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A Survey of Current Bronchoscopy Practices in Canada
© 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.11-1040
References 1. Mainardi T, Kapoor S, Bielory L. Complementary and alternative medicine: herbs, phytochemicals and vitamins and their immunologic effects. J Allergy Clin Immunol. 2009;123(2):283-294. 2. Goodwin J, McIvor RA. Alternative therapy: cupping for asthma. Chest. 2011;139(2):475-476. 3. Aaron SD, Vandemheen KL, Boulet LP, et al; Canadian Respiratory Clinical Research Consortium. Overdiagnosis of asthma in obese and nonobese adults. CMAJ. 2008;179(11):1121-1131. 4. Joyce DP, Jackevicius C, Chapman KR, McIvor RA, Kesten S. The placebo effect in asthma drug therapy trials: a meta-analysis. J Asthma. 2000;37(4):303-318.
A Survey of Current Bronchoscopy Practices in Canada A Dearth of Evidence or Evidence-Based Practice? To the Editor: Several surveys have previously described technical data on the practice of bronchoscopy in the United States, including a 39-question survey by the American College of Chest Physicians in 19911 and an 84-question survey by the American Association of Bronchology in 2000.2 We designed an analogous 64-question survey to provide unique Canadian data on similar variables of bronchoscopy practice and recently mailed it to all members of the Canadian Thoracic Society, with a response rate of approximately 40% (in contrast to response rates of 51% and 30% in the aforementioned American surveys, respectively). Our results are somewhat discomfiting, with striking variability in practice seen across multiple technical components of bronchoscopy; we present several such salient findings here. Although evidence is somewhat limited, the American College of Chest Physicians3 recommends only 4 h of “nothing by mouth” prebronchoscopy time. In contrast, only 45% of our respondents felt comfortable performing a bronchoscopy 4 h after the last liquid was ingested and 20% 4 h after the last solid. Such restricted practice necessarily incurs both logistical and financial costs, as well as unnecessary diagnostic and therapeutic delays. While the use of topical analgesia in the upper airway by application of lidocaine gargles, sprays, and pledgets was reported universally in our survey, the use of alternative topicalizing modalities was more provocative. In fact, 40% of our respondents reported using transtracheal lidocaine injection, and 65% reported using nebulized lidocaine at least some of the time, despite very limited evidence in support of either practice.4,5 Premedication using anticholinergic drugs previously has been performed under the pretext of reducing airway secretions, cough, bronchoconstriction, and vagal phenomena, although more recent recommendations have discouraged their use because of the negligible evidence of benefit and possible harm.6 Nevertheless, 53% of respondents in our survey reported the use of anticholinergic premedication at least some of the time, and 17% reported frequent or routine use. For IV sedation, a much more narrow range of procedural sedatives was reported in our survey than in the US studies cited www.chestpubs.org
previously, with fentanyl and midazolam used most frequently by far. Of note, the powerful anesthetic propofol has now emerged as an option in procedural sedation since those US studies (with use reported by 8% of our respondents); however, only 20% of our respondents reported receiving any training in the safe use of procedural sedation. Whereas observational studies have shown no benefit to the use of fluoroscopic guidance for transbronchial lung biopsy in diffuse parenchymal lung disease,7 68% of our respondents reported using it at least some of the time. Further, 67% of our respondents reported the routine use of chest radiography following transbronchial lung biopsy, despite available evidence showing that postprocedural films are indicated only in patients who are symptomatic.8 Given the well established and growing role of bronchoscopy in both diagnosis and therapy of multiple pulmonary pathologies, our data offer some important commentary. Although our survey provides the first Canadian data of its kind, to our knowledge, the wide variability in technical practices shown here is consistent with the US studies cited previously and with other studies. The general consensus appears to be that evidence is often weak or lacking for many routine aspects of bronchoscopy practice, yet when present, it is often disregarded. Cameron W. Pierce, MD, FCCP John A. Gjevre, MD, FCCP Regina M. Taylor-Gjevre, MD Saskatoon, SK, Canada Affiliations: From the Division of Respirology, Critical Care, and Sleep Medicine, Department of Medicine (Drs Pierce and Gjevre), and the Department of Medicine (Dr Taylor-Gjevre), University of Saskatchewan. 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. Correspondence to: Cameron W. Pierce, MD, FCCP, 5th Floor Ellis Hall, Royal University Hospital, 103 Hospital Dr, Saskatoon, SK,S7N 0W8, Canada; e-mail: [email protected]. © 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.11-0994
Acknowledgments Other contributions: Approval for this study was granted by the Behavioural Research Ethics Board at the University of Saskatchewan [Beh # 08-194].
