A study on the Effect of Perfume Inhalation in Preventing gag reflex during Fiberoptic Bronchoscopy.

Mubarack sani T.P1, Sajeev S2, Kasim kolakkadan3. 1- Faculty of Medicine, Jizan , KSA. 2,3 - Academy of Medical Sciences, Pariyaram, Kannur, Kerala, India.

Abstract.
Background.
Fibroptic Bronchoscopy ( FOB) is done usually under local anaesthesia to minimise gag reflex and coughing during the procedure. Lignocaine, the commonest local anaesthetic , used is absorbed in to the circulation and known to cause systemic toxic effects. To reduce the dose of the lignocaine used without increasing the gag reflex rate during bronchoscopy, we used a novel technique, viz, inhalation of pleasant smell ( Jasmine odour) during the procedure.

Objective.
The objective of the study was to compare the gags/minute produced during the bronchoscopy when lignocaine viscous was used as local anaesthetic in the upper respiratory tract, when perfume inhalation was used instead of lignocaine and when no lignocaine or perfume inhalation was used.

Methods.
Type of study Randomised Controlled double blind clinical study. 83 patients who underwent bronchoscopy for various lung lesions were grouped into three. 1. Lignocaine group - who received usual dose of lignocaine. 2. Perfume group - who did not receive lignocaine in the upper respiratory tract instead they were given a gauze piece with perfume ( Jasmine odour) sprayed in to it and was asked to inhale it during the procedure. 3. Placebo group who did not receive lignocaine or perfume inhalation.

Measurements.
The time taken for the bronchoscope to traverse the upper respiratory tract (nostril to the vocal cords), number of gags during this time, Time for which the bronchoscope in the lower respiratory tract (below the vocal cords), number of the time the patient gagged during this time and the total dose of the lignocaine used were measured.

Results.
The results showed that mean gags / minute in the respiratory tract in lignocaine group (0.1845) and perfume group (0.1714) did not show significant difference ( p value 0.758). But mean gags/ minute in the placebo group (0.4125) was higher than in the lignocaine group and perfume group( p- value <0.001 and P<0.001 respectively). The mean lignocaine dose used in the lignocaine group (340 mg) was higher than the perfume group(244 mg) and placebo group (256 mg).

Conclusion.
Inhalation of pleasant smell during FOB is as effective as applying lignocaine in the upper respiratory tract, in preventing gag reflex associated with the passage of bronchoscope through the respiratory tract.

Key Words: Fiberoptic bronchoscopy, Lignocaine, Perfume inhalation, Gag reflex.

Introduction .
Fiberoptic bronchoscopy (FOB) is a widely used procedure for the diagnosis of various pulmonary pathologies. The advantage of FOB is that it can be done under local anaesthesia with minimal discomfort to the patient. A commonly used local anaesthetic is lignocaine. Lignocaine is used to prevent gag reflex while the bronchoscope is in the upper respiratory tract(URT) and to minimise coughing while the FOB in the lower respiratory tract(LRT). Various preparations of the lignocaine used for achieving local anaesthesia during FOB are Lignocaine spray,4% solution, 2% gel, 2% viscous, for anaesthetizing the URT 1,2. And lignocaine 4%solution as trans-tracheal injection for anaesthetizing the LRT 3. During the FOB approximately 600 mg of lignocaine is introduced in to the respiratory tract and serum lignocaine level may reach upto3mg/L4,5. Serum lignocaine level more than 5 mg/L is associated with systemic toxic effects 6. Sniffing a strong pleasant smell is a household remedy for suppressing nausea. Our study was to find out how far inhalation of a pleasant smell (Jasmine odour) is useful in suppressing the gag reflex associated with passage of bronchoscope the respiratory tract.

Materials & Methods.

