Remifentanil Target Controlled Infusion Versus Standard of Care for Conscious Sedation During US-guided Transbronchial Needle Aspiration (EBUS-TBNA): a Randomized, Prospective, Control Study

BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has gained major relevance in diagnosis lung cancer and staging of mediastinal lymph nodes (LN). Adequate sedation is an important part of the procedure since it improves patient's comfort and tolerance potentially positively affecting the diagnostic yield. It is also considered a standard of care for patients undergoing fiberoptic bronchoscopy unless specifically contraindicated.

The choice of the different level of sedation (from conscious to moderate to deep sedation) has always been challenging and, to date, no standardized practice exists. Deep sedation may be preferred in those cases where additional procedures such as placement of endobronchial stents, are required, or in order to make the procedure more suitable by limiting the patients motion. In remaining cases, conscious sedation allows to complain with the clinical demand without affecting respiratory and cardiovascular function, decreasing the cough reflex and maintaining sufficient swallowing capacity.

Not appropriate sedation can have serious complications, including respiratory depression or even arrest, hypoxia and/or hypercapnia, and cardiovascular and neurological side effects.

Commonly used drugs for sedation include propofol and a combination of benzodiazepines and opioids. However, achieving the ideal level of sedation can be challenging, since it may occasionally lead to over sedation, with detrimental effects. These risks are even greater if the patients present with lung disease, obesity, or heart disease. Conversely, under sedation can result in discomfort for the patient and challenging procedure it for the healthcare provider. Furthermore, benzodiazepines and medium-long-acting opioids continue their effect even after the procedure is finished, thus lasting the negative effects of these drugs over the time of the procedure.

In a recent case series, Scarlata and colleagues have provided a preliminary evidence of a TCI remifentanil protocol safety and effectiveness, providing an ideal and performant condition for bronchoscopists and a satisfactory comfort for patients.