Skip to main content
SpringerLink
Log in

Hypoventilation patterns during bronchoscopic sedation and their clinical relevance based on capnographic and respiratory impedance analysis

  • Original Research
  • Published:
Journal of Clinical Monitoring and Computing Aims and scope Submit manuscript

Abstract

Capnography involves the measurement of end-tidal CO2 (EtCO2) values to detect hypoventilation in patients undergoing sedation. In a previous study, we reported that initiating a flexible bronchoscopy (FB) examination only after detecting signs of hypoventilation could reduce the risk of hypoxemia without compromising the tolerance of the patient for this type of intervention. We hypothesize that hypoventilation status could be determined with greater precision by combining thoracic impedance-based respiratory signals, RESP, and EtCO2 signals obtained from a nasal-oral cannula. Retrospective analysis was conducted on RESP and EtCO2 waveforms obtained from patients during the induction of sedation using propofol for bronchoscopic examination in a previous study. EtCO2 waveforms associated with hypoventilation were then compared with RESP patterns, patient variables, and sedation outcomes. Signals suitable for analysis were obtained from 44 subjects, 42 of whom presented indications of hypoventilation, as determined by EtCO2 waveforms. Two subtypes of hypoventilation were identified by RESP: central-predominant (n = 22, flat line RESP pattern) and non-central-predominant (n = 20, RESP pattern indicative of respiratory effort with upper airway collapse). Compared to cases of non-central-predominant hypoventilation, those presenting central-predominant hypoventilation during induction were associated with a lower propofol dose (40.2 ± 18.3 vs. 60.8 ± 26.1 mg, p = 0.009), a lower effect site concentration of propofol (2.02 ± 0.33 vs. 2.38 ± 0.44 µg/ml, p = 0.01), more rapid induction (146.1 ± 105.5 vs. 260.9 ± 156.2 s, p = 0.01), and lower total propofol dosage (96.6 ± 41.7 vs. 130.6 ± 53.4 mg, p = 0.04). Hypoventilation status (as revealed by EtCO2 levels) could be further classified by RESP into central-predominant or non-central-predominant types. It appears that patients with central-predominant hypoventilation are more sensitive to propofol during the induction of sedation. RESP values could be used to tailor sedation management specifically to individual patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Gaisl T, Bratton DJ, Heuss LT, Kohler M, Schlatzer C, Zalunardo MP, Frey M, Franzen D. Sedation during bronchoscopy: data from a nationwide sedation and monitoring survey. BMC Pulm Med. 2016;16(1):113. https://doi.org/10.1186/s12890-016-0275-4.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Jose RJ, Shaefi S, Navani N. Sedation for flexible bronchoscopy: current and emerging evidence. Eur Respir Rev. 2013;22(128):106–16. https://doi.org/10.1183/09059180.00006412.

    Article  PubMed  Google Scholar 

  3. Wahidi MM, Jain P, Jantz M, Lee P, Mackensen GB, Barbour SY, Lamb C, Silvestri GA. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest. 2011;140(5):1342–50. https://doi.org/10.1378/chest.10-3361.

    Article  CAS  PubMed  Google Scholar 

  4. Sheahan CG, Mathews DM. Monitoring and delivery of sedation. Br J Anaesth. 2014;113(Suppl 2):ii37–47. https://doi.org/10.1093/bja/aeu378.

    Article  PubMed  Google Scholar 

  5. Hinkelbein J, Lamperti M, Akeson J, Santos J, Costa J, De Robertis E, Longrois D, Novak-Jankovic V, Petrini F, Struys M, Veyckemans F, Fuchs-Buder T, Fitzgerald R. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol. 2018;35(1):6–24. https://doi.org/10.1097/EJA.0000000000000683.

