- •Foreword
- •Preface
- •Contents
- •About the Editors
- •Contributors
- •1: Tracheobronchial Anatomy
- •Trachea
- •Introduction
- •External Morphology
- •Internal Morphology
- •Mucous Layer
- •Blood Supply
- •Anatomo-Clinical Relationships
- •Bronchi
- •Main Bronchi
- •Bronchial Division
- •Left Main Bronchus (LMB)
- •Right Main Bronchus (RMB)
- •Blood Supply
- •References
- •2: Flexible Bronchoscopy
- •Introduction
- •History
- •Description
- •Indications and Contraindications
- •Absolute Contraindications
- •Procedure Preparation
- •Technique of FB Procedure
- •Complications of FB Procedure
- •Basic Diagnostic Procedures
- •Bronchoalveolar Lavage (BAL)
- •Transbronchial Lung Biopsy (TBLB)
- •Transbronchial Needle Aspiration (TBNA)
- •Bronchial Brushings
- •Advanced Diagnostic Bronchoscopy
- •EBUS-TBNA
- •Ultrathin Bronchoscopy
- •Transbronchial Lung Cryobiobsy (TBLC)
- •Therapeutic Procedures Via FB
- •LASER Bronchoscopy
- •Electrocautery
- •Argon Plasma Coagulation (APC)
- •Cryotherapy
- •Photodynamic Therapy
- •Airway Stent Placement
- •Endobronchial Valve Placement
- •Conclusion
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •Procedure Description
- •Procedure Planning
- •Target Approximation
- •Sampling
- •Complications
- •Future Directions
- •Summary and Recommendations
- •References
- •4: Rigid Broncoscopy
- •Innovations
- •Ancillary Equipment
- •Rigid Bronchoscopy Applications
- •Laser Bronchoscopy
- •Tracheobronchial Prosthesis
- •Transbronchial Needle Aspiration (TBNA)
- •Rigid Bronchoscope in Other Treatments for Bronchial Obstruction
- •Mechanical Debridement
- •Pediatric Rigid Bronchoscopy
- •Tracheobronchial Dilatation
- •Foreign Bodies Removal
- •Other Indications
- •Complications
- •The Procedure
- •Some Conclusions
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •Preprocedural Evaluation and Preparation
- •Physical Examination
- •Procedure-Related Indications
- •Application of the Technique
- •Topical Anesthesia
- •Anesthesia of the Nasal Mucosa and Nasopharynx
- •Anesthesia of the Mouth and Oropharynx
- •Superior Laryngeal Nerve Block
- •Recurrent Laryngeal Nerve Block (RLN)
- •Conscious Sedation
- •Monitored Anesthesia Care (MAC)
- •General Anesthesia
- •Monitoring the Depth of Anesthesia
- •Interventional Bronchoscopy Suites
- •Airway Devices
- •Laryngeal Mask Airway (LMA)
- •Endotracheal Tube (ETT)
- •Rigid Bronchoscope
- •Modes of Ventilation
- •Spontaneous Ventilation
- •Assisted Ventilation
- •Noninvasive Positive Pressure Ventilation (NIV)
- •Positive Pressure Controlled Mechanical Ventilation
- •Jet Ventilation
- •Electronic Mechanical Jet Ventilation
- •Postprocedure Care
- •Special Consideration
- •Anesthesia for Peripheral Diagnostic and Therapeutic Bronchoscopy
- •Anesthesia for Interventional Bronchoscopic Procedures During the COVID-19 Pandemic
- •Summary and Recommendations
- •Conclusion
- •References
- •Background
- •Curricular Structure and Delivery
- •What Is a Bronchoscopy Curriculum?
