Endobronchial Ultrasound Bronchoscopy Research Articles

A novel platform for electromagnetic navigated ultrasound bronchoscopy (EBUS).

PurposeEndobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of mediastinal lymph nodes is essential for lung cancer staging and distinction between curative and palliative treatment. Precise sampling is crucial. Navigation and multimodal imaging may improve the efficiency of EBUS-TBNA. We demonstrate a novel EBUS-TBNA navigation system in a dedicated airway phantom.MethodsUsing a convex probe EBUS bronchoscope (CP-EBUS) with an integrated sensor for electromagnetic (EM) position tracking, we performed navigated CP-EBUS in a phantom. Preoperative computed tomography (CT) and real-time ultrasound (US) images were integrated into a navigation platform for EM navigated bronchoscopy. The coordinates of targets in CT and US volumes were registered in the navigation system, and the position deviation was calculated.ResultsThe system visualized all tumor models and displayed their fused CT and US images in correct positions in the navigation system. Navigating the EBUS bronchoscope was fast and easy. Mean error observed between US and CT positions for 11 target lesions (37 measurements) was 2.8pm 1.0 mm, maximum error was 5.9 mm.ConclusionThe feasibility of our novel navigated CP-EBUS system was successfully demonstrated. An EBUS navigation system is needed to meet future requirements of precise mediastinal lymph node mapping, and provides new opportunities for procedure documentation in EBUS-TBNA.

A randomized controlled trial evaluating airway inspection effectiveness during endobronchial ultrasound bronchoscopy.

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) has revolutionized the evaluation of patients with mediastinal and hilar adenopathy. Limitations of conventional endobronchial ultrasound (C-EBUS) bronchoscopes include the inability to perform a complete airway inspection, low definition optics, and limited maneuverability. These limitations require the use of a standard bronchoscope to perform an airway examination prior to the EBUS procedure. Recently, a hybrid endobronchial ultrasound (H-EBUS) bronchoscope with high definition optics and increased maneuverability has been introduced. Our objective was to assess the ability of H-EBUS to perform a full airway inspection and TBNA. Patients referred for EBUS-TBNA were prospectively randomized to either form of EBUS from November 2013 to January 2014. The primary outcome was the airway segment visualization in each lobe using an EBUS bronchoscope. Secondary outcomes included the number of bronchoscopes used per procedure, procedure length, diagnostic yield and specimen adequacy. Sixty-two consecutive patients undergoing EBUS-TBNA were randomized to H-EBUS (n=30) or C-EBUS (n=32). In cases in which EBUS-TBNA was the only procedure performed (n=32), use of a second bronchoscope to perform an adequate airway inspection was significantly higher in C-EBUS compared to H-EBUS (5 vs. 0, P=0.046). There was better segmental visualization achieved in multiple lobes when using H-EBUS (P<0.01). No differences in TBNA sample diagnostic yield, specimen adequacy or procedure time were noted when comparing bronchoscopes (P= NS). Use of an H-EBUS may improve the ability to perform an adequate airway inspection potentially obviating the need for a conventional bronchoscope.

Bronchoscopist-directed Continuous Propofol Infusion for Targeting Moderate Sedation During Endobronchial Ultrasound Bronchoscopy

Propofol use for sedation during routine flexible bronchoscopy is expanding. However, there are concerns over propofol's reliability in targeting moderate sedation during more complex and lengthy procedures, such as endobronchial ultrasound (EBUS) bronchoscopy. Its delivery by continuous infusion, which provides a steady sedation effect, may be a practical model for achieving reliable outcomes in this setting. We tested a continuous propofol infusion protocol targeting moderate sedation for EBUS bronchoscopy. A fixed loading rate of 125 mcg/kg/min and initial maintenance rate of 75 mcg/kg/min were used. Sedation assessments were performed every 2.5 minutes. The infusion was adjusted by a nurse under the direction of the bronchoscopist to maintain moderate sedation, normal vital signs, and patient comfort. Prospectively collected data from the first 31 patients using the protocol were analyzed. A mix of EBUS types was performed in a fellowship training environment. Median procedure duration was 51 minutes (interquartile range, 41 to 75 min). Ninety-four percent of total bronchoscopy time was spent in moderate sedation, whereas only 1.9% was occupied by agitation-related delays. Average propofol dose per case was 0.07 mg/kg/min (±0.020), and infusion adjustments were required once every 8 minutes. Sampling goals were met in all patients, and diagnostic and nodal staging accuracies were 90% and 91%, respectively. All tumor specimens sent for genetics were sufficient for analysis. There were no major procedure-related complications. Bronchoscopist-directed continuous propofol infusion is effective and practical for reliably and safely targeting moderate sedation during EBUS bronchoscopy, without sacrificing the breadth and accuracy of the procedure.

