may be a practical model for achieving reliable outcomes in this setting. METHODS: We tested a continuous propofol infusion protocol targeting moderate sedation for EBUS bronchoscopy. A fixed loading rate of 125 mcg/kg/min and initial maintenance rate of 75 mcg/kg/min were used. Sedation assessments were performed every 2.5 minutes. The infusion was adjusted by a nurse under the direction of the bronchoscopist to maintain moderate sedation, normal vital signs, and patient comfort. Prospectively collected data from the first 31 patients using the protocol were analyzed. RESULTS: A mix of EBUS types was performed in a fellowship training environment. Median procedure duration was 51 minutes (interquartile range, 41 to 75 min). Ninety-four percent of total bronchoscopy time was spent in moderate sedation, whereas only 1.9% was occupied by agitation-related delays. Average propofol dose per case was 0.07 mg/kg/min (±0.020), and infusion adjustments were required once every 8 minutes. Sampling goals were met in all patients, and diagnostic and nodal staging accuracies were 90% and 91%, respectively. All tumor specimens sent for genetics were sufficient for analysis. There were no major procedure-related complications. CONCLUSION: Bronchoscopist-directed continuous propofol infusion is effective and practical for reliably and safely targeting moderate sedation during EBUS bronchoscopy, without sacrificing the breadth and accuracy of the procedure.

Nurse administered propofol sedation for pulmonary endoscopies requires a specific protocol.

INTRODUCTION: This study provides an evaluation and risk analysis of propofol sedation for endoscopic pulmonary procedures according to our unit's "gastroenterologic nurse-administered propofol sedation (NAPS) guideline". MATERIAL AND METHODS: The present study is a prospective descriptive study performed at the Endoscopy Unit, Gentofte Hospital, Copenhagen, from May to July 2009. The study comprised at total of 51 consecutive patients who underwent 77 endoscopic procedures. Only patients above the age of 16 years were eligible for treatment. The exclusion criteria were as follows: American Society of Anesthesiologists (ASA) class > 3, history of sedation-related complications, severe chronic obstructive pulmonary disease. Excluded were patients with a potentially difficult airway and ventricular retention. Data on the number and type of procedure, baseline characteristics, sedation time, propofol dose administered and adverse events were obtained from medical histories. RESULTS: A total of 23 cases of adverse events were recorded, including one event of hypotension and 22 events of hypoxaemia. Five patients needed assisted ventilation. The frequency of hypoxaemia in sessions involving bronchoscopy was 17 of 26 (65%) compared with transoesophageal endoscopic ultrasound (EUS) (17 of 45, 35%) and endoscopic bronchial ultrasound (EBUS) (three of six, 50%). Endoscopist assessment of working conditions was good and patient assessment of discomfort was low. No patients required endotracheal intubation and there was no mortality. CONCLUSION: This study supports the conclusion that propofol administered by nurses provides for good working conditions and satisfied patients. But our "NAPS for endoscopic gastroenterologic procedures" guideline was unsuited for endoscopic pulmonary procedures including EUS. FUNDING: This work was supported by the START research foundation at Gentofte Hospital. TRIAL REGISTRATION: not relevant.

Flexible bronchoscopy assisted by noninvasive positive pressure ventilation.

Noninvasive positive pressure ventilation is an alternative to intubation in critically ill patients with respiratory insufficiency or poor gas exchange who may require flexible bronchoscopy for diagnostic or therapeutic purposes. This ventilatory technique might help decrease the risk of bronchoscopy-related complications in patients with refractory hypoxemia, postoperative respiratory distress, severe emphysema, obstructive sleep apnea, and obesity hypoventilation syndrome and allows bronchoscopic assessment of patients with severe dyspnea from expiratory central airway collapse. In this review, the physiological rationale, indications, contraindications, techniques, and monitoring requirements for flexible bronchoscopy assisted by noninvasive positive pressure ventilation are described, with an emphasis on the role of critical care nurses in this procedure.

Bronchoscopy: What critical care nurses need to know.

Although bronchoscopies have been performed for over a century and are relatively safe when practice guidelines are followed, they are invasive and a real source of anxiety and fear for the patient. The role of the critical care nurse is essential to a successful outcome. This article provides an overview of the main diagnostic and therapeutic indications, contraindications, and possible complications. Also discussed are patient education; patient and staff safety; and considerations before, during, and after the procedure.

