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Drugs used for bronchoscopy and sedation 

Drugs used for bronchoscopy and sedation
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

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date: 27 January 2022

Table A5.1 Commonly used drugs for sedation and bronchoscopy (continued on  Drugs used for bronchoscopy and sedation p. [link]). Adapted from BTS guideline for diagnostic flexible bronchoscopy in adults, Thorax (2013);68:i1–i44, with permission from BMJ.

Drug

Dose

Pharmacology

Side effects

Midazolam

  • Slow IV injection—maximum rate 2mg/min

  • Initial dose: 2–2.5mg (0.5–1mg in the frail or elderly), given 5–10min before procedure

  • Supplemental doses, if required: 1mg (0.5–1mg in frail or elderly), at 2–10min intervals

  • Usual maximum total dose: 3.5–7mg (3.5mg in frail or elderly) for standard bronchoscopic procedures. May be higher in longer procedures

  • Onset within 2min, with maximum effect at 5–10min (may be longer in frail or elderly or those with chronic illnesses)

  • Duration of action variable, but typical range is 30–120min

  • Approximate half-life 1.5–2.5h

  • Respiratory depression, apnoea, bronchospasm, laryngospasm, hypotension, heart rate alterations, cardiac arrest

  • Life-threatening side effects and prolonged sedation are more likely in the elderly and those with impaired respiratory or cardiovascular status, hepatic impairment, renal impairment, myasthenia gravis, and with rapid IV injection

Fentanyl

  • Slow IV injection—usually over 1–3min

  • Initial dose: 25 micrograms

  • Supplemental doses, if required: 25 micrograms

  • Usual maximum total dose: 50 micrograms

  • Onset almost immediate, with maximum effect at 5min

  • Duration of action variable, but typical range is 30–60min

  • Approximate half-life 2–7h

  • Nausea, vomiting, and other GI upset, myoclonic movements, respiratory depression, apnoea, bronchospasm, laryngospasm, hypo/hypertension, arrhythmia, cardiac arrest

  • Caution in elderly patients and those with impaired respiratory or cardiovascular status, hepatic impairment, and myasthenia gravis

Alfentanil

  • Slow IV injection—usually over 30s

  • Initial dose: 250 micrograms

  • Supplemental doses, if required: 250 micrograms

  • Usual maximum total dose: 500 micrograms

  • Onset almost immediate onset and maximum effect

  • Duration of action variable, but usually shorter than fentanyl

  • Approximate half-life 1–2h

See Fentanyl

  • Lidocaine

  • (during

  • bronchoscopy)

  • Intranasal

  • Lidocaine 2% gel: 6mL (120mg)

  • Oropharnyx

  • Lidocaine 10% spray: three actuations (30mg)

  • Vocal cords, tracheobronchial tree

  • Lidocaine 1% solution: 2mL boluses applied topically, as required

  • Use minimum dose to achieve effective cough suppression and patient comfort. Subjective symptoms of lidocaine toxicity are common when ≥9.6mg/kg is used; much lower doses are usually sufficient

  • Onset 3–5min. Common mistake not to wait long enough for maximal effect, leading to unnecessary extra doses

  • Duration of action variable, but typical range is 60–90min

  • Approximate half-life 1.5–2h

  • CNS effects (confusion, blurred vision, dizziness, drowsiness, light-headedness, myoclonus, nausea, nystagmus, paraesthesiae, restlessness, tremulousness, coma, convulsions, respiratory failure)

  • CVS effects (hypotension, bradycardia, arrhythmia, cardiac arrest)

  • Methaemoglobinaemia (rare)

  • Caution in those with hepatic and cardiac dysfunction, and with significant renal impairment

Adrenaline (during bronchoscopy)

  • Topical

  • Adrenaline 1:10, 000: 2–10mL

Hypertension, tachycardia, arrhythmia, tremor

Table A5.2 Antagonists available for sedative drugs (adapted from BTS guideline for diagnostic flexible bronchoscopy in adults with permission)

Drug

Dose

Pharmacology

Side effects

Flumazenil

To reverse midazolam Initial dose: 200 micrograms IV over 15s Supplemental doses: 100 micrograms every 60s if inadequate response Typical cumulative dose range: 300–600 micrograms Maximum total dose: 1mg Note—when combined midazolam-opioid sedation used and reversal required, use flumazenil first (unless large dose of opioid given)

Onset 1min Duration of action 1–4h Approximate half-life 40–80min Duration of action may be shorter than midazolam l care to ensure sedation does not recur

Nausea, vomiting, anxiety, agitation, dizziness, hypertension, tachycardia May lower seizure threshold May cause withdrawal in chronic benzodiazepine users

Naloxone

To reverse opioids Initial dose: 100–200 micrograms IV Supplemental dose: 100 micrograms every 2min, if inadequate response

Onset 2–3min Duration of action 45min to 4h Approximate half-life 1–1.5h Duration of action may be shorter than opioid l care to ensure sedation does not recur

Nausea, vomiting, dizziness, headache, tachycardia, hypo/hypertension May cause withdrawal in chronic opioid users

Table A5.3 Doses and concentrations of lidocaine used for bronchoscopy (adapted from BTS guideline for diagnostic flexible bronchoscopy in adults with permission)

Drug

Dose per unit volume

Site of application

Comments

Lidocaine 2% gel

20mg/mL

Nasal

Gel preparation syringe typically contains 6mL (120mg)

Lidocaine 10% aerosol spray

10mg/actuation

Oropharynx

Three actuations (30mg) often sufficient

Lidocaine 10% aerosol spray

10mg/mL

Vocal cords, trachea, and bronchial tree

Further information

Du Rand IA et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults. Thorax 2013;68:i1–i44.Find this resource: