Pulmonary & Sleep Services

Endobronchial Ultrasound (EBUS) is a technique that uses ultrasound along with bronchoscope to visualize airway wall and structures adjacent to it.

TYPES OF EBUS:

There are two forms of EBUS; radial and linear (convex).

• Radial Probe-EBUS
  The system has ultrasound processor and balloon catheter that are attached to the probe. The balloon is fixed at the tip of the probe. It helps to take biopsies from the peripheral parts of lung which are otherwise not accessible by routine flexible bronchoscopy.
• Convex Probe-EBUS
  In contrast to the radial probe, convex probe has the advantage of accessing central lesions that are in or adjacent to the lung (mediastinum). High-resolution, real-time ultrasound imaging enables direct visualization of the needle as it penetrates the lymph node which optimises the biopsy sample and makes the procedure relatively safe.

INDICATIONS OF EBUS:

• Assess the extent of airway invasion
  EBUS has extended the vision beyond the tracheobronchial wall. With EBUS, the delicate multilayer structure of the tracheobronchial wall can be analyzed. This knowledge becomes decisive for the management of early cancer in the central airways.
• Peripheral intrapulmonary lesions
  Radial probe EBUS can be used to localize peripheral pulmonary nodules and sampling of the lesion can be done without fluoroscopy.
• Analysis of mediastinal lesions
  Assessment of mediastinal lymph nodes is important for lung cancer staging and planning appropriate treatment strategy. Once target lymph node is identified, linear probe EBUS allows real-time ultrasound guidance during needle insertion. EBUS-TBNA can be used in the evaluation of mediastinal adenopathy due to other aetiologies like sarcoidosis and tuberculosis.
• Guidance of endo-bronchial therapy
  EBUS provides useful additional information during various interventions including resection of endo-bronchial lesion, stricture dilatation, airway stenting, laser therapy and argon plasma coagulation.

CONTRAINDICATIONS

• Life-threatening cardiac arrhythmias
• Current or recent myocardial ischemia
• Poorly controlled heart failure
• Severe hypoxemia
• Uncooperative patient

Additional contraindications to EBUS-TBNA are related to bleeding risk and include following:

• Current anti-platelet agents (such as Ecosprin, Clopidogrel)
• Current anticoagulant therapy (such as warfarin)
• Coagulopathy
• Thrombocytopenia
• Elevated blood urea nitrogen or serum creatinine

COMPLICATIONS

EBUS and EBUS-TBNA are usually safe procedures. Reported complications are agitation, cough, hypoxia, laryngeal injury, fever, bacteraemia and infection, bleeding, pneumothorax and broken equipment becoming stuck in the airway.

Medical Thoracoscopy is a minimally invasive procedure that allows access to the pleural space (space between chest wall and lungs), using a combination of viewing and working instruments. It has become the second most important endoscopic procedure in respiratory medicine after bronchoscopy.

EQUIPMENT:

• Rigid Pleuroscope
• Semi-rigid Pleuroscope: Similar to video bronchoscope

INDICATIONS:

• Work-up and diagnosis of indeterminate pleural fluid (effusion)
• Staging of Lung cancer
• Site-directed biopsy of parietal pleura
• Staging of mesothelioma (pleural malignancy)

CONTRAINDICATIONS:

1. Absolute:

• Lack of pleural space

2. Relative:

• Refractory cough
• Severe hypoxemia (low O2 saturation)
• Coagulopathy including low platelet counts
• Unstable comorbidities or hemodynamic status
• Pulmonary arterial hypertension

COMPLICATIONS:

• Bleeding after a parietal pleura biopsy
• Lung perforation and air leak
• Infection in the pleural space

PREPARATIONS:

• Fasting for 6-8 hours
• Stop blood thinners 3-5 days before the procedure (to confirm with the doctor)
• Patient has to be in the hospital for 3-5 days

In rigid bronchoscopy, a long metal tube (rigid bronchoscope) is advanced into a person’s windpipe and main airways. The rigid bronchoscope’s large diameter allows the doctor to use more sophisticated surgical tools and techniques. Rigid bronchoscopy requires general anesthesia (unconsciousness with assisted breathing), like a surgical procedure. It is imperative to undergo evaluation by the physician as well as anesthesiologist prior to the procedure, which allows discussion of risks and benefits and correction of any reversible contraindication. After general anesthesia is administered, the patient is intubated with the rigid bronchoscope and attached to the ventilator.
Rigid Bronchoscopy is used in both therapeutic and diagnostic cases including: tumor excision, stent placement, foreign body removal and control of bleeding.

• Thermal ablative therapy: It is used for removal or debulking of tumours which are blocking the main airways and causing symptoms like bleeding or difficulty in breathing. The various modalities that are available for achieving this are electrocautery, argon plasma coagulation (APC), laser therapy, and cryotherapy.
• Airway dilatation/ Balloon bronchoplasty: A doctor advances a deflated balloon into a section of abnormally narrowed airway. By inflating the balloon with water, the airway is expanded, potentially relieving symptoms. Balloon bronchoplasty may be performed prior to airway stent placement to help expand a bronchus.
• Airway stenting (bronchial stent): Advanced cancer or certain other conditions like Tuberculosis can constrict or compress an airway tube (bronchus). If the bronchus becomes blocked, difficulty in breathing, cough, and pneumonia can occur. Using a bronchoscope, a doctor can advance a wire mesh stent into a narrowed airway. Expanding the stent can open a bronchus and relieve symptoms caused by the constriction.

PATIENT EDUCATION FOR BRONCHOSCOPY

• You should not eat or drink at least 6 hours before the procedure.
• You may be asked to discontinue blood thinning medications several days prior to the procedure.
• A thin tube called a bronchoscope is placed in the mouth. It is difficult to speak once the bronchoscope is in the airways.
• You will be monitored closely for two to four hours after the test. Chest x-ray will be performed, if needed.
• A family member or friend must be available to drive or accompany you home.
• You may have mild sore throat, hoarseness, cough or fever.
• If the lung is punctured, it can cause an air leak (pneumothorax), which results in lung collapse.
• If you have increasing chest pain or shortness of breath or if you cough up more than a few tablespoons of blood, you should contact your doctor.
• Result of the test may take few days.