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 ultrasound
Describe reported relation between PET negative lymph node size and malignancy.

2. Case 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 37.2C 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.

3. Case description (practical approach #7)
WBC 8000 (neutrophil 81%, lymphocyte 2%)
Hemoglobin 13 gm/dl, Platelets 310,000/mm3
Arterial 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

4. Case 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.

5. The Practical Approach
Initial Evaluation
Procedural Strategies
Techniques and Results
Long term Management
Examination and, functional status
Significant comorbidities
Support system
Patient preferences and expectations
Indications, contraindications, and results
Team experience
Risk-benefits analysis and therapeutic alternatives
Informed Consent
Anesthesia and peri-operative care
Techniques and instrumentation
Anatomic dangers and other risks
Results and procedure-related complications
Outcome assessment
Follow-up tests and procedures
Referrals
Quality improvement
BI #. Practical Approach Title

6. Initial Evaluations Exam Comorbidities Support system
Prolonged expiratory phase
ECOG performance status 1
Comorbidities
Severe COPD, HTN, Tobacco abuse
Support system
Wife and children all healthy and actively involved with patients care.
Patient preferences
Desires all available active treatment options.

7. Procedural Strategies
Indications:
Minimally invasive staging of non-small cell lung cancer with radiographically enlarged PET (-) node.
Contraindications:
None
Expected 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.

8. Procedural 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

9. Procedural 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;

10. Procedural Techniques and Results
Anesthesia and peri-operative care
Conscious sedation
Performed in clinic procedure room
Most commonly used drugs are midazolam and fentanyl
Cost savings when compared to OR and extra personnel required for general anesthesia
May make procedure more difficult for inexperienced operator
May 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):

11. Procedural Techniques and Results
Anesthesia and peri-operative care
General anesthesia with LMA
Mostly performed in OR but may be done in clinic
Total IV anesthesia with propofol is commonly used
LMA mask size 4 or 5 required
Allows easier biopsies of smaller nodes and complete mediastinal staging; better for less experienced operators
General anesthesia with ET tube
Size 8.5 in women and 9.0 in men
Allows for easier biopsies as above
Indications may include difficult LMA placement, obesity, and severe untreated GERD*
Causes EBUS scope to lie centrally in trachea
More difficult to visualize higher nodes
*JCVA, Vol 21, No 6 , 2007: pp

12. Procedural Techniques and Results
Instrumentation
EBUS scope provides direct real time US imaging with curved array ultrasound transducer incorporated in distal end of bronchoscope
As of 09/2009, types of Scopes and US processors
Olympus- BF-UC160F-OL8 Hybrid scope
2.0 mm working channel; 6.9 mm O.D
EU-C60 US processor 7.5 MHz with B-mode and color power doppler
Olympus BF-UC180F Hybrid scope
2.2 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 modes
May also be used with EU-C60 processor
Pentax EB-1970UK Videoscope
2.0 mm working channel; 6.3 mm O.D.
Hitachi HI Vision 5500 US processor 5MHz/7.5MHz/10MHz with B-mode and color Doppler

13. Aloka ProSound a5
Hitachi HI Vision 5500
EU-ME1

14. Procedural Techniques and Results
Instrumentation
Ultrasound processor
Adjustable gain and depth
Gain 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 capabilities
B-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.

15. Image quality adjustment
Gain adjustments
The amplifier is often controlled by the operator of the instrument, who sets the gain for various depths of the tissue
Frequency adjustments
Higher frequency
has better resolution
but less depth of
penetration
GAIN CONTROL
The 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.
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16. Bronchoscopy International
Penetration
Penetration: 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/2
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17. Penetration and resolution
Higher frequencies result in higher resolution.
Higher frequencies (20 MHz) do not penetrate as deep as low frequencies (7.5 MHz).
penetration
frequency
resolution
There is an indirect relationship between penetration and frequency.
Low frequencyhigh penetration
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18. Bronchoscopy International
Large transducers transmit powerful beams and increase penetration depth
Penetration depth is less for EBUS than for thoracic ultrasound.
PLEURAL
EFFUSION
There is an direct relationship between penetration and transducer size.
EBUS
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19. Bronchoscopy International
Scanning methods
For the convex probe, the scanning plane is parallel to the scope
Convex
Transducer
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20. BF-UC160F-OL8 Specifications
Ultrasonic
functions
Display mode
B-mode
Color Power Doppler mode
Scanning method
Electrical curved linear array
Scanning direction
Parallel to the insertion direction
Frequency
7.5MHz
Scanning range 50
Contacting method
Balloon method
Direct contact method
An electronic curved linear array ultrasonic transducer
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Bowling MR, South Med J May 101(5) 534-8 20 20

