Impact of Moderate Sedation versus Monitored Anesthesia Care on Outcomes and Cost of Endobronchial Ultrasound Transbronchial Needle Aspiration

Abstract

Background and Objectives. The ideal type of sedation for endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is not known. Two previous studies comparing the diagnostic yield between moderate sedation (MS) and deep sedation/general anesthesia (DS/GA) had provided conflicting results with one study clearly favoring the latter. No study had addressed cost. This is concerning for pulmonologists without routine access to anesthesia services. Our objective was to assess the impact of MS and Monitored Anesthesia Care (sedation administered and monitored by an anesthesiologist) on the outcomes and cost of EBUS-TBNA. Materials and Methods. We performed a retrospective review of prospectively collected data on consecutive EBUS-TBNA performed under two different types of sedation in a single academic center. A diagnostic TBNA was defined as an aspirate yielding any specific diagnosis or if subsequent surgery or follow-up of nondiagnostic/normal aspirates showed no pathology. Current Medicare time-based allowances were used for professional charges calculation. Results. There was no difference observed between MS and MAC in regards of the diagnostic yield (92.9% versus 91.9%), procedure duration, number, location, and size of lymph node (LN) sampled, but there were more passes per LN with MAC. The average charges were 74.30 USD for MS and 319.91 for MAC. There were more hypotensive and desaturations episodes with MAC but none required escalation of care. Conclusions. When performed under MS, EBUS-TBNA has similar diagnostic yield as under MAC but may be associated with less side effects. The difference in sedation cost is modest; however, an additional 245$ for each EBUS done under MAC would have significant cost implications on the health system. These findings are of critical importance for bronchoscopists without routine access to anesthesia services and for optimization of healthcare cost and resource utilization.

Impact of different sedation modalities on endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)

“…EBUS-TBNA is usually performed under sedation and there is no doubt that this facilitates the procedure and the patient’s comfort; in US the majority of all bronchoscopies are performed in mild sedation ( 2 ). Several studies have analyzed the results of EBUS-TBNA under different types of sedation ranging from conscious sedation to general anesthesia ( 2 - 5 , 7 , 11 ), with very few randomized protocols ( 9 , 12 , 13 ). Yarmus in 2013 reported a better diagnostic yield when EBUS-TBNA was performed in general anesthesia ( 14 ).…”

“…A higher statistical diagnostic yield, compared to those who received mild sedation is described in these series. However, it must be stressed that, general anesthesia or deep sedation with laryngeal mask must be performed in operative room by the anesthesiologist and, in addition to increasing cost, this is not always feasible for all bronchoscopists ( 2 ).…”

“…The spread of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has allowed the progressive improvement of the technique and of the methods of sedation ( 1 ). The sedation modality varies among centers and includes moderate sedation/conscious sedation ( 2 - 6 ), deep sedation and general anesthesia ( 7 - 9 ).…”

Efficacy and safety of EBUS‐TBNA under conscious sedation with meperidine and midazolam

“…Currently, the optimal sedation protocol for EBUS-TBNA is still a matter of discussion. 17,19 The aim of this study was to assess efficacy and safety of EBUS-TBNA under conscious sedation with meperidine and midazolam performed by pulmonologists, in terms of complete sampling of lymph nodes after consulting radiological imaging, diagnostic yield, and patient's satisfaction. The choice of these drugs is related with the current evidences: midazolam is the most used and recommended drug for conscious sedation during flexible bronchoscopy, 20,21 whereas meperidine, although discussed, 22 has been widely investigated and used both in bronchoscopic procedures 23 and in digestive endoscopic procedures 24,25 with good results.…”

Influencia de la estadificación multidisciplinar mediante ecobroncoscopia-ecoendoscopia en el cáncer de pulmón no microcítico con mediastino radiológicamente normal

“…Uno de ellos fue tratado con radioterapia y 3 con tratamiento multimodal. [114], en el que a pesar de su naturaleza retrospectiva, concluye que no hay cambios en la precisión de ambas técnicas y que la sedación moderada puede tener menos efectos secundarios y es más barata.…”