References 1. Prakash UBS, Offord KP, Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest. 1991;100(6):1668-1675. 2. Colt HG, Prakash UBS, Offord KP. Bronchoscopy in North America: survey by the American Association of Bronchology, 1999. J Bronchol. 2000;7(1):8-25. 3. Ernst A, Silvestri GA, Johnstone D; American College of Chest Physicians. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest. 2003; 123(5):1693-1717. 4. Graham DR, Hay JG, Clague J, Nisar M, Earis JE. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Chest. 1992;102(3):704-707. 5. Stolz D, Chhajed PN, Leuppi J, Pflimlin E, Tamm M. Nebulized lidocaine for flexible bronchoscopy: a randomized, CHEST / 140 / 3 / SEPTEMBER, 2011
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 7, 2011 © 2011 American College of Chest Physicians
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double-blind, placebo-controlled trial. Chest. 2005;128(3): 1756-1760. 6. Malik JA, Gupta D, Agarwal AN, Jindal SK. Anticholinergic premedication for flexible bronchoscopy: a randomized, doubleblind, placebo-controlled study of atropine and glycopyrrolate. Chest. 2009;136(2):347-354.
7. Anders GT, Johnson JE, Bush BA, Matthews JI. Transbronchial biopsy without fluoroscopy. a seven-year perspective. Chest. 1988;94(3):557-560. 8. Izbicki G, Shitrit D, Yarmolovsky A, et al. Is routine chest radiography after transbronchial biopsy necessary? A prospective study of 350 cases. Chest. 2006;129(6):1561-1564.
834
Correspondence
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 7, 2011 © 2011 American College of Chest Physicians
References 1. Mainardi T, Kapoor S, Bielory L. Complementary and alternative medicine: herbs, phytochemicals and vitamins and their immunologic effects. J Allergy Clin Immunol. 2009;123(2):283-294. 2. Goodwin J, McIvor RA. Alternative therapy: cupping for asthma. Chest. 2011;139(2):475-476. 3. Aaron SD, Vandemheen KL, Boulet LP, et al; Canadian Respiratory Clinical Research Consortium. Overdiagnosis of asthma in obese and nonobese adults. CMAJ. 2008;179(11):1121-1131. 4. Joyce DP, Jackevicius C, Chapman KR, McIvor RA, Kesten S. The placebo effect in asthma drug therapy trials: a meta-analysis. J Asthma. 2000;37(4):303-318.
A Survey of Current Bronchoscopy Practices in Canada A Dearth of Evidence or Evidence-Based Practice? To the Editor: Several surveys have previously described technical data on the practice of bronchoscopy in the United States, including a 39-question survey by the American College of Chest Physicians in 19911 and an 84-question survey by the American Association of Bronchology in 2000.2 We designed an analogous 64-question survey to provide unique Canadian data on similar variables of bronchoscopy practice and recently mailed it to all members of the Canadian Thoracic Society, with a response rate of approximately 40% (in contrast to response rates of 51% and 30% in the aforementioned American surveys, respectively). Our results are somewhat discomfiting, with striking variability in practice seen across multiple technical components of bronchoscopy; we present several such salient findings here. Although evidence is somewhat limited, the American College of Chest Physicians3 recommends only 4 h of “nothing by mouth” prebronchoscopy time. In contrast, only 45% of our respondents felt comfortable performing a bronchoscopy 4 h after the last liquid was ingested and 20% 4 h after the last solid. Such restricted practice necessarily incurs both logistical and financial costs, as well as unnecessary diagnostic and therapeutic delays. While the use of topical analgesia in the upper airway by application of lidocaine gargles, sprays, and pledgets was reported universally in our survey, the use of alternative topicalizing modalities was more provocative. In fact, 40% of our respondents reported using transtracheal lidocaine injection, and 65% reported using nebulized lidocaine at least some of the time, despite very limited evidence in support of either practice.4,5 Premedication using anticholinergic drugs previously has been performed under the pretext of reducing airway secretions, cough, bronchoconstriction, and vagal phenomena, although more recent recommendations have discouraged their use because of the negligible evidence of benefit and possible harm.6 Nevertheless, 53% of respondents in our survey reported the use of anticholinergic premedication at least some of the time, and 17% reported frequent or routine use. For IV sedation, a much more narrow range of procedural sedatives was reported in our survey than in the US studies cited www.chestpubs.org
