EBUS TBNA

Dicky Soehardiman
Respiratory Medicine Department
University of Indonesia
 Introduction
 EBUS has been used successfully:
 to visualize the airway wall layers in exquisite det
ail,
 to view the relationship between extraluminal nod
es-masses and vessels, and
 in guiding biopsy of mediastinal and hilar lymph
nodes as well as parenchymal lesions.
 Endobronchial ultrasonography (EBUS) using
a radial probe through the working channel of
the flexible bronchoscope has been used to id
entify mediastinal and hilar lymph nodes.
 In addition, EBUS guidance has recently been
reported to improve the yield of TBNA.
 Compared to the 20-MHz radial probe, EBUS,
which has an excellent resolution, is capable of
imaging even the layers of the bronchial wall
or lymph nodes that are not detectable on CT
scan, but the 7.5-MHz CP was not suited for
the evaluation of airway infiltration.
 Definition
 Endobronchial ultrasound: technique
used to obtain tomographic images of t
he tissue around the bronchi using ult
rasound probe which inserted to bronc
hi.
 TBNA:

Kurimoto N. Endobronchial ultrasound. 2001

 Mechanism of US Imaging
 US is attenuated when its travel through a
medium.
 US transducer produces a US image by
converting electrical and US signals based on
the principle that the US is partially reflected
and partially transmitted at the boundary of the
medium.

Kurimoto N. Endobronchial ultrasound. 2001

Figure
 Equipment
 Ultrasound Broncho  Object glass:
scope:  Formalin
 Ultrasound Processo  Alcohol 96%
r:
 TBNA needle:
 Syringe needle 20 m
L
 Indications:  Contraindications
 lnn staging of lung cance
r adjacent to the trachea
and main bronchi and no
t accessible by other met
hods apart from surgical i
ntervention.
 the primary diagnosis of s
olid lesions located adjac
ent to the trachea and ma
in bronchi and not access
ible by other methods ap
art from surgical interven
tion.
 determining the presence
of nodal metastases in th
e mediastinum.
Example of CT patients which need EBUS TBNA
 Advantages:  Disadvantages:
 Save  Low yield, the direction of
 Minimally invasive view of the scope is
 Accurate 30°forward oblique, making
the manipulation difficult.
 High sensitivity and specificity
 Poor access,
 Cytology, even histology
 Need for general anesthesia,
 Does not cause any radiation
 Complications,
 Does not require general
anesthesia
 Does not require hospitalization.

Chest 2004; 126:122–8.

 Complications

 Self-limited minor bleeding,

 Pneumothorax,
 Pneumomediastinum

Eur Respir J 2002;19:356-73

 Procedure
 EBUS TBNA was performed with the patients under
general/local anaesthesia.
 The ultrasonic bronchoscope was introduced via an
ETT or LMA
 EBUS TBNA was performed by direct transducer con
tact with the wall of the trachea or bronchus.
 When a lesion was outlined, a 22 gauge full length st
eel needle (Olympus XNA-200C) was introduced via
the biopsy channel of the endoscope.
 Power Doppler examination was used immediately b
efore the biopsy in order to avoid unintended punctu
re of vessels between the wall of the bronchi and the
lesion.
Thorax 2003;58:1083-6
Procedure
 Under real time ultrasonic guidance the needle was
placed in the lesion.
 Suction was applied with a syringe and the needle
was moved back and forth inside the lesion.
 The specimen was expelled onto glass slides and
smeared, air dried, and stained for cytological
examination.
 The necessary number of passes was judged
according to the macroscopic appearance of the
aspirate.
Thorax 2003;58:1083-6.
Preparation
 A 20 cc syringe filled with sterile
water is attached to the balloon
channel of the scope using an
arterial line with a stopcock, and
the channel filled with water.
 A disposable latex balloon is then
carefully placed over the
ultrasound probe, using the
provided applicator and then
inflated with saline.
 All air bubbles should be
evacuated from the balloon prior
to sealing it in place, which is
easily done by applying pressure
to the distal circular lip of the
balloon with the tip of a gloved
finger.

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 EBUS being performed under general intravenous
anesthesia with use of laryngeal mask airway.
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 A standard fiber optic br
onchoscope is first used
to determine anatomy, cl
ear secretions and ensur
e absence of endobrochi
al disease that might ma
ke EBUS superfluous.
 The EBUS scope is then
advanced into the trache
a.
 The balloon is then inflat
ed so that a small cresce
nt of it may be seen at th
e bottom of the fiber opti
c image www.ctcsnet.org
 The button on the
ultrasound processor
(EU-C60; Olympus
America Inc., Center
Valley, PA) toggles
between the fiber optic
and ultrasound views.
 Use of 2 monitors or a
single monitor with
picture-in-picture
display is useful.