- •Tradition, Teaching Styles, and Beliefs
- •Using Assessment Tools to Guide the Educational Process
- •The Ethics of Teaching
- •When Learners Teach: The Journey from Novice to Mastery and Back Again
- •The Future Is Now
- •References
- •Interventional Procedure
- •Assessment of Flow–Volume Curve
- •Dyspnea
- •Analysis of Pressure–Pressure Curve
- •Conclusions
- •References
- •Introduction
- •Adaptations of the IP Department
- •Environmental Control
- •Personal Protective Equipment
- •Procedure Performance
- •Bronchoscopy in Intubated Patients
- •Other Procedures in IP Unit
- •References
- •Introduction
- •Safety
- •Patient Safety
- •Provider Safety
- •Patient Selection and Screening
- •Lung Cancer Diagnosis and Staging
- •Inpatients
- •COVID-19 Clearance
- •COVID Clearance: A Role for Bronchoscopy
- •Long COVID: A Role for Bronchoscopy
- •Preparing for the Next Pandemic
- •References
- •Historical Perspective
- •Indications and Contraindications
- •Evidence-Based Review
- •Summary and Recommendations
- •References
- •Introduction
- •Clinical Presentation
- •Diagnosis
- •Treatment
- •History and Historical Perspectives
- •Indications and Contraindications
- •Benign and Malignant Tumors
- •Tumors with Uncertain Prognosis
- •Application of the Technique
- •Evidence Based Review
- •Summary and Recommendations
- •References
- •12: Cryotherapy and Cryospray
- •Introduction
- •Historical Perspective
- •Equipment
- •Cryoadhesion
- •Indications
- •Cryorecanalization
- •Cryoadhesion and Foreign Body Removal
- •Cryoadhesion and Mucus Plugs/Blood Clot Retrieval
- •Endobronchial Cryobiopsy
- •Transbronchial Cryobiopsy for Lung Cancer
- •Safety Concerns and Contraindications
- •Cryoablation
- •Indications
- •Evidence
- •Safety Concerns and Contraindications
- •Cryospray
- •Indications
- •Evidence
- •Safety Concerns and Contraindications
- •Advantages of Cryotherapy
- •Limitations
- •Future Research Directions
- •References
- •13: Brachytherapy
- •History and Historical Perspective
- •Indications and Contraindications
- •Application of the Technique
- •Evidence-Based Review
- •Adjuvant Treatment
- •Palliative Treatment
- •Complications
- •Summary and Recommendations
- •References
- •14: Photodynamic Therapy
- •Introduction
- •Photosensitizers
- •First-Generation Photosensitizers
- •M-Tetrahidroxofenil Cloro (mTHPC) (Foscan®)
- •PDT Reaction
- •Tumor Damage Process
- •Procedure
- •Indications
- •Curative PDT Indications
- •Palliative PDT Indications
- •Contraindications
- •Rationale for Use in Early-Stage Lung Cancer
- •Rationale
- •PDT in Combination with Other Techniques for Advanced-Stage Non-small Cell Lung Cancer
- •Commentary
- •Complementary Endoscopic Methods for PDT Applications
- •New Perspectives
- •Other PDT Applications
- •Conclusions
- •References
- •15: Benign Airways Stenosis
- •Etiology
- •Congenital Tracheal Stenosis
- •Iatrogenic
- •Infectious
- •Idiopathic Tracheal Stenosis
- •Distal Bronchial Stenosis
- •Diagnosis Methods
- •Patient History
- •Imaging Techniques
- •Bronchoscopy
- •Pulmonary Function Test
- •Treatment
- •Endoscopic Treatment
- •Dilatation
- •Laser Therapy
- •Stents
- •How to Proceed
- •Stent Placement
- •Placing a Montgomery T Tube
- •The Rule of Twos for Benign Tracheal Stenosis (Fig. 15.23)
- •Surgery
- •Summary and Recommendations
