Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Instructions | Online submissionContact Us   |  Subscribe   |  Advertise   |  Login  Page layout
Wide layoutNarrow layoutFull screen layout
Lung India Official publication of Indian Chest Society  
  Users Online: 384   Home Print this page  Email this page Small font size Default font size Increase font size


 
  Table of Contents    
ORIGINAL ARTICLE
Year : 2020  |  Volume : 37  |  Issue : 5  |  Page : 407-410  

Safety of chronic obstructive pulmonary disease patients undergoing carbon dioxide insufflation in extended endoscopic procedures


1 Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
2 Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA

Date of Submission04-Feb-2020
Date of Decision02-Apr-2020
Date of Acceptance19-Apr-2020
Date of Web Publication31-Aug-2020

Correspondence Address:
Dr. Scott A Helgeson
4500 San Pablo Road S, Jacksonville, FL 32224
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_74_20

Rights and Permissions
   Abstract 


Introduction: Carbon dioxide (CO2) insufflation for endoscopies has been shown to be more comfortable and safe, but only in patients without underlying chronic obstructive pulmonary disease (COPD). The aim of this study was to show that using CO2 is safe in COPD patients. Methods: Patients were retrospectively identified who underwent extended endoscopic procedures during the time period of January 2012 to December 2017. Patients were included if they also had COPD. A matched control group without COPD was created during the same timeframe. All the patients were sedated with continuous monitoring of their CO2 levels by end-tidal CO2 (EtCO2). Results: One hundred and ten patients had COPD and underwent an extended endoscopic procedure. These patients had a higher severity of their comorbidities (American Society of Anesthesiologists class 3 or 4) (93.6% [95% confidence interval [CI], 87.4%–96.9%] vs. 60.3% [95% CI, 51.1%–69.0%]; P < 0.01) and an increase of co-existing obstructive sleep apnea (33.6% vs. 6.3%, P < 0.01). There was no difference in baseline EtCO2, but the peak EtCO2 and postprocedure EtCO2 were both significantly higher in the COPD group. The only postprocedural complication found was an inability to be extubated immediately following the procedure with subsequent need to hospitalize the patient, which occurred in three patients (2.8%; 95% CI, 0.9%–7.9%) in the COPD group and one (0.9%; 95% CI, 0.2%–4.9%) in the non-COPD group (P = 0.37). Conclusion: The present study, which was the only study looking at CO2 insufflation specifically in COPD patients, provides evidence that CO2 insufflation is safe in COPD despite a slight increase in EtCO2.

Keywords: Anesthesia, carbon dioxide, chronic obstructive pulmonary disease, endoscopy, humans


How to cite this article:
Helgeson SA, Lewis KL, Carter LE, Saunders H, Patel NM. Safety of chronic obstructive pulmonary disease patients undergoing carbon dioxide insufflation in extended endoscopic procedures. Lung India 2020;37:407-10

How to cite this URL:
Helgeson SA, Lewis KL, Carter LE, Saunders H, Patel NM. Safety of chronic obstructive pulmonary disease patients undergoing carbon dioxide insufflation in extended endoscopic procedures. Lung India [serial online] 2020 [cited 2020 Oct 22];37:407-10. Available from: https://www.lungindia.com/text.asp?2020/37/5/407/293993




   Introduction Top


Carbon dioxide (CO2) insufflation is used laparoscopic surgery and only recently has been adopted in endoscopic procedures performed by gastroenterologists. There have been many studies showing that using CO2 in these procedures significantly reduces peri-procedural pain, but with concerns for CO2 retention.[1],[2],[3],[4],[5],[6],[7],[8],[9] Many studies have shown CO2 insufflation is safe in healthy sedated patients, associated with only minimal rises in either transcutaneous CO2 or end-tidal CO2 (EtCO2) measurements.[1],[2],[3],[10],[11],[12],[13],[14] All these studies excluded patients with underlying pulmonary disease. We sought to show the safety of CO2 insufflation in chronic obstructive pulmonary disease (COPD) patients.


   Methods Top


We conducted a retrospective cohort study at a single tertiary referral center, comparing the EtCO2 and postprocedural outcomes for COPD versus non-COPD patients for all extended endoscopic procedures performed between January 2012 and December 2017. The term “extended endoscopic procedure” was defined as an upper or lower enteroscopy using either a single or double balloon technique. COPD was defined as nonreversible airflow obstruction on a pulmonary function test. The institutional review board approved the study protocol 18-002171.