Type of study Randomised Controlled double blind clinical study. Eighty three patients who underwent FOB for various indications in our hospital ( academy of Medical Sciences, Pariyaram, Kannur, Kerala) during a period of one year were included in the study. Informed consent was taken from all the patients included in the study and the ethical committee of the ACME Medical College approved the study. The inclusion criteria for the study were 1. Informed consent. 2. Intact gag reflex (determined by tickling the oropharynx with cotton during clinical examination.) The exclusion criteria for the study were 1. 2. 3. 4. CNS disorders ( as the gag reflex may be impaired). CVS diseases. Asthmatics who give history of wheezing on exposure to strong smell. Hypersensitivity to lignocaine.

The bronchoscope used was Pentax FiberOptic Bronchoscope (EB 1830 TZ), with outer diameter 6 mm and single working channel. The diagnostic procedure done were transbronchial biopsy, brush biopsy, and direct punch biopsy from intra bronchial lesions, bronchial washings and bronchioalveolar lavage. The procedure varied from patient to patient depending upon the lung lesions. The odour of the perfume used was Jasmine ( Manufactured by the Mughal Cosmopharma, Trissur, Kerala). All the patients were tested for lignocaine sensitivity by skin prick test and was asked to starve after 10 pm. Next day morning premedications (0.6mg Atropine and 5.0 mg Diazepam IM) were given half hour before the procedure. The patients were randomly grouped in to three( by drawing lots). 1. Lignocaine group. 2. Perfume group. 3. Placebo group.

The investigator who noted the gags and other parameters and the patient were not aware of the group in which the patient belongs. To avoid bias in the duration of the procedure all the bronchoscopy procedure was done by the same investigator. 1. Lignocaine group In this group 5 ml of 2% lignocaine viscous solution ( Xylocaine Viscous 2% Astra- IDL)was poured in to the mouth of the patient and was asked to hold the solution in the throat for 5 minutes. Then it was spit out and 2 ml of 4% lignocaine solution (4% Xylocaine Topical, Astra IDL)was given as trans tracheal injection. Then the patient was given a gauze piece with normal saline sprayed in to it and was asked to sniff the gauze piece whenever he felt nausea or gag reflex. The FOB was introduced in to the nostril after lubricating with sterile KY-Jelly. 2. Perfume group. In this group 5 ml of normal saline was poured in to the mouth of the patient and was asked to hold the solution in the throat for 5 minutes. Then it was spit out and 2 ml of 4% lignocaine solution (4% Xylocaine Topical, Astra IDL)was given as trans tracheal injection. Then the patient was given a gauze piece with perfume (Jasmine smell) sprayed in to it and was asked to sniff the gauze piece whenever he felt nausea or gag reflex. The FOB was introduced in to the nostril after lubricating with sterile KY-Jelly. 3. Placebo group. In this group 5 ml of normal saline was poured in to the mouth of the patient and was asked to hold the solution in the throat for 5 minutes. Then it was spit out and 2 ml of 4% lignocaine solution (4% Xylocaine Topical, Astra IDL)was given as trans tracheal injection. Then the patient was given a gauze piece with normal saline sprayed in to it and was asked to sniff the gauze piece whenever he felt nausea or gag reflex. The FOB was introduced in to the nostril after lubricating with sterile KY-Jelly. In all the groups during the FOB procedure , whenever the patient coughed while bronchoscope was in the LRT, 1 ml of 4% lignocaine solution was instilled through the channel of the FOB. After the FOB all patients were asked to avoid oral intake for 3 hours. The time taken for the completion of the FOB procedure, number of gags during this time, time of entry in to the trachea, time of removal from LRT, number of times the patient gagged while the FOB was in the URT and LRT and the amount of lignocaine introduced to the respiratory tract was noted. The total dose of lignocaine administered was calculated by adding the total amount of 2% viscous and 4% solution introduced in to the respiratory tract.

Statistical Analysis
Relationship between the variables in the three groups were analysed using paired students t-test with 2 tailed distribution.