- •References
- •16: Endobronchial Prostheses
- •Introduction
- •Indications
- •Extrinsic Compression
- •Intraluminal Obstruction
- •Stump Fistulas
- •Esophago-respiratory Fistulas (ERF)
- •Expiratory Central Airway Collapse
- •Physiologic Rationale for Airway Stent Insertion
- •Stent Selection Criteria
- •Stent-Related Complications
- •Granulation Tissue
- •Stent Fracture
- •Migration
- •Contraindications
- •Follow-Up and Patient Education
- •References
- •Introduction
- •Overdiagnosis
- •False Positives
- •Radiation
- •Risk of Complications
- •Lung Cancer Screening Around the World
- •Incidental Lung Nodules
- •Management of Lung Nodules
- •References
- •Introduction
- •Minimally Invasive Procedures
- •Mediastinoscopy
- •CT-Guided Transthoracic Biopsy
- •Fluoroscopy-Guided Transthoracic Biopsies
- •US-Guided Transthoracic Biopsy
- •Thoracentesis and Pleural Biopsy
- •Thoracentesis
- •Pleural Biopsy
- •Surgical or Medical Thoracoscopy
- •Image-Guided Pleural Biopsy
- •Closed Pleural Biopsy
- •Image-Guided Biopsies for Extrathoracic Metastases
- •Tissue Acquisition, Handling and Processing
- •Implications of Tissue Acquisition
- •Guideline Recommendations for Tissue Acquisition in Mediastinal Staging
- •Methods to Overcome Challenges in Tissue Acquisition and Genotyping
- •Rapid on-Site Evaluation (ROSE)
- •Sensitive Genotyping Assays
- •Liquid Biopsy
- •Summary, Recommendations and Highlights
- •References
- •History
- •Data Source and Methodology
- •Tumor Size
- •Involvement of the Main Bronchus
- •Atelectasis/Pneumonitis
- •Nodal Staging
- •Proposal for the Revision of Stage Groupings
- •Small Cell Lung Cancer (SCLC)
- •Discussion
- •Methodology
- •T Descriptors
- •N Descriptors
- •M Descriptors
- •Summary
- •References
- •Introduction
- •Historical Perspective
- •Fluoroscopy
- •Radial EBUS Mini Probe (rEBUS)
- •Ultrasound Bronchoscope (EBUS)
- •Virtual Bronchoscopy
- •Trans-Parenchymal Access
- •Cone Beam CT (CBCT)
- •Lung Vision
- •Sampling Instruments
- •Conclusions
- •References
- •History and Historical Perspective
- •Narrow Band Imaging (NBI)
- •Dual Red Imaging (DRI)
- •Endobronchial Ultrasound (EBUS)
- •Optical Coherence Tomography (OCT)
- •Indications and Contraindications
- •Confocal Laser Endomicroscopy and Endocytoscopy
- •Raman Spectrophotometry
- •Application of the Technique
- •Supplemental Technology for Diagnostic Bronchoscopy
- •Evidence-Based Review
- •Summary and Recommendations, Highlight of the Developments During the Last Three Years (2013 on)
- •References
- •Introduction
- •History and Historical Perspective
- •Endoscopic AF-OCT System
- •Preclinical Studies
- •Clinical Studies
- •Lung Cancer
- •Asthma
- •Airway and Lumen Calibration
- •Obstructive Sleep Apnea
- •Future Applications
- •Summary
- •References
- •23: Endobronchial Ultrasound
- •History and Historical Perspective
- •Equipment
- •Technique
- •Indication, Application, and Evidence
- •Convex Probe Ultrasound
- •Equipment
- •Technique
- •Indication, Application, and Evidence
- •CP-EBUS for Malignant Mediastinal or Hilar Adenopathy
- •CP-EBUS for the Staging of Non-small Cell Lung Cancer
- •CP-EBUS for Restaging NSCLC After Neoadjuvant Chemotherapy
- •Complications
- •Summary
- •References
- •Introduction
- •What Is Electromagnetic Navigation?
