Safety and Efficacy of Ketamine Sedation for Infant Flexible Fiberoptic Bronchoscopy

doi:10.1378/chest.125.3.1132

Chest

Volume 125, Issue 3, March 2004, Pages 1132-1137

https://doi.org/10.1378/chest.125.3.1132 Get rights and content

Objective

To describe our experience with ketamine sedation during infant flexible fiberoptic bronchoscopy.

Design

Retrospective chart review. Infants were sedated with midazolam and ketamine with or without fentanyl. The sedation regimen, final procedure performed, procedure duration, and complications were recorded. Complication rates between infants ≤ 6 months or > 6 months of age and between infants with upper vs lower airway symptoms were compared by χ² test with a contingency table.

Results

Fifty-nine procedures were performed in 55 patients aged 6.1 ± 3.1 months (mean ± SD). Sedation was achieved with ketamine and midazolam (n = 30) or ketamine, midazolam, and fentanyl (n = 29). Bronchoscopy with BAL was performed in 44 patients and bronchoscopy alone in 3 patients. In 11 patients, severe upper airway obstruction and/or anomalies prevented subglottic passage of the bronchoscope. One patient could not be adequately sedated. There were no major complications. Minor complications occurred in 14 patients (23.7%), most commonly mild hypoxemia (n = 9). Brief central apnea developed in three patients. Complication rates were unaffected by age or indication for bronchoscopy.

Conclusions

Infant flexible fiberoptic bronchoscopy can be safely and effectively performed using ketamine sedation. Complications, especially mild hypoxemia, appear more common in infants, likely due to smaller airway diameter. Regardless of the sedative(s) used, additional vigilance is required when performing bronchoscopy in this population.

Section snippets

Bronchoscopy

This retrospective study was approved by the Institutional Review Board of the University of Missouri Health Sciences Center. All infants (< 1 year of age) who received ketamine during sedation for flexible fiberoptic bronchoscopy between June 1999 and December 2002 were reviewed. Patients in whom bronchoscopic evaluation occurred during endotracheal intubation and/or mechanical ventilation were excluded. All bronchoscopies were performed in the pediatric ICU by a pediatric pulmonologist with

Results

Fifty-nine sedations were performed on 55 patients during the study period. Patient characteristics are summarized in Table 1. Indications for bronchoscopy included chronic wheeze (n = 27), stridor (n = 22), cystic fibrosis microbiological surveillance (n = 9), chronic cough (n = 7), hemoptysis (n = 1), recurrent pneumonia (n = 1), and unexplained hypoxemia (n = 1). In some patients, multiple indications were present so the total number of indications exceeds the total number of procedures.

Discussion

The value of flexible fiberoptic bronchoscopy in the pediatric patient is well recognized,¹²³⁴ particularly in the younger patient where the common indications for bronchoscopy (eg, “noisy breathing,” chronic wheeze) are more likely to be associated with abnormal findings.²³⁴ While most authors¹²³⁴⁵⁶⁷ acknowledge the need for appropriate sedation during bronchoscopy in this population, few data exist regarding the effectiveness and safety of specific sedative agents or sedation regimens,

