Sedation during dynamic bronchoscopy for expiratory central airway collapse: Which is the ideal protocol?

• Published in: Respiratory medicine 2024-12, Vol.236, p.107904, Article 107904
• Main Authors: Funes-Ferrada, Rodrigo, Yu Lee-Mateus, Alejandra, Vaca-Cartagena, Bryan F., Valdes-Camacho, Sofia, Barrios-Ruiz, Alanna, Garza-Salas, Ana, Robertson, Kelly S., Fernandez-Bussy, Sebastian, Chadha, Ryan M., Abel, Martin D., Scott, Courtney L., Abia-Trujillo, David
• Format: Article
• Language: English
• Subjects: Dynamic bronchoscopy; Expiratory central airway collapse; Sedation
• ISSN: 0954-6111; 1532-3064; 1532-3064
• DOI: 10.1016/j.rmed.2024.107904

To compare sedation protocols for dynamic bronchoscopy (DB) in the evaluation of expiratory central airway collapse (ECAC). This observational study included adult patients (≥18 years) referred to Mayo Clinic, Jacksonville, FL, from March 2023 to July 2024, for suspected ECAC. Patients were grouped based on sedation protocols: propofol (Protocol 1), remimazolam (Protocol 2), and remimazolam/fentanyl (Protocol 3). The primary outcome was the quality of assessment during DB, rated on a 4-point Likert scale (1 = poor, 4 = excellent). Secondary outcomes included anesthesia duration and post-anesthesia care unit (PACU) length of stay. Statistical analyses included Fisher's exact test, ordinal logistic regression, and Kruskal-Wallis tests. Seventy-three patients met the inclusion criteria. Overall, DB quality of assessment was significantly associated with sedation protocol (P=0.01 Ordinal regression results suggest that protocol 3 (remimazolam/fentanyl) may be comparable to protocol 1 (propofol) (OR0.40, 95%CI 0.12–1.33, P = 0.13), with both showing a tendency for better performance than protocol 2 (remimazolam) (OR0.14, 95%CI 0.04–0.46 P=0.002 vs protocol 3; OR0.35, 95%CI 0.09–0.29 P=0.115 vs protocol 1). No significant differences were found in PACU length of stay among the three protocols (P = 0.13). No post-procedural complications were reported. Protocol 3 (remimazolam/fentanyl) demonstrated significantly higher odds of achieving a better quality of assessment compared to Protocol 2 (remimazolam) and showed comparable performance to Protocol 1 (propofol). These findings suggest that remimazolam/fentanyl is an effective sedation option for DB, providing improved assessment quality without increasing PACU stay. Larger prospective studies are necessary to confirm these results. •Sedation protocols impact assessment quality in dynamic bronchoscopy for expiratory central airway collapse.•Optimal sedation (RASS -1 to 0) ensures airway assessment reliability; oversedation or undersedation impairs results.•Protocol 3 (remimazolam/fentanyl) improves assessment quality compared to remimazolam and matches propofol's reliability.•There was no statistically significant difference among sedation protocols in Post-Anesthesia Care Unit length of stay.•Remimazolam/fentanyl enables optimal sedation by proceduralists, expanding access where propofol use is limited.