Results.
The mean dose of lignocaine used in Lignocaine group was 340 mg, Perfume group was 244 mg and Placebo group was 256mg. Gender Distribution of the cases Out of 83 patients 68(81.92%) were males and 15(18.08%)were females (Table 1). Age distribution of cases Maximum number of the patients in the older age group (>60) and least was in the age group 21 30 (Table 2). Disease-wise distribution of cases- Out of 83 patients 41 (49.39%) had lung cancer.The commonest type was squamous cell carcinoma( n=22). Mean time taken for bronchoscope to traverse the URT For the Lignocaine group the mean time taken was 1.482 minutes, for the Perfume group it was 1.276 and for the Placebo group it was 1.343 min. There was no statistical difference between these 3 groups, suggesting that the time in the URT for all the three groups is almost equal (table3). Mean number of gags while the bronchoscope was in the URT. Mean number of gags in the URT for the Lignocaine group was 0.9642, for Perfume group was 0.6785 and the Placebo group it was 2.1481 which was higher than the other 2 groups and was statistically significant ( Table3). Mean gags/minute in the URT For the Lignocaine group it was 0.6128, for the Perfume group was 0.5277 and the Placebo group it was 1.5891 which was higher than the other 2 groups ( Table3). Mean time spend by the bronchoscope in the LRT. For the Lignocaine group it was 6.7321 min, for Perfume group was 6.5982 min and the Placebo group it was 7.6204 min and there was no statistically significant difference between these 3 groups regarding the time spend by the bronchoscope in the LRT ( Table3).

Mean number of gags while the bronchoscope was in the LRT. Mean number of gags in the LRT for the Lignocaine group was 0.5714, for Perfume group was 0.6429 and the Placebo group it was 1.5926 which was higher than the other 2 groups and was statistically significant ( Table3). Mean gags/minute while the bronchoscope was in the LRT For the Lignocaine group it was 0.0741, for the Perfume group was 0.0997 and for the Placebo group it was 0.2009 which was higher than the other 2 groups and was statistically significant ( Table3). Mean total time spend by the bronchoscope in the RT There was no statistically significant difference in total time spend by the bronchoscope in the RT. For the Lignocaine group it was 8.2142 min, for the Perfume group was 7.875 min and for the Placebo group it was 8.9629 min ( Table3). Mean number of gags while the bronchoscope was in the RT. Mean number of gags in the RT for the Lignocaine group it was 1.537, for Perfume group it was 1.3214 and the Placebo group it was 3.7407 which was higher than the other 2 groups and was statistically significant ( Table3). Mean gags/minute while the bronchoscope was in the RT For the Lignocaine group it was 0.1845, for the Perfume group was 0.1714 and for the Placebo group it was 0.4127 which was higher than the other 2 groups and was statistically significant ( Table3).

Discussion
Lignocaine is a drug which is rapidly absorbed through the mucosal surfaces. Various studies have shown that during bronchoscopy the serum lignocaine significantly correlatedwith the total amount of lignocaine administered 4,5. A study by Langmack EL, Martin RJ,et al, showed that on an average 600 mg lignocaine is introduced to respiratory tract during the bronchoscopy and the serum lignocaine concentration ranged between 0.5 3.2mg/L, 30 minutes after completion of the bronchoscopy 4. They found that there was no significant relation between serum lignocaine concentration and subject age, sex and duration of the procedure. In another study by LoukiderS, Katsoulin K et al, mean peak serum concentration was well below the critical level of toxicity (5mg/L)and produced no side effects 5.

