Presentation on theme: "Describe the 15 steps to performing EBUS-TBNA."— Presentation transcript:
1#7. EBUS-TBNA for right paratracheal node in a patient with COPD and lung cancer Describe the 15 steps to performing EBUS-TBNA.Describe principles and use of endobronchial Doppler ultrasoundDescribe reported relation between PET negative lymph node size and malignancy.
2Case description (practical approach 7) 67 year old male with a 50 pack- year history of smoking developed cough and weight loss (15kg) for six months.Vital signs revealed a blood pressure of 160/80mmHg, heart rate 90/min, body temperature 37.2C and respiratory rate 18/min.Physical examination shows prolonged expiratory breath sounds and egophony in right upper lung field.He is a retired electrician and lives with his wife. He has no advance directives.He desires all available active treatment modalities if diagnosed with cancer.
3Case description (practical approach #7) WBC 8000 (neutrophil 81%, lymphocyte 2%)Hemoglobin 13 gm/dl, Platelets 310,000/mm3Arterial blood gas analysis pH 7.45, PaCO2 50 mmHg, PaO2 64 mmHg on 2L oxygen/min via nasal canula)Pulmonary function tests revealed FEV L (49% predicted), DLCO- 50% predicted
4Case description (practical approach 7) CT Chest:3 cm right upper lobe mass.1 cm right paratracheal lymph node is PET negative.CT guided transthoracic needle aspiration of the right upper lobe mass positive for non-small cell lung cancer.
5The Practical Approach Initial EvaluationProcedural StrategiesTechniques and ResultsLong term ManagementExamination and, functional statusSignificant comorbiditiesSupport systemPatient preferences and expectationsIndications, contraindications, and resultsTeam experienceRisk-benefits analysis and therapeutic alternativesInformed ConsentAnesthesia and peri-operative careTechniques and instrumentationAnatomic dangers and other risksResults and procedure-related complicationsOutcome assessmentFollow-up tests and proceduresReferralsQuality improvementBI #. Practical Approach Title
6Initial Evaluations Exam Comorbidities Support system Prolonged expiratory phaseECOG performance status 1ComorbiditiesSevere COPD, HTN, Tobacco abuseSupport systemWife and children all healthy and actively involved with patients care.Patient preferencesDesires all available active treatment options.
7Procedural Strategies Indications:Minimally invasive staging of non-small cell lung cancer with radiographically enlarged PET (-) node.Contraindications:NoneExpected Results: sensitivity and NPV of EBUS 93.8% and 96.9% respectively* for NSCLC with lymph nodes of 5–20 mm on chest CT*Lee HS. Chest 2008; 134: 368–374.
8Procedural Strategies Risks-benefits:EBUS-TBNA has no serious complications reported in the literature.Agitation, cough, and presence of blood at puncture site have been reported infrequently.*Same day procedure.Cost savings when compared to mediastinoscopy.**Increased risk in case general anesthesia required.*Eur Respir J 2009; 33: 1156–1164**Gastrointestinal Endoscopy 69, No. 2, Supp 1, 2009, S260
9Procedural Strategies Therapeutic alternatives:Endoscopic ultrasound difficult to access level 4 node compared with EBUS. In a head to head comparison* sensitivity and negative predictive value were 69% and 89% respectively) .Mediastinoscopy gold standard. 78% sensitivity**, but requires general anesthesia.VATS most invasive of alternatives. Only provides access to ipsilateral nodes. 75% sensitivity**. Benefits include definitive lobar resection at same time if frozen section negative.Informed consent:There were no barriers to learning identified. Patient has good insight into his disease and realistic expectations.*JAMA. 2008;299(5):**Chest 2007;132;
10Procedural Techniques and Results Anesthesia and peri-operative careConscious sedationPerformed in clinic procedure roomMost commonly used drugs are midazolam and fentanylCost savings when compared to OR and extra personnel required for general anesthesiaMay make procedure more difficult for inexperienced operatorMay be more appropriate for targeted biopsy than full staging of mediastinum*Has been used in combined staging TBNA, EBUS, EUS procedures***Chest 2008;134;**JAMA. 2008;299(5):
11Procedural Techniques and Results Anesthesia and peri-operative careGeneral anesthesia with LMAMostly performed in OR but may be done in clinicTotal IV anesthesia with propofol is commonly usedLMA mask size 4 or 5 requiredAllows easier biopsies of smaller nodes and complete mediastinal staging; better for less experienced operatorsGeneral anesthesia with ET tubeSize 8.5 in women and 9.0 in menAllows for easier biopsies as aboveIndications may include difficult LMA placement, obesity, and severe untreated GERD*Causes EBUS scope to lie centrally in tracheaMore difficult to visualize higher nodes*JCVA, Vol 21, No 6 , 2007: pp