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This likely would have made intubation more challenging, especially in the setting of severe bleeding [12]. Ketamine was used due to familiarity with the drug and its relative safety profile. [6,13,14]. There was no premedication for secretions, though preparations were made to manage them with glycopyrrolate and bedside equipment [13,14].
Epistaxis is a routine complaint in Emergency Medicine and presents most commonly in adults and children and its incidence increases with age. It is rare in infants and neonates. We discuss a case of epistaxis in a four-month-old male who presented to a critical access hospital. What initially appeared to be routine brisk epistaxis was later discovered to be a large, complex, epiglottic hemangioma. The patient was stabilized using topical tranexamic acid, nasal packing with ketamine sedation, and sent to a tertiary care center for definitive management. He required advanced airway management in the OR for definitive airway management for airway-obstructing hemangioma excision.
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A few studies have compared combinations of anesthetic agents and their effects on the upper airway. Berkenbosch et al. [57] reported on 55 infants undergoing flexible fiberoptic bronchoscopy with ketamine/midazolam with or without fentanyl and showed that infants tolerated this regimen well but with mild hypoxemia in 9 of 59 procedures (15%) [57]. In a different study, Berkenbosch et al. [58] reported that propofol/remifentanil can be used safely in children undergoing flexible fiberoptic bronchoscopy without causing hypoxemia but 5 of 15 (33%) required low-dose ketamine boluses to augment sedation.
To determine the best anesthetic technique for DISE based on a retrospective review of the current literature and to highlight research gaps that should be addressed in future studies.
A comprehensive retrospective review of the literature on anesthetic regimens for pediatric DISE through March 2020 was performed. Specific medical subject heading (MesH) terms included: drug-induced sleep endoscopy and anesthesia, DISE, child, obstructive sleep apnea, sleep disordered breathing.
Twelve articles were included. One study was a retrospective comparative study while the remaining 11 were case series. Five studies described anesthetic technique for DISE pre-T&A, two post-T&A, and four both pre- and post-T&A. The heterogeneity of the studies did not allow for a meta-analysis. A total of 1110 children ages 2 months to 19 years were included. Sedation depth and anesthetic outcomes with DISE were infrequently described. Eleven studies used a sevoflurane inhalational induction and mostly transitioned to a total IV anesthetic for maintenance. Propofol was the most commonly used sole anesthetic. A total of three studies used a combination of remifentanil and propofol, one used dexmedetomidine alone, one used sevoflurane alone, and one compared different regimens. Dexmedetomidine and ketamine have the most favorable profile for pediatric DISE but are not universally used. DISE completion, as reported in two studies, was 93% and 100%.
There are several anesthetic regimens for DISE that achieve good sedation and outcomes. The combination of ketamine and dexmedetomidine may be the ideal regimen. Limited data and lack of protocols/high-quality studies exist on anesthetic regimens for pediatric DISE.
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Higher doses of ketamine directly reduce cardiac contractility and can precipitate cardiovascular collapse especially in those with catecholamine depletion.2,5,18,19 Ketamine preserves respiratory drive, but increases respiratory secretions.20,21 Ketamine may increase intracranial pressure (ICP), and its administration in patients with elevated ICP is controversial.2,22,23
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It has previously been thought that young age (eg, <6 months) was a contraindication to the use of ketamine. However, a recent study indicates that ketamine is safe and effective even in neonates.43 Ketamine is probably the sedative of choice for asthmatic patients for many reasons.
Rapid sequence intubation is the process involving administration of a sedative (eg, induction agent) followed almost immediately by a neuromuscular blocking agent to facilitate endotracheal intubation The purpose of emergency RSI is to make emergent intubation easier and safer, thereby increasing the success rate of intubation while decreasing the complications. Possible disadvantages are complications from the additional drugs, prolonged intubation with hypoxia, and precipitating an emergent or crash airway. Controversy has arisen regarding various steps in RSI; however, RSI remains the standard of care in emergency medicine airway management.
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BronchoscopySafety and Efficacy of Ketamine Sedation for Infant Flexible Fiberoptic Bronchoscopy

Objective

Design

Results

Conclusions

Section snippets

Bronchoscopy

Results

Discussion

Pediatr Clin North Am

Ann Emerg Med

Br J Anaesth

Chest

Ann Emerg Med

Flexible fiberoptic bronchoscopy and laryngoscopy in infants and children

Laryngoscope

Yield from flexible bronchoscopy in children

Pediatr Pulmonol

Use of the paediatric bronchoscope, flexible and rigid, in 51 European countries

Eur Respir J

Ketamine for bronchoscopy of children

South Med J

Sedation and anesthesia for pediatric bronchoscopy

Curr Opin Pediatr

Amnestic agents in pediatric bronchoscopy

Chest

Bronchoscopy
Safety and Efficacy of Ketamine Sedation for Infant Flexible Fiberoptic Bronchoscopy