Endobronchial Ultrasound Procedures Research Articles

Factors Associated With Successful Diagnosis of Infections With Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Performed for Mediastinal or Hilar Lymphadenopathy

SESSION TITLE: Rapid Session: Interventional Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 03:15 PM - 04:15 PM PURPOSE: Although endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA) of lymph nodes is frequently performed to diagnose cancer or sarcoidosis, the yield of this procedure for diagnosing infectious causes of mediastinal lymphadenopathy is unknown. Reported use of EBUS-TBNA in diagnosing infections other than tuberculosis is limited to case reports and case series, and diagnostic sensitivity of EBUS-TBNA for diagnosing infections has not been evaluated in large-scale studies. It is unclear if the low incidence of infectious diagnoses by this approach is the result of TBNA samples not being submitted for microbiologic studies, a low incidence of infection in the population being examined or a true limitation of the procedure. We aimed to identify pre-procedure factors that were associated with an ultimate diagnosis of infection. METHODS: All patients undergoing EBUS-TBNA performed by pulmonary and critical care medicine physicians for hilar and/or mediastinal lymphadenopathy at Los Angeles County Medical Center and Keck Medical Center of the University of Southern California from 2010-2016 were included. We report counts with percentages and means with standard deviations; multivariate logistic regression results are reported as odds ratio (OR) with 95% confidence interval (CI). All analyses were performed with SAS 9.4. RESULTS: 166 patients who underwent EBUS TBNA were analyzed. Patients tended to be male (55%) with an average age of 60. Half the patients had a history of cancer, while 2.4% of patients were seropositive for human immunodeficiency virus. Final diagnoses were cancer, sarcoidosis, and infection (mainly mycobacterial and coccidioidal) in 49%, 14%, and 10%, respectively. In multivariate analyses, only the clinician’s pre-procedural indication of “rule out infection” was associated with an infectious diagnosis (OR 5.51, 95% CI 1.40 - 21.74). Patient-specific variables such as age, past medical history, and lymph node or lung parenchymal radiographic features were not associated with final infectious diagnoses. The EBUS procedure was non-diagnostic in 3 cases that were subsequently diagnosed with infections by other means. CONCLUSIONS: In a retrospective review in an endemic region, Shah et al found that only 5 of 119 diagnostic EBUS-TBNA cases yielded a diagnosis of coccidioidomycosis, while Harris et al reported only 3 infections in 82 EBUS-TBNA sampled patients. The diagnosis of infections with EBUS-TBNA is uncommon, and often unexpected. Our small study shows that this diagnosis cannot be predicted from any patient demographic, lymph node or parenchymal radiographic patterns. However, a pre-procedural suspicion for infection significantly increased the odds of an infection being ultimately diagnosed with EBUS-TBNA. CLINICAL IMPLICATIONS: In patients undergoing EBUS-TBNA for mediastinal or hilar lymphadenopathy, subjective clinical suspicion for an infectious etiology was the only factor that correlated with an eventual infectious diagnosis. We suggest that clinicians consider sending EBUS-TNBA samples in such patients also for microbiological studies. Whether this practice would lead to more infectious diagnoses with EBUS-TBNA remains to be determined. DISCLOSURE: The following authors have nothing to disclose: Udit Chaddha, Andrew Morado, Ching-Fei Chang, Alex Balekian, Ramyar Mahdavi No Product/Research Disclosure Information

Endobronchial ultrasound transbronchial biopsy with guide-sheath for the diagnosis of solitary pulmonary nodules.

The aim of this study was to assess the usefulness of endobronchial ultrasound transbronchial biopsy with guide-sheath (EBUS-GS-TBB) for the diagnosis of solitary pulmonary nodules (SPNs). One hundred and eighty patients, who were diagnosed with SPNs and underwent an endobronchial ultrasound procedure. The diagnostic yield, safety and the associated factors were analyzed. Mean EBUS-GS procedure time was 14±8 min. The average number of biopsy specimens obtained in each SPNs was 5±1.2. One hundred and thirty-four SPNs were diagnosed by EBUS-GS-TBB and the diagnostic rate was 74.4 %. The diagnosis rate of malignancy was 83.3 %, while that of benign disease was 56.7 %. The most important factors that helped enhance EBUS-GS diagnostic accuracy included lesion diameter greater than 20mm, EBUS probe within the lesions and central lesions. No pneumothorax, hemoptysis or other serious complications occurred with the diagnostic procedures. EBUS-GS-TBB is a safe and effective method for diagnosing SPNs.

