Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

2.

Ultrasound processor (e.g., EU-C2000/EU-ME1/EU-ME2 by Olympus Ltd; ALOKA by Hitachi Ltd)

3.

A special needle apparatus for EBUS-TBNA with suction syringe. Examples are ViziShot (Olympus Ltd), SonoTip EBUS PRO (Medi-Globe Ltd), etc.

4.

Additional containers, fixing solutions, and the like for obtaining specimen for pathologic analysis, microbiologic culture, and/or molecular studies

23.3 Actual Procedures

In this section, we describe the procedure of EBUS-TBNA with the use of the Olympus EBUS bronchoscope (BF-UC260FW) and needle apparatus (ViziShot).

23.3.1 Insertion of the Bronchoscope

It is important to note that compared with the conventional direct viewing bronchoscope, the convex EBUS bronchoscope has a forward-oblique view (horizontal visible range of 80°; vertical visible range of 30°). For beginners, passing through the larynx and the vocal cords may be difficult and requires mastery of techniques (Fig. 23.2). Therefore, laryngopharyngeal anesthesia becomes even more important than that during conventional bronchoscopy. Table 23.1 shows the anesthesia techniques that we employ at our hospital. If bronchoscope insertion is difficult or not feasible, inserting an endotracheal tube before EBUS-TBNA is another option.

Fig. 23.2

Insert the EBUS scope to the trachea using this view angle of the vocal cords

Table 23.1

Anesthesia and sedation for EBUS-TBNA

Preliminary medication	Pethidine hydrochloride (Opystan^®) 35 mg/1 mL is injected intravenously at the following doses:
	Weight >50 kg → 0.5 mL
	Weight ≤50 kg → 0.25 mL
	Age >80 years old → 0.25 mL
	Age ≤80 years old → 0.5 mL
Local anesthesia before bronchoscopy	A total of 5 mL of 4 % lidocaine is applied using a Jackson spray to anesthetize the pharyngeal and laryngeal areas
Sedation before bronchoscopy	Midazolam 10 mg/2 mL (Dormicum^®) is diluted in 8 mL of saline to make a 10 mL solution; 2–3 mL of this diluted solution is administered intravenously as follows:
	Weight >50 kg → 3 mL
	Weight ≤50 kg → 2 mL
	Age >80 years old → 2 mL
	Age ≤80 years old → 3 mL
Local anesthesia and sedation during bronchoscopy	If severe coughing occurs, 1–2 mL of 2 % lidocaine is injected through the working channel of the bronchoscope. Additional 1–2 mL of diluted midazolam solution may be administered intravenously

23.3.2 Visualizing Lymph Nodes

Inflate the balloon with about 0.3 mL of sterile distilled water or saline solution ad flex the convex EBUS probe tip on the corresponding tracheal or bronchial mucosa to visualize the lymph nodes. Move the bronchoscope slowly, back and forth and from side to side, while scanning to confirm the maximum cross-sectional area of the lymph nodes. Switch to Doppler mode to confirm the location of the large vessels and bronchial arteries, as well as the vascularity within the lymph nodes (Fig. 23.3a). It is often difficult to collect an adequate specimen for diagnosis from lesions without hyperechoic vessels, in which case, tissue necrosis is likely (Fig. 23.3b). Fortunately, the ultrasound processor has been developed and equipped with elastography to enable assessment of tissue hardness by color (Chap. 24) [1].

Fig. 23.3

Visualization of a lesion by EBUS. (a) Confirmation of blood flow by Doppler mode; (b) scattered hyperechoic areas suggest the presence of necrosis

To stage lung cancer accurately, knowledge on the anatomical position of hilar/mediastinal lymph nodes (Fig. 23.4) and a good understanding of the corresponding location of these lymph nodes on the tracheobronchial lumen (Fig. 23.5) are necessary [2]. The most important points are summarized in Table 23.2.