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    Descending projections from auditory cortex modulate sensitivity in the midbrain to cues for spatial position. Nakamoto Kyle T,Jones Simon J,Palmer Alan R Journal of neurophysiology The function of the profuse descending innervation from the auditory cortex is largely unknown; however, recent studies have demonstrated that focal stimulation of auditory cortex effects frequency tuning curves, duration tuning, and other auditory parameters in the inferior colliculus. Here we demonstrate that, in an anesthetized guinea pig, nonfocal deactivation of the auditory cortex alters the sensitivity of populations of neurons in the inferior colliculus (IC) to one of the major cues for the localization of sound in space, interaural level differences (ILDs). Primary and secondary auditory cortical areas were inactivated by cooling. The ILD functions of 46% of IC cells changed when the cortex was inactivated. In extreme cases, the ILD functions changed from monotonic to nonmonotonic during cooling and vice versa. Eight percent of the cells became unresponsive after deactivation of the auditory cortex. Deactivation of the cortex has previously been shown to alter the maximum spike count of cells in the IC; the change in normalized ILD functions is shown to be separate from this effect. In some cases, the ILD function changed shape when there was no change in the maximum spike count and in other cases there was no change in the shape of the ILD function even though there was a large change in the maximum spike count. Overall, the sensitivity of the IC neural population to ILD is radically altered by the corticofugal pathway. 10.1152/jn.01326.2007
    A strategy to improve the yield of transbronchial needle aspiration. Phua Ghee Chee,Rhee Kyung-Jae,Koh Mariko,Loo Chian Min,Lee Pyng Surgical endoscopy BACKGROUND:Transbronchial needle aspiration (TBNA) is a bronchoscopic technique that provides access to masses within the mediastinum. It is operator dependent, and factors such as needle type, lymph node site, and endobronchial ultrasosonography (EBUS) have been implicated as having an impact on its accuracy. This study aimed to develop a strategy for TBNA and specimen preparation techniques as the first step toward improving TBNA yield, and to determine whether EBUS can augment its application. METHODS:Intervention included standardizing the use of the histology needle and the direct smear method. As competency improved, radial probe (RP) and linear EBUS were incorporated into TBNA. RESULTS:The study assessed 35 conventional TBNA procedures before and 45 of these procedures after intervention as well as 45 RP-EBUS and 50 linear EBUS-guided TBNA procedures. Frequently sampled lymph node stations were 7, 4R, and 4L in the American Thoracic Society classification. The preintervention conventional TBNA yield was 43%, which improved to 82% after intervention. Although EBUS did not have an impact on TBNA yield (p = 0.44) compared with the intervention (p = 0.001), EBUS was useful for lymph nodes smaller than 2 cm (p < 0.0001). Linear EBUS did not confer higher diagnostic accuracy than RP-EBUS (p = 0.47). CONCLUSION:Proper TBNA and specimen preparation techniques are the first steps toward improving TBNA yield, and EBUS can be used to guide TBNA of small lymph nodes. 10.1007/s00464-010-0906-4
    Sequential multimodality bronchoscopic investigation of peripheral pulmonary lesions. Steinfort Daniel P,Bonney Asha,See Katharine,Irving Louis B The European respiratory journal Multiple guidance modalities may be combined during bronchoscopic investigation of peripheral pulmonary lesions (PPLs). The relative contribution of each modality to diagnostic performance remains uncertain.Endobronchial ultrasound (EBUS) with virtual bronchoscopy (VB) was routinely performed, with electromagnetic navigation (EMN) utilised only where EBUS was unable to locate PPLs or where the probe was adjacent to the lesion and on-site cytologic examination was nondiagnostic.236 consecutive patients with 245 PPLs had lesion size 22.8±12.4 mm (mean±sd). PPLs were localised using EBUS+VB alone in 188 (77%) and was diagnostic in 134 of these (71.3%). EBUS localisation was predicted by PPL size (23.7±10.5 versus 19.7±9.8 mm, p=0.003), but not by bronchus sign, PPL-hilum distance or PPL-pleura distance. EMN in 57 patients achieved EBUS localisation in a further 17 patients (30.9%), improving overall visualisation yield to 85%. Nine of these 57 procedures achieved a definitive diagnosis (16%), improving overall diagnostic yield to 58.4%. Probe position and lesion type influenced overall diagnostic yield. Sensitivity for diagnosis of lung cancer was 70% (131/188; 95% CI 63-76%).Localisation rate and diagnostic sensitivity of radial probe EBUS+VB alone for diagnosis of PPLs is high. EBUS localisation rates and procedural yield are improved only modestly (by 8% and 4%, respectively) with addition of EMN. Sampling following EMN should include all available methods to maximise diagnostic yield. 10.1183/13993003.00786-2015
    Recent advances in diagnostic bronchoscopy. Ong Philip G,Debiane Labib G,Casal Roberto F Journal of thoracic disease The field of diagnostic bronchoscopy has been revolutionized in the last decade primarily with the advent of endobronchial ultrasound (EBUS) but also with the addition of multiple different techniques for "guided-bronchoscopy". These advances have had a substantial impact in the management of lung cancer with bronchoscopy now providing both diagnosis and mediastinal staging in a single procedure. EBUS has, in fact, become the first choice for staging of the mediastinum over cervical mediastinoscopy (CM). Although EBUS is now a well-established technique, there are continuous efforts from the scientific community to improve its diagnostic performance, and these will be reviewed in this manuscript. The term "guided-bronchoscopy" was recently coined to describe a myriad of techniques that guide our bronchoscopes or bronchoscopic tools into the periphery of the lungs in addition to our conventional fluoroscopy. Electromagnetic and non-electromagnetic navigation, thin and ultrathin scopes, as well as radial-probe EBUS have collectively increased our yield for smaller peripheral lung lesions and continue to evolve. Despite this improved diagnostic yield, there is still ample room for improvement and newer techniques are under way. With new therapies available for patients with interstitial lung disease, achieving a specific histologic diagnosis is now of paramount importance. Given the high morbidity and mortality of surgical biopsies, bronchoscopic cryobiopsy is being rapidly adopted as a safer and effective alternative, and it is likely going to play a major role in the management of these diseases in the near future. This manuscript we will focus on recent advances in EBUS, guided-bronchoscopy, and the use of cryobiopsy. 10.21037/jtd.2016.12.70
    Bronchoscopy for the diagnosis of peripheral lung lesions. Dhillon Samjot Singh,Harris Kassem Journal of thoracic disease Peripheral pulmonary lesions (PPLs) are generally considered as lesions in the peripheral one-third of the lung although a precise definition and radiographic anatomical landmarks separating central and peripheral lesion does not yet exist. The radiographic detection of such lesions has increased significantly with the adoption of lung cancer screening programs. These lesions are not directly visible by regular flexible bronchoscopes as they are usually distal to the lobar and segmental bronchi. Traditionally, depending on location and clinical stage at presentation, these lesions were typically sampled by computerized tomography (CT) guided needle or surgical biopsy although some centers also used ultrasound and fluoroscopy guided percutaneous needle biopsy. Due to lack of direct visualization, the yield for bronchoscopic guided sampling especially of the small <2 cm pulmonary nodules was very low. Therefore, sampling has been preferentially performed by percutaneous CT guidance, which had high yield of above 90% but it comes at the cost of higher risk complications like pneumothorax with reported rate of 15% to 28%. Directly proceeding to surgical resection is also considered in appropriate candidates with high suspicion of malignancy without any evidence of distant metastasis but the proportion of such cases of lung cancer is low. The manuscript discussed the various bronchoscopic diagnostic modalities for peripheral pulmonary lesions. It is important to note that most of the studies in this field are relatively small, not randomized, suffer from selection bias, have considerable heterogeneity in sampling methodology/instruments and usually have been performed in high volume institutions by dedicated highly experienced proceduralists. The prevalence of malignancy in most of the reported cohorts has also been high which may result in higher diagnostic yields. All these factors need to be kept in mind before generalizing the results to individual centers and practices. 10.21037/jtd.2017.05.48
    RP EBUS as a guide for transbronchial pulmonary biopsy in the diagnosis of organizing pneumonia. Cicchitto Gaetano,Polverino Mario,Capuozzo Antonio,Cacace Luigi,Cavallera Antonietta,Mauro Imma,Ferrigno Francesco,Polverino Francesca Multidisciplinary respiratory medicine Diffuse parenchymal lung diseases (DPLDs) include a wide variety of manifestations characterized by different degrees of inflammation and fibrosis with various patterns of secondary lobule alterations, such that the diagnosis often requires histopathological confirmation in addition to clinical and radiological data. Radial probe endobronchial ultrasonography (RP EBUS) can be used as a guide for transbronchial pulmonary biopsy (TBPB) to obtain tissue samples, and thus can be a useful tool in the diagnostic management of peripheral pulmonary lesions. Organizing pneumonia (OP) is a particular type of DPLD characterized by lung inflammation and scarring that obstruct the small airways and air sacs of the lung. In this study, we describe how and when RP EBUS can be used to guide TBPB and significantly help in the diagnosis of OP. 10.4081/mrm.2020.658
    Cone beam computed tomography-guided thin/ultrathin bronchoscopy for diagnosis of peripheral lung nodules: a prospective pilot study. Casal Roberto F,Sarkiss Mona,Jones Aaron K,Stewart John,Tam Alda,Grosu Horiana B,Ost David E,Jimenez Carlos A,Eapen George A Journal of thoracic disease BACKGROUND:Despite advances in bronchoscopy, its diagnostic yield for peripheral lung lesions continues to be suboptimal. Cone beam computed tomography (CBCT) could be utilized to corroborate the accuracy of our bronchoscopic navigation and hopefully increase its diagnostic yield. However, data on radiation exposure and feasibility of CBCT-guided bronchoscopy is scarce. METHODS:Prospective pilot study of bronchoscopy for peripheral lung nodules under general anesthesia with thin/ultrathin bronchoscope, radial-probe endobronchial ultrasound (RP-EBUS), and CBCT. Main objective was to estimate radiation dose and secondary objective was the additional value of CBCT in terms of navigational and diagnostic yield. RESULTS:A total of 20 patients were enrolled. Median lesion size was 2.1 (range, 1.1-3) cm and distance from pleura was 2.1 (range, 0-2.8) cm. "Bronchus sign" was present in 12 (60%) of the lesions. Totally, 12 lesions (60%) were invisible on fluoroscopy. CBCT identified atelectasis obscuring the target in 4 cases (20%). Eleven patients (55%) underwent 1 CBCT scan and 9 patients (45%) 2. The mean estimated effective dose (E) to patients resulting from CBCT ranged between 8.6 and 23 mSv, depending on utilized conversion factors. Both pre-CBCT navigation and diagnostic yield were 50%. Additional post-CBCT maneuvers increased navigation yield to 75% (P=0.02) and diagnostic yield to 70% (P=0.04). One patient developed a pneumothorax. CONCLUSIONS:CBCT-guided bronchoscopy is associated with an acceptable radiation dose. CBCT may potentially increase both navigation and diagnostic yield of thin/ultrathin bronchoscopy for peripheral lung nodules. The above findings as well as the incidental but relevant finding of intra-procedural atelectasis need to be confirmed in larger prospective studies. TRIAL REGISTRATION:This study is registered in ClinicalTrials.gov as number NCT02978170. 10.21037/jtd.2018.11.21
    Interventional pulmonology: an update for internal medicine physicians. Beaudoin E L,Chee A,Stather D R Minerva medica Interventional pulmonology is a subspecialty that uses advanced diagnostic and therapeutic procedures to care for patients with benign and malignant diseases of the lung, airways and pleura. There has been a rapid proliferation of new pulmonary procedural technologies over the last decade. Common diagnostic applications include endobronchial ultrasound, guided bronchoscopy and a number of pleural disease interventions. Endobronchial ultrasound is performed with a specially design flexible bronchoscope and allows safe and accurate sampling of intrathoracic structures through the airway wall under direct visualization. Guided bronchoscopy methods are granting significant improvement in the diagnostic yield of flexible bronchoscopy. Virtual bronchoscopy, radial probe endobronchial ultrasound and electromagnetic navigational bronchoscopy are examples of these methods. Interventional pulmonologists can also be trained to perform ultrasound guided thoracentesis, closed-needle pleural biopsy and medical thoracoscopy to help in the diagnosis of different pleural pathologies. Therapeutic applications can be used to efficiently bring symptomatic relief of benign and malignant central airway obstruction by using a myriad of flexible and rigid bronchoscopy techniques. Airway stenting and ablative techniques such as laser, electrocautery, cryosurgery and microdebrider techniques are example of resources that can be used by interventional pulmonologists for therapeutic purposes. A number of effective therapies for the management of malignant pleural disease have been studied in recent years, including chemical pleurodesis and tunnelled pleural catheters, greatly adding to our understanding of which therapy to use in which patient. In addition, flexible bronchoscopy approaches to more common disease, such as asthma and chronic obstructive pulmonary disease are currently available or are being developed. This update aims to provide the internal medicine physician with a brief overview of some of the common clinical procedures performed by interventional pulmonary specialists and the current indications and evidence for their use.