- •SuperDimension Navigation System (EMN-SD)
- •Computerized Tomography
- •Computer Interphase
- •The Edge Catheter: Extended Working Channel (EWC)
- •Procedural Steps
- •Planning
- •Detecting Anatomical Landmarks
- •Pathway Planning
- •Saving the Plan and Exiting
- •Registration
- •Real-Time Navigation
- •SPiN System Veran Medical Technologies (EMN-VM)
- •Procedure
- •Planning
- •Navigation
- •Biopsy
- •Complications
- •Limitations
- •Summary
- •References
- •Introduction
- •Image Acquisition
- •Hardware
- •Practical Considerations
- •Radiation Dose
- •Mobile CT Studies
- •Future Directions
- •Conclusion
- •References
- •26: Robotic Assisted Bronchoscopy
- •Historical Perspective
- •Evidence-Based Review
- •Diagnostic Yield
- •Monarch RAB
- •Ion Endoluminal Robotic System
- •Summary
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •General
- •Application of the Technique
- •Preoperative Care
- •Patient’s Position and Operative Field
- •Incision and Initial Dissection
- •Palpation
- •Biopsy
- •Control of Haemostasis and Closure
- •Postoperative Care
- •Complications
- •Technical Variants
- •Extended Cervical Mediastinoscopy
- •Mediastinoscopic Biopsy of Scalene Lymph Nodes
- •Inferior Mediastinoscopy
- •Mediastino-Thoracoscopy
- •Video-Assisted Mediastinoscopic Lymphadenectomy
- •Transcervical Extended Mediastinal Lymphadenectomy
- •Evidence-Based Review
- •Summary and Recommendations
- •References
- •Introduction
- •Case 1
- •Adrenal and Hepatic Metastases
- •Brain
- •Bone
- •Case 1 Continued
- •Biomarkers
- •Case 1 Concluded
- •Case 2
- •Chest X-Ray
- •Computerized Tomography
- •Positive Emission Tomography
- •Magnetic Resonance Imaging
- •Endobronchial Ultrasound with Transbronchial Needle Aspiration
- •Transthoracic Needle Aspiration
- •Transbronchial Needle Aspiration
- •Endoscopic Ultrasound with Needle Aspiration
- •Combined EUS-FNA and EBUS-TBNA
- •Case 2 Concluded
- •Case 3
- •Standard Cervical Mediastinoscopy
- •Extended Cervical Mediastinoscopy
- •Anterior Mediastinoscopy
- •Video-Assisted Thoracic Surgery
- •Case 3 Concluded
- •Case 4
- •Summary
- •References
- •29: Pleural Anatomy
- •Pleural Embryonic Development
- •Pleural Histology
- •Cytological Characteristics
- •Mesothelial Cells Functions
- •Pleural Space Defense Mechanism
- •Pleura Macroscopic Anatomy
- •Visceral Pleura (Pleura Visceralis or Pulmonalis)
- •Parietal Pleura (Pleura Parietalis)
- •Costal Parietal Pleura (Costalis)
- •Pleural Cavity (Cavitas Thoracis)
- •Pleural Apex or Superior Pleural Sinus [12–15]
- •Anterior Costal-Phrenic Sinus or Cardio-Phrenic Sinus
- •Posterior Costal-Phrenic Sinus
- •Cost-Diaphragmatic Sinus or Lateral Cost-Phrenic Sinus
- •Fissures18
- •Pleural Vascularization
- •Parietal Pleura Lymphatic Drainage
- •Visceral Pleura Lymphatic Drainage
- •Pleural Innervation
- •References
- •30: Chest Ultrasound
- •Introduction
- •The Technique
- •The Normal Thorax
- •Chest Wall Pathology
- •Pleural Pathology
- •Pleural Thickening
- •Pneumothorax
- •Pulmonary Pathology
- •Extrathoracic Lymph Nodes
- •COVID and Chest Ultrasound
- •Conclusions
- •References
- •Introduction
- •History of Chest Tubes
- •Overview of Chest Tubes
- •Contraindications for Chest Tube Placement
- •Chest Tube Procedural Technique
- •Special Considerations
- •Pneumothorax
- •Empyema
- •Hemothorax
- •Chest Tube Size Considerations
- •Pleural Drainage Systems
- •History of and Introduction to Indwelling Pleural Catheters
- •Indications and Contraindications for IPC Placement
- •Special Considerations
- •Non-expandable Lung
- •Chylothorax
- •Pleurodesis
- •Follow-Up and IPC Removal
- •IPC-Related Complications and Management
- •Competency and Training
- •Summary
- •References
- •32: Empyema Thoracis
- •Historical Perspectives
- •Incidence
- •Epidemiology
- •Pathogenesis
