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Michael A. Jantz, MD, FCCP
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From the Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida.

Correspondence to: Michael A. Jantz, MD, FCCP, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, 1600 SW Archer Rd, Box 100225, Gainesville, FL 32610-0225; e-mail: Michael.Jantz@medicine.ufl.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 (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(6):1490-1491. doi:10.1378/chest.10-0549
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To the Editor:

I appreciate the comments provided by Drs Mönkemüller and Zimmermann regarding my editorial in CHEST (January 2009).1 I agree that propofol, in general, is an ultra-short-acting sedative-hypnotic agent. My statement was intended to emphasize that fospropofol is a sedative-hypnotic agent with different characteristics from propofol and, in addition, is not a general anesthetic, as opposed to stating that propofol is classified only as a general anesthetic. I believe that there is some perception, however, that propofol is a general anesthetic despite its being used for moderate and deep sedation as well as general anesthesia. Many pharmacology and anesthesia textbooks place propofol in the section on intravenous anesthetics.

I would agree that there is a growing body of evidence that propofol-assisted sedation during various GI endoscopic procedures is safe and efficacious. As noted in the study by Rex et al,2 which was cited by Drs. Mönkemüller and Zimmermann, a total of 569,220 cases of endoscopist-directed propofol sedation were indentified from various institutions worldwide. The overall number of cases requiring bag-valve-mask ventilation was 489 (0.1%) and 11 cases required intubation. The American Association for the Study of Liver Diseases, the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy recently published a joint position statement on the use of non-anesthesiologist-administered propofol for GI endoscopy.3

There is also a growing body of evidence that propofol sedation for bronchoscopy is safe and efficacious. In one recent study, 84 patients were randomized in a double-blind fashion to propofol or midazolam. Patients were assessed with bispectral index (BIS) monitoring and the Observer Assessment of Alertness/Sedation score. Recovery of neuropsychiatric capacities was evaluated with a computer-generated continuous performance test (CPT). The EEG recovery time (BIS value > 90) was shorter in the propofol group. At 60 min, the reaction time and incorrect responses on the CPT were lower in the propofol group. Rating of the procedure by the patients at 60 min was better in the propofol group for global tolerance, pain, nausea, and breathlessness, but not cough. At 24 h, only global tolerance was significant. The number of desaturations was similar for each group. Two patients in the midazolam group required ventilatory support.4

In another recent study, 80 patients were randomly assigned to four groups: (1) topical lidocaine only, (2) propofol with topical lidocaine, (3) alfentanil with topical lidocaine, and (4) midazolam with topical lidocaine.5 Patients were evaluated using a composite score of side effects such as coughing, bronchospasm, hypoxemia, respiratory depression, agitation, level of consciousness, nausea, arrhythmia, and hypotension. The propofol group demonstrated the lowest composite score. Cough was less severe in patients receiving propofol or alfentanil. No differences in development of hypoxemia were observed. In a third recent study, 200 patients were randomized to propofol or a combination of hydrocodone and midazolam.6 The number of saturations ≤ 90% was equal for both groups. In terms of readiness for discharge, at 1 h after the procedure, 16 patients in the combined group were unable to answer any questions, compared with one patient in the propofol group. At 2 h after the procedure, eight patients in the combined group and one patient in the propofol group were unable to speak because of sedation. Cough scores as assessed by the bronchoscopist were similar between the two groups, whereas cough scores rated by the patients were lower in the combined group. The use of nurse-administered propofol sedation for bronchoscopy was also described recently.7 Propofol was administered by nurses who had completed a training protocol. After 1 to 2 mg of midazolam and 25 to 50 μg of fentanyl, patients were given a 20- to 40-mg bolus of propofol, followed by 10- to 20-mg boluses as needed to maintain sedation. In a retrospective analysis of 498 procedures, transient hypoxemia occurred in 3.8%, respiratory failure in 0.8%, and hypotension in 1.0% of procedures. Other older studies comparing propofol to midazolam have noted similar efficacy and safety between the two, with faster recovery, as assessed by psychometric and motor testing, with propofol.8,9

I agree with Drs. Mönkemüller and Zimmermann that any physician performing moderate or deep sedation, whether it is with propofol/fospropofol or benzodiazepines and opioids, should be trained in the pharmacology of sedative drugs, airway management, and advanced life support. I would strongly agree with their statement that pulmonologists have an advantage over GI endoscopists in terms of handling upper airway obstruction, respiratory depression, and hypoxemia. Based on the fact that the vast majority of pulmonologists are able to manage the airway, perform intubation if necessary, and manage hypotension, as well as on data from currently published studies, I have previously stated my belief that fospropofol can be used safely by pulmonologists for moderate sedation during bronchoscopic procedures without the need for anesthesiologist administration. I would agree with Drs. Mönkemüller and Zimmermann in extending this statement to include propofol.

