Paper details

Instructions Complete a full draft of your research paper. This should have all the sections of the final paper including: 1-Hypothesis (research questionor statement), introduction and quality of literature (references) 30% 2-Method of study and body of paper 30% 3-Discussion / conclusion, abstract 30% 4-AMA format, spelling/grammar, structure 10% ((Attached is a copy of a sample paper from a former student who won an ARCF foundation award for her paper.)) 5- please use the 10 articles that i attached 6- you should at least write one or tow paragraphs of each article

Flexible Bronchoscopy Is Safe and Effective in Adult Subjects
Supported With Extracorporeal Membrane Oxygenation

Nirmal S Sharma MD, Timothy Peters MD, Tejaswini Kulkarni MD MPH, Charles W Hoopes MD,
Scott C Bellot MD, Keith M Wille MD MSPH, and Enrique Diaz-Guzman MD

BACKGROUND: Previous studies have demonstrated the safety of flexible bronchoscopy (FB) in
mechanically ventilated subjects. However, the safety of FB in adult subjects receiving extracor-
poreal membrane oxygenation (ECMO) has not been described previously. METHODS: A retro-
spective review was conducted of all adult subjects who underwent FB while receiving ECMO
support at the University of Alabama at Birmingham Hospital from January 1, 2013, to December
31, 2014. Physiologic variables, pre- and post-FB ECMO, and ventilator settings were recorded.
RESULTS: 79 adult subjects underwent FB receiving ECMO with a total of 223 bronchoscopies.
The most common indications for bronchoscopy included diagnostic evaluation of infection in
subjects with pneumonia (29%) and clearance of excessive secretions (22%). In 70% of subjects,
moderate or greater amounts of secretions were noted. FB yielded positive culture data in 37
subjects (47%), which resulted in a change to the antibiotic regimen in 14 subjects (38%) with
positive culture data. No significant differences in mean PaO2/FIO2, mean ECMO flow, mean sweep
gas, ventilator settings, or hemodynamic parameters (heart rate, oxygen saturation, and mean blood
pressure) were noted before and after FB. Complications were mild and transient: blood-tinged
secretions after FB in 21% cases, which resolved spontaneously, intraprocedural hypoxemia in
2.2% of cases, and dysrhythmia in <1% of cases. There were no episodes of ECMO cannula
dislodgement or inadvertent extubation. CONCLUSIONS: FB can be used safely in adult subjects
supported with ECMO and is not associated with significant hemodynamics changes, bleeding, or
mechanical complications during ECMO support. Key words: ECMO; bronchoscopy; ARDS; cardio-
respiratory failure; veno-venous ECMO; veno-arterial ECMO. [Respir Care 2016;61(5):646 –651. © 2016
Daedalus Enterprises]

Introduction

In the past decade, there has been an increase in the
utilization of extracorporeal membrane oxygenation
(ECMO) to support critically ill patients with cardiopul-

monary failure.1,2 ECMO-supported patients often have
respiratory infections and increased airway secretions com-
plicating the course of their illness.3 To aid in the diagno-
sis of respiratory infections and facilitate secretion clear-
ance, flexible bronchoscopy (FB) has become a necessary
tool in modern critical care practice.4,5 Although FB is a
relatively safe procedure in most patients, it can be asso-
ciated with complications, such as worsening hypoxemia,
endotracheal tube (ETT) dislodgement, and airway trauma,
in critically ill subjects receiving mechanical vent

Site of Bronchoalveolar Lavage Via Flexible Bronchoscopy
and Fluid Return in Children

Christian Rosas-Salazar, MD, MPH,* Stephen A. Walczak, RRT,w
Geoffrey Kurland, MD,w and Jonathan E. Spahr, MDw

Background: Despite its widespread use as a diagnostic
tool, the procedure for bronchoalveolar lavage (BAL)
via flexible bronchoscopy is not standardized in chil-
dren. Our objective was to examine the dissimilarities
in fluid return between the different lobes in children
undergoing flexible bronchoscopies with BAL.