Nontuberculous Mycobacterium, Myobacterium and Mixed Pulmonary Infections: A Case Report

In the 1980’s, nontuberculous myobacteria (NTM) was recognized as the common cause of disseminated infection in patients who were severely immunocompromised. In Thailand, a study was reported where almost half of the disseminated NTM infections in HIV negative cases were related to farming. NTM contaminated soil and water lead to tissue invasion and cause disease. In recent years, Bangkok Hospital Medical Center has observed a constant rise of patients diagnosed with NTM with or without accompanying disease or infection. Diagnosing NTM has been made easier with the availability and aid of endobronchial ultrasound (EBUS) in collecting specimens for culture and to indicate sensitivity. OBJECTIVES: To illustrate 10 different cases and management of NTM. MATERIALS AND METHODS: From 2012-2014, data from NTM positive patients from culture and sensitivity results were collected. RESULTS: 10 HIV negative cases of NTM were identified by bronchoscopy, endobronchial ultrasonogram guided sheath (EBUS-GS) and sputum culture. The age ranged from 41 to 89 years old with a mean of 64 years. There were eight females (80%), most were menopausal (87.5%) and two males (20%). Underlying conditions included diabetes mellitus (30%), coexisting Tuberculosis (50%) and 10% with lung cancer. All suffered from respiratory symptoms such as fever, dyspnea, sputum production and abnormal chest x-ray and chest CT scan results. All were identified by using EBUS (70%) or sputum culture (20%) or bronchoscopy (10%). Bacteria recorded were myobacterium avium complex (MAC) (30%), myobacterium intracellulare complex (MIC) (10%) and 60% were unidentified specific NTM bacteria. All responded well to Macrolide and Quinolone treatment. Specimens obtained from EBUS are highly reliable with the right laboratory setting to identify specific types of NTM.

A randomized controlled trial evaluating airway inspection effectiveness during endobronchial ultrasound bronchoscopy

A randomized controlled trial evaluating airway inspection effectiveness during endobronchial ultrasound bronchoscopy

Assessment of the new thin convex probe endobronchial ultrasound bronchoscope and the dedicated aspiration needle: a preliminary study in the porcine lung.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) allows for accurate minimally invasive mediastinal lymph node staging of lung cancer. The current convex probe EBUS (CP-EBUS) has limitations in the access to certain N1 lymph nodes (lobar and segmental) because of its size. The aim of this study was to assess the new thin CP-EBUS (TCP-EBUS) and an aspiration needle for sampling of N1 lymph nodes in a porcine model. The prototype TCP-EBUS (BF-Y0046, Olympus Medical Systems Corp.) with a thinner tip (5.9 mm) and larger bending angle (170 degrees upward) was used. Accessibility, operability, and TBNA capability of the TCP-EBUS were assessed and compared with the current CP-EBUS using porcine lungs. The endoscopic visibility range and the maximum reach were evaluated at the left upper lobe bronchus, tracheobronchus, and right lower lobe bronchus. The prototype aspiration needle (Olympus Medical Systems Corp.) was used for EBUS-TBNA. In all of the evaluated bronchi (n=9), the TCP-EBUS had a greater reach (14.7 mm in the endoscopic visibility range, 16.0 mm in the maximum reach) than the current CP-EBUS. The TCP-EBUS was able to visualize 1 to 3 distal bifurcations farther compared with the current CP-EBUS. Adequate lymph node sampling from lobar and segmental lymph nodes was possible using the aspiration needle. The TCP-EBUS has improved accessibility to peripheral bronchi with excellent operability and is capable of sampling lobar and segmental lymph nodes using the dedicated aspiration needle.