In the time period listed, we identified all patients (≥18 years of age) diagnosed with COPD who underwent an extended endoscopic procedure with CO2 insufflation. Patients were excluded from this group if they did not have a pulmonary function test within 1 year of the procedure. A control group was defined by a matched group of non-COPD patients who underwent an extended endoscopic procedure during the same timeframe.

All patients were monitored by either an anesthesiologist or certified registered nurse anesthetist. Patients received sedation by propofol, midazolam, fentanyl, or any combination. In order to obtain the duration of procedure, the insertion and withdrawal times were recorded. EtCO2 measurements were used to estimate the CO2 levels. Continuous monitoring was possible as most patients were intubated and when not intubated a capnograph was attached to a nasal cannula. The EtCO2 readings were recorded every 5 min throughout the procedures. For this study, only EtCO2 readings from the start, peak EtCO2 achieved, and end of the procedure were used.

The primary endpoint for the present study was that the procedure was safe with no more complications, including hospitalizations, inability to be extubated, and mortality. Secondary endpoints were EtCO2 levels were going to be higher throughout the study.

Statistical analyses were performed using JMP version 14.0.0 (SAS Institute Inc., Cary, North Carolina, United States). Continuous data were analyzed using a nonparametric Wilcoxon rank sum test. Pearson's Chi-square or Fisher's exact test, depending on the size of analyzed variables, was used for categorical data. Complication rates were analyzed by exact binomial 95% confidence intervals. P < 0.05 was considered statistically significant.


   Results Top


A total of 220 patients who underwent an extended endoscopic procedure were selected for this study with 110 of those patients having COPD. The baseline characteristics of both groups are displayed in [Table 1]. Both groups had similar age, sex, and race breakdowns. The COPD group had significantly more comorbidities (American Society of Anesthesiologists [ASA] Class 3 and 4) (93.6% [95% confidence interval [CI], 87.4%–96.9%] vs. 60.3% [95% CI, 51.1%–69.0%]; P < 0.01), along with more current smokers, more patients with co-existing obstructive sleep apnea, and supplemental oxygen use. In the COPD group, the mean FEV1 was 59.45% ±15.93%. In the COPD group, 108 patients (98.18%) were on a short-acting beta-agonist, 34 patients (30.91%) were on a long-acting muscarinic agent, 37 patients (33.62%) were on a long-acting beta-agonist, and 43 patients (39.09%) were on inhaled corticosteroid.
Table 1: Baseline patient characteristics

Click here to view


The specifics of the procedure including type of procedure, length of procedure, endotracheal intubation rate, type of sedating medications, and amount of sedating medications were all similar in both groups [Table 2]. From the continuously monitored EtCO2, there was no significant difference between the groups at the start of the procedure. In the COPD group, both the peak EtCO2 (50 ± 12.9 vs. 46.6 ± 7.4; P = 0.01) and postprocedural EtCO2 (43.2 ± 13.2 vs. 37.1 ± 12.4; P < 0.01) were higher [Table 2]. In both groups, there was a slight increase in EtCO2 from baseline, but for the non-COPD group, it was in the normal range [Figure 1].
Table 2: Parameters of enteroscopy in chronic obstructive pulmonary disease and nonchronic obstructive pulmonary disease groups

Click here to view
Figure 1: End-tidal CO2 measured values with 95% confidence interval for COPD and non-COPD groups. CO2: Carbon dioxide, COPD: Chronic obstructive pulmonary disease, EtCO2: End-tidal CO2

Click here to view


In this cohort in which the majority were intubated, there was no difference in total complications (P = 0.37) between the COPD (2.8%; 95% CI; 0.9%–7.85%) and non-COPD (0.9%; 95% CI; 0.1%–4.97%) groups [Table 3]. The only complication that occurred in both groups was an inability to extubate the patient immediately following the procedure, resulting in a short hospital stay (maximum length of stay was 3 days). This complication occurred in three patients (2.8%; 95% CI, 0.9%–7.9%) in the COPD group and one (0.9%; 95% CI, 0.2%–4.9%) in the non-COPD group (P = 0.37). The anesthesiologist was concerned for an inability to protect the airway with potentially increased secretions for all patients who were not extubated immediately following the procedure in both groups. There was no difference in complication rate by severity of COPD (two patients had severe and one had moderate; P = 0.47), length of procedure (1 of 100 min, 1 of 110 min, 1 of 135 min, and 1 of 185 min; P = 0.65), ASA class (1 in Class 2 and 3 in Class 3; P = 0.93), OSA (0 in OSA patients; P = 0.32), oxygen use (0 in patients who used oxygen; P = 0.48), and smoking status (one former smoker and three never smokers; P = 0.17).
Table 3: Outcome data for both chronic obstructive pulmonary disease and nonchronic obstructive pulmonary disease groups