previously, with fentanyl and midazolam used most frequently by far. Of note, the powerful anesthetic propofol has now emerged as an option in procedural sedation since those US studies (with use reported by 8% of our respondents); however, only 20% of our respondents reported receiving any training in the safe use of procedural sedation. Whereas observational studies have shown no benefit to the use of fluoroscopic guidance for transbronchial lung biopsy in diffuse parenchymal lung disease,7 68% of our respondents reported using it at least some of the time. Further, 67% of our respondents reported the routine use of chest radiography following transbronchial lung biopsy, despite available evidence showing that postprocedural films are indicated only in patients who are symptomatic.8 Given the well established and growing role of bronchoscopy in both diagnosis and therapy of multiple pulmonary pathologies, our data offer some important commentary. Although our survey provides the first Canadian data of its kind, to our knowledge, the wide variability in technical practices shown here is consistent with the US studies cited previously and with other studies. The general consensus appears to be that evidence is often weak or lacking for many routine aspects of bronchoscopy practice, yet when present, it is often disregarded. Cameron W. Pierce, MD, FCCP John A. Gjevre, MD, FCCP Regina M. Taylor-Gjevre, MD Saskatoon, SK, Canada Affiliations: From the Division of Respirology, Critical Care, and Sleep Medicine, Department of Medicine (Drs Pierce and Gjevre), and the Department of Medicine (Dr Taylor-Gjevre), University of Saskatchewan. 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. Correspondence to: Cameron W. Pierce, MD, FCCP, 5th Floor Ellis Hall, Royal University Hospital, 103 Hospital Dr, Saskatoon, SK,S7N 0W8, Canada; e-mail: [email protected]. © 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.11-0994
Acknowledgments Other contributions: Approval for this study was granted by the Behavioural Research Ethics Board at the University of Saskatchewan [Beh # 08-194].
References 1. Prakash UBS, Offord KP, Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest. 1991;100(6):1668-1675. 2. Colt HG, Prakash UBS, Offord KP. Bronchoscopy in North America: survey by the American Association of Bronchology, 1999. J Bronchol. 2000;7(1):8-25. 3. Ernst A, Silvestri GA, Johnstone D; American College of Chest Physicians. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest. 2003; 123(5):1693-1717. 4. Graham DR, Hay JG, Clague J, Nisar M, Earis JE. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Chest. 1992;102(3):704-707. 5. Stolz D, Chhajed PN, Leuppi J, Pflimlin E, Tamm M. Nebulized lidocaine for flexible bronchoscopy: a randomized, CHEST / 140 / 3 / SEPTEMBER, 2011
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 7, 2011 © 2011 American College of Chest Physicians
833
double-blind, placebo-controlled trial. Chest. 2005;128(3): 1756-1760. 6. Malik JA, Gupta D, Agarwal AN, Jindal SK. Anticholinergic premedication for flexible bronchoscopy: a randomized, doubleblind, placebo-controlled study of atropine and glycopyrrolate. Chest. 2009;136(2):347-354.
7. Anders GT, Johnson JE, Bush BA, Matthews JI. Transbronchial biopsy without fluoroscopy. a seven-year perspective. Chest. 1988;94(3):557-560. 8. Izbicki G, Shitrit D, Yarmolovsky A, et al. Is routine chest radiography after transbronchial biopsy necessary? A prospective study of 350 cases. Chest. 2006;129(6):1561-1564.
834
Correspondence
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 7, 2011 © 2011 American College of Chest Physicians