A Stomach Through the Eyes of EBUS Bronchoscopy

Introduction: Hiatal hernias are frequently an incidental finding on an upper endoscopy, barium swallow, manometry study or abdominal/chest imaging. We present the first reported case of a sliding hiatal hernia as an incidental finding on EBUS bronchoscopy. Case Report: A 72-year-old man with a history of a pituitary macroadenoma was transferred to the medical ICU with altered mental status, hypotension and worsening of non-productive cough. Upon further workup, a computed tomography of the chest demonstrated mediastinal adenopathy in addition to migration of subdiaphragmatic stomach into the chest cavity (Figure 1). While navigating the airway with EBUS bronchoscopy, stomach tissue was identified at the medial wall of the left main bronchus consistent with a hiatal hernia (Figure 2).Figure 1: CT scan demonstrating hiatal hernia.Figure 2: Endobronchial ultrasound (EBUS) bronchoscopy revealing contour of a stomach at the medial wall of the left main bronchus.Discussion: A hiatal hernia is described by the protrusion of the gastroesophageal junction into the chest cavity. It can be seen in up to 80% of the general population. It is usually suspected in patient with gastroesophageal reflux disease and has been associated with Barrett’s esophagus. It is frequently an incidental finding on an upper endoscopy, barium swallow, manometry study or abdominal/chest imaging. Hiatal hernia has been recently reported as an extra-cardiac finding on echocardiographic exams. To the best of our knowledge this is the first reports of a sliding hiatal hernia as an incidental finding on EBUS bronchoscopy.

Endobronchial Ultrasound Bronchoscope Insertion Through a Flexible Tracheostomy Tube: A Novel Approach to Perform EBUS in Patients With Closed Upper Airway

Endobronchial Ultrasound Bronchoscope Insertion Through a Flexible Tracheostomy Tube: A Novel Approach to Perform EBUS in Patients With Closed Upper Airway

Endoscopic ultrasound-guided fine needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration: Are two better than one in mediastinal staging of non–small cell lung cancer?

The role of combined endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with a single bronchoscope is poorly understood. The purpose of the present study was to elucidate the roles of EBUS-TBNA and EUS-FNA with a single bronchoscope in the preoperative hilar and mediastinal staging of non-small cell lung cancer (NSCLC). A total of 150 patients with potentially resectable known or suspected NSCLC were enrolled in our prospective study. EBUS-TBNA was performed, followed by EUS-FNA, with an EBUS bronchoscope for N2 and N3 nodes≥5 mm in the shortest diameter on ultrasound images, in a single session. EBUS-TBNA was performed for 257 lymph nodes and EUS-FNA for 176 lymph nodes. Of the 150 patients, 146 had a final diagnosis of NSCLC. Of these 146 patients, 33 (23%) had N2 and/or N3 nodal metastases. The sensitivity of EBUS-TBNA, EUS-FNA, and the combined approach per patient was 52%, 45%, and 73%, respectively (EBUS-TBNA vs the combined approach, P=.016, McNemar's test). The corresponding negative predictive value was 88%, 86%, and 93%. Two patients (1%) developed severe cough from EBUS-TBNA. The combined endoscopic approach with EBUS-TBNA and EUS-FNA is a safe and accurate method for preoperative hilar and mediastinal staging of NSCLC, with better results than with each technique by itself.

The Usefulness of Endobronchial Ultrasonography–guided Transbronchial Needle Aspiration at the Lobar, Segmental, or Subsegmental Bronchus Smaller Than a Convex-type Bronchoscope

Endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) is a standard procedure for approaching the lesion adjacent to extrapulmonary bronchus. We started to use wedge insertion of a convex endobronchial ultrasound bronchoscope into bronchi narrower than the diameter of the bronchoscope itself to perform EBUS-TBNA. Our objective was to investigate the bronchus in which EBUS-TBNA was possible and safe. In this prospective study, we examined 15 lesions that were adjacent to lobar, segmental, or subsegmental bronchi narrower than the 6.9 mm external diameter of the convex scope. The cross-sectional area and maximum, minimum, and mean internal diameters of the airway lumen adjacent to the lesion were calculated using the measurement software. We investigated the airway branch in which EBUS-TBNA was possible, the narrowest airway diameter adjacent to the lesion for which insertion and diagnosis could be performed, the feasibility of puncture, and techniques for ensuring procedural success. The mean cross-sectional area of the lumen for the 13 lesions that could be punctured was ≥ 15.9 mm2 and the mean internal diameter was ≥ 4.5 mm. Cytologic or histologic diagnosis by EBUS-TBNA was possible in 11 of the 15 cases. In 2 of the 4 undiagnosed lesions, the mean internal diameter was <4.5 mm, and the convex scope was unable to reach the lesion. There was no occurrence of complications in any case. EBUS-TBNA can be performed by inserting a 6.9 mm EBUS bronchoscope into airways with a mean diameter ≥ 4.5 mm as measured on computed tomography before bronchoscopy.

Safety of Endobronchial Ultrasound Bronchoscopy in Patients With Intracranial Masses

Safety of Endobronchial Ultrasound Bronchoscopy in Patients With Intracranial Masses

Neo-adjuvant chemotherapy in early stage non-small cell lung cancer.

