Analysis of factors affecting patient comfort during fiberoptic bronchoscopy and endobronchial ultrasonography

Fiberoptic bronchoscopy (FOB) and endobronchial ultrasonography (EBUS) are among the widely used techniques in diagnosis and treatment of lung diseases. Most of the patients however, report discomfort after their FOB and EBUS sessions and due to their unpleasant experience, they even refuse a subsequent session. In this work, which took place between April 2011 and April 2012, we investigated the factors which effect the comfort of patients who receive diagnostic fiberoptic bronchoscopy and diagnostic endobronchial ultrasonography for the first time. We recorded the demographics, smoking histories, additional diseases, prior medication usage, symptoms, premedication, the anesthesia applied during the procedure, the experience of the operator, the insertion technique of the bronchoscope, bronchoscopic operations, the duration of the sessions and the anxiety levels of the patients before the session. Following the procedure, patients were inquired for their anxiety levels and their willingness for subsequent sessions. The study is conducted among 250 patients between 21 to 87 years old, 174 (69.6 %) of whom were male and 76 (30.4 %) of whom were female. They were 56.48±13.68 years old on the average. FOB and EBUS group patients were 56.2±13.9 and 57.8±12.1 years old on the average respectively. No relationship between the patients? age and their levels of discomfort during the procedure was detected.We recorded discomfort in 77.6 and 63.6 percent of the cases in the FOB and EBUS groups respectively. The main complaint for both groups were coughing which occured in 75.7 percent of the cases in the FOB group and in 61.1 cases in the EBUS group. We attributed the frequent coughing to disuse of antitussive drugs.The median discomfort levels were 40.0 VAS for FOB sessions and 27.5 VAS for EBUS sessions. We credited the high discomfort levels in FOB sessions to the larger number of operations involved in a FOB session and to the less stimulant effect of EBUS-TBNA compared to BAL, TBB and PB.We found that the the rate of discomfort during the operation was statistically significantly high in the TBNA applied patients of the FOB group.For the EBUS group the administration of midazolam did not effect the discomfort levels of the patients. The patients who experienced greater unease in the FOB group were administered with high dosages of midazolam and their cooperation and comfort did not increase due to it. We attributed this to the fact that, in the EBUS group midazolam was routinely used whereas in the FOB group it was administered only to the relatively more anxious patients before the operation and compared to the EBUS group patients FOB group patients were subject to more operations involving insertion.The 81.3 percent of the FOB cases were conducted by less experienced bronchoscopists while the rest were performed by those with more experience. All of the 36 cases of EBUS were performed by experienced bronchoscopists. The experience of the operator had no effect on the comfort of the patient. This result is attributed to the following. First, less experienced bronchoscopists had trained theoretically and practically on fiberoptic bronchoscopy applications from the very beginning of their education. Second, while the less experienced bronchoscopists were on duty, an attending experienced colleague was always present who inspected the process and observed the possible complicationsThe average anxiety level of the FOB group patients was found to be 52.7±3.4 VAS, whereas that of EBUS group patients was 38.3±32.8 VAS. For both groups, it is observed that the anxiety levels prior to the procedure were significantly higher for the patients who were highly uncomfortable during the process. Moreover we found that the anxiety level prior to the procedure was an independent risk factor which increased the level of discomfort during the procedure.We noticed that as the number and type of operations involved in the bronchoscopy increased, the level of unease felt by the patients grew considerably. For the FOB group patients who received TBB and BAL the level of discomfort during the procedure was detected to be significantly high. The feeling of suffocation was considerably higher for the patients of the FOB group who received bronchial biopsy compared to those who did not. Similarly in the FOB group, the discomfort due to the coughing and the feeling of suffocation was significantly more for the patients who received TBB with respect to those who did not. The operations of the procedure did not effect the discomfort levels of the patients of the EBUS group. In the EBUS group when the patients received TBNA with BL, the level of discomfort felt by the patients increased though not statistically significantly.The additional diseases and the medication history of the patients prior to the procedure had no significant effect on the levels of discomfort. This was true for both FOB and EBUS groups. The fact that the level of discomfort was found to be significantly higher for the EBUS group patients who were on antihypertensive medication is attributed to that these patients were administered with a vasoconstricitive agent (cold saline,lidocaine and adrenaline) in order to control bleeding, resulting elevation of aspiration and the longer procedural time.For the patients who felt low levels discomfort in the FOB group, the average time of procedure was 22.1±10.3 minutes. This figure was measured as 26.3±10.4 minutes for the patients who felt high levels of discomfort. This difference was found to be considerably large. Although the procedural time was longer for the patients of EBUS group with higher level of discomfort, the difference from that of the other patients in the group was not deemed significant.The 8.8 percent of the operations were conducted orally and 91.2 percent was performed nasally in the FOB group. All of the EBUS group operations were performed orally. For the FOB group, the nasal insertion was found to be an independent risk factor that the increased the level of discomfort. We attributed this result to the fact that there were few patients in the FOB group who received oral insertion.In the FOB group it was the women who felt more discomfort. We connected this to the fact that the female patients felt more anxious before the procedure. In the EBUS group no difference was detected betweeen the levels of discomfort experienced by females and males.The percentages of willingness for a subsequent procedure were determined to be 69.6 and 86.1 for FOB and EBUS groups respectively. In both groups, the numbers of positive responses regarding a repetition of the procedure were significantly higher from those patients who felt less discomfort.As a result, for FOB group, level of discomfort increases as the procedural time grows, when insertion is performed nasally, as the number of sample collections increases and if the patients have high level of anxiety before the procedure. The frequency of discomfort is higher among female patients.In the EBUS group, as the level of anxiety of the patients prior to the procedure gets higher, the level of discomfort during the procedure increases. However the willingness of the patients of this group for another session of the procedure is more.In this study we found that as the level of the discomfort lessens, the affirmatory feelings of the patients towards a repetition of the procedure elevates