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Clayton T. Cowl, MD, FCCP
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From the Mayo Clinic.

Correspondence to: Clayton T. Cowl, MD, FCCP, Mayo Clinic, 200 First St SW, Baldwin 5A, Rochester, MN 55905; e-mail: cowl.clayton@mayo.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(5):1277-1278. doi:10.1378/chest.10-1574
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To the Editor:

Dr Apiliogullari and colleagues express concerns about the design of two studies in CHEST (July 2000 and August 2009) that compared the use of antisialogogic agents as pretreatment strategies for adult bronchoscopy,1,2 citing that midazolam used concurrently for sedation can confound results because midazolam itself can also result in a reduction in secretions (as shown in their own recent study of a small cohort of pediatric patients [N = 40] who underwent measured simulated salivary flow rates).3 Unfortunately, they seem to have missed the entire point of the prior discussion.4

The clinical question hinges on whether the use of antisialogogic agents such as atropine or glycopyrrolate is necessary prior to adult bronchoscopy to increase patient tolerance of the procedure or improve visualization of the airway anatomy. The use of these drugs adds cost to each procedure and, in some cases, can actually result in unnecessary, untoward side effects. It has been known for years that midazolam can, by itself or in combination with other sedative-analgesic agents, have some minor antisialogogic properties.5,6 The study by Apiliogullari et al3 further bolsters the argument that if there is indeed an antisialogogic effect from the use of midazolam, then the use of other secretion-reducing agents is clearly not needed. A clinically significant result in the initial randomized trials would have meant that the use of antisialogogic drugs provides a clear benefit to the bronchoscopist and patient in terms of the ability to inspect the airway and improves the overall comfort of the procedure above and beyond that provided without their use. That was not determined in those studies, even after randomization of > 1,000 patients between the two trials. Although Apiliogullari and colleagues3 should be congratulated for their efforts in quantitating salivary flow rates, that result does not alter the fact that the use of antisialogogues is unnecessary prior to routine adult bronchoscopy and does not ultimately affect the measured clinical endpoints, as outlined in the original randomized trials.

Cowl CT, Prakash UBS, Kruger BR. The role of anticholinergics in bronchoscopy: a randomized clinical trial. Chest. 2000;1181:188-192. [CrossRef] [PubMed]
 
Malik JA, Gupta D, Agarwal AN, Jindal SK. Anticholinergic premedication for flexible bronchoscopy: a randomized, double-blind, placebo-controlled study of atropine and glycopyrrolate. Chest. 2009;1362:347-354. [CrossRef] [PubMed]
 
Apiliogullari S, Sener Y, Can S, Yegin Y, Tosun G, Selin JB. Effect of midazolam on salivary flow rate in children. J Selcuk U Dent Fac. 2010;192:3-7
 
Cowl CT. Use of antisialogogues in bronchoscopy. Chest. 2010;1373:738. [CrossRef] [PubMed]
 
Morse Z, Sano K, Kanri T. Decreased intraoral secretions during sedation-analgesia with propofol-ketamine and midazolam-ketamine combinations. J Anesth. 2001;154:197-200. [CrossRef] [PubMed]
 
Saarnivaara L, Lindgren L, Klemola UM. Comparison of chloral hydrate and midazolam by mouth as premedicants in children undergoing otolaryngological surgery. Br J Anaesth. 1988;614:390-396. [CrossRef] [PubMed]
 

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References

Cowl CT, Prakash UBS, Kruger BR. The role of anticholinergics in bronchoscopy: a randomized clinical trial. Chest. 2000;1181:188-192. [CrossRef] [PubMed]
 
Malik JA, Gupta D, Agarwal AN, Jindal SK. Anticholinergic premedication for flexible bronchoscopy: a randomized, double-blind, placebo-controlled study of atropine and glycopyrrolate. Chest. 2009;1362:347-354. [CrossRef] [PubMed]
 
Apiliogullari S, Sener Y, Can S, Yegin Y, Tosun G, Selin JB. Effect of midazolam on salivary flow rate in children. J Selcuk U Dent Fac. 2010;192:3-7
 
Cowl CT. Use of antisialogogues in bronchoscopy. Chest. 2010;1373:738. [CrossRef] [PubMed]
 
Morse Z, Sano K, Kanri T. Decreased intraoral secretions during sedation-analgesia with propofol-ketamine and midazolam-ketamine combinations. J Anesth. 2001;154:197-200. [CrossRef] [PubMed]
 
Saarnivaara L, Lindgren L, Klemola UM. Comparison of chloral hydrate and midazolam by mouth as premedicants in children undergoing otolaryngological surgery. Br J Anaesth. 1988;614:390-396. [CrossRef] [PubMed]
 
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