Lung cancer treatment has evolved during the last decade from the non-specific cytotoxic drugs to targeted therapy. New diagnostic equipment such as the endobronchial ultrasound bronchoscopy and positron emission tomography has enhanced early lung cancer diagnosis. However; we still need additional novel biomarkers to assist the already used diagnostic techniques. Surgery is the still the best treatment for early lung cancer treatment. Several surgical techniques are being used based on the tumour location and cardiothoracic centre's experienced. There are however marginal situations where neo-adjuvant chemotherapy provides a "pre-step" for the patient. In the current work we will provide current data for the patients needing neo-adjuvant chemotherapy before proceeding to curative surgery.

&amp;ldquo;One-stop shop&amp;rdquo; spectral imaging for rapid on-site diagnosis of lung cancer: a future concept in nano-oncology

BackgroundThere are currently many techniques and devices available for the diagnosis of lung cancer. However, rapid on-site diagnosis is essential for early-stage lung cancer, and in the current work we investigated a new diagnostic illumination nanotechnology.MethodsTissue samples were obtained from lymph nodes, cancerous tissue, and abnormal intrapulmonary lesions at our interventional pulmonary suites. The following diagnostic techniques were used to obtain the samples: endobronchial ultrasound bronchoscopy; flexible bronchoscopy; and rigid bronchoscopy. Flexible and rigid forceps were used because several of the patients were intubated using a rigid bronchoscope. In total, 30 tissue specimens from 30 patients were prepared. CytoViva® illumination nanotechnology was subsequently applied to each of the biopsy tissue slides.ResultsA spectral library was created for adenocarcinoma, epidermal growth factor receptor mutation-positive adenocarcinoma, squamous cell carcinoma, usual interstitial pneumonitis, non-specific interstitial pneumonitis, typical carcinoid tumor, sarcoidosis, idiopathic pulmonary fibrosis, small cell neuroendocrine carcinoma, thymoma, epithelioid and sarcomatoid mesothelioma, cryptogenic organizing pneumonia, malt cell lymphoma, and Wegener’s granulomatosis.ConclusionThe CytoViva software, once it had created a specific spectral library for each entity, was able to identify the same disease again in subsequent paired sets of slides of the same disease. Further evaluation of this technique could make this illumination nanotechnology an efficient rapid on-site diagnostic tool.

Linear Probe Endobronchial Ultrasound Bronchoscopy with Guided Transbronchial Needle Aspiration (EBUS–TBNA) in the Evaluation of Mediastinal and Hilar Pathology: Introducing the Procedure to a Teaching Institution

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an important tool in the diagnosis of mediastinal and hilar pathology. We describe our experience with EBUS-TBNA performed in a teaching institution primarily under conscious sedation. Patients who underwent EBUS-TBNA were included in this retrospective review. We focused on the diagnostic yield of EBUS-TBNA in relationship to the nature of the mediastinal or hilar lesions (suspected malignancy vs. benign disease), incremental 25 procedures aliquots, lymph node (LN) station, LN size, and the number of needle aspirations per LN station. Of the 212 patients who underwent EBUS-TBNA, 200 patients had adequate follow-up information and were included in this analysis. The procedure was performed under conscious sedation in 97 % of patients and 133 patients (67 %) were suspected to have malignancy before the procedure. A total of 690 TBNAs were performed from 294 LN stations. The mean number of LN stations sampled per procedure was 1.47 ± 0.6. The mean number of TBNAs per LN station was 2.35 ± 0.91. The mean number of TBNAs per procedure was 3.45 ± 1.2. The overall sensitivity, specificity, negative predictive value (NPV), and diagnostic accuracy for all procedures were 87.41 % (CI 80.76-91.99), 100 % (CI 93.12-100), 75.36 % (CI 64.04-84.01), and 90.91 % (CI 85.92-94.25), respectively. The NPV increased significantly after the initial 25 procedures and remained high thereafter. EBUS-TBNA was more accurate (96.12 % (CI 91.25-98.33)) with higher NPV (90.74 % (CI 80.09-95.98)) in patients with suspected malignancy compared with patients with suspected benign disease (79.31 % (CI 67.23-87.75), 20 % (7.05-45.19)). Samples from relatively smaller LN (>5 to ≤20 mm) and from all analyzed LN stations were similarly accurate with high sensitivity and NPV. EBUS-TBNA allows safe real-time sampling of mediastinal and hilar lesions under conscious sedation with high diagnostic accuracy. The NPV is high and increased significantly after the initial 25-50 procedures. This is comparable to available surgical techniques, including mediastinoscopy, when malignancy is suspected. The NPV for specific benign disease remains low in our experience. The diagnostic yield is not affected by the LN station, size, or the number of passes per LN station.