12Procedural Techniques and Results InstrumentationEBUS scope provides direct real time US imaging with curved array ultrasound transducer incorporated in distal end of bronchoscopeAs of 09/2009, types of Scopes and US processorsOlympus- BF-UC160F-OL8 Hybrid scope2.0 mm working channel; 6.9 mm O.DEU-C60 US processor 7.5 MHz with B-mode and color power dopplerOlympus BF-UC180F Hybrid scope2.2 mm working channel; 6.9 mm O.D.ALOKA prosound US processor 5, 7.5, 10, 12 MHz and B, M, D-mode, flow and power flow modesMay also be used with EU-C60 processorPentax EB-1970UK Videoscope2.0 mm working channel; 6.3 mm O.D.Hitachi HI Vision 5500 US processor 5MHz/7.5MHz/10MHz with B-mode and color Doppler
14Procedural Techniques and Results InstrumentationUltrasound processorAdjustable gain and depthGain is the degree of brightness with which a given signal intensity is displayed. Analogous to a volume control knob on a stereo.Depth- allows optimal display of an area of interest on the screen.B mode and Doppler capabilitiesB-mode (brightness mode) uses an array of transducers to scan a plane through the tissue to produce a two-dimensional image on the screen.Doppler mode measures velocity of moving tissue. It detects blood flow in vessels and subsequently superimposes the display over the 2-D image.
15Image quality adjustment Gain adjustmentsThe amplifier is often controlled by the operator of the instrument, who sets the gain for various depths of the tissueFrequency adjustmentsHigher frequencyhas better resolutionbut less depth ofpenetrationGAIN CONTROLThe loss in amplitude is usually corrected by amplifying the signal proportional to the depth from which the echo came. The amplifier is often controlled by the operator of the instrument, who sets the gain for various depths of the tissue.The time variable gain is for high frequencies.Bronchoscopy International151515
16Bronchoscopy International PenetrationPenetration: refers to the distance between an imaged area and the transducer.The time delay between the energy going into the body and returning to the US probe determines the depth from which the signal arises ( longer times= greater depths)Depth=velocity X time/2Bronchoscopy International1616
17Penetration and resolution Higher frequencies result in higher resolution.Higher frequencies (20 MHz) do not penetrate as deep as low frequencies (7.5 MHz).penetrationfrequencyresolutionThere is an indirect relationship between penetration and frequency.Low frequencyhigh penetrationBronchoscopy International171717
18Bronchoscopy International Large transducers transmit powerful beams and increase penetration depthPenetration depth is less for EBUS than for thoracic ultrasound.PLEURALEFFUSIONThere is an direct relationship between penetration and transducer size.EBUSBronchoscopy International181818
19Bronchoscopy International Scanning methodsFor the convex probe, the scanning plane is parallel to the scopeConvexTransducerBronchoscopy International1919
20BF-UC160F-OL8 Specifications UltrasonicfunctionsDisplay modeB-modeColor Power Doppler modeScanning methodElectrical curved linear arrayScanning directionParallel to the insertion directionFrequency7.5MHzScanning range50Contacting methodBalloon methodDirect contact methodAn electronic curved linear array ultrasonic transducerBronchoscopy International20Bowling MR, South Med J May 101(5) 534-82020
21Procedural Techniques and Results InstrumentationNeedleOlympus NA-201SX-4022 or Medi-Globe SonoTip II22 gauge echogenic needle with styletNeedle guide system locks to scopeLockable needle and sheathPrecise needle projection up to 4 cmAnatomic dangers and other risksMajor blood vessels- azygous, PA, aorta, SVC and Left atriumPneumothorax and pneumomediastinumA case of bacterial pericardial effusion and nodal infection have recently been reported as complications following EBUS with full needle extension***.*Chest 2004;126;**Eur Respir J 2002; 19:356–373***Eur Respir J 2009; 33:
22Procedural Techniques and Results Results and procedure-related complicationsThe 4R node was successfully sampled with EBUS under general anesthesia and a 9.0 cuffed endotracheal tube.There was representative tissue on cytology and it was negative for malignancy.There were no complications.