    Endoscopic Doppler optical coherence tomography and autofluorescence imaging of peripheral pulmonary nodules and vasculature. Pahlevaninezhad Hamid,Lee Anthony M D,Ritchie Alexander,Shaipanich Tawimas,Zhang Wei,Ionescu Diana N,Hohert Geoffrey,MacAulay Calum,Lam Stephen,Lane Pierre Biomedical optics express We present the first endoscopic Doppler optical coherence tomography and co-registered autofluorescence imaging (DOCT-AFI) of peripheral pulmonary nodules and vascular networks in vivo using a small 0.9 mm diameter catheter. Using exemplary images from volumetric data sets collected from 31 patients during flexible bronchoscopy, we demonstrate how DOCT and AFI offer complementary information that may increase the ability to locate and characterize pulmonary nodules. AFI offers a sensitive visual presentation for the rapid identification of suspicious airway sites, while co-registered OCT provides detailed structural information to assess the airway morphology. We demonstrate the ability of AFI to visualize vascular networks in vivo and validate this finding using Doppler and structural OCT. Given the advantages of higher resolution, smaller probe size, and ability to visualize vasculature, DOCT-AFI has the potential to increase diagnostic accuracy and minimize bleeding to guide biopsy of pulmonary nodules compared to radial endobronchial ultrasound, the current standard of care. 10.1364/BOE.6.004191
    Use of navigation bronchoscopy for biopsy and endobronchial fiducial placement. Linden Philip A Innovations (Philadelphia, Pa.) Electromagnetic navigation bronchoscopy (ENB) is a technique that can be used to biopsy pulmonary lesions beyond areas that are traditionally accessible by bronchoscopy. It can also guide biopsies of peribronchial lymph nodes and guide the placement of fiducial markers for stereotactic radiosurgery. With ENB, the patient is placed in a magnetic field and their anatomy is merged with a 3D reconstructed chest cat scan (CCT). A locatable, steerable probe is used to guide a working channel to the target, usually a peripheral tumor. Biopsies can be taken, and markers can be placed. The accuracy of this system depends largely on a small bronchus leading toward to target. The diagnostic yield is similar to CT-guided biopsies, with a false-negative rate of about 30%, although results may be improved with combined ENB and radial endoscopic ultrasound (EUS). The incidence of pneumothorax is 5% to 8% with ENB-directed biopsies compared with approximately 30% with CT-guided transthoracic biopsy. 10.1097/IMI.0b013e31822c516f
    Incidence and Location of Atelectasis Developed During Bronchoscopy Under General Anesthesia: The I-LOCATE Trial. Sagar Ala-Eddin S,Sabath Bruce F,Eapen George A,Song Juhee,Marcoux Mathieu,Sarkiss Mona,Arain Muhammad H,Grosu Horiana B,Ost David E,Jimenez Carlos A,Casal Roberto F Chest BACKGROUND:Despite the many advances in peripheral bronchoscopy, its diagnostic yield remains suboptimal. With the use of cone-beam CT imaging we have found atelectasis mimicking lung tumors or obscuring them when using radial-probe endobronchial ultrasound (RP-EBUS), but its incidence remains unknown. RESEARCH QUESTION:What are the incidence, anatomic location, and risk factors for developing atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS:We performed a prospective observational study in which patients undergoing peripheral bronchoscopy under general anesthesia were subject to an atelectasis survey carried out by RP-EBUS under fluoroscopic guidance. The following dependent segments were evaluated: right bronchus 2 (RB2), RB6, RB9, and RB10; and left bronchus 2 (LB2), LB6, LB9, and LB10. Images were categorized either as aerated lung ("snowstorm" pattern) or as having a nonaerated/atelectatic pattern. Categorization was performed by three independent readers. RESULTS:Fifty-seven patients were enrolled. The overall intraclass correlation agreement among readers was 0.82 (95% CI, 0.71-0.89). Median time from anesthesia induction to atelectasis survey was 33 min (range, 3-94 min). Fifty-one patients (89%; 95% CI, 78%-96%) had atelectasis in at least one of the eight evaluated segments, 45 patients (79%) had atelectasis in at least three, 41 patients (72%) had atelectasis in at least four, 33 patients (58%) had atelectasis in at least five, and 18 patients (32%) had atelectasis in at least six segments. Right and left B6, B9, and B10 segments showed atelectasis in > 50% of patients. BMI and time to atelectasis survey were associated with increased odds of having more atelectatic segments (BMI: OR, 1.13 per unit change; 95% CI, 1.034-1.235; P = .007; time to survey: OR, 1.064 per minute; 95% CI, 1.025-1.105; P = .001). INTERPRETATION:The incidence of atelectasis developing during bronchoscopy under general anesthesia in dependent lung zones is high, and the number of atelectatic segments is greater with higher BMI and with longer time under anesthesia. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov; No.: NCT03523689; URL: www.clinicaltrials.gov. 10.1016/j.chest.2020.05.565
    Airway wall structure assessed by endobronchial ultrasonography and bronchial hyperresponsiveness in patients with asthma. Kita Toshiyuki,Fujimura Masaki,Kurimoto Noriaki,Sone Takashi,Inuzuka Kanako,Hirose Tatsuki,Oribe Yoshitaka,Myou Shigeharu,Nakao Shinji Journal of bronchology & interventional pulmonology BACKGROUND AND OBJECTIVE:The purpose of this study was to evaluate the relationship between the wall structure assessed by using endobronchial ultrasonography (EBUS) and bronchial hyperresponsiveness in patients with asthma. METHODS:Twenty-four patients with stable asthma and 11 individuals without asthma were studied. EBUS was performed with a radial 20-MHz ultrasonic probe inserted into the intermediate bronchus undergoing flexible bronchoscopy to assess the airway wall structure. The percentage of airway wall thickness {WT%; defined as [(ideal outer diameter-ideal luminal diameter)/ideal outer diameter]×100} was determined by EBUS. We measured bronchial hyperresponsiveness to methacholine [the provocative concentration of methacholine causing a decrease of 20% or more in forced expiratory volume in 1 s (PC20)]. RESULTS:Percentage wall thickness measured by EBUS was significantly greater in patients with asthma than that in subjects without asthma (P<0.01). The evaluation of the laminar structure using EBUS indicated that the thickness of the second layer in patients with asthma was greater than that in subjects without asthma (P<0.05). PC20 was negatively correlated with the thickness of the second layer (r=0.52, P<0.01) but was not significantly correlated with other layers in patients with asthma. CONCLUSIONS:The evaluation of the bronchial mural structure using EBUS might be advantageous for assessing the relationship between airway wall remodeling and bronchial hyperresponsiveness. 10.1097/LBR.0b013e3181f9f09b
    3-D endobronchial ultrasonography--a post mortem study. Andreassen Alf Henrik,Ellingsen Ivar,Nesje Lars Birger,Gravdal Karsten,Odegaard Svein Ultrasound in medicine & biology Endobronchial ultrasonography (EBUS) using balloon-embedded probes may cause airway obstruction and requires a rapid scanning procedure. Three-dimensional (3-D) postprocessing of sequential 2-D images may allow detailed studies on a rapidly acquired image volume. We applied a 3-D reconstruction program on EBUS recordings acquired with a radial-scanning probe during a controlled pullback procedure in water-filled airways in five corpses. The aim was to acquire EBUS images under optimized conditions and to test a 3-D software program for postprocessing. Under post mortem conditions, 3-D images were obtained, allowing any-plane imaging and measurements, application of different rendering and visualization algorithms and merging of overlapping volumes. 10.1016/j.ultrasmedbio.2005.01.002
    Advanced bronchoscopic techniques for the diagnosis of peripheral pulmonary lesions. Mudambi Lakshmi,Ost David E Current opinion in pulmonary medicine PURPOSE OF REVIEW:The review describes recent advances in bronchoscopic modalities used to diagnose peripheral pulmonary lesions. RECENT FINDINGS:The pooled diagnostic yield and sensitivity of radial probe endobronchial ultrasound (r-EBUS) has been reported to be 56% for lesions less than 2 cm and 78% for lesions more than 2 cm and 73%, respectively. The pooled diagnostic yield and sensitivity of electromagnetic navigational bronchoscopy (ENB) has been reported to be 65 and 71%, respectively. However, significant heterogeneity between studies was evident for both r-EBUS and ENB (sensitivity of r-EBUS: I = 75%; sensitivity of ENB: I = 57% and diagnostic yield of ENB: I = 66%). Recent studies show that these technologies do not perform in the clinical setting as well as reported in the literature. Conceptually, the domains of advanced bronchoscopic modalities that affect performance are navigation, maneuverability, and location verification. Combining technologies that deal with different domains, such as ENB (navigation) and r-EBUS (location verification), has led to synergistic effects with improved outcomes. SUMMARY:The performance characteristics of the different advanced bronchoscopic modalities reported in the literature may not be representative of performance in clinical practice because of clinical and statistical heterogeneity in the published literature. However, evidence is accumulating that synergistic combinations of technologies may ultimately lead to better performance. 10.1097/MCP.0000000000000284
    Multi-gene analyses from waste brushing specimens for patients with peripheral lung cancer receiving EBUS-assisted bronchoscopy. Tsai Tzu-Hsiu,Yang Ching-Yao,Ho Chao-Chi,Liao Wei-Yu,Jan I-Shiow,Chen Kuan-Yu,Wang Jann-Yuan,Ruan Sheng-Yuan,Yu Chong-Jen,Yang James Chih-Hsin,Yang Pan-Chyr,Shih Jin-Yuan Lung cancer (Amsterdam, Netherlands) OBJECTIVES:Although flexible bronchoscopy with the assistance of miniature radial-probe endobronchial ultrasound (EBUS) is increasingly employed to diagnose peripheral lung cancer, transbronchial biopsies typically offer an insufficient amount of tissue to conduct additional molecular analysis. We evaluated the feasibility of multi-gene analyses from waste brushing samples obtained by EBUS-assisted bronchoscopy. MATERIALS AND METHODS:For lung cancer patients with positive brushing cytology, analysis of EGFR, K-ras and EML4-ALK fusions were carried out, utilizing reverse transcription-polymerase chain reaction and Sanger sequencing on the cell-derived RNA retrieved from waste brushing samples. RESULTS:EBUS-guided brushings were judged positive for tumor cells in 84 (68.9%) of the 122 patients with peripheral lung cancer receiving flexible bronchoscopy. Genotyping of EGFR and K-ras was successfully implemented in 80 (95.2%) of the 84 cytology-proven brushing samples, along with satisfactory yields to detect EGFR (55.0%) and K-ras (2.5%) mutations. The results of EGFR genotyping from the brushing specimens were highly concordant with those provided from other corresponding samples (concordance rate: 94%, kappa: 0.92). Of the 19 patients with adenocarcinoma or non-small cell lung cancer not otherwise specified harboring wild-type EGFR and K-ras, two cases (10.5%) were identified to harbor EML4-ALK fusions. CONCLUSION:Our results suggest that multi-gene analyses from waste brushing specimens using RNA-based Sanger sequencing is highly feasible. This approach offers an opportunity to overcome the dilemma of flexible bronchoscopy in molecular diagnostics for lung cancer, and could potentially recruit more patients for targeted therapy according to the molecular characteristics of the tumor cells. 10.1016/j.lungcan.2013.10.005