Decreasing wait times for endobronchial ultrasound (EBUS).

192 Background: The department of pulmonary medicine evaluates manifestations of cancer and complications of therapy that affect the lungs. It is a procedurally oriented specialty with many diagnostic and therapeutic interventions. Endobronchial ultrasound with transbronchial fine needle aspiration (EBUS-TBNA) is a minimally invasive procedure that allows real time image guided sampling of tissue in the mediastinum. Current guidelines recommend use of EBUS for the initial test to diagnosis and stage lung cancer. It has a low complication rate, but needs specialized equipment as well as anesthesia support. Alternatives include CT-guided biopsy or surgery. The delay from time of referral to EBUS procedure has the potential to delay diagnosis and treatment, create patient anxiety, frustration and expense of travel for multiple appointments. The staff is under pressure to perform excessive cases on a daily basis resulting in overtime staffing costs. Our objectives were to reduce delays in diagnosis/treatment, improve patient satisfaction, improve referring services satisfaction and optimize the use of resources and improve staff working conditions. Methods: We used a Plan, Do, Study, Act process. Initially the process flow diagram was utilized along with a fishbone diagram to allow us to focus on the issues. The aim was to decrease EBUS wait time 20% by 7/2016. Our process flow sheet was arranged into swimlanes in order to identify focus areas. This allowed us to redesign the workflow to improve capacity and improve existing resources to be more efficient. Results: Working with anesthesia services and the cardiopulmonary center staff, we were able to open a second bronchoscopy suite 2 days a week for additional EBUS cases. We also had monthly meetings with issues and to monitor delays to other services. Conclusions: We were able to reduce our wait time from 7.5 days to 4.27 work days. The added capacity allows for surge in demand for EBUS. Our future studies will concentrate on patient and referring service satisfaction, cost savings with reduction in overtime, quantifying impact on decreasing delays in diagnosis and subsequent treatment.

Electromagnetic Navigation Bronchoscopy

OBJECTIVE: Suspicious pulmonary nodules have become a more common finding since the advent of CT scans as a screening method for lung cancer. The challenge is to find a safer, practical and more accurate way to diagnose peripheral nodules and lesions while minimizing harm to the patient. Electromagnetic Navigation Bronchoscopy (ENB) is a cutting edge technology that enables pulmonologists to precisely target small and difficult to reach peripheral pulmonary nodules by using technology similar to a global positioning system (GPS).This study describes our experience in using ENB with Endobronchial ultrasound (EBUS) as a diagnostic tool on patients suspected of lung malignancy. MATERIALS AND METHODS: A retrospective analysis was conducted for 33 patients between November 2014 and November 2015 at our institution. Yield was determined by attaining final diagnosis from tissue analysis of every patient who underwent the ENB and EBUS procedure for suspected lung malignancy. Patients with no definite diagnosis were referred to surgery for further examination. Intraoperative and postoperative complications were recorded. RESULTS: The ENB and EBUS procedure was completed in all 33 subjects on lung nodules measuring from 2 to 108mm. The patients were 67% (22) male, 33% (11) female, 88% (29) Asian, with a mean age of 61 years old. Lung nodules were located in the upper lobe (52%), lower lobe (43%) and middle lobe (5%). Lymph node involvement was present in 33% of cases. Of the patients in the study, 26 cases (79%) were accurately diagnosed using ENB and EBUS, 6 cases (18%) were referred to surgery and 1 patient (3%) refused further investigation. No bleeding or pneumothorax complications were reported. CONCLUSION: ENB is an effective, accurate and a novel method that provides real time directions toward lung lesions and nodules. This tool allows flexibility that aids biopsy of hard to reach areas, and attains adequate tissue samples. This instrument compliments other bronchoscopic methods such as EBUS.