    Article  PubMed  Google Scholar 

  6. Force ASoAT. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004–17.

    Article  Google Scholar 

  7. Lo YL, Lin TY, Fang YF, Wang TY, Chen HC, Chou CL, Chung FT, Kuo CH, Feng PH, Liu CY, Kuo HP. Feasibility of bispectral index-guided propofol infusion for flexible bronchoscopy sedation: a randomized controlled trial. PLoS ONE. 2011;6(11):e27769. https://doi.org/10.1371/journal.pone.0027769.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Lin TY, Lo YL, Hsieh CH, Ni YL, Wang TY, Lin HC, Wang CH, Yu CT, Kuo HP. The potential regimen of target-controlled infusion of propofol in flexible bronchoscopy sedation: a randomized controlled trial. PLoS ONE. 2013;8(4):e62744. https://doi.org/10.1371/journal.pone.0062744.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Clark G, Licker M, Younossian AB, Soccal PM, Frey JG, Rochat T, Diaper J, Bridevaux PO, Tschopp JM. Titrated sedation with propofol or midazolam for flexible bronchoscopy: a randomised trial. Eur Respir J. 2009;34(6):1277–83. https://doi.org/10.1183/09031936.00142108.

    Article  CAS  PubMed  Google Scholar 

  10. Worsnop C, Kay A, Pierce R, Kim Y, Trinder J. Activity of respiratory pump and upper airway muscles during sleep onset. J Appl Physiol. 1998;85(3):908–20.

    Article  CAS  Google Scholar 

  11. Brown EN, Lydic R, Schiff ND. General anesthesia, sleep, and coma. N Engl J Med. 2010;363(27):2638–50. https://doi.org/10.1056/NEJMra0808281.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Lo YL, Ni YL, Wang TY, Lin TY, Li HY, White DP, Lin JR, Kuo HP. Bispectral index in evaluating effects of sedation depth on drug-induced sleep endoscopy. J Clin Sleep Med. 2015;11(9):1011–20. https://doi.org/10.5664/jcsm.5016.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Eastwood PR, Platt PR, Shepherd K, Maddison K, Hillman DR. Collapsibility of the upper airway at different concentrations of propofol anesthesia. Anesthesiology. 2005;103(3):470–7.

    Article  CAS  Google Scholar 

  14. Lin T-Y, Fang Y-F, Huang S-H, Wang T-Y, Kuo C-H, Wu H-T, Kuo H-P, Lo Y-L. Capnography monitoring the hypoventilation during the induction of bronchoscopic sedation: a randomized controlled trial. Sci Rep. 2017;7(1):8685. https://doi.org/10.1038/s41598-017-09082-8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. (1996) Heart rate variability: standards of measurement, physiological interpretation and clinical use. Circulation. 93(5):1043–1065.

    Article  Google Scholar 

  16. Daubechies I, Lu J, Wu H-T. Synchrosqueezed wavelet transforms: an empirical mode decomposition-like tool. Appl Comput Harmonic Anal. 2011;30(2):243–61. https://doi.org/10.1016/j.acha.2010.08.002.

    Article  Google Scholar 

  17. Tang Y, Turner MJ, Baker AB. Effects of lung time constant, gas analyser delay and rise time on measurements of respiratory dead-space. Physiol Meas. 2005;26(6):1103–14. https://doi.org/10.1088/0967-3334/26/6/019.

    Article  PubMed  Google Scholar 

  18. Proctor DN, Beck KC. Delay time adjustments to minimize errors in breath-by-breath measurement of Vo2 during exercise. J Appl Physiol (1985). 1996;81(6):2495–9. https://doi.org/10.1152/jappl.1996.81.6.2495.

    Article  CAS  Google Scholar 

  19. Lichtenbelt BJ, Mertens M, Vuyk J. Strategies to optimise propofol-opioid anaesthesia. Clin Pharmacokinet. 2004;43(9):577–93.

    Article  CAS  Google Scholar 

  20. Lysakowski C, Dumont L, Pellegrini M, Clergue F, Tassonyi E. Effects of fentanyl, alfentanil, remifentanil and sufentanil on loss of consciousness and bispectral index during propofol induction of anaesthesia. Br J Anaesth. 2001;86(4):523–7.

    Article  CAS  Google Scholar 

  21. Mertens MJ, Olofsen E, Burm AG, Bovill JG, Vuyk J. Mixed-effects modeling of the influence of alfentanil on propofol pharmacokinetics. Anesthesiology. 2004;100(4):795–805.

    Article  CAS  Google Scholar 

  22. Murphy M, Bruno MA, Riedner BA, Boveroux P, Noirhomme Q, Landsness EC, Brichant JF, Phillips C, Massimini M, Laureys S, Tononi G, Boly M. Propofol anesthesia and sleep: a high-density EEG study. Sleep. 2011;34(3):283–91A.