    Competence in endosonographic techniques. Candoli Piero,Ceron Loris,Trisolini Rocco,Romagnoli Micaela,Michieletto Lucio,Scarlata Simone,Galasso Thomas,Leoncini Fausto,Pasini Valeria,Dennetta Donatella,Marchesani Francesca,Zotti Mariagioconda,Corbetta Lorenzo Panminerva medica Endobronchial ultrasound (EBUS) has revolutionized the field of bronchoscopy because it allows to observe peribronchial structures and distal peripheral lung lesions. The use of EBUS was first described by Hurte and Hanrath in 1992. EBUS technology exists in two forms: radial and convex transducer probes. The radial EBUS probe has a 20-MHZ (12-30 MHz available) rotating transducer that can be inserted together with or without a guide sheath through the working channel (2.0-2.8 mm) of a standard flexible bronchoscope. The transducer rotates and produces a 360-degree circular image around the central position of the probe. There are two types of radial EBUS probes: "peripheral" probes, used to identify parenchymal lung lesions, and "central" probes, with balloon sheaths, used for the assessment of airway walls and peribronchial lymph nodes. 10.23736/S0031-0808.18.03570-X
    Endobronchial treatment of peripheral tumors: ongoing development and perspectives. Vieira Thibault,Stern Jean-Baptiste,Girard Philippe,Caliandro Raffaelle Journal of thoracic disease The expanded possibilities to explore the lung deeper with new tools such as electromagnetic navigation bronchoscopy (ENB) or radial probe endobronchial ultrasonography (radial EBUS), combined with miniaturization of traditional local therapies such as radiofrequency ablation (RFA), radiotherapy, cryotherapy or photodynamic therapy, let the bronchoscopists hope for new ways of endoscopic treatments. This challenge could change the practice in the upcoming decades but raise some physical and technical issues. Safety and efficacy need to be solidly established to face the serious concurrence of stereotactic radiotherapy (SBRT) or percutaneous RFA. Here we describe ongoing development and perspectives for endobronchial treatment of peripheral lung tumors. 10.21037/jtd.2018.01.86
    Cone-Beam CT Image Guidance With and Without Electromagnetic Navigation Bronchoscopy for Biopsy of Peripheral Pulmonary Lesions. Verhoeven Roel L J,Fütterer Jurgen J,Hoefsloot Wouter,van der Heijden Erik H F M Journal of bronchology & interventional pulmonology BACKGROUND:Bronchoscopic diagnosis of small peripheral lung lesions suspected of lung cancer remains a challenge. A successful endobronchial diagnosis comprises navigation, confirmation, and tissue acquisition. In all steps, 3-dimensional information is essential. Cone-beam computed tomography (CBCT) imaging can provide computed tomography information and 3-dimensional augmented fluoroscopy imaging. We assessed whether CBCT imaging can improve navigation and diagnosis of peripheral lesions by 2 clinical workflows with a cross-over design: (1) a primary CBCT and radial endobronchial ultrasound mini probe imaging-based approach and (2) a primary electromagnetic navigation (EMN) and radial endobronchial ultrasound mini probe imaging-based approach. METHODS:All patients with a peripheral lung lesion biopsy indication were eligible for study inclusion and randomly assigned to study arms. Commercially available equipment was used. The main study goals were to assess CBCT-confirmed navigation success and diagnostic accuracy. Surgery or unambiguous clinical follow-up served as the gold standard. RESULTS:Eighty-seven patients with 107 lesions were included. Lesion mean longest axis size in the CBCT arm was 16.6 mm (n=47) and 14.2 mm in the EMN arm (n=40). The primary CBCT approach and primary EMN approach had 76.3% and 52.2% navigation success, respectively. Addition of EMN to the CBCT approach increased navigation success to 89.9%. Addition of CBCT imaging to the EMN approach significantly increased navigation success to 87.5% per lesion. The overall diagnostic accuracy per patient was significantly lower than the navigation success, being 72.4%. CONCLUSION:CBCT imaging is a valuable addition to navigation bronchoscopy. Although overall navigation success was high, the diagnostic accuracy remains to be improved. Future research should focus on improving the tissue acquisition methodology. 10.1097/LBR.0000000000000697
    Bronchoscopic Diagnostic Procedures Available to the Pulmonologist. Burks A Cole,Akulian Jason Clinics in chest medicine In the diagnosis of lung cancer, pulmonologists have several tools at their disposal. From the tried and true convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration to robotic bronchoscopy for peripheral lesions and new technology to unblind the biopsy tools, this article elucidates and expounds on the tools currently available and being developed for lung cancer diagnosis. 10.1016/j.ccm.2019.11.002
    Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions. Ishiwata Tsukasa,Gregor Alexander,Inage Terunaga,Yasufuku Kazuhiro Expert review of respiratory medicine : The incidence of peripheral pulmonary lesions (PPLs) is growing following the adoption of lung cancer screening by low-dose chest CT. Although CT-guided transthoracic needle aspiration has been the standard method to diagnose PPLs, the field of interventional bronchoscopy is rapidly advancing to overcome complications of the transthoracic approach yet maintain the yield. : This article reviews the clinical evidence of recent emerging interventional bronchoscopic techniques for diagnosis of PPLs. : Recent advances in interventional bronchoscopy contribute to not only the safety of transbronchial approaches to PPLs but also the higher diagnostic yield. To perform accurate sampling of PPLs, bronchoscopists must select the correct airway, approach the target as close as possible, and confirm the location of the target before sampling. These key steps can be assisted by recently developed technologies. However, it is important for bronchoscopists to understand the strengths and limitations of these emerging technologies. 10.1080/17476348.2019.1645600
    Current status of diagnostic and therapeutic bronchoscopy in Japan: 2016 national survey of bronchoscopy. Horinouchi Hirohisa,Asano Fumihiro,Okubo Kenichi,Okada Yoshinori,Ohsaki Yoshinobu,Komase Yuko,Hashizume Toshinori,Kohno Mitsutomo,Aoe Motoi Respiratory investigation BACKGROUND:The safety management committee of the Japan Society for Respiratory Endoscopy (JSRE) conducted national surveys to clarify the state of diagnostic and therapeutic bronchoscopy in 2016. METHODS:Questionnaire forms were mailed to 532 JSRE-accredited facilities throughout Japan. We surveyed the actual condition of clinical practice and cases of bronchoscopy during 2016. RESULTS:Four hundred and thirty-three facilities responded giving a response rate of 81.4%; 67.6% held more than 400 beds. The average number of board accredited senior Fellows and Fellows per facility was 1.9 and 3.2, respectively. Diagnostic bronchoscopy was performed in a hospitalized setting in 74.6% of all facilities. The radial type ultrasound probe was operated in 51.7% of all facilities. The number of facilities has markedly increased compared with that reported in the 2010 survey (19.6%). The bronchoscopic navigation system had been in operation in 41.7% of all facilities. Antithrombotic drugs were adjusted before biopsy in 96.8% of all facilities. For intravenous sedation, midazolam was the first choice in 76.9% of all facilities. Endobronchial ultrasound guided transbronchial lymph node needle aspiration (EBUS-TBNA) has become popular over the decade (19.6% in 2010 to 68.1% in 2016). The mean number of the board accredited senior Fellows and board accredited Fellows increased in comparison with that in 2010. As a new technique, radial type ultrasound-guided peripheral approach has become popular. CONCLUSIONS:Through this survey, the advanced safety of bronchoscopic examination has been secured in many facilities. A continuous monitoring of bronchoscopic practices with respect to safety management is recommended. 10.1016/j.resinv.2018.12.007
    Transbronchial evaluation of peripheral pulmonary lesions using ultrasonic spectrum analysis in lung cancer patients. Ishiwata Tsukasa,Terada Jiro,Nakajima Takahiro,Tsushima Kenji,Tatsumi Koichiro Respirology (Carlton, Vic.) BACKGROUND AND OBJECTIVE:Analysis of the endobronchial ultrasound (EBUS) radiofrequency spectrum has been used for convex-probe EBUS technology. Quantitative imaging analysis is also warranted for guided bronchoscopy using radial-probe EBUS (RP-EBUS) targeting peripheral pulmonary lesions (PPL). This study aimed to determine the feasibility of radiofrequency spectrum analysis for distinguishing malignant and benign PPL during diagnostic bronchoscopy. METHODS:Raw RP-EBUS images with radiofrequency data, including backscatter signals, were prospectively recorded. The ultrasonic spectral parameters, such as intercept, midband-fit and slope within the region of interest, were retrospectively computed by linear regression analysis and compared with the final diagnosis. RESULTS:A total of 71 PPL, including 45 malignant and 26 benign lesions, were analysed. Malignant PPL showed a significantly lower intercept (P < 0.0001), lower midband-fit (P < 0.0001) and higher slope (P = 0.014) than benign PPL. Analyses of the area under the curve of receiver operating characteristic plots demonstrated that the intercept showed the best diagnostic performance among three parameters (0.87, 0.77 and 0.69 for intercept, midband-fit and slope, respectively). The sensitivity, specificity, accuracy, positive likelihood and negative likelihood were 75.6%, 96.2%, 83.1%, 19.6 and 0.25 for the intercept; 88.9%, 57.7%, 77.5%, 2.1 and 0.19 for the midband-fit; and 68.9%, 73.1%, 70.4%, 2.6 and 0.43 for the slope. CONCLUSION:Spectrum analysis of EBUS radiofrequency can be used as a novel non-invasive predictor of malignant or benign PPL. Analysis of the 'intercept' of the targeted lesion may provide useful supporting data for real-time sampling from PPL during diagnostic bronchoscopy. 10.1111/resp.13534
    [Endobronchial ultrasonography for diagnosis of peripheral pulmonary lesions]. Kurimoto Noriaki Kyobu geka. The Japanese journal of thoracic surgery Endobronchial ultrasonography (EBUS) with a radial scanning probe provides cross-sectional images of peripheral pulmonary lesions. We devised a technique of EBUS for the diagnosis of peripheral pulmonary lesions. EBUS using a thick guide sheath (GS) [2.5 mm in diameter] covering a miniature probe, and 150 lesions were evaluated in a prospective open study. In the procedure of EBUS-GS, the probe covered by a GS is introduced into the lesion via the working channel of a bronchoscope. The probe is withdrawn, while the GS is left in situ. A brush or biopsy forceps is introduced through the GS into the lesion. EBUS visualized the image in 93% of the peripheral pulmonary lesions. One hundred sixteen (77%) of 150 EBUS-GS procedures were diagnostic. Cases in which the probe was located within the lesion, had a significantly higher diagnostic yield (105/121, 87%) than when the probe was located adjacent to it (8/19, 42%). Diagnostic yield from EBUS-GS in lesions < or = 10 mm (16/21, 76%), 10<, < or = 15 mm (19/25, 76%, p=0.99, chi2), 15<, < or = 20 mm (24/35, 69%, p=0.41, chi2), and 20<, < or = 30 mm (33/43, 77%, p=0.96, chi2) were similar, demonstrating the efficacy of EBUS-GS even in lesions < or = 20 mm in diameter.