P1.04-003 Incidence of Non-Caseating Granulomas Diagnosed in PET Avid Mediastinal/Hilar Nodes in Patients with Known Breast Cancer

Breast cancer is known to metastasize to the lung.. Most breast malignancies are clinically staged using radiographic modalities (e.g. PET scans). Importantly, many inflammatory disorders will present similar lymph node FDG-uptake on PET- as that of metastasized breast cancer. The latter confuses the treatment for individuals within whom both undiagnosed autoimmune disorders and breast cancer co-occur. We aim to examine the frequency of non-caseating granulomas diagnosed in PET avid mediastinal/hilar nodes in patients with known breast cancer. Between March 2013 and December 2015, 46 patients diagnosed with breast cancer were staged by PET-CT. Those with positive result in the mediastinum/hilum underwent linear endobronchial ultrasound (EBUS) for pathologic diagnosis and ensuing treatment. Of the 46 patients with avid mediastinal/hilar adenopathy, 31 (67%) had malignant cytology on EBUS; the remaining 15 had positive PET but negative cytology for malignancy. Twelve of the 15 patients with false positive PET had reactive lymph nodes, and 3 had non-caseating granulomas on cytology (table 1). Table 1Results from EBUS Procedure and Resulting Percentage Following Identification of Sarcoid-like SymptomsTotal Number of patients in study: n=46 with positive PETNumber of patientsPercentage of total (all PET positive patients)Percentage among negative patientsPositive EBUS3167.40%Negative EBUS1226.10%80%Negative/Non-caseating granulomas EBUS36.50%20% Open table in a new tab Twenty percent of the patients with negative cytology and positive PET had non-caseating granuloma, and 6.5 % of all patients with positive PET had non-caseating granulomas. This study represents the largest cohort of breast cancer patients, where the incidence of non-caseating granulomas is investigated in PET-positive mediastinal/hilar nodes. We conclude that PET may not be sufficient for staging the mediastinum in patients with breast cancer and, in selected patients, pathologic staging should be done. In addition, the finding of non-caseating granulomas in these patients may either indicate an incidental diagnosis of early stage sarcoidosis, or an inflammatory reaction to the current treatment (sarcomatoid reaction). We also suggest that these patients should be followed for any manifestations of sarcoidosis.

Re-biopsy by endobronchial ultrasound procedures for mutation analysis of non-small cell lung cancer after EGFR tyrosine kinase inhibitor treatment.

BackgroundRe-biopsy for resistant non-small cell lung cancer (NSCLC) after treatment with epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) is important for selection of better therapy, but there have been no reports about the utility of endobronchial ultrasound (EBUS)-guided procedures for such purpose. The aim of this study was to evaluate the utility of EBUS-guided re-biopsy for resistant NSCLC after treatment with EGFR-TKIs.MethodsFrom January 2013 to December 2015, 53 consecutive patients who underwent EBUS-guided re-biopsy for mutation analysis of NSCLC after EGFR-TKI treatment were assessed.ResultsNine patients underwent EBUS-guided transbronchial needle aspiration (EBUS-TBNA) and 44 patients underwent EBUS with a guide sheath (EBUS-GS) transbronchial biopsy. The technical success rates were 100 %. As for mutation analysis, all 9 specimens (100 %) from EBUS-TBNA and 33 specimens (75.0 %) from EBUS-GS were adequate for gene profiling. The remaining 11 specimens from EBUS-GS procedures were inadequate for mutation analysis owing to the absence of tumor component in the sample (n = 6) or insufficient specimen (n = 5). There were no related severe complications.ConclusionsRe-biopsy by both EBUS-TBNA and EBUS-GS were useful and safe sampling procedures for mutation analysis of EGFR-TKI resistant NSCLC.