- •Clinical Presentation
- •Radiologic Evaluation
- •Biochemical Analysis
- •Microbiology
- •Non-operative Management
- •Prognostication
- •Surgical Management
- •Survivorship
- •Summary and Recommendations
- •References
- •Evaluation
- •Initial Intervention
- •Pleural Interventions for Recurrent Symptomatic MPE
- •Especial Circumstances
- •References
- •34: Medical Thoracoscopy
- •Introduction
- •Diagnostic Indications for Medical Thoracoscopy
- •Lung Cancer
- •Mesothelioma
- •Other Tumors
- •Tuberculosis
- •Therapeutic Indications
- •Pleurodesis of Pneumothorax
- •Thoracoscopic Drainage
- •Drug Delivery
- •Procedural Safety and Contraindications
- •Equipment
- •Procedure
- •Pre-procedural Preparations and Considerations
- •Procedural Technique [32]
- •Medical Thoracoscopy Versus VATS
- •Conclusion
- •References
- •Historical Perspective
- •Indications and Contraindications
- •Evidence-Based Review
- •Endobronchial Valves
- •Airway Bypass Tracts
- •Coils
- •Other Methods of ELVR
- •Summary and Recommendations
- •References
- •36: Bronchial Thermoplasty
- •Introduction
- •Mechanism of Action
- •Trials
- •Long Term: Ten-Year Study
- •Patient Selection
- •Bronchial Thermoplasty Procedure
- •Equipment
- •Pre-procedure
- •Bronchoscopy
- •Post-procedure
- •Conclusion
- •References
- •Introduction
- •Bronchoalveolar Lavage (BAL)
- •Technical Aspects of BAL Procedure
- •ILD Cell Patterns and Diagnosis from BAL
- •Technical Advises for Conventional TLB and TLB-C in ILD
- •Future Directions
- •References
- •Introduction
- •The Pediatric Airway
- •Advanced Diagnostic Procedures
- •Endobronchial Ultrasound
- •Virtual Navigational Bronchoscopy
- •Cryobiopsy
- •Therapeutic Procedures
- •Dilation Procedures
- •Thermal Techniques
- •Mechanical Debridement
- •Endobronchial Airway Stents
- •Metallic Stents
- •Silastic Stents
- •Novel Stents
- •Endobronchial Valves
- •Bronchial Thermoplasty
- •Discussion
- •References
- •Introduction
- •Etiology
- •Congenital ADF
- •Malignant ADF
- •Cancer Treatment-Related ADF
- •Benign ADF
- •Iatrogenic ADF
- •Diagnosis
- •Treatment Options
- •Endoscopic Techniques
- •Stents
- •Clinical Results
- •Stent Complications
- •Other Available Stents
- •Other Endoscopic Methods
- •References
- •Introduction
- •Anatomy and Physiology of Swallowing
- •Functional Physiology of Swallowing
- •Epidemiology and Risk Factors
- •Types of Foreign Bodies
- •Organic
- •Inorganic
- •Mineral
- •Miscellaneous
- •Clinical Presentation
- •Acute FB
- •Retained FB
- •Radiologic Findings
- •Bronchoscopy
- •Airway Management
- •Rigid Vs. Flexible Bronchoscopy
- •Retrieval Procedure
- •Instruments
- •Grasping Forceps
- •Baskets
- •Balloons
- •Suction Instruments
- •Ablative Therapies
- •Cryotherapy
- •Laser Therapy
- •Electrocautery and APC
- •Surgical Management
- •Complications
- •Bleeding and Hemoptysis
- •Distal Airway Impaction
- •Iron Pill Aspiration
- •Follow-Up and Sequelae
- •Conclusion
- •References
- •Vascular Origin of Hemoptysis
- •History and Historical Perspective
- •Diagnostic Bronchoscopy
- •Therapeutic Bronchoscopy
- •General Measures
- •Therapeutic Bronchoscopy
- •Evidence-Based Review
- •Summary
- •Recommendations
- •References
- •History
- •“The Glottiscope” (1807)
- •“The Esophagoscope” (1895)
- •The Rigid Bronchoscope (1897–)
- •The Flexible Bronchoscope (1968–)
- •Transbronchial Lung Biopsy (1972) (Fig. 42.7)
- •Laser Therapy (1981–)
- •Endobronchial Stents (1990–)
- •Electromagnetic Navigation (2003–)
- •Bronchial Thermoplasty (2006–)
- •Endobronchial Microwave Therapy (2004–)
- •American Association for Bronchology and Interventional Pulmonology (AABIP) and Journal of Bronchology and Interventional Pulmonology (JOBIP) (1992–)
- •References
- •Index
