Experiences of Patients Who Have Undergone Bronchoscopy With ‘Cautious’ Sedation and Analgesia

Background

Bronchoscopy is a procedure that is used to investigate and treat respiratory conditions and disease. Sedation and analgesia are administered during the procedure to reduce the side effects of discomfort and cough. The use of sedation and analgesia is cautioned in patients with chronic obstructive pulmonary disease (a high-risk respiratory disease), due to the perceived increased risk of complications. A review of the associated literature examining adult patients’ experiences during flexible bronchoscopy found no qualitative articles on the subject. Due to the numerous quantitative survey-based studies, a significant gap in the literature was identified; that of the patient experience during bronchoscopy.

Aim

The overarching aim of this research was to investigate the experiences of patients undergoing bronchoscopy with sedation and analgesia. This investigation was conducted in two parts: i) a systematic review of the associated literature and ii) a qualitative study involving patients with high-risk respiratory disease. The aim of the systematic review of patient experiences during bronchoscopy with sedation and analgesia was to provide a synthesis of current information on the subject, highlight best practices in the field, and identify gaps in the literature. A qualitative study was then conducted to investigate patients' experiences during bronchoscopy with ‘cautious’ sedation and analgesia. The aim of this study was to understand the lived experience of patients with high-risk respiratory disease who have undergone bronchoscopy.

Methods

A systematic literature review, based on Cochrane methodology, was undertaken to identify randomised controlled trials involving adult patients who had undergone fibreoptic bronchoscopy with or without sedation. Eight databases were searched (CINAHL, MEDLINE Complete, Cochrane, PubMed, Web of Science, EMBASE, PsycINFO, and Scopus. Two reviewers independently screened titles and abstracts of the resultant database searches. Studies were excluded if they did not include outcome measures that assessed the patient experience of the procedure. After screening was completed, two independent reviewers then assessed the included studies for quality and extracted the relevant data. Any discrepancies between reviewers were then assessed by a third independent reviewer.

The qualitative interview study was performed using a phenomenological approach, based on the descriptive and interpretive writings of van Manen (1990, 1997). Participants (n = 13) were interviewed twice using unstructured interviews; the first, two hours post-procedure and the second, 1–7 days post-procedure. Interviews were transcribed and then analysed using hermeneutic phenomenological reflection (van Manen, 1990). The principal intention of hermeneutic phenomenological research is to uncover, examine and reflect upon the lived experience.

Results

The systematic review identified 19 studies for inclusion. Cochrane’s risk-of-bias tool was implemented to identify evidence-based methodological features that are known to increase the risk of bias in trials. In a number of studies, assessing for risk of bias was problematic due to the number of unclear descriptions of the study methodology, particularly in aspects of sequence generation, allocation concealment, and blinding. It should be noted that blinding was not always an option, due to physical differences of interventions for treatment and control arms of the included studies. Further, selective outcome reporting bias was indeterminable as study protocols were rarely available. Self-reported patient outcomes included pain, comfort, cough, satisfaction, memory of the test, breathlessness, asphyxiation, fear, distress, global tolerance, nausea, dreaming, secretions, worst moment of the experience, and willingness to repeat the procedure. Data from five studies were published with limited findings represented in bar graphs, and only one study author responded to requests for further data. In all studies, data were collected via survey using closed-ended questions. Patients were mostly asked to rate outcomes of the procedure on various scales, otherwise they were asked dichotomous questions (yes/no responses) to determine the existence of any procedural outcomes. Results were published as means (with standard deviations) or median scores with or without score ranges.

In the interview study, themes were identified that included fears such as the participants may have lung cancer or the procedure would be distressing. Some participants were fully aware during the procedure, which included negative experiences of choking and coughing. For several, this was quite traumatic. Some participants were unaware during the procedure. Post-procedure participants commonly reported experiences of sore throat, cough and aggravation of asthma. However, most participants accepted the negative aspects of their experience, regarding them as a necessary evil in order to obtain a diagnosis for their respiratory condition. The care and expertise of the bronchoscopy staff, as perceived by the participants, helped to offset some of their fears.

Conclusions

The eligible studies in the literature review showed that the risk of bias was more likely to be low in most areas except selective outcome reporting. The risk of bias was more likely to be unclear in relation to selective outcome reporting due to the general lack of published study protocols. Overall, when comparing the participants’ experiences of pain, coughing and willingness to repeat the procedure, the studies identified that greater amounts of sedation and/or analgesia resulted in subjects reporting fewer negative outcomes. A meta-analysis was not conducted due to the heterogeneity between studies, namely the varied manner in which results were published and the lack of consistency of the outcome measures that were reported.

The qualitative interview study showed that many participants who underwent bronchoscopy with cautious sedation experienced awareness during the procedure. Whilst the degree of participants’ awareness was variable, more often than not awareness resulted in a negative patient experience. This was, for the most part, due to the discomfort of the procedure and to the participants’ contextual fears and concerns about their diagnosis. A number of recommendations have been made to help manage the patient experience. The use of effective communication strategies by healthcare workers throughout the peri-bronchoscopy procedure could elicit patient fears and aid in resolving these fears. Provision of educational material that informs the patient about what to expect from the procedure and how it might make them feel may reduce their fears of the procedure as hurtful. In addition, medical management of common patient experiences may reduce the extent of these experiences. In conclusion, although the use of deeper sedation might ameliorate much of the negative patient experience, this must always be balanced against their risk of respiratory complications.