Establishment of an endobronchial ultrasound-guided transbronchial fine needle aspiration service with rapid on-site evaluation: 2 years experience of a single UK centre.

Endobronchial ultrasound (EBUS)-guided transbronchial fine needle aspiration (TBFNA) is now well established as a minimally invasive, effective investigation which can provide information on both diagnosis and stage of lung cancer and is also useful in the investigation of mediastinal lymphadenopathy of uncertain aetiology. The service can be provided with or without rapid on-site evaluation (ROSE) for specimen triage and provisional diagnosis. We outline our experience from the first 2 years of providing an EBUS service with ROSE, highlighting the practicalities of service provision, pitfalls encountered and lessons learned. Aspirates from all EBUS procedures performed during the first 2 years of our service from 16 October 2012 to 15 October 2014 are included. We describe the activities undertaken prior to each EBUS list, the EBUS TBFNA procedure, specimen handling and procedure for ROSE. A total of 591 aspirates were performed from 352 patients, including 573 (97%) lymph node aspirates, 17 (2.9%) lung mass samples and one aspirate from a retrosternal thyroid cyst (0.1%). There were 498 (84.1%) adequate samples at ROSE, 82 (13.9%) inadequate, one (0.2%) abandoned and 11 (1.9%) where ROSE was not performed. Four hundred and seventy (79.5%) samples showed concordance between the ROSE and final diagnoses. No adequate samples were obtained for 11 patients (3.1%) after final cytological analysis, resulting in a final adequacy rate of 96.9%. In our experience, ROSE provides a clear advantage in providing a patient-centred EBUS service by facilitating specimen triage, ensuring adequate sampling and providing a rapid provisional diagnosis, however, there is a learning curve for both the clinicians and cytopathologists involved.

Endosonography for mediastinal disease: esophageal ultrasound vs. endobronchial ultrasound.

Background and study aims: One can approach mediastinal pathology via esophageal ultrasound (EUS) and/or endobronchial ultrasound (EBUS). It has been suggested that EUS is better tolerated by patients. If so, EUS might be the procedure of choice when suspect lesions are accessible via EUS. We studied procedural characteristics of EUS with fine needle aspiration (EUS-FNA) and EBUS with transbronchial needle aspiration (EBUS-TBNA) to see how they differed. Patients and methods: Retrospective review of consecutive EBUS and EUS procedures performed on patients over nine months. One hundred fifty-five procedures were analyzed (61 EUS, 73 EBUS, 21 EUS + EBUS). For EUS, EBUS, and EUS + EBUS, 1.4, 2.0 and 2.5 sites (mean) were sampled, respectively. EUS required approximately one-half of the time of EBUS or the combined procedures; 13.1 vs. 24.1 and 26.9 min, respectively (P < 0.0001 for EUS vs. both EBUS and EUS + EBUS). Sedation dosing was statistically lower for EUS and not significantly different between EBUS and the combined approach. EUS also involved lower oxygen requirements and shorter time to discharge. Because fewer mean sites were sampled with EUS than with EBUS or the combined procedure, we performed analysis restricted to procedures that involved sampling of ≤ 2 sites to determine whether approach-related differences in procedure characteristics were preserved. There were 56 such EUS procedures and 52 such EBUS procedures. EUS remained significantly faster and required less patient sedation. Conclusions: EUS involved statistically significant economies of time and sedation. This has implications with respect to safety and productivity. When applicable, EUS is the procedure of choice.

Differentiating benign from malignant mediastinal lymph nodes visible at EBUS using grey-scale textural analysis.