    Endobronchial Ultrasound-directed Transbronchial Needle Aspiration in Diagnosis of Mediastinal Lesions: Initial Egyptian Experience. Safwat Tarek,Khattab Adel,Haddad Salwa El,Mostafa Yasser,Korraa Emad,Madkour Ashraf,Fattah Wael Abd El Journal of bronchology & interventional pulmonology Mediastinal lesions represent a diagnostic challenge and often require invasive approaches. We evaluated the role of radial probe endobronchial ultrasound-directed transbronchial needle aspiration (EBUS-TBNA) in the evaluation of mediastinal lesions. Between March 2005 to February 2006, 30 consecutive patients with enlarged mediastinal lymph nodes from unknown etiologies or suspicious for metastatic bronchogenic carcinoma and mediastinal masses underwent EBUS-TBNA and were clinically followed up. EBUS-TBNA was applied under topical anesthesia, midazolam sedation with a mean dose of 4.6+1.7 mg and prolonged the examination by 14.7 minutes on average. EBUS-directed TBNA was performed in 17 lymph nodes and 13 mediastinal masses, achieving specific diagnosis in 82.3% (14/17) and 84.6% (11/13) of examined lesions, respectively, with an overall yield of 83%. The sensitivity, specificity, and accuracy of EBUS-TBNA in distinguishing benign from malignant mediastinal lesions were 89.4%, 100%, and 93.3%, respectively. EBUS was well tolerated by most of the patients with no TBNA-related complications. In conclusion, EBUS-TBNA of mediastinal lesions is a minimally invasive safe diagnostic technique with high yield, even in the hands of those with initial experience. This initial study is convincing and stimulating for widespread application of EBUS-TBNA in Egyptian bronchoscopy practice. 10.1097/LBR.0b013e3181968f17
    Differentiating peripheral pulmonary lesions based on images of endobronchial ultrasonography. Chao Tung-Ying,Lie Chien-Hao,Chung Yu-Hsiu,Wang Jui-Long,Wang Yi-Hsi,Lin Meng-Chih Chest PURPOSE:To attempt to develop a simple method to discriminate between neoplasm and nonneoplasm peripheral pulmonary lesions based on images of endobronchial ultrasonography (EBUS). METHODS:Between June 2004 and June 2005, 151 patients with bronchoscopic peripheral lesions that could not be detected via a conventional bronchoscope underwent EBUS for advanced localization with a 20-MHz miniature radial probe in a tertiary-referral teaching hospital. The image characteristics were applied subsequently to correlate definite histopathologic results in studied patients. RESULTS:Based on an initial 20 consecutive patients with a definite diagnosis, four image characteristics were issued: (1) continuous hyperechoic margin outside the lesion, (2) homogeneous, or heterogeneous internal echoes, (3) hyperechoic dots in the lesion, and (4) concentric circles along the echo probe. In the following 131 patients, excluding five cases due to inconsistent typing, 93 patients (73.8%) established a diagnosis later. Most cases involving the image characteristics of homogenous internal echoes and concentric circles had nonneoplasm lesions (18 of 19 cases, 94.7%, and 14 of 16 cases, 87.5%, respectively). The difference shown in these two respects with neoplasm lesions was significant by univariate analysis (p < 0.001), although only concentric circles had a significant p value after multivariate analysis. Another two image patterns (continuous hyperechoic margins and hyperechoic dots) did not yield a significant difference (p = 0.090 and p = 0.079, respectively). The average additional time for EBUS was 3.94 min (1.5 to 10 min). CONCLUSION:EBUS can provide characteristic information to differentiate the nature of a peripheral pulmonary lesion from the image characteristics of concentric circles. 10.1378/chest.130.4.1191
    The diagnostic utility of endobronchial ultrasonography with a guide sheath and tomosynthesis images for ground glass opacity pulmonary lesions. Izumo Takehiro,Sasada Shinji,Chavez Christine,Tsuchida Takaaki Journal of thoracic disease BACKGROUND:With the widespread use of computed tomography (CT), the frequency of discovering ground glass opacity (GGO) pulmonary lesions has increased. There have been some reports on surgery or transthoracic needle aspiration (TTNA) for diagnostic sampling of GGOs but none on transbronchial biopsy (TBB). The purpose of this study was to evaluate the diagnostic utility of chest tomosynthesis images and TBB through endobronchial ultrasonography with a guide sheath (EBUS-GS) for GGO. METHODS:This study included 40 patients (19 men, 21 women; age 66.9±8.7 years, mean ± standard deviation, SD). The mean lesion diameter was 22±10 mm (mean ± SD). Chest tomosynthesis images served as maps prior to bronchoscopic sampling using radial EBUS probe with a guide sheath kit. RESULTS:The overall diagnostic yield of EBUS-GS-guided TBB was 65.0% (26 of 40 lesions). In a multivariate analysis, diagnostic yield of lesions with EBUS images (79.2%, 19 of 24 cases) was significantly higher than those lesions without EBUS images detected (43.8%, 7 of 16 cases) (P=0.017). Detectability on chest tomosynthesis was not a significant contributing factor. Only one complication was observed: pneumothorax that did not require chest tube drainage. CONCLUSIONS:TBB through EBUS-GS can be considered as one of the diagnostic methods for GGO. Further technological development is required to identify the location of the target GGO lesion more precisely. 10.3978/j.issn.2072-1439.2013.11.30
    Endobronchial ultrasonography: current status and future directions. Yasufuku Kazuhiro,Nakajima Takahiro,Chiyo Masako,Sekine Yasuo,Shibuya Kiyoshi,Fujisawa Takehiko Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer Endobronchial ultrasonography (EBUS) has emerged as a new diagnostic tool that allows the bronchoscopist to see beyond the airway. The radial probe EBUS was first introduced to evaluate the airway structure, which has been shown to be useful for identifying the extent of tumor invasion in the central airway. With advance in technology, smaller radial probes are now available that are capable of visualizing peripheral lung nodules. EBUS is also used as a tool to assist in a biopsy in respiratory diseases. The radial probe EBUS-guided transbronchial needle aspiration (TBNA) increases the yield of TBNA of mediastinal processes. By the use of the ultra-miniature probe EBUS along with the guide sheath, peripheral lung lesions can be accessed without the exposure to radiation. However, it is still not a real-time procedure with target visualization. The newest development is the convex probe EBUS (CP-EBUS) with a curvilinear electronic transducer on the tip of a flexible bronchovideoscope. CP-EBUS allows real-time EBUS-guided TBNA. Although the main indication for EBUS-TBNA is lymph node staging, it can also be used for diagnosis of intrapulmonary tumors, of unknown hilar and/or mediastinal lymphadenopathy, and of mediastinal tumors. To date, there are no reports of complications related to EBUS-guided TBNA. It is a novel approach that has a good diagnostic yield with excellent potential in assisting safe and accurate diagnostic interventional bronchoscopy. The aim of this review is to highlight the current status of the different EBUS techniques available and to discuss the future direction of EBUS. 10.1097/JTO.0b013e318153fd8d
    Additional transbronchial needle aspiration through a guide sheath for peripheral pulmonary lesions that cannot be detected by radial EBUS. Hayama Manabu,Izumo Takehiro,Chavez Christine,Matsumoto Yuji,Tsuchida Takaaki,Sasada Shinji The clinical respiratory journal BACKGROUND:Endobronchial ultrasound with a guide sheath (EBUS-GS) has resulted to better diagnostic outcome for peripheral pulmonary lesions (PPLs), although the yield is not satisfactory for lesions that cannot be located by EBUS. We aimed to evaluate whether the addition of a new technique, transbronchial needle aspiration through a guide sheath (GS-TBNA), can increase the yield for these cases. METHODS:This was a retrospective review of cases that were not located by EBUS during EBUS-GS for PPL diagnosis. From September 2012 to August 2014, 67 PPLs had 'invisible' EBUS-GS location prior to transbronchial sampling. The patients were divided into two groups according to the use of additional GS-TBNA: GS-TBNA group (n=22) and non-GS-TBNA group (n=45). Diagnostic yields were compared and multivariate analysis was performed to determine the factors associated with increased diagnostic yield. RESULTS:The diagnostic yield was significantly higher in the GS-TBNA group than in the non-GS-TBNA group (54.5% vs 17.8%, P<0.01). The complication rate was not significantly different between the GS-TBNA group and the non-GS-TBNA group (0% vs 4.4%, P=1.0). Multivariate analysis showed that only performing GS-TBNA was significantly associated with increased diagnostic yield (odds ratio 3.99, P=0.03). CONCLUSION:GS-TBNA is a safe technique for PPL diagnosis and may be useful when the EBUS probe cannot reach the lesion. 10.1111/crj.12413
    Endobronchial ultrasound morphology of expiratory central airway collapse. Murgu Septimiu,Kurimoto Noriaki,Colt Henri Respirology (Carlton, Vic.) Differences in central airway wall structure in patients with various forms of expiratory central airway collapse can be identified by endobronchial ultrasound using a 20 MHz radial probe. In tracheobronchomalacia due to relapsing polychondritis, the cartilage is thick and irregular while the membranous portion is normal. In malacia due to chronic inflammation after tracheotomy, the cartilage is thick and irregular and the membranous portion is also thick. In excessive dynamic airway collapse associated with COPD, on the contrary, the cartilage is normal and the posterior membrane is thin when compared to the normal airway wall structures identified in a patient with physiological dynamic airway collapse. These findings may support the hypothesis that various clinical forms of expiratory central airway collapse are not only different morphologically, physiologically and aetiologically, but also structurally. 10.1111/j.1440-1843.2007.01216.x
    [Endobronchial ultrasonography with distance by thin bronchoscopy in diagnosing peripheral pulmonary lesions]. Zhang Sujuan,Zhou Jun,Zhang Qiudi,Xu Qianqian,Xu Xiong Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases OBJECTIVE:To evaluate the efficacy, safety and factors related to diagnostic yield of transbronchial biopsy (TBB) using thin bronchoscopy to endobronchial ultrasonography with distance ( EBUS-D) for peripheral pulmonary lesions (PPLs). METHODS:Between October 2013 to September 2014, 117 patients [67 males and 50 females, aged (62.2 ± 10.9 ) years] underwent EBUS-D-guided TBB for the diagnosis of PPLs [mean size (22.9 ± 9.5) mm] and their medical records were retrospectively reviewed and analysed. EBUS was performed using a 4-mm thin bronchoscope and a 1.4 mm radial ultrasound probe. EBUS-D was to measure the distance between the PPL to the target bronchial orifice or to the outer orifice of the working channel of the bronchoscope when an EBUS image of the PPL was observed, and then the biopsy forceps were advanced to this measured distance and biopsy followed. RESULTS:The visualization yield of EBUS was 77.8% (91/117). The overall diagnostic yield was 65.0% (76/117) by EBUS-D-guided TBB, and the diagnostic yield in malignant and benign lesions was 75.0% (66/88) and 34.5% (10/29), respectively. The diagnostic yield for PPLs > 20 mm in diameter was significantly higher than that for those ≤ 20 mm in diameter (78.7%,48/61 versus 50.0%, 28/56) (χ² 10.56, P=0.001). There was no significant difference in diagnostic yield between lobar distribution (right upper lobe 61.8%, 21/34; right middle lobe 91.7%, 11/12; right lower lobe 59.1%, 13/22; left upper lobe 57.1%,12/21; lingula 80.0%,4/5; left lower lobe 65.2%,15/23) (χ² = 5.31, P=0.38). The diagnostic sensitivity was only 18.2% for lesions close to visceral pleura with mean size ≤ 20 mm. Sometimes radial probe could pass through the PPL without resistance, and the diagnostic yield was lower in this situation. Complications including bleeding and chest pain recovered spontaneously. CONCLUSION:Using EBUS-D-TBB with a thin bronchoscope, the vast majority of peripheral pulmonary lesions could be identified. The modality was far more cost-effective than EBUS-GS and there were no significant complications associated with this procedure. Lesion size, connection to the visceral pleura and radial probe through the lesion influenced the diagnostic yield.