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and better ways to approach peripheral lung lesions. The development of thin and ultrathin bronchoscopes has improved the ability to maneuver distally through the bronchial tree. Additionally, virtual bronchoscopy and electromagnetic navigation have given us a threedimensional road map to the target lesion with bronchoscopic tracking. The synergistic combination of these bronchoscopic modalities with RP-EBUS has shown to improve diagnostic outcomes for peripheral lung lesions. Asashina et al. combined virtual bronchoscopy with RP-EBUS and guide sheath to perform biopsies of small peripheral lung lesions in 29 patients. They reported a sensitivity of 92% for lesions between 20 and 30 mm in size but only 44% for lesions less than 20 mm [23]. Ishida and colleagues constructed a similar study of 199 patients with small peripherally located lung lesions who were randomized to either RP-EBUS with virtual bronchoscopy or RP-EBUS alone and reported a diagnostic yield of 80% and 67%, respectively [24]. Eberhardt et al. randomized 120 patients with peripherally located lung lesions to undergo biopsy using either electromagnetic navigational bronchoscopy (ENB), RP-EBUS, or a combination of both techniques. The reported diagnostic yield was 88% with combined ENB/ RP-EBUS, 69% with RP-EBUS, and 59% with ENB alone [25]. The current literature suggests that there is synergy when using multimodal approaches to biopsy peripherally located lung lesions.
As discussed, once CP-EBUS became the tool of choice for mediastinal staging and the balloon catheter for the RP-EBUS to evaluate airway walls was discontinued, the RP-EBUS had become primarily a tool used for peripheral lung nodule localization. In addition to peripheral lung lesion biopsies, it can be used during placement of fducial markers to guide stereotactic radiation [26]. In areas where the balloon catheter is available, it has been used to visualize airway walls in the setting of tumor infltration, lung transplantation, and asthma [27–29].
Convex Probe Ultrasound
Description oftheEquipment and Technique
Equipment
CP-EBUS, also known as linear EBUS, is a bronchoscope with the addition of an integrated curvilinear ultrasound transducer at the distal end. At the tip of the bronchoscope, you will fnd a 10 mm long curved linear array electronic transducer in front of a 30° oblique facing fber-optic lens with 80° angle view (Fig. 23.5). In order to obtain an ultrasound image, the transducer must be in contact with the airway wall. To assist in obtaining contact, a balloon attached to the tip of the bronchoscope can be in ated with saline. The bronchoscope has an additional angulation range of 160° ante exed and 90° retro exed to assist with maneuverability and wall contact. The outer diameter of the insertion tube is 6.3 mm and the distal end outer diameter is 6.9 mm with a working channel of 2.2 mm. The ultrasound frequency ranges from 7.5 to 12.5 MHz with a penetration depth of about 5 cm and has a scanning view of 70–90° with respect to the longitudinal axis of the bronchoscope. This provides a real-time high-resolution ultrasound image of the surrounding tissue and enables direct visualization of the echogenic needle as it penetrates the target. The CP-EBUS scope also has the ability to perform a real-time Doppler examination prior to penetrating the tissue in order to avoid any unwanted puncture of nearby vessels (Fig. 23.6).
During CP-EBUS-TBNA, two monitors are required to visualize both the bronchoscopic image and the ultrasound image. The CP-EBUS is connected to a central ultrasound scanner where the images are processed (Fig. 23.2). Ultrasound scanners are commonly equipped with color Doppler and even power Doppler modes. The ultrasound scanner can also capture images and take two-dimensional size measurements.