Methods: We conducted a review of all pediatric flexible
bronchoscopies with BAL conducted at a single insti-
tution over a 2-year period. Our predictor of interest
was the site of the BAL. Our outcome of interest was
the percent of fluid return. We used 1-way analysis of
variance with subsequent pairwise comparisons for
unadjusted analyses and multivariable linear regression
for adjusted analyses.

Results: We identified 529 procedures that met pre-
specified criteria. The mean (SD) percent of fluid return
was 52.1 (14.4) for the right middle lobe, 50.7 (16.0) for
the lingula (LIN), 50.5 (18.6) for the right or left upper
lobes other than LIN (R/L-UL), and 42.2 (18.7) for the
right or left lower lobes (R/L-LL). The R/L-LL had
significantly lower fluid return when compared with each
of the other lobes (P <0.05 for all pairwise compar-
isons); in contrast, there was no significant difference in
fluid return between the other lobes. In our main analysis
adjusting for potential confounders, performing the BAL
in the right middle lobe, LIN, or R/L-UL increased the
fluid return by 11.1% [95% confidence interval (CI), 6.2-
16.1], 9.5% (95% CI, 3.2-15.8), and 8.7% (95% CI, 0.9-
16.5%), respectively, when compared with the R/L-LL.

Conclusion: Our results suggest that the lower lobes
provide the lowest BAL fluid return in children,
whereas the other lobes seem to perform similarly.

Key Words: bronchoalveolar lavage, flexible bronchoscopy,
children

(J Bronchol Intervent Pulmonol 2016;23:210–214)

Respiratory illnesses are a leading cause ofmorbidity, mortality, school absenteeism, and
increased health care expenditures in children
worldwide.1,2 Bronchoalveolar lavage (BAL) via
flexible bronchoscopy is an essential tool that can
help to establish an early diagnosis and guide
appropriate management in children with respira-
tory illnesses of different etiologies (including
immunologic, inflammatory, and infectious proc-
esses).3–6 Thus, if performed correctly, it can
decrease the risk of potential complications and
reduce the burden associated to these conditions.4,7

The clinical value of the BAL is thought to be
linked to the volume of fluid recovered, as a lower
percentage of volume retrieved may represent a
proximal (nonalveolar) sample and has been asso-
ciated with a decreased diagnostic yield.6,8–13 One
essential aspect that can aff

Sub-Saharan Africa: Post-Independence

Starting in the late 1950s, Sub-Saharan Africans intensified the struggle for independence from their European colonizers, and the
white rulers. So came to Sub-Saharan Africa the process known as
decolonization. Following World War II, the region’s European rulers
came to realization that their control over the colonies could not
continue as usual. Two main forces emerged to challenge the
European domination of Africans. First, challenges came from
African nationalists who wanted something so simple yet so difficult
to realize: Africa for Africans. Second, after World War II, which was
framed as epic battle against undemocratic tyranny of
totalitarianism, Africans began to challenge why the allies could not
uphold the same democratic values in Africa. To many African
nationalists, it was an example of supreme irony that nations that
defeated Nazism and Fascism were doing something Hitler’s
Germany wanted to do in Europe, conquest and exploitation. (The
above is a picture of the founding members of the anti-apartheid
organization later became African National Congress.) They

obviously felt justified in resisting European colonization more aggressively after World War II, which, by the way, destroyed and
weakened European societies.

This decolonization process was relatively peaceful in countries like Kenya, Tanzania, and Ivory Coast. However, independence did
not come easily in southern part of Africa. In Rhodesia, a formal British colony, 250,000 white
residents who owned the country’s farmlands refused to let their power and domination pass away

peacefully. Instead of accepting the black majority rule, they
declared Rhodesia independent as a white-supremacist state.
The blacks in turn declared war against the white rulers and
the civil war continued until 1975 when the Rhodesian
government capitulated. So came the birth of Zimbabwe, but
at a heavy human and material cost.

