Complete Mediastinal and Hilar Lymph Node Staging of Primary Lung Cancer by Endobronchial Ultrasound: Response

Abstract

To the Editor: We thank Dr. Kennedy and his colleagues1Kennedy MP Shweiwat Y Sarkiss M et al.Complete mediastinal and hilar lymph node staging of primary lung cancer by endobronchial ultrasound: moderate sedation or general anesthesia?.Chest. 2008; 134: 1350-1351Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar for their comments regarding the level of sedation during endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA).2Herth FJF Eberhardt R Krasnik M et al.Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer.Chest. 2008; 133: 887-891Abstract Full Text Full Text PDF PubMed Scopus (307) Google Scholar The use of propofol and a laryngeal mask airway is certainly an additional option available to the bronchoscopist. It is important to remember, though, that there is currently no proof that any level of anesthesia deeper than moderate sedation is required for performing the procedure. This applies for the goal of the procedure (full staging vs targeted biopsy) as much as for the level of experience. Even though we agree that general anesthesia may make it easier especially for the relatively inexperienced operator, some issues require consideration before asking the anesthesiologist to provide deep sedation or general anesthesia for a patient. Part of the advantage of EBUS TBNA is the ease and minimal patient impact compared with surgical staging, as well as the potential economic advantage. Deeper levels of sedation may partially negate these advantages by adding additional personnel and requiring operating room-type facilities in some institutions. An additional drawback to adding more resources that really are probably not required is the recent severe reimbursement cutback on the facility-based reimbursement (Hospital Outpatient Prospective Payment System) for EBUS TBNA procedures by the Centers for Medicare and Medicaid Services in January 2008.3Centers for Medicare and Medicaid Services.Federal Register. 2007; : 72Google Scholar We need to choose the best approach for our patients but need to manage and minimize the resource use at the same time.