Jantz MA. The old and the new of sedation for bronchoscopy. Chest. 2009;1351:4-6. [CrossRef] [PubMed]
 
Rex DK, Deenadayalu VP, Eid E, et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology. 2009;1374:1229-1237. [CrossRef] [PubMed]
 
Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Am J Gastroenterol. 2009;10412:2886-2892. [CrossRef] [PubMed]
 
Clark G, Licker M, Younossian AB, et al. Titrated sedation with propofol or midazolam for flexible bronchoscopy: a randomised trial. Eur Respir J. 2009;346:1277-1283. [CrossRef] [PubMed]
 
Leite AG, Xavier RG, da Silva Moreira J, et al. Anesthesia in flexible bronchoscopy: randomized clinical trial comparing the use of topical lidocaine alone or in association with propofol, alfentanil, or midazolam. J Bronchol. 2008;154:233-239. [CrossRef]
 
Stolz D, Kurer G, Meyer A, et al. Propofol versus combined sedation in flexible bronchoscopy: a randomised non-inferiority trial. Eur Respir J. 2009;345:1024-1030. [CrossRef] [PubMed]
 
Bosslet GT, Devito ML, Lahm T, Sheski FD, Mathur PN. Nurse-administered propofol sedation: feasibility and safety in bronchoscopy. Respiration. 2010;794:315-321. [CrossRef] [PubMed]
 
Clarkson K, Power CK, O’Connell F, Pathmakanthan S, Burke CM. A comparative evaluation of propofol and midazolam as sedative agents in fiberoptic bronchoscopy. Chest. 1993;1044:1029-1031. [CrossRef] [PubMed]
 
Crawford M, Pollock J, Anderson K, Glavin RJ, MacIntyre D, Vernon D. Comparison of midazolam with propofol for sedation in outpatient bronchoscopy. Br J Anaesth. 1993;704:419-422. [CrossRef] [PubMed]
 

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References

Jantz MA. The old and the new of sedation for bronchoscopy. Chest. 2009;1351:4-6. [CrossRef] [PubMed]
 
Rex DK, Deenadayalu VP, Eid E, et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology. 2009;1374:1229-1237. [CrossRef] [PubMed]
 
Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Am J Gastroenterol. 2009;10412:2886-2892. [CrossRef] [PubMed]
 
Clark G, Licker M, Younossian AB, et al. Titrated sedation with propofol or midazolam for flexible bronchoscopy: a randomised trial. Eur Respir J. 2009;346:1277-1283. [CrossRef] [PubMed]
 
Leite AG, Xavier RG, da Silva Moreira J, et al. Anesthesia in flexible bronchoscopy: randomized clinical trial comparing the use of topical lidocaine alone or in association with propofol, alfentanil, or midazolam. J Bronchol. 2008;154:233-239. [CrossRef]
 
Stolz D, Kurer G, Meyer A, et al. Propofol versus combined sedation in flexible bronchoscopy: a randomised non-inferiority trial. Eur Respir J. 2009;345:1024-1030. [CrossRef] [PubMed]
 
Bosslet GT, Devito ML, Lahm T, Sheski FD, Mathur PN. Nurse-administered propofol sedation: feasibility and safety in bronchoscopy. Respiration. 2010;794:315-321. [CrossRef] [PubMed]
 
Clarkson K, Power CK, O’Connell F, Pathmakanthan S, Burke CM. A comparative evaluation of propofol and midazolam as sedative agents in fiberoptic bronchoscopy. Chest. 1993;1044:1029-1031. [CrossRef] [PubMed]
 
Crawford M, Pollock J, Anderson K, Glavin RJ, MacIntyre D, Vernon D. Comparison of midazolam with propofol for sedation in outpatient bronchoscopy. Br J Anaesth. 1993;704:419-422. [CrossRef] [PubMed]
 
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