Something similar happened in Angola and Mozambique,
both Portuguese colonies. When Lisbon refused to grant
independence to these countries, people of Angola and
Mozambique turned to guerrilla warfare. The war in Angola

became even more violent, when the U.S. and the Soviet Union turned that civil war into a theater
of their own superpower competition. The Marxist groups within guerrilla movement, supported by the Soviet Union and Cuba,

eventually succeeded in forcing Portugal to leave Angola and Mozambique, and setup leftist governments. The U.S. and South Africa
perceived the leftist governments in Angola and Mozambique as thereat to their interests and financed guerrilla forces seeking to

topple the Marxist government of Angola and Mozambique. The fighting continued
well into the 1980s. The war ended at least in Mozambique due in large part to the
Soviet

Bronchoalveolar Lavage and Lung Biopsy in Patients With
Cancer and Hematopoietic Stem-Cell Transplantation
Recipients: A Systematic Review and Meta-Analysis
DeepakBabu Chellapandian, Thomas Lehrnbecher, Bob Phillips, Brian T. Fisher, Theoklis E. Zaoutis,
William J. Steinbach, Joseph Beyene, and Lillian Sung

DeepakBabu Chellapandian, Joseph
Beyene, and Lillian Sung, The Hospital
for Sick Children, Toronto; Joseph
Beyene, McMaster University, Hamil-
ton, Ontario, Canada; Thomas Lehrn-
becher, Johann Wolfgang Goethe
University, Frankfurt, Germany; Bob
Phillips, Centre for Reviews and
Dissemination, University of York, York,
United Kingdom; Brian T. Fisher and
Theoklis E. Zaoutis, Children’s Hospital
of Philadelphia, Philadelphia, PA; and
William J. Steinbach, Duke University
Medical Center, Durham, NC.

Published online ahead of print at
www.jco.org on January 5, 2015.

Authors’ disclosures of potential
conflicts of interest are found in the
article online at www.jco.org. Author
contributions are found at the end of
this article.

Corresponding author: Lillian Sung, MD,
PhD, Division of Haematology/Oncology,
The Hospital for Sick Children, 555 Univer-
sity Ave, Toronto, ON, Canada M5G 1X8;
e-mail: [email protected].

© 2015 by American Society of Clinical
Oncology

0732-183X/15/3305w-501w/$20.00

DOI: 10.1200/JCO.2014.58.0480

A B S T R A C T

Purpose
The objective of this study was to describe the diagnostic yield and complication rate of
bronchoalveolar lavage (BAL) and lung biopsy in the evaluation of pulmonary lesions in patients
with cancer and recipients of hematopoietic stem-cell transplantation (HSCT).

Methods
We conducted a systematic literature review and performed electronic searches of Ovid
MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Studies were included if
patients had cancer or were recipients of HSCT, and if they underwent BAL or lung biopsy for the
evaluation of pulmonary lesions. Only English language publications were included.

Results
In all, 14,148 studies were screened; 72 studies of BAL and 31 of lung biopsy were included. The
proportion of procedures leading to any diagnosis was similar by procedure type (0.53 v 0.54; P �
.94) but an infectious diagnosis was more common with BAL compared with lung biopsy (0.49 v
0.34; P � .001). Lung biopsy more commonly led to a noninfectious diagnosis (0.43 v 0.07; P �
.001) and was more likely to change how the patient was managed (0.48 v 0.31; P � .002)
compared with BAL. However, complications were more common with lung biopsy (0.15 v 0.08;
P � .006), and procedure-related mortality was four-fold higher for lung biopsy (0.0078) compared
with BAL (0.0018).

Conclusion
BAL may be the preferred diagnostic modali

731

□ ORIGINAL ARTICLE □

Safety and Efficacy of Bronchoalveolar Lavage Using
a Laryngeal Mask Airway in Cases of Acute Hypoxaemic

Respiratory Failure with Diffuse Lung Infiltrates

Takafumi Matsumoto, Yoko Sato, Satoshi Fukuda, Shinshu Katayama, Yuya Miyazaki,
Makoto Ozaki and Toru Kotani