    Endobronchial ultrasound in pediatric pulmonology. Steinfort Daniel P,Wurzel Danielle,Irving Louis B,Ranganathan Sarath C Pediatric pulmonology Endobronchial ultrasound (EBUS) is a recently introduced technique that has significantly advanced bronchoscopic techniques in adult medicine. Use of ultrasound allows far more accurate localization and sampling of both peripheral pulmonary, as well as mediastinal and hilar lesions. This has led to greater diagnostic success, with a reduced rate of complications. Its performance characteristics in adult populations are equivalent to surgical procedures previously considered gold standard, but it has dramatically reduced morbidity and mortality among patients requiring invasive diagnostic procedures, when compared to surgical approaches. We describe the types of EBUS in clinical use, the method of use, the clinical indications for each procedure, and the potential role for EBUS in pediatric pulmonology. Radial probe EBUS is used in the investigation of peripheral lung lesions and could be adopted in children to achieve accurate biopsy of such lesions. Linear probe EBUS allows minimally invasive biopsy of mediastinal and hilar lesions. It has potentially greater performance characteristics than current biopsy techniques, with no significant complications reported to date. It may be useful in the diagnosis of lymphoma, or neurogenic tumors, as well as many other diseases resulting in mediastinal or hilar lymphadenopathy. EBUS is a minimally invasive technique that allows tissue sampling of peripheral lung lesions, or mediastinal/hilar masses, with a high diagnostic accuracy, and a significantly lower morbidity and mortality than alternative approaches. The indications for and the use of EBUS in pediatric patients is certain to increase in the future. 10.1002/ppul.20991
    Endobronchial ultrasound. Sheski Francis D,Mathur Praveen N Chest UNLABELLED:During flexible fiberoptic bronchoscopy (FB), a solitary pulmonary nodule (SPN) is sampled by means of transbronchial needle aspiration (TBNA), brush, or transbronchial lung biopsy under fluoroscopy; and mediastinal lymph nodes are sampled using "blind" TBNA. Endobronchial ultrasound (EBUS) was developed to help visualize the lesion at the time of biopsy in order to improve the diagnostic yield. METHODS:There are two types of EBUS techniques: using a radial probe (RP) with a rotating transducer at the distal tip, which produces a 360 degrees image to the long axis of the bronchoscope; and using an EBUS bronchoscope with a linear transducer at its distal tip, producing a 50 degrees image parallel to its long axis. RESULTS:In biopsies of SPNs < 2 cm using an RP, EBUS demonstrates a higher diagnostic yield than conventional FB techniques. With mediastinal and hilar nodal stations, except for the subcarina, EBUS shows a higher yield over blind TBNA. The current procedural terminology code for EBUS is 31620, a "ZZZ" code submitted in addition to other performed procedures (31622-31638). In 2007, an estimate of physician Medicare reimbursement for EBUS is $70.49. Reimbursement is locality dependent and based on economic-exchange conversion factors. Incorporating an ultrasound image into the report substantiates the use of this technique. LIMITATIONS:The physician must learn ultrasound image interpretation and the EBUS technique, and be skilled in TBNA. Maintaining competency requires frequent performance of EBUS. CONCLUSION:EBUS-directed biopsy improves the yield over conventional FB for SPNs < 2 cm and for most mediastinal or hilar nodal stations. This reduces the need to conduct additional diagnostic procedures. 10.1378/chest.06-1735
    Bronchoscopy and endobronchial ultrasound for diagnosis and staging of lung cancer. Almeida Francisco Aécio Cleveland Clinic journal of medicine Various techniques, including standard bronchoscopy, transthoracic needle aspiration and mediastinoscopy, are used for diagnosis and staging of lung cancer. Minimizing the number of invasive procedures for lung cancer diagnosis and staging is preferred, however, and a growing number of bronchoscopic techniques are being used. Currently available techniques for the initial diagnosis of lung cancer include electromagnetic navigation bronchoscopy with computed tomography mapping and sample collection, endobronchial ultrasound (EBUS) using radial or convex probe tips, and the combination of the two approaches. EBUS with transbronchial needle aspiration (EBUS-TBNA) is highly specific and sensitive for the examination of mediastinal lymph nodes. Several studies have demonstrated the utility of this approach for less invasive lung cancer mediastinal staging. EBUS-TBNA has also been used in the collection of tissue samples for the analysis of tumor biomarkers that significantly influence the selection of cancer treatment strategies. Evidence suggests that EBUS-TBNA may be less useful for restaging patients with lung cancer after cytotoxic therapy. 10.3949/ccjm.79.s2.03
    Scientific evidence and principles for the use of endobronchial ultrasound and transbronchial needle aspiration. Colt Henri G,Davoudi Mohsen,Murgu Septimiu Expert review of medical devices Endobronchial ultrasound (EBUS), using the radial EBUS probe and convex-probe EBUS-guided transbronchial needle aspiration, are increasingly advocated for a wide array of minimally invasive thoracic procedures. The effectiveness of EBUS-guided procedures has been demonstrated to a degree that, in many institutions, EBUS is becoming standard of practice for the diagnosis, staging and restaging of mediastinal lymphadenopathy in lung cancer, the diagnosis of sarcoidosis, and for bronchoscopic biopsy of peripheral lung lesions. Its role in other bronchoscopic procedures requires further study despite an already strong body of literature: diagnosis of lymphoma and benign infectious disease, diagnosis of early lung cancer and airway wall disorders, imaging of thoracic vascular disease such as pulmonary embolism, and therapeutic procedures such as placement of fiducial markers. In this article, we illustrate some of the principles of EBUS, describe major technical aspects pertaining to the procedure itself and provide a narrative review of original research addressing proposed roles of EBUS in a variety of indications. In closing, we describe future perspectives including new educational processes and philosophies that could favorably impact the rapid and safe dissemination of this evolving technology into clinical practice. 10.1586/erd.11.14
    Current clinical applications of endobronchial ultrasound. Yasufuku Kazuhiro Expert review of respiratory medicine Endobronchial ultrasound (EBUS) is an evolving diagnostic tool in respiratory medicine that allows the bronchoscopist to see beyond the airway. The radial probe EBUS was first introduced to evaluate the central airway structure. With advances in technology, the small radial probes can now visualize and assist transbronchial biopsies of peripheral lung nodules without exposure to radiation. The newest development is the convex probe EBUS (CP-EBUS) consisting of a curvilinear electronic transducer on the tip of a flexible bronchovideoscope. CP-EBUS allows real-time EBUS-guided transbronchial needle aspiration (EBUS-TBNA). EBUS-TBNA has access to all of the mediastinal lymph nodes accessible by mediastinoscopy as well as N1 nodes. EBUS-TBNA is primarily used for lymph-node staging and diagnosis of lung cancer, but is also used for the diagnosis of unexplained mediastinal and hilar lymphadenopathy. It is a minimally invasive approach that is safe and has a good diagnostic yield. 10.1586/ers.10.39
    Randomized study of endobronchial ultrasound-guided transbronchial biopsy: thin bronchoscopic method versus guide sheath method. Oki Masahide,Saka Hideo,Kitagawa Chiyoe,Kogure Yoshihito,Murata Naohiko,Adachi Takashi,Ando Masahiko Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer INTRODUCTION:In endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB), techniques using a thin bronchoscope or a guide sheath have been proposed for accurate biopsy instrument reinsertion into the bronchial route indicated by a radial ultrasonic probe. The purpose of this study was to compare the diagnostic yields of these techniques for peripheral pulmonary lesions. METHODS:Patients with suspected peripheral pulmonary lesions were included in this prospective, randomized, noninferiority study and assigned to undergo EBUS-TBB under fluoroscopic guidance using a prototype 3.4-mm thin bronchoscope or a 4.0-mm bronchoscope with a guide sheath. RESULTS:A total of 205 patients were enrolled and randomized, of whom 203 patients (101 thin bronchoscopic method; 102 guide sheath method) were included in the analysis. Diagnostic histologic specimens were obtained in 65% (41% for benign and 75% for malignant lesions) of the thin bronchoscopy group and 62% (25% for benign and 71% for malignant lesions) of the guide sheath group. Diagnostic performance of the thin bronchoscopic method was confirmed to be noninferior to the guide sheath method (difference in diagnostic yields, 3.6%; 90% confidence interval, -7.5 to 14.7%). Mean procedure time was significantly shorter in the thin bronchoscopy group than the guide sheath group (27 versus 33 minutes; p = 0.002). Complications including pneumothorax, moderate bleeding, and pneumonia occurred in 5% and 2% in the respective groups (p = 0.28). CONCLUSIONS:EBUS-TBB using the thin bronchoscope was noninferior to the guide sheath method for the diagnosis of peripheral pulmonary lesions and was associated with shorter procedural time. 10.1097/JTO.0b013e3182417e60
    The role of endobronchial ultrasound in lung cancer diagnosis and staging: a comprehensive review. Kokkonouzis Ioannis,Strimpakos Alexios S,Lampaditis Ioannis,Tsimpoukis Sotirios,Syrigos Kostas N Clinical lung cancer Endobronchial ultrasound (EBUS) technology is a relatively new bronchoscopic method of visualizing the tracheobronchial tree, the surrounding pulmonary parenchyma, and the mediastinal structures, with a particular role in lung cancer diagnosis, staging, and treatment. There are 2 types of probes used in EBUS: the peripheral or radial probe (RP) and the linear or convex probe (CP) EBUS, which have technical differences and distinct diagnostic abilities. Both are used for EBUS-guided biopsies and transbronchial needle aspirations (TBNA), which increases the diagnostic yield over conventional bronchoscopic techniques, thus providing advanced information on staging, diagnosis, and treatment. Complications of EBUS are rare, and they are usually related to the underlying biopsy procedure and the operator's experience. EBUS examination duration is usually short, and it can be performed as an outpatient procedure. Interestingly, EBUS combinations with other current and evolving techniques, eg, electromagnetic navigation, are feasible and have a role in therapeutic interventions and molecular diagnostics. In conclusion, EBUS is a safe and accurate technique that is comparable with current criterion standard procedures, eg, mediastinoscopy. More training is required for the vast majority of respiratory physicians, and precise diagnostic algorithms are needed so that more patients benefit from this development. 10.1016/j.cllc.2012.05.001