    Article  Google Scholar 

  23. Hillman DR, Walsh JH, Maddison KJ, Platt PR, Kirkness JP, Noffsinger WJ, Eastwood PR. Evolution of changes in upper airway collapsibility during slow induction of anesthesia with propofol. Anesthesiology. 2009;111(1):63–71. https://doi.org/10.1097/ALN.0b013e3181a7ec68.

    Article  CAS  PubMed  Google Scholar 

  24. Dahan A, Teppema LJ. Influence of anaesthesia and analgesia on the control of breathing. Br J Anaesth. 2003;91(1):40–9.

    Article  CAS  Google Scholar 

  25. Krauss B, Hess DR. Capnography for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2007;50(2):172–81. https://doi.org/10.1016/j.annemergmed.2006.10.016.

    Article  PubMed  Google Scholar 

  26. Nagler J, Krauss B. Capnography: a valuable tool for airway management. Emerg Med Clin N Am. 2008;26(4):881–97. https://doi.org/10.1016/j.emc.2008.08.005.

    Article  Google Scholar 

  27. Kodali BS. Capnography outside the operating rooms. Anesthesiology. 2013;118(1):192–201. https://doi.org/10.1097/ALN.0b013e318278c8b6.

    Article  PubMed  Google Scholar 

  28. Iohom G, Ni Chonghaile M, O’Brien JK, Cunningham AJ, Fitzgerald DF, Shields DC. An investigation of potential genetic determinants of propofol requirements and recovery from anaesthesia. Eur J Anaesthesiol. 2007;24(11):912–9. https://doi.org/10.1017/S0265021507000476.

    Article  CAS  PubMed  Google Scholar 

  29. Mikstacki A, Zakerska-Banaszak O, Skrzypczak-Zielinska M, Tamowicz B, Prendecki M, Dorszewska J, Molinska-Glura M, Waszak M, Slomski R. The effect of UGT1A9, CYP2B6 and CYP2C9 genes polymorphism on individual differences in propofol pharmacokinetics among Polish patients undergoing general anaesthesia. J Appl Genet. 2017;58(2):213–20. https://doi.org/10.1007/s13353-016-0373-2.

    Article  CAS  PubMed  Google Scholar 

  30. Taylor MB, Grounds RM, Mulrooney PD, Morgan M. Ventilatory effects of propofol during induction of anaesthesia. Comparison with thiopentone. Anaesthesia. 1986;41(8):816–20.

    Article  CAS  Google Scholar 

  31. Bailey PL, Streisand JB, East KA, East TD, Isern S, Hansen TW, Posthuma EF, Rozendaal FW, Pace NL, Stanley TH. Differences in magnitude and duration of opioid-induced respiratory depression and analgesia with fentanyl and sufentanil. Anesth Analg. 1990;70(1):8–15.

    Article  CAS  Google Scholar 

  32. Wilkinson JN, Thanawala VU. Thoracic impedance monitoring of respiratory rate during sedation—is it safe? Anaesthesia. 2009;64(4):455–6. https://doi.org/10.1111/j.1365-2044.2009.05908.x.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

This study was supported by Chang-Gung Memorial Hospital (Grant No. CMRPG3E2241).

Author information

Authors and Affiliations

  1. Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, 199 Tun-Hwa N. Rd., Taipei, Taiwan

    Yu-Lun Lo, Han-Pin Kuo & Ting-Yu Lin

  2. Department of Mathematics and Department of Statistical Science, Duke University, Durham, NC, USA

    Hau-Tieng Wu

  3. Mathematics Division, National Center for Theoretical Sciences, Taipei, Taiwan

    Hau-Tieng Wu

  4. Department of Anesthesiology, Taipei-Veterans General Hospital, Taipei, Taiwan

    Yu-Ting Lin

Authors
  1. Yu-Lun Lo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hau-Tieng Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yu-Ting Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Han-Pin Kuo
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ting-Yu Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ting-Yu Lin.

Ethics declarations

Conflict of interest

We declare no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lo, YL., Wu, HT., Lin, YT. et al. Hypoventilation patterns during bronchoscopic sedation and their clinical relevance based on capnographic and respiratory impedance analysis. J Clin Monit Comput 34, 171–179 (2020). https://doi.org/10.1007/s10877-019-00269-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10877-019-00269-0

Keywords

Search

Navigation