Abstract

Objective Fibre-optic bronchoscopy with bronchoalveolar lavage (FOB-BAL) is an important tool for diag-
nosing and selecting treatment for acutely hypoxaemic patients with diffuse lung infiltrates. However, FOB-
BAL carries a risk of significant hypoxaemia and subsequent tracheal intubation during and after the proce-
dure. The application of FOB-BAL using a laryngeal mask airway (LMA) in combination with continuous
positive airway pressure (CPAP) may minimize the incidence of hypoxaemia; however, the safety and effi-
cacy of this procedure have not been investigated.
Methods A retrospective chart review was performed from April to September 2013. Data regarding the re-
covered volume of BAL fluid, incidence of tracheal intubation within eight hours after the completion of
FOB-BAL, respiratory and haemodynamic parameters and treatment modifications were collected for the
evaluation.
Results Ten trials of FOB-BAL using an LMA and CPAP were performed in nine patients with severe
acute hypoxaemia associated with diffuse lung infiltrates. The BAL fluid recovery rate was 56%, and the pro-
cedure was completed without subsequent complications. In addition, the percutaneous arterial oxygen satura-
tion decreased to 95.7%±3.8%, although it was never lower than 90.0% during the procedure, and no patients
required intubation. Furthermore, the arterial blood pressure significantly but transiently decreased due to se-
dation, and the procedure yielded diagnostic information in all nine patients.
Conclusion FOB-BAL using LMA and CPAP appears to be safe and effective in patients who develop se-
vere acute hypoxaemia.

Key words: bronchoalveolar lavage, continuous positive airway pressure, fibre-optic bronchoscopy, laryngeal
mask airway, sedation

(Intern Med 54: 731-735, 2015)
(DOI: 10.2169/internalmedicine.54.2686)

Introduction

In acutely hypoxaemic patients with diffuse pulmonary
infiltrates, it is important to establish the specific cause of
pulmonary disease so that appropriate therapy may be pro-
vided immediately. Fibre-optic bronchoscopy with bron-
choalveolar lavage (FOB-BAL) is an important tool for di-
agnosing diffuse pulmonary infiltrates (1). Although FOB-
BAL is generally considered to be safe (2), it is well known

that the arterial blood oxygen saturation usually decreases
during and/or after the procedure (3-6). Therefore, FOB-
BAL is contraindicated in non-intubated, severely hypoxae-
mic patients (7). Positive end-expiratory pressure ameliorates
hypoxaemia by preventing alveolar collapse, although some
type of airway manage

RESEARCH ARTICLE

Flexible Bronchoscopy with Multiple
Modalities for Foreign Body Removal in
Adults
Yueh-Fu Fang1,2‡, Meng-Heng Hsieh1,2‡, Fu-Tsai Chung1,2, Yao-Kuang Huang2,3, Guan-
Yuan Chen1,2, Shu-Min Lin1,2, Horng-Chyuan Lin1,2, Chin-Hwa Wang1,2, Han-Pin Kuo1,2*

1 Department of Thoracic Medicine, Chang Gung Foundation, Chang Gung Memorial Hospital, Taoyuan,
Taiwan, 2 College of Medicine, Chang Gung University, Taoyuan, Taiwan, 3 Division of Thoracic and
Cardiovascular Surgery, Chang Gung Memorial Hospital, Chia-Yi, Taiwan

‡ Contributed equally to this work with: Yueh-Fu Fang, Meng-Heng Hsieh.
* [email protected]

Abstract

Objectives
Aspiration of the lower airways due to foreign body is rare in adults. This study aimed to de-
termine the outcome of patients who received flexible bronchoscopy with different modali-
ties for foreign body removal in the lower airways.

Patients and Methods
Between January 2003 and January 2014, 94 patients diagnosed with foreign body in the
lower airways underwent flexible bronchoscopy with different modalities, which included for-
ceps, loop, basket, knife, electromagnet, and cryotherapy. The clinical presentation, foreign
body location and characteristics, and applications of flexible bronchoscopy were analyzed.

Results
Forty (43%) patients had acute aspiration, which developed within one week of foreign body
entry and 54 (57%) had chronic aspiration. The most common foreign bodies were teeth or
bone. More patients with chronic aspiration than those with acute aspiration were referred
from the out-patient clinic (48% vs. 28%), but more patients with acute aspiration were re-
ferred from the emergency room (35% vs. 6%) and intensive care unit (18% vs. 2%). Flexi-
ble bronchoscopy with different modalities was used to remove the foreign bodies (85/94,
90%). Electromagnet or cryotherapy was used in nine patients to eliminate the surrounding
granulation tissue before foreign body removal. In the nine patients with failed flexible bron-
choscopy, eight underwent rigid bronchoscopy instead and one had right lower lung lobec-
tomy for lung abscess.