23Long-term Management Plan Outcome assessmentPatient underwent RUL lobectomy. Intraoperative mediastinal staging confirmed negative nodes.At 1 month post operatively patient was back to preoperative baseline functional status.Follow-up tests and proceduresClinical evaluation every 3-6 months for the first 2 years with surveillance imaging every 6 months (CXR or CT)*ReferralsHe was also referred to oncology for consideration of adjuvant chemotherapy for I B disease.Quality improvementEarly staging and definitive treatment of non-small cell lung caExpected 5 year survival for Stage Ib ~ 55%***Chest :355S-367S**Lung Cancer (2007) 55,
24Q 1: Describe the 15 steps to performing EBUS-TBNA
25Procedure TechniqueStep 1 Advance needle through the working channel (neutral position)Step 2 Secure the needle housing by sliding the flange
26Procedure Technique Step 3 Release the sheath screw Step 4 Advance and lock the sheath when it touches the wall
27Procedure Technique Step 5 Release the needle screw Step 6 Advance the needle using the “jab” technique
28Procedure Technique Step 7 Visualize needle entering target node Step 8 Move the stylet in and out a few times to dislodge bronchial wall debris.
29Procedure TechniqueStep 9 Remove the styletStep 10 Attach syringe
30Procedure Technique Step 11 Apply suction Step 12 Pass the needle in and out of the node 15 times
31Procedure Technique Step 13 Release suction by removing syringe Step 14 Retract the needle into the sheath
32Procedure TechniqueStep 15 Unlock and remove the needle and sheath and prepare smears.
33Q 2: Describe principles and use of endobronchial Doppler ultrasound 33
34Doppler ultrasoundB-mode (brightness mode) uses an array of transducers to scan a plane through the tissue to produce a two-dimensional image on the screen.Doppler mode measures velocity of moving tissue. It detects blood flow in vessels and subsequently superimposes the display over the 2-D image.34
35Doppler ultrasound: Color Power Doppler Bronchoscopy International3535
36Bronchoscopy International Doppler EffectThe frequency of the reflected ultrasound wave is changed when it strikes a moving object ( i.e blood in vessels)= Doppler effectDoppler frequency shift=ΔF= Ft-Fr=2 X Ft X (v/c) X cos θFt transmitted frequency, Fr received frequency, v speed of moving target, c speed of sound in soft tissue, θ angle between the direction of blood flow and direction of the transmitted sound phaseThe Doppler angle needs to be 60 degrees or slightly less to the long axis of the vessel to obtain the correct velocityBronchoscopy International3636
37Bronchoscopy International Ascending aortaBronchoscopy International373737
38Bronchoscopy International The Doppler angle needs to be 60 degrees or slightly less to the long axis of the vessel to obtain the correct velocityStrong Doppler signal is obtained whenthe scanning plane forms a sharp anglewith the blood vesselΔF= Ft-Fr=2 X Ft X (v/c) X cos θcosine(60 degrees) = 0.5Bronchoscopy International3838
39Bronchoscopy International The Doppler angle needs to be 60 degrees or slightly less to the long axis of the vessel to obtain the correct velocityΔF= Ft-Fr=2 X Ft X (v/c) X cos θVery weak or no Doppler signal is obtainedwhen the scanning plane is perpendicular tothe blood vesselcosine(90 degrees) = 0Bronchoscopy International3939
40Q 3: Describe reported relation between PET negative lymph node size and malignancy. 40
41The size of PET (-) nodes impacts probability of malignancy Mediastinal lymph nodes and relation with metastatic involvement: a Metanalysis. Langen et al, Eur J Cardiothorac Surg 2006;29:26-29Probability for malignancy in lymph nodes measuring mm in the short axis is 29%,and about 60% if nodes are larger.If nodes mm and PET Negative, probability for malignancy is 5%.Refrain from mediastinoscopy, proceed with thoracotomyIf nodes > 16 mm and PET Negative, probability for malignancy is 21%.Proceed with mediastinoscopySo if node is small, mediastinsocopy will be positive one out of twenty time, where as if node is large, mediastinoscopy will be positive one out of five times.
42All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as:Bronchoscopy International: Practical Approach, an Electronic On-Line Multimedia Slide Presentation. Published 2007 (Please add “Date Accessed”).Thank you
43BI Practical Approach #1 Prepared with the assistance of Steven Escobar MD and Septimiu Murgu MDBI Practical Approach #1