    Endobronchial ultrasound in the management of nonsmall cell lung cancer. Dooms Christophe,Muylle Inge,Yserbyt Jonas,Ninane Vincent European respiratory review : an official journal of the European Respiratory Society Flexible bronchoscopy plays a major role in the diagnosis and staging of lung cancer. One of the most important advances in this field is the development of endobronchial ultrasound (EBUS), which has extended the view of the bronchoscopist. These techniques are safe and allow assessment of the depth of tumour invasion in the central airways, detection of peripheral tumours before sampling, localisation of the central tumour in the lung parenchyma close to the central airways for real-time guided sampling, and staging of lymph nodes within the mediastinum. Progress in handling and analyses of the small samples obtained during EBUS procedures also allow modern pathological and molecular studies to be performed. This article reviews the data currently available in the field of convex and radial probe EBUS for the diagnosis and staging of nonsmall cell lung cancer and highlights the strengths but also the weaknesses of these new techniques. 10.1183/09059180.00001113
    Endobronchial ultrasound with a guide sheath for small malignant pulmonary nodules: a retrospective comparison between central and peripheral locations. Chavez Christine,Sasada Shinji,Izumo Takehiro,Watanabe Junko,Katsurada Masahiro,Matsumoto Yuji,Tsuchida Takaaki Journal of thoracic disease OBJECTIVE:Radial endobronchial ultrasound with a guide sheath (EBUS-GS) has improved the diagnostic accuracy of transbronchial biopsy (TBB) for malignant peripheral pulmonary nodules (PPNs). Many underscore the importance of tumor localization but reproducible results on other aspects that affect yield are few. We aimed to analyze the diagnostic performance of TBB with EBUS-GS and to know what group of patients can benefit most. METHODS:The database of patients with malignant PPNs (≤30 mm) who underwent EBUS-GS TBB at the National Cancer Center Hospital, Tokyo, Japan from April 2012 to March 2013 was retrospectively reviewed and analysed based on lesion and procedural characteristics. RESULTS:Most PPNs (N=212) were adenocarcinoma, measuring 20 mm [mean, standard deviation (SD) 5.45]. Overall diagnostic accuracy was 67.5% (143 of 212 cases). Factors that significantly affected and predicted diagnostic success were EBUS probe within (P=0.001) and parenchymal location that was not adjacent to the costal visceral pleura (P=0.001). When combined, these variables achieved an 87% (59 of 68 lesions) diagnostic yield. CT scan characteristic, lesion size, lobe location, and GS size were non-contributory. CONCLUSIONS:EBUS-GS TBB is an acceptable diagnostic method for small peripheral lung cancer. It can be maximized for PPNs that are away from the pleura and when the EBUS probe can be placed within the lesion. 10.3978/j.issn.2072-1439.2015.03.04
    [Pathological basis of air bronchogram examined by endobronchial ultrasound in patients with peripheral lung cancer]. Li Jing,Chen Zhengxian Zhongguo fei ai za zhi = Chinese journal of lung cancer BACKGROUND AND OBJECTIVE:Air bronchogram were visible in endobronchial ultrasound images of benign and malignant lesions. The aim of this study is to analyze the endobronchial ultrasound images of different characteristics of air bronchogram and clinical significance combined with pathologic section. METHODS:From June 1, 2005 to December 30, 2008, 92 patients were found pulmonary peripheral lesions by X-ray and CT examinations, and confirmed that lesions were located lower to the segmental bronchial orifice by flexible bronchoscopy examinations. These patients were examined by radial endobronchial ultrasound probe afterwards. RESULTS:Seventy-eight patients clarified with benign or malignant diagnosis of lesions were analyzed, among whom, 22 of 47 (46.8%) were of malignant lesion without air bronchogram, 22 patients in 25 of lesions without air bronchogram were confirmed malignant (88%), among whom, 66.7% (2/3), were of small cell lung cancer, 43.9% (18/41) were of non-small cell lung cancer, and 50% (5/10) were of poorly differentiated adenocarcinoma, no sign of air bronchogram was found in corresponding pathological sections. Among those patients with malignant lesion, 51.1% (24/47) were of irregular air bronchogram. For patients with malignant lesions, irregular air bronchogram was most commonly found in adenocarcinoma, 55.2% (16/29) of pathological sections showed signs of air bronchogram, similar sign was also found in 2 patients with moderately differentiated adenocarcinoma and 1 patient with poorly differentiated adenocarcinoma. The total percentage of patients without air bronchogram and with irregular air bronchogram was 97.9% (46/47), only one of them (with medium differentiated adenocarcinoma) showed regular air bronchogram (1.3%). 80.6% (25/31) patients with benign lesion showed regular sign of air bronchogram distributed in the shape of concentric circles, the percentage of patients without air bronchogram or with irregular air bronchogram was both 3.8% (3/31). CONCLUSION:When there's no air bronchogram, or irregular air bronchogram sign found by endobronchial ultrasound examination, it is highly indicated that there is a malignant lesion, while there's regular sign of air bronchogram distributed in the shape of concentric circles, it is likely to be a benign lesion. 10.3779/j.issn.1009-3419.2010.05.09
    Endobronchial ultrasound-guided transbronchial biopsy using novel thin bronchoscope for diagnosis of peripheral pulmonary lesions. Oki Masahide,Saka Hideo,Kitagawa Chiyoe,Kogure Yoshihito,Mori Kouki,Kajikawa Shigehisa Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer BACKGROUND:The aim of this study was to evaluate the diagnostic utility of endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) using a novel 3.4-mm thin bronchoscope and a 1.4-mm ultrasonic probe for peripheral pulmonary lesions. METHODS:A total of 86 patients with suspected peripheral lesions were included in this prospective study. EBUS-TBBs were performed using a prototype 3.4-mm thin bronchoscope and a 1.4-mm radial ultrasonic probe under fluoroscopic guidance. RESULTS:Twelve patients with endobronchial lesions within the segmental bronchi and three patients who did not return to follow-up were excluded from this analysis. Thus, a total of 71 patients with peripheral pulmonary lesions (mean size, 31.2 +/- 12.7 mm) were included in the final analysis. The mean bronchus level reached with the thin bronchoscope was 4.6 generations. Diagnostic histologic specimens were obtained in 49 of 71 patients (69%:80% for malignant lesions and 52% for benign lesions). A definitive diagnosis of malignancy for lesions > or =20 mm and lesions < 20 mm was made in 82% (31 of 38) and 67% (four of six), respectively. There were no significant complications. CONCLUSION:The EBUS-TBB using a 3.4-mm thin bronchoscope and a 1.4-mm radial probe is feasible, accurate, and safe for the diagnosis of peripheral pulmonary lesions. 10.1097/JTO.0b013e3181b623e1
    The dose and risk factors for radiation exposure to medical staff during endobronchial ultrasonography with a guide sheath for peripheral pulmonary lesions under X-ray fluoroscopy. Katsurada Masahiro,Izumo Takehiro,Nagai Yuichi,Chavez Christine,Kitagawa Mayumi,Torii Jun,Iwase Takumi,Aso Tomohiko,Tsuchida Takaaki,Sasada Shinji Japanese journal of clinical oncology OBJECTIVE:Therapy for lung cancer has recently evolved to include molecular targeted therapy and adequate amounts of lung cancer tissue are needed to identify particular phenotypes. For this purpose, quite a number of investigations on diagnostic bronchoscopy have been undertaken. Corollary to the increasing number of transbronchial biopsies for peripheral pulmonary nodules is the increased chances of radiation exposure during fluoroscopy. Our aim was to determine the dose and risk factors of radiation exposure to medical staff. METHODS:Endobronchial ultrasonography with a guide sheath under X-ray fluoroscopy was performed on 132 cases of peripheral pulmonary lesions. The radiation exposure dose to medical staff (operator physicians, assistant physicians, nurses and radiological technologists) was measured. RESULTS:The median time of fluoroscopy was 7.6 min (range 1.5-23.9). The median radiation exposure dose to operator physicians was 12 μSv/exam (range 1-99), while that of the other medical staff was lower. In a multivariate analysis, body mass index and the location of the radial ultrasound probe had significantly higher odds ratios. CONCLUSIONS:The risk factors for an increased radiation exposure dose were patients' BMI and the location of the radial ultrasound probe. But even then, the radiation exposure dose to medical staff during endobronchial ultrasonography with a guide sheath was very low, especially for nurses and radiological technologists in whom the exposure dose was negligible. 10.1093/jjco/hyt224
    Usefulness of endobronchial ultrasound (EBUS) in the diagnosis of peripheral pulmonary lesions in a general hospital. Kokkonouzis Ioannis,Lampaditis Ioannis,Charpidou Andriani,Kainis Elias,Syrigos Konstantinos In vivo (Athens, Greece) AIM:To investigate the efficiency of guided bronchoscopy compared to blind techniques in the study of non-visible pulmonary lesions. MATERIALS AND METHODS:A one-year, retrospective, study was conducted comparing two populations: Biopsies were either performed conventionally (FB-B) with the help of static images and the second where biopsies were performed after guidance (FB-EBUS). A 20-MHz radial-type ultrasound probe was used to obtain images. Sampling techniques, like bronchial brushing and transbronchial biopsies, were conducted in both populations by two separate bronchoscopists. If diagnosis was not achieved a surgical biopsy or observation followed. RESULTS:Forty patients appeared with non-visible lesions and were included in this study. Twenty were examined with the use of FB-EBUS and in 20 cases FB-B was conducted. At the FB-EBUS population a pathologic lesion was visualized in 16 cases (80%) and in 15 cases (75%) a diagnosis was achieved. All lesions that weren't visualized had a diameter less than 30 mm. At the FB-B population a diagnosis was achieved in 11 cases (55%). In pulmonary lesions with a diameter more than 30 mm, the diagnostic yield was 87, 5% using guidance and 61, 5% using FB-B and in lesions less than 30 mm 66, 67% and 42, 85% respectively. Moreover, left lower lobe was the most promising to obtain a diagnosis. CONCLUSION:Our results suggest that in patients with a non-visible pulmonary lesion a diagnostic strategy involving the choice of EBUS-guided biopsy is a reasonable and effective choice.
