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Javid Ahmad Malik, MD; Dheeraj Gupta, MD, FCCP; Ashutosh N. Agarwal, MD; Surinder K. Jindal, MD, FCCP
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From the Department of Pulmonary and Critical Care Medicine, Postgraduate Institute of Medical Education and Research.


Financial/nonfinancial disclosures: The authors have 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 (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(3):738-739. doi:10.1378/chest.09-2734
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To the Editor:

We thank Dr Cowl for his interest in our article recently published in CHEST (August 2009).1 Anticholinergic premedication continues to be used during bronchoscopy at many centers despite no clear evidence of benefit and potential for harm. Therefore, we felt the need to more clearly investigate the role of such medication. Inevitably, our study had to have several similarities in design with some previous studies in this regard, including one by Cowl et al.2 However, as acknowledged by Dr Cowl, our study involved a larger number of patients from a different population, which increases the generalizability of conclusions on the subject matter. In addition, we investigated the differences in the main outcome measures after adjusting for potentially confounding variables, which was not done in the earlier studies.

Although, as pointed out by Dr Cowl, a prior power calculation was not performed in our study, this limitation would be unlikely to have affected the conclusions drawn from the study. We observed that in unadjusted comparisons there was a borderline-significant difference in the bronchoscopist-assessed airway secretions between patients receiving anticholinergic premedication and those receiving placebo. However, after adjusting for age, sex, smoking history, bronchoscopic biopsy, procedure time, operator experience, and baseline hemodynamic variables and oxygen saturation, the use of anticholinergic premedication was associated with significantly lower airway secretions as reported by the bronchoscopist. Because excessive airway secretions are rarely encountered at bronchoscopy,3 the antisecretory effects of atropine-like drugs might not have been appreciated in the earlier studies, given their limitations in sample size and failure to account for confounding factors. The absence of excessive airway secretions at bronchoscopy, even without antisecretory premedication, might also explain why such premedication may not be associated with clear clinical benefit to the patient in terms of reduction in cough, patient discomfort, development of oxygen desaturation, or time taken for bronchoscopy. In summary, the comments by Dr Cowl that antisecretory drugs prior to bronchoscopy are not beneficial and actually could be harmful in some patients and that the routine use of anticholinergic premedication during bronchoscopy should be abandoned are well supported by evidence, including that from the current study.

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]
 
Cowl CT, Prakash UBS, Kruger BR. The role of anticholinergics in bronchoscopy. A randomized clinical trial. Chest. 2000;1181:188-192. [CrossRef] [PubMed]
 
Makker H, Kishen R, O’Driscoll R. Atropine as premedication for bronchoscopy. Lancet. 1995;3458951:724-725. [CrossRef] [PubMed]
 

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References

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]
 
Cowl CT, Prakash UBS, Kruger BR. The role of anticholinergics in bronchoscopy. A randomized clinical trial. Chest. 2000;1181:188-192. [CrossRef] [PubMed]
 
Makker H, Kishen R, O’Driscoll R. Atropine as premedication for bronchoscopy. Lancet. 1995;3458951:724-725. [CrossRef] [PubMed]
 
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