Recent data suggest that grey-scale textural analysis on endobronchial ultrasound (EBUS) imaging can differentiate benign from malignant lymphadenopathy. The objective of studies was to evaluate grey-scale textural analysis and examine its clinical utility. Images from 135 consecutive clinically indicated EBUS procedures were evaluated retrospectively using MATLAB software (MathWorks, Natick, MA, USA). Manual node mapping was performed to obtain a region of interest and grey-scale textural features (range of pixel values and entropy) were analysed. The initial analysis involved 94 subjects and receiver operating characteristic (ROC) curves were generated. The ROC thresholds were then applied on a second cohort (41 subjects) to validate the earlier findings. A total of 371 images were evaluated. There was no difference in proportions of malignant disease (56% vs 53%, P = 0.66) in the prediction (group 1) and validation (group 2) sets. There was no difference in range of pixel values in group 1 but entropy was significantly higher in the malignant group (5.95 vs 5.77, P = 0.03). Higher entropy was seen in adenocarcinoma versus lymphoma (6.00 vs 5.50, P < 0.05). An ROC curve for entropy gave an area under the curve of 0.58 with 51% sensitivity and 71% specificity for entropy greater than 5.94 for malignancy. In group 2, the entropy threshold phenotyped only 47% of benign cases and 20% of malignant cases correctly. These findings suggest that use of EBUS grey-scale textural analysis for differentiation of malignant from benign lymphadenopathy may not be accurate. Further studies are required.

Diagnosis of pulmonary embolism by endobronchial ultrasound.

This is a case report of a young 20-year-old male who was referred for an endobronchial ultrasound (EBUS) procedure to investigate a fever and a left hilar lymph node and patchy pleural-based opacities seen on CT of the chest. During the EBUS procedure besides the left hilar node, a large thrombus was noticed in the main pulmonary artery and another one in the right pulmonary artery. EBUS proved invaluable in making a diagnosis in an unsuspected case of pulmonary embolism.

P275 Ebus Or Eus In The Diagnosis Of Sarcoidosis?

Introduction The utility of endoscopic ultrasonography in the diagnosis of sarcoidosis was shown in the GRANULOMA trial. 1 However, in the study, two thirds of samples were obtained using Endoscopic Ultrasound (EUS) via the gastrointestinal tract, and one third by Endobronchial Ultrasound (EBUS). Since this does not reflect typical practice in many areas, we assessed the diagnostic sensitivity of EBUS in suspected sarcoidosis and whether sampling nodes not accessible by EUS confers benefit. Methods We retrospectively collected data relating to 128 consecutive patients in two separate experienced centres, who underwent EBUS over a 3 year period (2011–2013) with a pretest differential diagnosis of sarcoidosis. Final diagnosis was based on decision at subsequent clinic review. Results 129 EBUS procedures were performed in 128 patients (57% male, mean (range) age 49 (22–79) years. 221 nodal stations were sampled (median of 2 stations each patient) with no significant complications. Concurrent trans-bronchial biopsy (TBB) was carried out in 30 patients and endobronchial biopsy (EBB) in 10. Overall diagnostic sensitivity (for each biopsy procedure alone) was as follows: EBB 44%, TBB 50%, EBUS 71%, while combining EBUS with EBB/TBB conferred a sensitivity of 79%. Diagnostic sensitivity of EBUS was 77% for stage 1 and 62% for stage 2 sarcoidosis, and increased according to number of stations sampled (1 station 66%, 2 stations 70%, ≥3 stations 92%). Sensitivity from EUS-accessible nodes (Stations 7 and 4) was 72%, while this was 56% in EUS- inaccessible nodes (Stations 2, 10 and 11). If EUS-accessible nodes were present and sampled, additional sampling of EUS-inaccessible nodes did not further the diagnosis. Conclusions In suspected sarcoidosis, the diagnostic yield of EBUS was 71%. Using additional bronchial biopsy techniques increased this by 8%. Mediastinal nodes, accessible by both EUS and EBUS, would appear to be the preferred site of sampling. However, EBUS allows sampling of nodes not accessible to EUS, which may be diagnostic if there is isolated hilar lymphadenopathy. Reference von Bartheld MB, Dekkers OM, Szlubowski A, et al . Endosonography vs Conventional Bronchoscopy for the Diagnosis of Sarcoidosis. JAMA ; 2013;309(23): 2547-2464

Real-time prediction of mediastinal lymph node malignancy by endobronchial ultrasound