Esophageal nasogastric tube misplacement in an infant following laser supraglottoplasty.

Nasogastric (NG) tube misplacement continues to be one of the most common problems associated with enteral tube feedings. Current methods of testing appropriate NG tube placement are ineffective in detecting tube misplacement in a clinically significant number of infants and children. This case study describes an NG tube misplacement into the esophagus in an infant following laser supraglottoplasty; the misplacement was detected on a radiograph obtained as part of a study protocol. Other testing methods used failed to detect the tube misplacement, which could have led to aspiration pneumonia or other complications if the radiograph had not shown the misplacement.

The development of the first nurse-led bronchoscopy post in the United Kingdom.

Nurses routinely practice Gastrointestinal endoscopy in the United Kingdom (UK) but, to our knowledge, bronchoscopy has never been introduced as a nursing discipline. The need for a nurse bronchoscopist was identified within our respiratory unit and the post was developed. This process involved: (1) seeking a precedent for the role of nurse bronchoscopist, (2) designing an appropriate teaching programme, (3) obtaining hospital accreditation for the programme, (4) supervising and completing the training, and (5) implementing a nurse-led bronchoscopy service. The development phase took approximately 1 year. No precedent was found for nurse-led bronchoscopy in the UK or elsewhere. The training programme defined minimum entry requirements and was modelled on UK nurse GI endoscopy training and the British Thoracic Society bronchoscopy guidelines. The role of nurse bronchoscopist was deemed to comply with professional codes of nursing practice by the chief nurse and the hospital management board authorised a service framework for the post. The first trainee completed the programme in January 2003 and has now examined 125 patients independently [endobronchial tumour biopsy hit-rate = 95% (95% CI 76-99%)]. The post of nurse bronchoscopist has been successfully developed and accredited within our hospital.

Developing and implementing the role of the nurse bronchoscopist.

Recent years have seen a growing range of new roles being created for nurses, often in areas previously considered to be part of the medical domain. This paper discusses the development of the nurse bronchoscopist role and a training programme and service framework to support it in order to develop a nurse-led service for patients requiring this procedure.

Preparing and supporting patients undergoing a bronchoscopy.

A bronchoscopy is an endoscopic examination of the upper respiratory tract, trachea and bronchial tree. The technique was developed in the 1960s and introduced into clinical practice a decade later (Stradling, 1991). The use of a flexible, fibreoptic instrument that incorporates a light source, biopsy and suction channel is inserted via the mouth or nose. This enables the bronchoscopist to inspect the airways visually, identify any abnormalities and obtain samples of secretions, cells or tissue biopsies (Lesser, 2003).

The role of the nurse bronchoscopist.

Fibre-optic bronchoscopy has traditionally been performed by respiratory physicians and registrars. It is an invaluable investigation for diagnosing lung cancer and other respiratory diseases. Modern bronchoscopy techniques make the procedure safe for most patients, apart from those who are gravely ill, or who have a gross reduction in respiratory reserve (Stradling, 1991).

Fibrobroncoscopia como medio de diagnóstico. Labor de enfermería / Fibrobronchoscopy as a diagnostic means. Nursing work

Se realizó un estudio descriptivo, transversal y retrospectivo de 352 pacientes con afecciones neumológicas, a quienes se les realizó fibrobroncoscopia en el Departamento de Pruebas Endoscópicas del Hospital Clinicoquirúrgico Docente ôDr. Ambrosio Grillo Portuondoö de Santiago de Cuba, desde noviembre de 1991 hasta diciembre de 1996, con el propósito de exponer los resultados de este medio de diagnóstico y otras variables de interés. En la serie investigada, el hallazgo de neoplasia del pulmón coincidió con la identificación de tumores pulmonares (48,6(por ciento) y su relación con el hábito de fumar. Las complicaciones fueron mínimas durante la ejecución de este proceder, atribuible fundamentalmente a la gran participación y responsabilidad del personal de enfermería en el equipo de salud. Para la presentación de los datos se utilizó el método porcentual)AU)