Click here to view



   Discussion Top


This study is the first to demonstrate the safety of CO2 insufflation in COPD patients for extended endoscopies. Our results show that it is safe for COPD patients, despite severity, to undergo these procedures while intubated. This study does show that the patient's EtCO2 will rise, but without an increase rate of complications.

Concerns over the safety of CO2 insufflation in the COPD population have been expressed. Several studies looked at the COPD population in specifically gastric endoscopic submucosal dissection.[15],[16] In both of these studies, the total procedure time was about 60 min, which is approximately half of the total procedure time of the current study. Second, moderate sedation was used without any patients being intubated. Third, the severity of COPD in these studies was very mild with a FEV1 above 70%. The patients in those studies had a minimal risk to develop complications from the procedure based on their severity level. Our study included all severity levels of COPD along with having these patients undergo procedures at least twice as long.

The maximum EtCO2 reached was 79 mmHg in the COPD group and 73 mmHg in the non-COPD group. The elevated EtCO2 is likely due to the CO2 insufflation with some respiratory depression, which other studies have shown.[17],[18],[19],[20] These maximum levels were not maintained long because the patient was mechanically ventilated. In addition, the postprocedure EtCO2 was in the normal range for both groups. With COPD patients, this study shows their EtCO2 level can increase to a dangerous level, but with close EtCO2 monitoring and anesthesia support there are minimal complications.

This study has some limitations. First, this was a single-center retrospective analysis. Second, this study did not look at one type of procedure but any extended endoscopic procedure, so we can only generalize about extended procedures. The procedures included in the study were all significantly longer than esophagogastroduodenoscopies and colonoscopies, which the length of time under sedation increases the risk for COPD patients to retain CO2. Third, the sedation medication or intubation was not standardized and at the discretion of the anesthesiologist. Furthermore, there was no accounting of actual minute ventilation at the time of measurements which would have varied by anesthesiologist. This variation could have occurred because of experience with COPD patients and recognizing that this group of patients needs to be ventilated more aggressively.


   Conclusion Top


This study suggests that CO2 insufflation is safe for patients with COPD undergoing extended endoscopies. In these COPD patients, the majority were intubated for the procedure for easier ventilation, but there remains a risk for a dangerous increase in CO2, so EtCO2 should be monitored closely.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.



 
   References Top

1.
Bretthauer M, Lynge AB, Thiis-Evensen E, Hoff G, Fausa O, Aabakken L. Carbon dioxide insufflation in colonoscopy: Safe and effective in sedated patients. Endoscopy 2005;37:706-9.  Back to cited text no. 1
    
2.
Bretthauer M, Seip B, Aasen S, Kordal M, Hoff G, Aabakken L. Carbon dioxide insufflation for more comfortable endoscopic retrograde cholangiopancreatography: A randomized, controlled, double-blind trial. Endoscopy 2007;39:58-64.  Back to cited text no. 2
    
3.
Bretthauer M, Thiis-Evensen E, Huppertz-Hauss G, Gisselsson L, Grotmol T, Skovlund E, et al. NORCCAP (Norwegian colorectal cancer prevention): A randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflation in colonoscopy. Gut 2002;50:604-7.  Back to cited text no. 3
    
4.
Dellon ES, Hawk JS, Grimm IS, Shaheen NJ. The use of carbon dioxide for insufflation during GI endoscopy: A systematic review. Gastrointest Endosc 2009;69:843-9.  Back to cited text no. 4
    
5.
Domagk D, Bretthauer M, Lenz P, Aabakken L, Ullerich H, Maaser C, et al. Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: A randomized, controlled, double-blind trial. Endoscopy 2007;39:1064-7.  Back to cited text no. 5
    
6.
Hussein AM, Bartram CI, Williams CB. Carbon dioxide insufflation for more comfortable colonoscopy. Gastrointest Endosc 1984;30:68-70.  Back to cited text no. 6
    