ObjectiveTo evaluate the utility of different ultrasonographic (US) features in differentiating benign and malignant lymph node (LN) by endobronchial ultrasound (EBUS) and validate a score for real-time clinical application. MethodsA total of 208 mediastinal LNs acquired from 141patients were analyzed. Six different US criteria were evaluated (short axis ≥10mm, shape, margin, echogenicity, central hilar structure [CHS], and presence of hyperechoic density) by two observers independently. A simplified score was generated where the presence of margin distinction, round shape and short axis ≥10mm were scored as 1, and heterogeneous echogenicity and absence of CHS were scored as 1.5. The score was evaluated prospectively for real-time clinical application in 65 LNs during EBUS procedure in 39patients undertaken by two experienced operators. These criteria were correlated with the histopathological results and the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated. ResultsBoth heterogenicity and absence of CHS had the highest sensitivity and NPV (≥90%) for predicting LN malignancy with acceptable inter-observer agreement (92% and 87% respectively). On real-time application, the sensitivity and specificity of the score >5 were 78% and 86% respectively; only the absence of CHS, round shape and size of LN were significantly associated with malignant LN. ConclusionsA combination of different US criteria can be useful for the prediction of mediastinal LN malignancy and valid for real-time clinical application.

Learning Experience of Linear Endobronchial Ultrasound Among Pulmonary Trainees

Linear endobronchial ultrasound (EBUS) allows real-time guidance of transbronchial needle aspiration of thoracic structures and has become an increasingly important diagnostic tool for chest physicians. Little has been published about the learning experience of operators with this technology. The purpose of this study was to define the learning experience of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) among pulmonary trainees. This was a multicenter cohort study of fellows in pulmonary medicine over the first 2 years of their training. Prior to performing EBUS-TBNA, all participants had to complete 30 conventional bronchoscopies, an EBUS-specific didactic curriculum, and a simulation session with a plastic airway model. Each consecutive EBUS procedure was scored with a checklist that evaluated the ability to pass a bronchoscope through vocal cords, identify the appropriate node for sampling, acquire adequate ultrasound images, guide the bronchoscopy team through the technical steps of EBUS-TBNA, and obtain adequate tissue samples. Thirteen pulmonary trainees from three training programs were enrolled in the study and were observed over a 2-year period. The majority of trainees were able to perform all essential steps of EBUS-TBNA and obtain adequate tissue after performing an average of 13 (95% CI, 7-16) procedures. Pulmonary trainees needed an average of 13 procedures to achieve first independent successful performance of EBUS-TBNA following a training protocol that included a didactic curriculum and simulation-based practice. Our findings could guide pulmonary fellowship directors in planning EBUS training and establishing a reasonable juncture to assess EBUS skills with validated assessment tools.

Predicción en tiempo real de la malignidad de ganglios linfáticos mediastínicos mediante ecografía endobronquial

ObjectiveTo evaluate the utility of different ultrasonographic (US) features in differentiating benign and malignant lymph node (LN) by endobronchial ultrasound (EBUS) and validate a score for real-time clinical application. Methods208 mediastinal LN acquired from 141patients were analyzed. Six different US criteria were evaluated (short axis ≥10mm, shape, margin, echogenicity, and central hilar structure [CHS], and presence of hyperechoic density) by two observers independently. A simplified score was generated where the presence of margin distinction, round shape and short axis ≥10mm were scored as 1 and heterogeneous echogenicity and absence of CHS were scored as 1.5. The score was evaluated prospectively for real-time clinical application in 65 LN during EBUS procedure in 39patients undertaken by two experienced operators. These criteria were correlated with the histopathological results and the sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated. ResultsBoth heterogenicity and absence of CHS had the highest sensitivity and NPV (≥90%) for predicting LN malignancy with acceptable inter-observer agreement (92% and 87% respectively). On real-time application, the sensitivity and specificity of the score >5 were 78% and 86% respectively; only the absence of CHS, round shape and size of LN were significantly associated with malignant LN. ConclusionsCombination of different US criteria can be useful for prediction of mediastinal LN malignancy and valid for real-time clinical application.