The Intubated Patient With Mediastinal Disease—A Role for Esophageal Access Using the Endobronchial Ultrasound Bronchoscope

Ultrasound-guided transbronchial needle aspiration using the bronchoscope with a dedicated curvilinear probe has emerged as a primary tool for the investigation of mediastinal pathology. Recently, the utility of this scope has been expanded to include access via the esophagus. In this case series, we describe a role for esophageal ultrasound using the endobronchial ultrasound bronchoscope in the diagnostic evaluation of critically ill/intubated patients with mediastinal disease. Esophageal access with the ultrasound bronchoscope allows the pulmonologist to diagnose mediastinal disease in the intubated patient with minimal risk.

46 Benign ultrasound appearances of intra-thoracic lymph nodes during endobronchial ultrasound (EBUS) bronchoscopy predicts benign aetiology

46 Benign ultrasound appearances of intra-thoracic lymph nodes during endobronchial ultrasound (EBUS) bronchoscopy predicts benign aetiology

45 Proposed quality measures and quality indicators for providing an endobronchial ultrasound (EBUS) bronchoscopy service

45 Proposed quality measures and quality indicators for providing an endobronchial ultrasound (EBUS) bronchoscopy service

ROTIG (Rapid Orotracheal Intubation Guide): A Novel New Device for Ease of Intubation With the Endobronchial Ultrasound Bronchoscope (EBUS

ROTIG (Rapid Orotracheal Intubation Guide): A Novel New Device for Ease of Intubation With the Endobronchial Ultrasound Bronchoscope (EBUS

Endobronchial-Ultrasound Guided Miniforceps Biopsy of Mediastinal and Hilar Lesions

Linear array endobronchial ultrasound (EBUS) has greatly improved the diagnostic yield of transbronchial needle aspiration (TBNA) for the diagnosis of non-small cell lung carcinoma though its yield in granulomatous disease and lymphoproliferative disorders is less robust. The EBUS-miniforceps biopsy (MFB) uses miniforceps and the convex probe EBUS bronchoscope to obtain forceps biopsies of centrally located lesions under continuous ultrasound guidance. In this prospective study we evaluate the efficacy of this technique for diagnosing mediastinal and hilar abnormalities in patients with a low suspicion for non-small cell lung carcinoma. Patients presenting with mediastinal or hilar lymphadenopathy and a low likelihood of non-small cell lung carcinoma underwent EBUS-TBNA and EBUS-MFB of mediastinal and hilar abnormalities. The diagnostic yield EBUS-TBNA and EBUS-MFB was compared as was the combined yield of both techniques versus either technique alone. Between June 2008 and July 2010, 50 patients underwent EBUS-TBNA and EBUS-MFB of 74 lymph node stations. The overall diagnostic yield of EBUS-TBNA and EBUS-MFB was 81% (60 of 74) and 91% (67 of 74), respectively (p=0.09). When the 2 techniques were combined, the overall diagnostic yield was 97% (72 of 74) (p<0.001), which was significant when compared with EBUS-TBNA alone. No complications were observed as a result of EBUS-MFB, and EBUS-MFB did not appear to significantly prolong the procedure. The EBUS-miniforceps biopsy is an effective, safe, and efficient method of obtaining histopathologic specimens from mediastinal and hilar abnormalities in patients with a low likelihood of non-small cell lung carcinoma, particularly when the technique is combined with EBUS-TBNA.

Transesophageal Bronchoscopic Ultrasound-Guided Fine-Needle Aspiration for Diagnosis of Peripheral Lung Cancer

Peripheral lung cancer is still a diagnostic challenge. The transbronchial approach with bronchoscopy or the transthoracic approach with radiologic imaging has been used extensively for the pathologic diagnosis of peripheral lung cancer. However, the explorability or feasibility with these modalities depends on the lesion location or patient's respiratory function. Herein, we report a case with severe pulmonary emphysema and lung cancer located at a parenchymal region difficult to access through an airway with a bronchoscope. Successful diagnosis was obtained by a transesophageal ultrasound-guided needle aspiration using an endobronchial ultrasound bronchoscope. This technique is accurate and less invasive in the primary diagnosis of lung cancer adjoining the esophagus.