7.
Sumanac K, Zealley I, Fox BM, Rawlinson J, Salena B, Marshall JK, et al. Minimizing postcolonoscopy abdominal pain by using CO2 insufflation: A prospective, randomized, double blind, controlled trial evaluating a new commercially available CO2 delivery system. Gastrointest Endosc 2002;56:190-4.  Back to cited text no. 7
    
8.
Wong JC, Yau KK, Cheung HY, Wong DC, Chung CC, Li MK. Towards painless colonoscopy: A randomized controlled trial on carbon dioxide-insufflating colonoscopy. ANZ J Surg 2008;78:871-4.  Back to cited text no. 8
    
9.
Magno R, Medegård A, Bengtsson R, Tronstad SE. Acid-base balance during laparoscopy. The effects of intraperitoneal insufflation of carbon dioxide and nitrous oxide on acid-base balance during controlled ventilation. Acta Obstet Gynecol Scand 1979;58:81-5.  Back to cited text no. 9
    
10.
Geyer M, Guller U, Beglinger C. Carbon dioxide insufflation in routine colonoscopy is safe and more comfortable: Results of a randomized controlled double-blinded trial. Diagn Ther Endosc 2011;2011:378906.  Back to cited text no. 10
    
11.
Li X, Zhao YJ, Dai J, Li XB, Xue HB, Zhang Y, et al. Carbon dioxide insufflation improves the intubation depth and total enteroscopy rate in single-balloon enteroscopy: A randomised, controlled, double-blind trial. Gut 2014;63:1560-5.  Back to cited text no. 11
    
12.
Lord AC, Riss S. Is the type of insufflation a key issue in gastro-intestinal endoscopy? World J Gastroenterol 2014;20:2193-9.  Back to cited text no. 12
    
13.
Seo EH, Kim TO, Park MJ, Kim HJ, Shin BC, Woo JG, et al. The efficacy and safety of carbon dioxide insufflation during colonoscopy with consecutive esophagogastroduodenoscopy in moderately sedated outpatients: A randomized, double-blind, controlled trial. J Clin Gastroenterol 2013;47:e45-9.  Back to cited text no. 13
    
14.
Yamano HO, Yoshikawa K, Kimura T, Yamamoto E, Harada E, Kudou T, et al. Carbon dioxide insufflation for colonoscopy: Evaluation of gas volume, abdominal pain, examination time and transcutaneous partial CO2 pressure. J Gastroenterol 2010;45:1235-40.  Back to cited text no. 14
    
15.
Takada J, Araki H, Onogi F, Nakanishi T, Kubota M, Ibuka T, et al. Safety and efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection. World J Gastroenterol 2015;21:8195-202.  Back to cited text no. 15
    
16.
Yoshida M, Imai K, Hotta K, Yamaguchi Y, Tanaka M, Kakushima N, et al. Carbon dioxide insufflation during colorectal endoscopic submucosal dissection for patients with obstructive ventilatory disturbance. Int J Colorectal Dis 2014;29:365-71.  Back to cited text no. 16
    
17.
Kikuchi T, Fu KI, Saito Y, Uraoka T, Fukuzawa M, Fukunaga S, et al. Transcutaneous monitoring of partial pressure of carbon dioxide during endoscopic submucosal dissection of early colorectal neoplasia with carbon dioxide insufflation: A prospective study. Surg Endosc 2010;24:2231-5.  Back to cited text no. 17
    
18.
Nonaka S, Saito Y, Takisawa H, Kim Y, Kikuchi T, Oda I. Safety of carbon dioxide insufflation for upper gastrointestinal tract endoscopic treatment of patients under deep sedation. Surg Endosc 2010;24:1638-45.  Back to cited text no. 18
    
19.
Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y, et al. A pilot study to assess the safety and efficacy of carbon dioxide insufflation during colorectal endoscopic submucosal dissection with the patient under conscious sedation. Gastrointest Endosc 2007;65:537-42.  Back to cited text no. 19
    
20.
Suzuki T, Minami H, Komatsu T, Masusda R, Kobayashi Y, Sakamoto A, et al. Prolonged carbon dioxide insufflation under general anesthesia for endoscopic submucosal dissection. Endoscopy 2010;42:1021-9.  Back to cited text no. 20
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Methods
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed201    
    Printed0    
    Emailed0    
    PDF Downloaded46    
    Comments [Add]    

Recommend this journal