Training for Linear Endobronchial Ultrasound Among US Pulmonary/Critical Care Fellowships: A Survey of Fellowship Directors

Endobronchial ultrasound (EBUS) has revolutionized the ability of bronchoscopists to visualize and sample structures surrounding the tracheobronchial tree. It has been shown to be safe, minimally invasive, and highly accurate in the staging and diagnosing of mediastinal diseases. A prior survey of pulmonary fellowship program directors conducted in 2004 showed that only 2% of programs offered EBUS training. Surveys were mailed to 154 pulmonary/critical care fellowship directors in the United States and Puerto Rico. Demographics of the fellowship and details of EBUS training were recorded. A comparison of EBUS volume was made between programs with and without an identifiable interventional pulmonologist (IP). The survey response rate was 71%. EBUS equipment was available at 89% of programs. Of those without EBUS, 100% expressed the goal of obtaining equipment within the year. An identifiable IP was present in 70% of programs. This was associated with more EBUS procedures performed by trainees ( P , .01). Only 30% of programs have a formal protocol in place to evaluate EBUS competency. Conventional transbronchial needle aspiration is routinely taught in 89% of fellowship programs. EBUS exposure has rapidly disseminated into fellowship training programs, and programs with an identifiable IP are more likely to provide fellows with more EBUS procedures. The findings of this survey point out the need to develop a standardized protocol for EBUS competency that includes current recommendations and may require training with simulation.

Evaluation of a Novel Method of Teaching Endobronchial Ultrasound: Physician- Versus Respiratory Therapist-Proctored Simulation Training

Computer endobronchial ultrasound (EBUS) simulators have been demonstrated to improve trainee procedural skills before attempting to perform EBUS procedures on patients. To compare EBUS performance following training with computer simulation proctored by EBUS-trained respiratory therapists versus the same simulation training proctored by an interventional respirologist. The present analysis was a prospective study of respiratory medicine trainees learning EBUS. Two cohorts of trainees were evaluated using a previously validated method using simulated cases with performance metrics measured by the simulator. Group 1 underwent EBUS training by performing 15 procedures on an EBUS simulator (n=4) proctored by an interventional respirologist. Group 2 received identical training proctored by a respiratory therapist with special training in EBUS (n=10). No significant differences between group 1 and group 2 were apparent for the primary outcome measures of total procedure time (15.15±1.34 min versus 14.78±2.88 min; P=0.816), the percentage of lymph nodes successfully identified (88.8±5.4 versus 80.91±8.9; P=0.092) or the percentage of successful biopsies (100.0±0.0 versus 98.75±3.95; P=0.549). The learning curves were similar between groups, and did not show an obvious plateau after 19 simulated procedures in either group. Acquisition of basic EBUS technical skills can be achieved using computer EBUS simulation proctored by specially trained respiratory therapists or by an interventional respirologist. There appeared to be no significant advantage to having an interventional respirologist proctor the computer EBUS simulation.

Optical Differentiation Between Malignant and Benign Lymphadenopathy by Grey Scale Texture Analysis of Endobronchial Ultrasound Convex Probe Images

Morphologic and sonographic features of endobronchial ultrasound (EBUS) convex probe images are helpful in predicting metastatic lymph nodes. Grey scale texture analysis is a well-established methodology that has been applied to ultrasound images in other fields of medicine. The aim of this study was to determine if this methodology could differentiate between benign and malignant lymphadenopathy of EBUS images. Lymph nodes from digital images of EBUS procedures were manually mapped to obtain a region of interest and were analyzed in a prediction set. The regions of interest were analyzed for the following grey scale texture features in MATLAB (version 7.8.0.347 [R2009a]): mean pixel value, difference between maximal and minimal pixel value, SEM pixel value, entropy, correlation, energy, and homogeneity. Significant grey scale texture features were used to assess a validation set compared with fluoro-D-glucose (FDG)-PET-CT scan findings where available. Fifty-two malignant nodes and 48 benign nodes were in the prediction set. Malignant nodes had a greater difference in the maximal and minimal pixel values, SEM pixel value, entropy, and correlation, and a lower energy (P < .0001 for all values). Fifty-one lymph nodes were in the validation set; 44 of 51 (86.3%) were classified correctly. Eighteen of these lymph nodes also had FDG-PET-CT scan assessment, which correctly classified 14 of 18 nodes (77.8%), compared with grey scale texture analysis, which correctly classified 16 of 18 nodes (88.9%). Grey scale texture analysis of EBUS convex probe images can be used to differentiate malignant and benign lymphadenopathy. Preliminary results are comparable to FDG-PET-CT scan.