PLOS ONE | DOI:10.1371/journal.pone.0118993 March 13, 2015 1 / 9

OPEN ACCESS

Citation: Fang Y-F, Hsieh M-H, Chung F-T, Huang Y-
K, Chen G-Y, Lin S-M, et al. (2015) Flexible
Bronchoscopy with Multiple Modalities for Foreign
Body Removal in Adults. PLoS ONE 10(3):
e0118993. doi:10.1371/journal.pone.0118993

Academic Editor: Jeffrey A. Gold, Oregon Health
and Science University, UNITED STATES

Received: June 24, 2014

Accepted: January 8, 2015

Published: March 13, 2015

Copyright: © 2015 Fang et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, w

journal.publications.chestnet.org 739

A Randomized Trial of 1% vs 2% Lignocaine by the
Spray-as-You-Go Technique for Topical Anesthesia
During Flexible Bronchoscopy
Harpreet Kaur , MSc ; Sahajal Dhooria , MD , DM ; Ashutosh N. Aggarwal , MD , DM , FCCP ; Dheeraj Gupta , MD , DM , FCCP ;
Digambar Behera , MD , FCCP ; and Ritesh Agarwal , MD , DM , FCCP

BACKGROUND: Th e optimal concentration of lignocaine to be used during fl exible bronchos-
copy (FB) remains unknown. Th is randomized controlled trial compared the effi cacy and
safety of 1% and 2% lignocaine solution for topical anesthesia during FB.
METHODS: Consecutive patients were randomized to receive either 1% or 2% lignocaine solu-
tion through the bronchoscope by the “spray-as-you-go” technique. Th e primary outcome of
the study was the assessment of cough by the operator and the patient using the visual analog
scale (VAS) and pain assessment using the faces pain rating scale. Th e secondary outcomes
included total lignocaine dose, oxygenation status, adverse reactions related to lignocaine, and
others.
RESULTS: Five hundred patients were randomized (median age, 51 years; 71% men) 1:1 to
either group. Th e median operator VAS score for cough was signifi cantly higher (25 vs 21,
P 5 .015) in the 1% group; however, the patient VAS score was not significantly different
(32 vs 27, P 5 .065). Th e pain rating was similar between the two groups. Th e median cumulative
dose of lignocaine was signifi cantly higher in the 2% group (397 mg vs 312 mg, P 5 .0001;
7.1 mg/kg vs 5.7 mg/kg, P 5 .0001). About 28% of patients in the 2% group exceeded the maxi-
mum recommended dose ( . 8.2 mg/kg) of lignocaine. No adverse event related to lignocaine
overdose was seen in either group.
CONCLUSIONS: One percent lignocaine was found to be as eff ective as 2% solution for topical
anesthesia during FB, albeit at a signifi cantly lower dose as the latter. Th us, 1% lignocaine
should be the preferred concentration for topical anesthesia during FB.
TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01955824; URL: www.clinicaltrials.gov
CHEST 2015; 148 ( 3 ): 739 – 745

[ Original Research Pulmonary Procedures ]

Manuscript received January 5, 2015; revision accepted March 2, 2015;
originally published Online First March 26, 2015.
ABBREVIATIONS: EBB 5 endobronchial biopsy; FB 5 flexible bron-
choscopy; RCT 5 randomized controlled trial; TBLB 5 transbronchial
lung biopsy; TBNA 5 transbronchial needle aspiration; VAS 5 visual
analog scale
AFFILIATIONS: From the Department of Pulmonary Medicine, Post-
graduate Institute of Medical Education and Research, Chandigarh, India.
FUNDING/SUPPORT: The authors have reported to CHEST that no
funding was received for this study.

CORR

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for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).