But lignocaine used during bronchoscopy can cause severe systemic side effects like methemoglobinemia 7, cardiac arrhythmias, and even death 8. Further lignocaine has to be used with caution in cardiac, renal and hepatic disorders 6. In our study mean dose of lignocaine used in the Lignocaine-group was 340 mg while in the Perfume-group it was 244 mg and Placebo-group it was 256 mg. In spite of a low dose of lignocaine, the mean gags/minute in the Perfume group was lower than the Lignocaine-group, even though not statistically significant. It was lower than the Placebo-group and was statistically significant (Table3). The higher value of mean gags /minute in the Lignocaine-group when compared to the Perfume-group may be because, even after repeated instructions some patients were unable to hold the viscous solution in the throat properly. Instead they kept in the oral cavity, so the pharyngeal anaesthesia may be less. On the contrary sniffing the gauze piece is very simple and we have seen that patients readily uses it as he feels the gag. The number of males requiring bronchoscopy is higher than females. This is reflected in our study, which had 81.92 % male and 18.08% females. Out of the 83 patients 41 (49.39%) had lung cancer predominantly squamous cell carcinoma. The disadvantage of perfume inhalation is that it may induce bronchospasm in asthmatic patients who gives history of wheezing on exposure to strong small. Our study did not include asthmatics. To determine the use of this technique in other procedure like fiberoptic gastrointestinal-endoscopy or rigid bronchoscopy , further studies required. upper

Summary
Our study shows that inhalation of pleasant odour ( Perfume) instead of topical solution of lignocaine during FOB is helpful in reducing gag reflex associated with FOB. Thus this technique may be helpful in reducing the dose of lignocaine instilled in the respiratory tract during FOB for local anaesthesia, thereby reducing the risk of lignocaine associated systemic toxicity.

Gender Male Female

Table-1 GENDER DISTRIBUTION OF CASES Lignocaine Perfume 24 23 4 5

Placebo 21 6

Age Lignocaine Perfume Placebo

21-30 0 1 0

Table -2 AGE DISTRIBUTION 31-40 41-50 51-60 1 5 6 1 3 7 0 7 8

>60 16 16 12

Table 3 Relationship between various parameters in 3 groups. Parameter Groups Mean + SD p-value in relation to Time taken to pass the bronchoscope to Lignocaine 1.4820 + 0.4406 Perfume group-0.041 pass the URT Perfume 1.2768 + 0.275 Placebo group -0.433 Placebo 1.3426 + 0.3407 Lignocaine group-0.196 Number of gags while the bronchoscope Lignocaine 0.9643 + 0.9616 Perfume group-0.202 was in the URT Perfume 0.6785 + 0.6696 Placebo group <0.001 Placebo 2.1481 + 1.0991 Lignocaine group<0.001 Mean gags/min while the bronchoscope Lignocaine 0.6128 + 0.5870 Perfume group-0.567 was in the URT Perfume 0.5277 + 0.5168 Placebo group <0.001 Placebo 1.5891 + 0.6746 Lignocaine group<0.001 Time spend by the bronchoscope in the Lignocaine 6.7321 + 2.480 Perfume group-0.838 LRT Perfume 6.5982 +2.3876 Placebo group -0.124 Placebo 7.6204 + 2.4655 Lignocaine group-0.189 Number of gags while the bronchoscope Lignocaine 0.5714 + 0.6341 Perfume group-0.672 was in the RT Perfume 0.6429 + 0.6215 Placebo group <0.001 Placebo 1.5926 + 1.0099 Lignocaine group<0.001 Number of gags while the bronchoscope Lignocaine 0.0741 + 0.0812 Perfume group-0.296 was in the LRT Perfume 0.0997 + 0.0999 Placebo group <0.001 Placebo 0.2009 + 0.1376 Lignocaine group<0.001 Total time spend by the bronchoscope in Lignocaine 8.2142 + 2.627 Perfume group-0.622 the RT Perfume 7.8750 + 2.494 Placebo group -0.112 Placebo 8.9629 + 2.493 Lignocaine group-0.284 Total gags while the bronchoscope in the Lignocaine 1.5357 + 1.3189 Perfume group-0.484 RT Perfume 1.3124 + 1.1564 Placebo group <0.001 Placebo 3.7407 + 1.953 Lignocaine group<0.001 Mean gags/min while the bronchoscope Lignocaine 0.1845 + 0.1617 Perfume group-0.758 was in the RT Perfume 0.1714 + 0.1563 Placebo group <0.001 Placebo 0.4127 + 0.2033 Lignocaine group<0.001

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