21. Procedural Techniques and Results
Instrumentation
Needle
Olympus NA-201SX-4022 or Medi-Globe SonoTip II
22 gauge echogenic needle with stylet
Needle guide system locks to scope
Lockable needle and sheath
Precise needle projection up to 4 cm
Anatomic dangers and other risks
Major blood vessels- azygous, PA, aorta, SVC and Left atrium
Pneumothorax and pneumomediastinum
A 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:

22. Procedural Techniques and Results
Results and procedure-related complications
The 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.

23. Long-term Management Plan
Outcome assessment
Patient 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 procedures
Clinical evaluation every 3-6 months for the first 2 years with surveillance imaging every 6 months (CXR or CT)*
Referrals
He was also referred to oncology for consideration of adjuvant chemotherapy for I B disease.
Quality improvement
Early staging and definitive treatment of non-small cell lung ca
Expected 5 year survival for Stage Ib ~ 55%**
*Chest :355S-367S
**Lung Cancer (2007) 55,

24. Q 1: Describe the 15 steps to performing EBUS-TBNA

25. Procedure Technique
Step 1 Advance needle through the working channel (neutral position)
Step 2 Secure the needle housing by sliding the flange

26. Procedure Technique Step 3 Release the sheath screw
Step 4 Advance and lock the sheath when it touches the wall

27. Procedure Technique Step 5 Release the needle screw
Step 6 Advance the needle using the “jab” technique

28. Procedure Technique Step 7 Visualize needle entering target node
Step 8 Move the stylet in and out a few times to dislodge bronchial wall debris.

29. Procedure Technique
Step 9 Remove the stylet
Step 10 Attach syringe

30. Procedure Technique Step 11 Apply suction
Step 12 Pass the needle in and out of the node 15 times

31. Procedure Technique Step 13 Release suction by removing syringe
Step 14 Retract the needle into the sheath

32. Procedure Technique
Step 15 Unlock and remove the needle and sheath and prepare smears.

33. Q 2: Describe principles and use of endobronchial Doppler ultrasound33

34. Doppler ultrasound
B-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

35. Doppler ultrasound: Color Power Doppler
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36. Bronchoscopy International
Doppler Effect
The frequency of the reflected ultrasound wave is changed when it strikes a moving object ( i.e blood in vessels)= Doppler effect
Doppler frequency shift=
ΔF= Ft-Fr=2 X Ft X (v/c) X cos θ
Ft 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 phase
The Doppler angle needs to be 60 degrees or slightly less to the long axis of the vessel to obtain the correct velocity
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37. Bronchoscopy International
Ascending aorta
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38. Bronchoscopy International
The Doppler angle needs to be 60 degrees or slightly less to the long axis of the vessel to obtain the correct velocity
Strong Doppler signal is obtained when
the scanning plane forms a sharp angle
with the blood vessel
ΔF= Ft-Fr=2 X Ft X (v/c) X cos θ
cosine(60 degrees) = 0.5
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39. Bronchoscopy International
The Doppler angle needs to be 60 degrees or slightly less to the long axis of the vessel to obtain the correct velocity
ΔF= Ft-Fr=2 X Ft X (v/c) X cos θ
Very weak or no Doppler signal is obtained
when the scanning plane is perpendicular to
the blood vessel
cosine(90 degrees) = 0
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40. Q 3: Describe reported relation between PET negative lymph node size and malignancy.40

41. The 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;29:26-29
Probability 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 thoracotomy
If nodes > 16 mm and PET Negative, probability for malignancy is 21%.
Proceed with mediastinoscopy
So 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.

42. All 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

43. BI Practical Approach #1
Prepared with the assistance of Steven Escobar MD and Septimiu Murgu MD
BI Practical Approach #1