International Journal of COPD 2017:12 177–187

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O R I G I N A L R E S E A R C H

open access to scientific and medical research

Open Access Full Text Article

http://dx.doi.org/10.2147/COPD.S119575

Flexible bronchoscopy with moderate sedation
in COPD: a case–control study

Peter Grendelmeier
Michael Tamm
Kathleen Jahn
Eric Pflimlin
Daiana Stolz
Clinic of Pulmonary Medicine
and Respiratory Cell Research,
University Hospital Basel,
Petersgraben, Basel, Switzerland

Background: Flexible bronchoscopy is increasingly used for diagnostic and therapeutic
purposes. We aimed to examine the safety of flexible bronchoscopy with moderate sedation
in patients with COPD.
Methods: This study is a prospective, longitudinal, case–control, single-center study including
1,400 consecutive patients. After clinical and lung function assessments, patients were dichoto-
mized in COPD or non-COPD groups. The primary end point was the combined incidence of
complications.
Results: The incidence of complications was similar in patients with and without COPD and
independent of forced expiratory volume in the first second % predicted. Patients with COPD
more frequently required insertion of a naso- or oropharyngeal airway; however, this differ-
ence was no longer significant after adjustment for age, gender, and duration of the procedure.
Hypotension was significantly more common among patients with COPD. The number of epi-
sodes of hypoxemia �90% did not differ between the groups. However, patients with COPD
had a lower mean and nadir transcutaneous oxygen saturation. Transcutaneous carbon dioxide
tension (PtcCO

2
) change over the time course was similar in both groups, but both peak PtcCO

2

and time on PtcCO
2
�45 mmHg were higher in the COPD group. There were no differences

in patient-reported outcomes.
Conclusion: The safety of flexible bronchoscopy is similar in patients with and without COPD.
This finding confirms the suitability of the procedure for both clinical and research indications.
Keywords: bronchoalveolar lavage, propofol, complication,

Propofol sedation for flexible
bronchoscopy: a randomised,
noninferiority trial

Peter Grendelmeier, Michael Tamm, Eric Pflimlin and Daiana Stolz

Affiliation:
Clinic of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Basel, Switzerland.

Correspondence:
D. Stolz, Clinic of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Petersgraben
4, 4031 Basel, Switzerland.
E-mail: [email protected]

ABSTRACT Propofol has been established as a reliable method for sedation in flexible bronchoscopy.

There are no data comparing propofol administered as intravenous boluses versus continuous infusion.

702 consecutive patients undergoing flexible bronchoscopy were randomly allocated to receive

intravenous propofol using either an intermittent bolus technique or a continuous infusion. The primary

end-point was the number of adverse events assessed at the end of flexible bronchoscopy and at 24 h.

The number of any adverse event was similar in both randomised groups (219 versus 211, p50.810).

There were complications in eight cases (seven major bleedings, one respiratory failure). As compared with

the bolus group, the amount of propofol required was significantly higher in the infusion group (226

¡147 mg versus 308¡204.8 mg, p,0.0001). In a multivariate regression model, this difference remained

significant independent of the duration and the interventions performed during the procedure. The

duration of bronchoscopy was significantly longer in the infusion group (median 14 (interquartile range

9–24) versus 17 (12–27) min, p,0.0001).

Propofol continuous infusion is as safe as bolus administration; however, it is associated with higher

propofol requirements and a longer duration of the bronchoscopy.

@ERSpublications

Propofol continuous infusion is as safe as bolus administration, but has higher requirements and
longer bronchoscopy http://ow.ly/r4Uas

Received: Dec 12 2012 | Accepted after revision: July 02 2013 | First published online: July 30 2013

Clinical trial: This study is registered at www.controlled-trials.com with identifier number ISRCTN66129676.

Support statement: D. Stolz was supported by grants from the Swiss National Foundation (PP00P3_128412/1).
Additional funding was provided by the Clinic of Pulmonary Medicine and Respiratory Cell Research, University
Hospital Basel, Basel, Switzerland.

Conflict of interest: None declared.