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 Ultrasound image of R main pulmonary artery with
(right) and without (left) color Doppler
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 Biopsy of right parat
racheal node with s
uperior vena cava vi
sualized in its long a
xis anteriorly

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TBNA Needle Insertion

 Biopsy needle secured t

o biopsy port of EBUS s
cope.
 The sheath screw is first
released to allow the sh
eath to approximate the
tracheobronchial wall.
 When the sheath is in c
ontact with the bronchi
al wall a slight distortin
g effect can be seen at t
he upper right corner of
the US image. www.ctcsnet.org
TBNA Needle Insertion
 With the sheath
appropriately advanced
and secured by
retightening the screw,
the biopsy screw is then
released.
 This will allow the
biopsy guard to slide out
of the way in preparation
for needle advancement.

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TBNA Needle Insertion

 Once the needle scr

ew has been release
d, the biopsy needle
can usually be easily
advanced through th
e tracheobronchial
wall and into the no
de using a quick, sli
ghtly forceful jab.

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 Once the needle is visualized within the lymph node, th
e stylet is moved in an out a few times to dislodge any br
onchial epithelium that may have entered the needle, an
d then withdrawn.
 Suction is applied to the biopsy needle (typically negativ
e 20 cc of air using a Vac-Loc syringe) and the needle p
assed in and out of the node approximately 10 times un
der US visualization.
 Suction is then released and the entire biopsy needle wi
thdrawn.
 Smears are prepared by advancing the needle out of the
sheath, reinserting the stylet and applying a drop of the
aspirate to frosted glass slides.
 Air is used to ‘flush’ remaining aspirate material either
onto additional slides or into RPMI medium for cell bloc
k analysis. Ideally 3 separate passes should be made int
o each nodal station to maximize yield
Preliminary experienced with new method
of endoscopic transbronchial real time ultra
sound guided biopsy for diagnosis of media
stinal and hilar lesions.

Krasnik M, Vilmann P, Larsen S

S, Jacobsen G K.

Thorax 2003;58:1083-6.
 EBM 1
 EBUS TBNA was performed in 11 patients.
Selection of the patients for EBUS-FNA was
based on CT scan in 10 patients and on PET in
one.
 No complications were experienced.
 The size of the lesions ranged from 7 - 80 mm.

Thorax 2003;58:1083-6.
A total of 15 lesions were punctured.

1 lesion

1 lesion

3 lesions 1 lesion

4 lesions

1 lesion 4 lesions

Thorax 2003;58:1083-6.
The size of the lesions ranged from 7 - 80 mm.

Both lesions sampled were lymph nodes below 10 mm in size

Thorax 2003;58:1083-6.
Conclusion
 EBUS TBNA is a promising technique f
or lnn staging of lung cancer as well as
for the primary diagnosis of solid lesion
s located adjacent to the trachea and m
ain bronchi and not accessible by other
methods apart from surgical interventio
n.

Thorax 2003;58:1083-6.
Real-time EBUS-Guided TBNA of
Mediastinal and Hilar Lymph Nod
es
Yasufuku K, Chiyo M, Sekine , Chha
jed PN, Shibuya K, Iizasa T, and Fuji
sawa T

Chest 2004; 126:122–8.

 EBM 2
 Between March 2002 and September 2003
 70 patients having mediastinal and/or hilar
lymphadenopathy of 1 cm and with known
or suspected malignancy were included in t
he study.
 A chest radiograph and CT scan of the ches
t (plain and contrast enhanced) were perfor
med in all patients

Chest 2004; 126:122–8.

Chest 2004; 126:122–8.
Chest 2004; 126:122–8.
Chest 2004; 126:122–8.
Chest 2004; 126:122–8.
 The results of this study demonstrate th
at direct real-time CP-EBUS-guided TB
NA is a safe and accurate method of ev
aluating both mediastinal and hilar lym
ph nodes.
 CP-EBUS-guided TBNA had :
 a sensitivity of 95.7% (45 of 47 patients),
 a specificity of 100%,

 an accuracy of 97.1% (68 of 70 patients) in

distinguishing benign from malignant medi
astinal and/or hilar lymph nodes.
 No major complications Chest 2004; 126:122–8.
 Disadvantages of this study
 The direction of view of the scope is 30°
forward oblique, making the manipulati
on difficult.
 The subaortic and paraesophageal lymp
h nodes were not accessible during CP-
EBUS-guided TBNA.
 Inadequate sampling  cytology. (1:4 h
istology)

Chest 2004; 126:122–8.

 Conclusions
 Real-time TBNA of the mediastinal and
hilar lymph nodes under direct EBUS gu
idance using the new ultrasound punctu
re bronchoscope is a novel approach tha
t is safe and has a good diagnostic yield.
 This new ultrasound puncture bronchos
cope has an excellent potential in assisti
ng safe and accurate diagnostic interven
tional bronchoscopy.
Chest 2004; 126:122–8.
Conventional vs Endobronchial
Ultrasound-Guided Transbronchial
Needle Aspiration

Herth F, Becker HD, and Ernst A

Chest 2004; 125:322–5.