Lingual Nerve Paralysis After Endobronchial Ultrasound Utilizing Laryngeal Mask Airway

A 52-year-old woman developed loss of sensation and taste in the anterior two thirds of her tongue after undergoing endobronchial ultrasound-guided transbronchial needle aspiration using a laryngeal mask airway (LMA). This was believed to be due to bilateral lingual nerve injury, likely caused by stretching of tissue of the upper airway because of repetitive movements of LMA during attempts to obtain a clearer ultrasound image to direct needle insertion. To the best of our knowledge, this is the first report of lingual nerve injury after an endobronchial ultrasound procedure using LMA.

Pseudoaneurysm of brachiocephalic artery mimicking the mediastinal tumor

58 year-old male admitted to the Hospital of Lithuanian University of Health Sciences due to suspicion of mediastinal tumor for diagnostic endobronchial ultrasound procedure (EBUS). The main patient's complain was progressive dyspnea. Objective investigation revealed no major findings: normal breath sounds, heart rate – 96 bpm, blood pressure – 120/80 mmHg. Chest CT scan showed the mediastinal tumor of 3.8 × 3.5 cm. During bronchoscopy smooth intratracheal nodule of 5 mm was found. Superficial biopsy showed normal airway mucosa. During EBUS procedure no clear lymph node structure or blood flow was detected. It was decided to observe the patient clinically. One month later massive hemoptysis started. Urgent bronchoscopy revealed large right-sided mass and intratracheal wall dislocation due to the possible mediastinal tumor in the same location as the polyp in the previous investigation. Repeated chest CT scan showed increasing tumor of size 4.0 × 3.2 × 4.0 cm in the mediastinum and pseudoaneurysm of brachiocephalic artery was suspected. The diagnosis was later confirmed by aortography. The patient underwent successful aneurysmectomy.

A comparative study on endobrochial ultrasound-guided and fluoroscopic-guided transbronchial lung biopsy of peripheral pulmonary lesions

Bronchoscopic lung biopsy using fluoroscopic guidance is the standard procedure for the diagnosis of peripheral pulmonary lesions. Peripheral lesions can also be biopsied using endobronchial ultrasound (EBUS) guidance, which is equally effective and does not expose the patient or staff to radiation. We determined the diagnostic yield of EBUS- and fluoroscopic-guided bronchoscopic lung biopsy (BLB) under everyday, clinical conditions, and compared our results to published data. A total of 304 consecutive patients with peripheral pulmonary lesions who underwent EBUS- or fluoroscopy-guided BLB were included in this study. We compared the diagnostic yield of EBUS- and fluoroscopy-guided bronchoscopic lung biopsy (BLB) to determine which method is more sensitive for the diagnosis of peripheral pulmonary lesions. EBUS-guided BLB was performed in 116 patients, and fluoroscopy-guided BLB was used in 188. The median diameter of the peripheral pulmonary lesions in the EBUS group was 31.5 mm (9-125) compared with 34.5 mm (6-100) in the fluoroscopy group. Diagnostic biopsy samples were obtained from 89 (77%) patients using EBUS and from 139 (74%) patients using fluoroscopy-guided BLB. The difference in the diagnostic outcome between these methods was not statistically significant. The results of our study showed that the diagnostic yield was similar between EBUS- and fluoroscopy-guided BLB, although our findings suggest that more positive outcomes are expected with EBUS. The EBUS procedure is safer because it does not involve exposure of the patient or medical staff to radiation.