While multiple needle gauges are available, 21-gauge and 22-gauge needles are most com-
23 Endobronchial Ultrasound |
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Fig. 23.5 On the left, illustration of the 35° oblique facing fber-optic lens with an 80° angle of view at the tip of the CP-EBUS. On the right, the image demonstrates the
oblique angle of view bronchoscopically (Reprinted with permission from Olympus)
Fig. 23.6 The use of color Doppler while performing CP-EBUS to assist in avoiding biopsy of nearby vessels
monly used to perform EBUS-TBNA and will ft through the 2.2 mm working channel of the bronchoscope. The needle has adjustable settings that act as safety mechanisms to prevent damage to the bronchoscope as well as harm to the patient. The needle will exit the bronchoscope at a 20° angle with respect to the longitudinal axis of the bronchoscope and will extend to a maximum of 40 mm (Fig. 23.7). As the needle is passed outside of the bronchoscope, it can be visualized by the optic and the ultrasound as it passes through the tissue.
Technique
CP-EBUS-TBNA can be performed under conscious sedation or general anesthesia as an outpatient procedure. Under conscious sedation, the bronchoscope is inserted orally due to inability to pass the large distal tip of the scope easily through the nose. Additionally, under conscious sedation the cough re ex is still active which is signifcantly reduced with general anesthesia. An endotracheal tube or laryngeal mask airway (LMA) is used with general anesthesia with both having their advantages and disadvantages [30].
The CP-EBUS is initially inserted orally or through a LMA passed the vocal cords unless an endotracheal tube was used. The bronchoscope is then advanced to the area of interest and the balloon is in ated with normal saline to obtain optimal wall contact. A technical aspect to be aware of is that due to the 30° oblique angle of the optic, to obtain an en face view or the airway, the bronchoscope must be slightly retro exed. This technique can decrease contact between the ultrasound transducer and the wall requiring adjustment to either bronchoscopic position or balloon in ation. Locating the target, whether it be a lymph node or a parenchymal lesion, is done by using both airway and ultrasound landmarks. The bronchoscopic image provides a general starting point to allow a more precise and detailed scan with the ultrasound image. Vascular landmarks are the key to identifying the
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Fig. 23.7 (a) Identifes |
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the adjustable sheath |
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and guard to prevent |
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the patient. (b) The |
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balloon attached to the |
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in ated with saline and |
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the needle advanced |
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outside of the |
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(Reprinted with |
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specifc lymph node stations according to the International Lymph Node Map by the International Association for the Study of Lung Cancer (Table 23.1) [31]. The Doppler on the CP-EBUS can also help recognize the surrounding blood vessels to assist in determining the borders of the lymph node stations and prevent unwanted vessel punctures. Sonographic lymph node features associated with an increased risk of malignancy, which include size greater than 1 cm, heterogeneous echogenicity, sharp border, round or oval shape, and the presence coagulation necrosis, can help guide the decision to biopsy the lymph node [32].
After the lesion to be biopsied has been identifed, the point of entry is determined by using the bronchoscopic view to visualize landmarks on the airway wall. This may require relaxation of the exion on the bronchoscope. The TBNA needle is then passed through the working channel of the bronchoscope while in the neutral position and locked into place. The needle has a sheath adjuster knob so that the sheath can be placed just outside the bronchoscope tip, which can be visualized on the bronchoscopic image, to prevent damage to the scope. Bronchoscopic exion is then used to reinitiate contact with the airway