 EBM 3
 Between June 2001 and March 2002
 All patients referred for TBNA of enlarg
ed mediastinal lymph nodes were rand
omized in an EBUS-guided and a conve
ntional TBNA arm.

Chest 2004; 125:322–5.

Chest 2004; 125:322–5.
Chest 2004; 125:322–5.
 The mean time required for:
 EBUS plus TBNA was 6.3 min,
 conventional TBNA was 3.8 min (p  0.05).

 The average number of needle passes was

four.
 No complications

Chest 2004; 125:322–5.

 Conclusions
 EBUS guidance significantly increases t
he yield of TBNA in all stations except i
n the subcarinal region.
 It should be considered to be a routine
adjunct to TBNA.
 On-site cytology may be unnecessary, a
nd the number of necessary needle pas
ses required is low.

Chest 2004; 125:322–5.

Endobronchial and endoscopic
ultrasound-guided real-time fine-
needle aspiration for mediastinal
staging
Rintoul RC, Skwarski KM, Murchiso
n JT, Wallace WA, Walker WS and P
enman ID

Eur Respir J 2005; 25: 416–21.

 EBM 4
 In 20 patients selected by CT scanning
 a linear-array ultrasound bronchoscope was used t
o visualise paratracheal and hilar lymph nodes, and
 TBNA was performed under direct ultrasonic contr
ol.
 In 7 cases, sequential endoscopic ultrasound (EU
S) was used to assess posteroinferior mediastinal ly
mph nodes.
 All procedures were performed under conscious se
dation.
 The mean number of passes per lesion was two (ra
nge 1–3).
 Lymph node size ranged 6–20 mm in short-axis dia
meter.
Eur Respir J 2005; 25: 416–21.
EBUS-TBNA provided a primary diagnosis for 8 patients.

Eur Respir J 2005; 25: 416–21.

Eur Respir J 2005; 25: 416–21.
Eur Respir J 2005; 25: 416–21.
 The real-time EBUS-guided TBNA can be us
ed to identify and aspirate lymph nodes adj
acent to the trachea and main bronchi from
lymph node stations 2, 3, 4, 5, 7, 10 and 11.
 EBUS can be combined with EUS, which all
ows access to the posteroinferior lymph nod
e stations 5, 7, 8 and 9.
 There were no procedural complications.
 Sensitivity, specificity and accuracy for EBU
S-TBNA were 85%, 100% and 89%, respecti
vely.
Eur Respir J 2005; 25: 416–21.
EBUS lnn stations 2, 3, 4, 5, 7, 10 and 11.

EUS lnn stations 5, 7, 8 and 9.

Eur Respir J 2005; 25: 416–21.

 Conclusions
 EBUS with real-time TBNA offers impro
ved sensitivity and accuracy for staging
of the middle mediastinum, and, combi
ned with endoscopic ultrasound, shoul
d allow investigation of the majority of t
he mediastinum.

Eur Respir J 2005; 25: 416–21.

EBUS Guidance for TBNA Using a
Double-Channel Bronchoscope

Kanoh K, Miyazawa T, Kurimoto N, Iwa

moto Y, Miyazu Y, and Kohno N

Chest 2005; 128:388–93.

 The diagnostic accuracy rate of EBUS-D and E
BUS-S were statistically significantly different
(97% vs 76%, respectively; p  0.025).
 On second attempt of TBNA, the diagnostic rat
e of the EBUS-D group was superior to that of t
he EBUS-S group (85.7% vs 33.3%, respectivel
y; p  0.036).
 The mean number of penetrations was 1.24 in
the EBUS-D group and 1.36 in the EBUS-S gro
up.
 No complications were observed in the EBUS-
D group, but a self-limiting hemorrhage occurr
ed in a patient in the EBUS-S group.
A: the left catheter shown is the EBUS probe with a balloon sheath, a
nd the right
catheter is the TBNA catheter by which a right hilar lymph node was
penetrated.

D: the EBUS image shows a hyperechoic point (arrow)

and the acoustic shadow (arrow head) in the lesion.
 The weak point of this study
 The locations of the penetrated lymph
nodes were not exactly equalized.
 If many patients with lymphadenopathy
in the left paratracheal/aortopulmonary
window had been included in this stud
y, the diagnostic rate might be decrease
d because TBNA in this location is mor
e difficult than in any other site.
 Conclusions
 EBUS double channel is useful for diag
nosing intrathoracic lymphadenopathy
 The obtained specimen with real-time c
onfirmation of the needle is directly pro
portional to an accurate diagnosis.