Copyright �ERS 2014

ORIGINAL ARTICLE
BRONCHOSCOPY

Eur Respir J 2014; 43: 591–601 | DOI: 10.1183/09031936.00200412 591

www.controlled-t

ORIGINAL ARTICLE

Target-controlled versus fractionated propofol sedation in flexible
bronchoscopy: A randomized noninferiority trial

DANIEL FRANZEN, DANIEL J. BRATTON, CHRISTIAN F. CLARENBACH, LUTZ FREITAG AND MALCOLM KOHLER

1Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland

ABSTRACT

Background and objective: Fractionated propofol
administration (FPA) in flexible bronchoscopy (FB)
may lead to oversedation and an increased risk of
adverse events, because a stable plasma concentration
of propofol is not maintainable. The purpose of this
randomized noninferiority trial was to evaluate whether
target-controlled infusion (TCI) of propofol is non-
inferior to FPA in terms of safety in FB.
Methods: Coprimary outcomes were the mean lowest
arterial oxygen saturation (SpO2) during FB and the
number of propofol dose adjustments in relation to
procedure duration. Secondary outcomes were the
number of occasions with SpO2 < 90% and/or oxygen
desaturations of >4% from baseline, number of
occasions with systolic blood pressure < 90 mm Hg,
cough frequency, cumulative propofol dose, recovery
time, maximum transcutaneous CO2, mean SpO2 and
O2 delivery during FB.
Results: Seventy-seven patients were included. TCI was
noninferior to FPA in terms of mean (standard deviation)
lowest SpO2 during the procedure (88.3% (5.4%) vs 86.9%
(7.3%)) and required fewer dose adjustments (0.04/min
vs 0.28/min, P< 0.001) but a higher cumulative propofol
dose (264 vs 194mg, P= 0.003). All other secondary
outcomes were comparable between the groups.
Conclusion: We suggest that TCI of propofol is a
favourable sedation technique for FB with equal safety
issues and fewer dose adjustments compared with FPA.

Clinical trial registration: NCT02246023 at ClinicalTrials.gov

Key words: flexible bronchoscopy, propofol, sedation.

Abbreviations: ASA, American Society of Anesthesiology; BAL,
bronchoalveolar lavage; BMI, body mass index; CI, confidence
interval; CV, collateral ventilation; EBUS, endobronchial ultrasound;
FB, flexible bronchoscopy; FPA, fractionated propofol administration;
GFR, glomerular filtration rate; NAAP, nonanaesthesiologist adminis-
tration of propofol; SBP, systolic blood pressure; SD, standard
deviation; SpO2, oxygen saturation; TBNA, transbronchial needle
aspiration; TCI, target-controlled infusion; tcpCO2, transcutaneous
carbon dioxide pressure value.

INTRODUCTION

Nonanaesthesiologist administration of propofol (NAAP)
has been shown to be a feasible and safe sedation
method for flexible bronchoscopy (FB).1,2 In daily
clinical practice, propofol sedation is given manually
in repeated doses (fractionated) by a specially trained
nurse in attendance of the bronchoscopist. However,
fractionated propofol administration (FPA) may lead
to oversedation and an increased risk of side effects
(i.e. oxygen desaturation or arter

7

Alpha-1-Antitrypsin Deficiency: Emphysema Without Smoking.

Christin Nott

Table of Contents

Introduction……………………………………………………3

History……………………………………………………………………………3

Alpha-1-antitrypsin therapies………………………………….4

Risk factors of acquiring emphysema………………………….6

Knowledge in the medical community…………………………7

Medical treatments for emphysema……………………………9

Summary………………………………………………………………………..14

References cited…………………………………………………………..15

INTRODUCTION

Alpha-1-Antitrypsin Deficiency (AATD) is a devastating genetic disease that literally steals the breath away from people, silently destroying lung tissue, then revealing itself in the prime of one’s life, leaving that person unable to do anything about what has already been lost. Although smoking is the usual cause of emphysema, AATD can also cause emphysema, and not only can it cause emphysema without a prior smoking history, it does so in people in their 30’s and 40’s rather than in later life. One would think that something this significant would require knowledge in the medical community so that steps could be taken to prevent the destruction, but there has not been a great deal of research on this issue until recently. Even now, many respiratory therapists are unaware of what AATD is, what causes it, and what it means to care