    Comparison between endobronchial ultrasound-guided transbronchial biopsy and CT-guided transthoracic lung biopsy for the diagnosis of peripheral lung cancer: a systematic review and meta-analysis. Zhan Ping,Zhu Qing-Qing,Miu Ying-Ying,Liu Ya-Fang,Wang Xiao-Xia,Zhou Ze-Jun,Jin Jia-Jia,Li Qian,Sasada Shinji,Izumo Takehiro,Tu Chih-Yen,Cheng Wen-Chien,Evison Matthew,Lv Tang-Feng,Song Yong, Translational lung cancer research BACKGROUND:With the release of the National Lung Screening Trial results, the detection of peripheral pulmonary lesions (PPLs) is likely to increase. Computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and radial probe endobronchial ultrasound (r-EBUS)-guided transbronchial lung biopsy (TBLB) are recommended for tissue diagnosis of PPLs. METHODS:A systematic review of published literature evaluating the accuracy of r-EBUS-TBLB and CT-PTNB for the diagnosis of PPLs was performed to determine point sensitivity and specificity, and to construct a summary receiver-operating characteristic curve. RESULTS:This review included 31 publications dealing with EBUS-TBLB and 14 publications dealing with CT-PTNB for the diagnosis of PPLs. EBUS-TBLB had point sensitivity of 0.69 (95% CI: 0.67-0.71) for the diagnosis of peripheral lung cancer (PLC), which was lower than the sensitivity of CT-PTNB (0.94, 95% CI: 0.94-0.95). However, the complication rates observed with EBUS-TBLB were lower than those reported for CT-PTNB. CONCLUSIONS:This meta-analysis showed that EBUS-TBLB is a safe and relatively accurate tool in the investigation of PLC. Although the yield remains lower than that of CT-PTNB, the procedural risks are lower. 10.21037/tlcr.2017.01.01
    Report on the breakage of the tip of a radial endobronchial ultrasonic probe sheath during bronchoscopy. Yaguchi Daizo,Ichikawa Motoshi,Inoue Noriko,Kobayashi Daisuke,Shizu Masato,Imai Naoyuki Respirology case reports A lesion in a 73-year-old woman that was suspected to be right lung cancer was biopsied under ultrasound-guided bronchoscopy with a guide sheath. The procedure was completed without a noticeable problem, but after 3 days, it was found that the tip of the ultrasonic probe sheath was broken and that the broken fragment was missing. Based on the concern that the fragment had been left in the lung, the patient was examined by computed tomography scan 4 days after the biopsy, and bronchoscopy was repeated 38 days after the biopsy, but no fragment was detected. These procedures and an investigation by the Olympus Corporation led to the conclusion that the fragment was not in the lung, and it was not found in a subsequent surgical specimen. Breakage of devices may occur at any time regardless of progression of fatigue (wear) with increased use, and thorough device management before, during, and after use is important. 10.1002/rcr2.311
    Radial Endobronchial Ultrasound (EBUS) Guided Suction Catheter-Biopsy in Histological Diagnosis of Peripheral Pulmonary Lesions. Zaric Bojan,Stojsic Vladimir,Carapic Vladimir,Kovacevic Tomi,Stojanovic Goran,Panjkovic Milana,Kioumis Ioannis,Darwiche Kaid,Zarogoulidis Konstantinos,Stratakos Grigoris,Tsavlis Drosos,Hohenforst-Schmidt Wolfgang,Pitsiou Georgia,Zissimopoulos Athanasios,Sachpekidis Nikos,Karapantzos Ilias,Karapantzou Chrysanthi,Zarogoulidis Paul,Perin Branislav Journal of Cancer BACKGROUND:EBUS guided trans-bronchial biopsy became routine in diagnosis of peripheral pulmonary lesions (PPL). Suction catheter-biopsy is a technique for obtaining a tissue sample from peripheral lung parenchyma. Aim of this study was to evaluate diagnostic efficiency, feasibility and safety of EBUS guided suction catheter-biopsy (SCB) in comparison to trans-bronchial biopsy (TBB) in diagnosis of PPL. The main intention was to demonstrate non-inferiority of the technique over trans-bronchial biopsy, especially when used under navigation of the EBUS. METHODS:Radial EBUS probe (UM-3R, Olympus Co, Japan.) without guiding sheath was used to navigate suction catheter and TBB forceps to the PPL. The catheter was connected to the collection canister via vacuum pump. The SCB specimens were fixed with 10% buffered formalin. RESULTS:There were 168 patients enrolled in this study; 69.9% males and 30.1% females. Main lesion diameter was 4.1±1.9 cm. Majority of patients, 131(77.9%) were diagnosed with lung cancer. Per-biopsy calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for EBUS-SCB were 92.4%, 100%, 100% and 67.7%, respectively. Corresponding values for EBUS-TBB were 92.3%, 100%, 100% and 69.7%. Only the size of the lesion significantly influenced (p=0.005) diagnostic performance. Complications occurred in 2 patients; one pneumothorax and one excessive bleeding. CONCLUSION:EBUS guided SCB is efficient, feasible and safe in diagnosis of peripheral lung cancer. The technique is complementary to trans-bronchial biopsy. 10.7150/jca.13081
    Can computed tomography characteristics predict outcomes in patients undergoing radial endobronchial ultrasound-guided biopsy of peripheral lung lesions? Evison Matthew,Crosbie Philip A J,Morris Julie,Martin Julie,Barber Philip V,Booton Richard Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer INTRODUCTION:Percutaneous computed tomography (CT)-guided lung biopsy is a standard minimally invasive technique for sampling peripheral lung lesions. Radial endobronchial ultrasound (EBUS) offers an alternative approach but it has yet to be defined which patients are most suited to this procedure. The primary aim of this study was to investigate whether CT characteristics could predict the success of radial EBUS-guided sampling. METHODS:The University Hospital South Manchester provides a radial EBUS service, under conscious sedation without fluoroscopy, double-hinged curettes, or guide sheaths, to a large cancer Network in the United Kingdom. This retrospective analysis of a prospectively maintained database included all patients undergoing radial EBUS from January 2011 to June 2013. Lesion size, structure, location, and presence of a bronchus sign on thoracic CT were analyzed against predefined outcomes using multivariate analysis. RESULTS:One-hundred and seventeen patients underwent radial EBUS in the study period (mean age 69.5, mean lesion size 36.6 mm). The presence of a bronchus sign on CT was the only independent predictor of all predefined outcomes: (1) lesion identification with radial EBUS, (2) positioning of probe within the center of the lesion, and (3) accurate pathological diagnosis; odds ratio (OR) 31.1 (7.8-123.9, p < 0.0001), OR 44.8 (5.6-354.9, p < 0.0001) and OR 46.6 (11.1-195.3, p < 0.0001) respectively. The sensitivity and diagnostic accuracy for those patients with a bronchus sign on CT was 87.3% and 86.7% compared with 12.5% and 11.1% for those lacking the bronchus sign. DISCUSSION:The patients most likely to benefit from radial EBUS, without the use of adjuncts, are those with a bronchus sign on CT. 10.1097/JTO.0000000000000249
    A simple endoscopic method with radial endobronchial ultrasonography for low-migration rate coil-tailed fiducial marker placement. Journal of thoracic disease BACKGROUND:Fiducial markers (FMs) are useful for tracking small peripheral lung nodules (PLN) before stereotactic radiotherapy, but migration over the course of treatment may result in inaccurate dosing to the tumor. To minimize FM migration, coil-tailed FMs have been designed. Our objective was to assess both the feasibility of radial endobronchial ultrasonography (r-EBUS) placement and the migration rate of coil-tailed FMs. METHODS:In this retrospective study, we included patients who received r-EBUS guided placement of coil-tailed FMs for PLN <25 mm from June 2015 to May 2018. We introduced the FM into the nodule with the use of bronchial brush, without fluoroscopy. RESULTS:Thirty patients had r-EBUS guided placement of a coil-tailed FM before stereotactic radiation therapy. Nodule's median long- and short-axis diameters were 15 mm (8-25 mm) and 8 mm (5-20 mm), respectively; short diameter of 27 nodules (90%) was less than 15 mm. All nodules were reached and visualized with r-EBUS, with an ultrasound (US) signal showing a centered or tangential probe in 26 and 4 cases, respectively. No immediate complication was reported. Twenty-three patients had stereotactic radiation therapy within a median time of 29 days (14-126 days). No FM migration occurred between r-EBUS placement and radiotherapy. Pre-treatment planning and 3-month follow-up CT scans showed that all FMs stayed in direct contact with the lesions. CONCLUSIONS:r-EBUS is a safe procedure for the placement of nitinol coil FMs, which have a low migration rate. 10.21037/jtd.2020.02.37
    Role of radial endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of pulmonary nodules: Case report and literature review. Dhooria Sahajal,Sehgal Inderpaul Singh,Gupta Nalini,Aggarwal Ashutosh Nath,Behera Digambar,Agarwal Ritesh Lung India : official organ of Indian Chest Society The diagnosis of pulmonary nodules can be made using several methods including computed tomography (CT)-guided fine-needle aspiration (FNA), radial endobronchial ultrasound (EBUS)-guided sampling techniques (transbronchial lung biopsy [TBLB], transbronchial brush, bronchoalveolar lavage, or transbronchial needle aspiration [TBNA]), or occasionally with convex probe (CP) EBUS-TBNA. While CT-guided FNA is associated with a high (25%) rate of pneumothorax, the CP-EBUS cannot reach lesions beyond the interlobar region. Radial EBUS-guided TBLB and transbronchial brushing are excellent modalities in the evaluation of peripheral pulmonary lesions. However, these techniques cannot access lesions that are located adjacent to the proximal segmental bronchus, due to the presence of a cartilaginous wall. Herein, we describe a 58-year-old man, who presented with a lung nodule in the right middle lobe, wherein radial EBUS-guided TBNA proved to be the most appropriate diagnostic modality. We also discuss the current utility of radial EBUS-guided TBNA in day-to-day practice. 10.4103/0970-2113.197094
    [Diagnostic value of computed tomography-guided percutaneous needle biopsy versus radial probe endobronchial ultrasound-guided transbronchial lung biopsy in peripheral pulmonary lesions]. Wang Changguo,Zeng Daxiong,Lei Wei,Jiang Junhong,Zhu Yehan,Huang Jian'an Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases OBJECTIVE:To evaluate the value of computed tomography-guided percutaneous needle biopsy (CT-PNB) and radial probe endobronchial ultrasound-guided transbronchial lung biopsy (EBUS-TBLB) in the diagnosis of peripheral pulmonary lesions(PPLs). METHODS:The clinical data of 213 patients who were diagnosed as to have PPLs in the First Affiliated Hospital of Soochow University between December 1, 2012 and October 1, 2014 were studied retrospectively. The patients were divided into CT-PNB group and EBUS-TBLB group, according to biopsy methods. The diagnostic yield, complications and influencing factors of both groups were evaluated. RESULTS:The diagnostic yield (87.2%, 102/117) and complication rate (18.8%, 22/117) of the CT-PNB group were higher than those of the EBUS-TBLB group(61.5%, 59/96 and 18.8%, 22/117, respectively), the differences being statistically significant (χ(2)=18.906, P=0.000 and χ(2)=10.542, P=0.001, respectively). Analysis of the influencing factors showed that there were statistically significant correlations between pneumothorax and the lesion diameter(χ(2)=5.785, P=0.016) and location(χ(2)=7.559, P=0.006) in the CT-PNB group. The diagnostic yield was correlated with lesion diameter(χ(2)=7.995, P=0.004) and location(χ(2)=4.608, P=0.027) in the EBUS-TBLB group. There was no complicated pneumothorax if the lesions were attached to the chest wall in the CT-PNB group. CONCLUSIONS:The diagnostic yield of CT-PNB in PPLs was better than that of EBUS-TBLB. Although CT-PNB had a higher complication rates, most complications were mild.
