The results of a questionnaire survey, of the current preparation for and practice of diagnostic bronchoscopy in England and Wales, are reported in this paper. The British Thoracic Society (BTS) has recently published guidelines on bronchoscopy and these provide a consensus statement on the current evidence base. There is no specific guidance on drugs or techniques, although it is recommended that all patients should be offered sedation, except where there are contraindications.In the present survey, there was a response rate of 76% (344 responses to 452 questionnaires) and the median number of bronchoscopies performed per session was 5 (interquartile range 4-6). Most operators use lignocaine gel to the nose (65%), spray to the throat (70%), followed by the "spray as you go" method (84%), recommended by the BTS. Atropine is routinely used by 13% contrary to the guidelines and despite concerns about its side-effects. Most operators use sedation with midazolam (85%) or a wide variety of combinations of sedative, analgesic, and anaesthetic agents (27%), and 27% perform unsedated bronchoscopies, with only 0.1% routinely performing unsedated bronchoscopies. A total 251 (77%) responders stated they assessed adequacy of sedation, with most using patient observation alone (149 (46%)). Only three operators assessed sedation using a formal sedation score. Thus, most centres routinely perform sedated bronchoscopies and the systematic level of monitoring is poor.The current controversies about sedation and safe sedation practice are discussed. There is a need for more evidence to allow more specific guidance to be produced in this difficult area. Eur Respir J 2003; 22: 203-206 The bronchoscopic technique is not standardised and the ideal preparation for diagnostic bronchoscopy is not known. The current British Thoracic Society (BTS) guidelines [1] provide a consensus statement on the current evidence base without specific guidance on drugs or techniques and without defining methods of sedation. The guidelines recommend offering sedation to all undergoing diagnostic flexible fibreoptic bronchoscopy, except where there are contraindications [1]. The aim is to achieve good patient tolerance, comfort and cooperation whilst reducing complications. The issues of sedation are controversial. If a centre has experience of performing unsedated diagnostic flexible fibreoptic bronchoscopy, it is reported that patient cooperation is not improved with sedation [2]. Furthermore there is worrying evidence that insufficient monitoring of sedated patients occurs, potentially placing patients at risk [3]. One-half of deaths reported are related to sedation [4]. It is unclear what constitutes optimum sedation. A Report by an Intercollegiate Working Party suggests safety measures for sedation undertaken by an operator who is not anaesthetics-trained (table 1) [5]. As bronchoscopy may be performed safely without sedation, when it is used there is emphasis on its safe administration.In this survey, the authors aimed to obtain a "snap sh...

Two cases of pseudoexfoliation of the lens capsule are presented in which unilateral shallowing of the anterior chamber caused an acute rise in intraocular pressure. Both patients were elderly women. In one case anterior chamber shallowing was precipitated by administration of pilocarpine and the second followed central retinal vein occlusion. We suggest that pseudoexfoliation of the lens capsule weakened the zonule allowing forward shift to the lens and secondary angle closure.

Subconjunctival injection of 2% lignocaine at the 12 o'clock position was used as the local anaesthetic in 19 eyes undergoing a primary trabeculectomy for open angle glaucoma. The appearance of the bleb and mean post-operative intraocular pressure (IOP) were compared with those in 29 eyes with the same diagnosis undergoing trabeculectomy under general anaesthesia by the same surgeons over the same time period. The two groups of eyes were similar with regard to treatment with beta blockers (p > 0.1), miotics (p > 0.25), sympathomimetics (p > 0.25), carbonic anhydrase inhibitors (p > 0.5), or no treatment (p > 0.25). Seventy-seven per cent of the local anaesthetic group and 25% of the general anaesthetic group developed avascular, thin-walled drainage blebs (p < 0.001). The mean post-operative IOP was significantly lower in the group receiving local anaesthetic (p < 0.001). The reasons for and significance of these observations are discussed, and the merits and disadvantages of thin-walled blebs are evaluated.

No abstract