wall to visualize the target on ultrasound and the needle is advanced in real-time under ultrasound to the appropriate depth (Fig. 23.8). The needle also has an internal stylet that is agitated within the needle to clear out the internal lumen of any unwanted bronchial tissue or debris. The stylet is then removed, and a syringe is attached that provides negative pressure while within the target prior to any passes taking place. Negative pressure is not required and in instances of hypervascular lesions it is not recommended as it may cause bloody samples. The needle can then be moved back and forth with a smooth motion traversing from the most proximal to most distal portion of the target if possible. Important tips to improve the sample quality while taking passes through the target include assuring the ultrasound image is in the same axis as the needle to allow visualization of each pass and not coming out or passing through the lesion. Lastly, the needle is retracted back into the sheath and unattached from the bronchoscope. The processing of the specimen from the TBNA is also key to achieve optimal results. To prepare the specimen for processing, the inner stylet is usually placed back into the needle to push out the frst few drops of the specimen onto a glass slide for rapid onsite
23 Endobronchial Ultrasound |
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401 |
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Table 23.1 Lymph node stations |
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|
Lymph node |
Defnition |
Bronchoscopic landmark |
CP-EBUS landmark |
Station |
– Right interlobar lymph node that |
– RLL superior segment |
– Descending interlobar |
11Ri |
lies between the RML and RLL |
laterally, RML medially, |
artery anteriorly |
|
bronchi |
proximal to the RLL medial |
|
|
|
basal bronchi |
|
|
|
– Transducer placed in the |
|
|
|
RLL bronchus and scan |
|
|
|
between 8 and 11 o’clock |
|
|
|
|
|
Station |
– Right interlobar lymph node that |
– RUL and RC1 laterally |
– Truncus anterior and |
11Rs |
lies between the RUL and RML |
– Transducer placed in the RBI |
descending interlobar |
|
bronchus |
and scan between 1 and 4 |
anteriorly |
|
|
o’clock |
|
|
|
|
|
Station |
– Right hilar lymph node that lies |
– Right tracheobronchial angle |
– Azygos vein proximally |
10R |
along the RMS distal to the azygos |
proximally and the RUL |
and the right pulmonary |
|
and proximal to the RUL |
bronchus distally |
artery distally |
|
|
– Transducer placed in the |
|
|
|
RMS and scan between 11 |
|
|
|
and 3 o’clock |
|
|
|
|
|
Station 4R |
– Right lower paratracheal lymph |
– Main carina distal and |
– Lower border of the |
|
node that lies along the right mid/ |
medial, RMS distal and |
azygos veins distally, |
|
lower trachea proximal to the |
lateral, mid to upper trachea |
SVC anteriorly, |
|
azygos vein and distal to the |
proximally |
brachiocephalic vein |
|
brachiocephalic vein |
– Transducer placed in the |
anterior and proximally |
|
|
lower trachea and scan |
|
|
|
between 11 and 3 o’clock |
|
|
|
|
|
Station 2R |
– Right upper paratracheal lymph |
– Upper trachea looking to the |
– Proximal to the right |
|
node that lies along the right mid/ |
right lateral aspect |
lateral aspect of the |
|
upper trachea proximal to the |
– Transducer placed in the |
brachiocephalic vein |
|
brachiocephalic vein |
upper trachea and scan |
anteriorly |
|
|
between 11 and 3 o’clock |
|
Station 7 |
– Subcarinal lymph node that lies |
– Main carina medially, |
– Right pulmonary artery |
|
between the mainstem bronchi |
proximal to the RML |
anteriorly when in the |
|
|
bronchus |
RMS and the main |
|
|
– Transducer can be placed in |
pulmonary artery |
|
|
the RMS and scan between 9 |
anteriorly when in the |
|
|
and 12 o’clock or placed in |
LMS |
|
|
the LMS and scan between |
|
|
|
12 and 3 o’clock |
|
|
|
|
|
Station 2L |
– Left upper paratracheal lymph |
– Upper trachea looking to the |
– Proximal to the superior |
|
node that lies along the left upper/ |
left lateral aspect |
border of the aortic arch |
|
mid trachea proximal to the |
– Transducer can be placed in |
laterally |
|
superior border of the aortic arch |
the upper trachea and scan |
|
|
|
between 8 and 11 o’clock |
|
Station 4L |
– Left lower paratracheal lymph |
– Mid/lower trachea, main |
– Proximal to the superior |
|
node that lies along the left mid/ |
carina medially, proximal to |
border of the left main |
|
lower trachea proximal to the |
the left secondary carina |
pulmonary artery, distal |
|
LMS, proximal to the superior |
– Transducer placed in the |
to the superior border of |
|
border of the left main pulmonary |
LMS and scan between 9 and |
the aortic arch |
|
artery, and distal to the inferior |
12 o’ clock or in the lower |
|
|
border of the aortic arch |
trachea scan between 9 and |
|
|
|
11 o’ clock |
|
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(continued) |
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