    Radial probe endobronchial ultrasound and novel navigation biopsy techniques. Chenna Praveen,Chen Alexander C Seminars in respiratory and critical care medicine Peripheral pulmonary lesions are an increasingly common finding in clinical practice. While many nodules are followed with radiographic surveillance, some may require biopsy. Conventional bronchoscopy with transbronchial lung biopsy has traditionally performed poorly for small, peripheral lesions, and transthoracic needle aspiration with computed tomographic (CT) guidance has been favored as the diagnostic test of choice. Despite the high diagnostic yield of transthoracic needle aspiration, procedural complications such as pneumothorax continue to be problematic. New technology has been developed to improve the diagnostic yield of bronchoscopy for peripheral lesions over conventional methods, while maintaining the favorable safety profile of a bronchoscopic approach. Virtual bronchoscopy and electromagnetic navigation are CT-based image guidance systems that create virtual bronchoscopic representations of the tracheobronchial tree to assist the bronchoscopist in locating peripheral lesions. Radial probe endobronchial ultrasound utilizes real-time ultrasound to confirm the location of peripheral lesions before biopsy. This article summarizes the technical platforms, procedures, and clinical evidence for these emerging technologies. 10.1055/s-0034-1395499
    Radial probe endobronchial ultrasound: factors influencing visualization yield of peripheral pulmonary lesions. Tay Jun H,Irving Louis,Antippa Phillip,Steinfort Daniel P Respirology (Carlton, Vic.) BACKGROUND AND OBJECTIVE:Endobronchial ultrasound (EBUS) has improved the diagnostic yield of transbronchial biopsy of peripheral pulmonary lesions (PPL). While EBUS diagnostic yield has been the focus of the majority of publications, few have investigated factors associated with EBUS visualization yield. This study evaluated the factors predicting visibility of PPL using EBUS-guided bronchoscopy. METHODS:We performed a retrospective analysis of 196 consecutive patients who underwent investigation with radial EBUS. Size and distance of the lesion from the hilum and pleura measured on computed tomography scans were correlated with malignancy status, gender and EBUS visualization yields. Final diagnosis was obtained from pathology. RESULTS:A definitive diagnosis was established for 109 PPL (56%) using radial EBUS. Visualized lesion by EBUS probe had a higher diagnostic yield (65%) than EBUS-invisible lesions (20%; P = 0.0001). In multivariate analysis, lesion size, final diagnosis and distance from hilum to lesion were all found to significantly affect EBUS visualization yield. Lesions of ≥ 20 mm had a significantly greater visualization yield (85%) than lesions of <20 mm (63%; P = 0.0022). Malignant lesions had a higher visualization rate (85%) than benign lesions (66%; P value = 0.0025). Distance of hilum ≤ 50 mm to PPL was found to have a significantly higher visualization yield (91%) than lesions located >50 mm from the hilum. (66%; P = 0.0001). CONCLUSIONS:Lesion size, malignancy status and distance from hilum to lesion are significant predictors of EBUS visualization yield. Clinicians should review these factors in patients to guide choice of optimal investigation and diagnosis of PPL. 10.1111/j.1440-1843.2012.02276.x
    Diagnostic utility of endobronchial ultrasound with a guide sheath under the computed tomography workstation (ziostation) for small peripheral pulmonary lesions. Matsumoto Yuji,Izumo Takehiro,Sasada Shinji,Tsuchida Takaaki,Ohe Yuichiro The clinical respiratory journal BACKGROUND AND AIMS:The application of radial probe endobronchial ultrasound (R-EBUS) and virtual bronchoscopic navigation has improved the diagnostic outcome of bronchoscopy for peripheral pulmonary lesions (PPLs). Nonetheless, while existing navigation systems are very useful for selecting the bronchus containing the target lesion, the associated introductory costs are high. Therefore, we focused on virtual bronchoscopy (VB) using the workstation, ziostation that was already available in many countries as an adjunct modality. METHODS:Consecutive patients who underwent bronchoscopy with R-EBUS for PPLs (major diameter ≤30 mm) were enrolled. From late June 2013 to November 2013, 121 patients were examined with ziostation, and from September 2012 to early June 2013, 113 patients were examined without ziostation. We compared the diagnostic yield, EBUS detection rate and procedure time between two groups to evaluate the utility of the VB. RESULTS:The ziostation group had significantly higher diagnostic yield than the non-ziostation group (77.7% vs 64.6%, P = 0.030). Following the multivariate analysis, use of ziostation was a significant factor affecting the diagnostic yield. Meanwhile, EBUS detection rate was significantly higher in the ziostation group (94.2% vs 75.2%, P < 0.001). And, procedure time was significantly shorter in the ziostation group (mean ± standard deviation: 24.0 ± 7.4 min vs 26.9 ± 7.9 min, P = 0.005). CONCLUSION:VB offered by the workstation was a valuable tool that facilitated more accurate and rapid bronchoscopy procedure for diagnosis of PPLs. 10.1111/crj.12321
    Radial-probe EBUS for the diagnosis of peripheral pulmonary lesionsAUTHORS' REPLYRadial-probe EBUS for the diagnosis of peripheral pulmonary lesionsFactors influencing visibility and diagnostic yield of transbronchial biopsy using endobronchial ultrasound in peripheral pulmonary lesionsRadial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis. Guarize Juliana,Donghi Stefano,Saueressig Maurício Guidi Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia 10.1590/S1806-37562016000000379
    Localization of Peripheral Pulmonary Lesions Using a Method of Combining Analysis of Chest Computed Tomographic Imaging with Radial Probe Endobronchial Ultrasound Imaging. Tunsupon Pichapong,Harris Kassem Annals of the American Thoracic Society 10.1513/AnnalsATS.201607-563LE
    Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis. Steinfort D P,Khor Y H,Manser R L,Irving L B The European respiratory journal Improved diagnostic sensitivity of bronchsocopy for the investigation of peripheral pulmonary lesions (PPLs) with the use of radial probe endobroncial ultrasound (EBUS) has been reported, although diagnostic performance varies considerably. A systematic review of published literature evaluating radial probe EBUS accuracy was performed to determine point sensitivity and specificity, and to construct a summary receiver-operating characteristic curve. Sub-group analysis and linear regression was used to identify possible sources of study heterogeneity. 16 studies with 1,420 patients fulfilled inclusion criteria. Significant inter-study variation in EBUS method was noted. EBUS had point specificity of 1.00 (95% CI 0.99-1.00) and point sensitivity of 0.73 (95% CI 0.70-0.76) for the detection of lung cancer, with a positive likelihood ratio of 26.84 (12.60-57.20) and a negative likelihood ratio of 0.28 (0.23-0.36). Significant inter-study heterogeneity for sensitivity was observed, with prevalence of malignancy, lesion size and reference standard used being possible sources. EBUS is a safe and relatively accurate tool in the investigation of PPLs. Diagnostic sensitivity of EBUS may be influenced by the prevalence of malignancy in the patient cohort being examined and lesion size. Further methodologically rigorous studies on well-defined patient populations are required to evaluate the generalisability of our results. 10.1183/09031936.00075310
    Value of radial probe endobronchial ultrasound-guided transbronchial biopsy and computer tomography-guided transthoracic needle aspiration in the diagnosis of peripheral pulmonary lesions. Zhang Qiudi,Zhang Sujuan,Xu Xiong,Xu Qianqian,Zhou Jun Medicine Computer tomography-guided transthoracic needle aspiration (CT-TTNA) is a minimally invasive technique for sampling peripheral lung lesions. Radial endobronchial ultrasound-guided transbronchial biopsy (rEBUS-TBB) is an alternative. The present study analyzed and compared rEBUS-TBB and CT-TTNA in the diagnosis of peripheral pulmonary lesions (PPL).Clinical data of 513 patients with PPL who underwent an rEBUS-TBB or CT-TTNA examination were analyzed retrospectively. The positive diagnostic rate, complication rate, and influencing factors of the 2 methods were compared.The positive diagnostic rate and complication rate were significantly higher in CT-TTNA than rEBUS-TBB (P = .001; P < .001, respectively). The rEBUS-TBB group showed a higher positive diagnostic rate in larger lesions (>2 cm) than in smaller (≤2 cm) (P = .012), and was lower in the lesions proximal to the chest wall than those distally located (P = .046); no significant difference was observed in the different pulmonary segments (P = .109). In the CT-TTNA group, the positive diagnostic rate in larger lesions did not differ significantly than the smaller lesions (P = .05); it differed significantly in different segments (P = .044). The incidence of pneumothorax was lower in lesions proximal to the chest wall than those located distally (P = .037). In the rEBUS-TBB group, the success rate of the exploration and biopsy of the lesions was 87.4%; the rate of exploration of larger lesions and with bronchial sign was higher than smaller lesions and without bronchial sign (P < .001; P < .001, respectively) while that of lesions close to the chest wall was lower than those distally located (P = .006).rEBUS-TBB and CT-TTNA are effective and safe in the diagnosis of PPL. The positive diagnostic rate of CT-TTNA is higher than rEBUS-TBB. The incidence of pneumothorax in CT-TTNA is higher than rEBUS-TBB. CT-TTNA is selected for smaller lesions close to the chest wall; rEBUS-TBB is used for lesions larger, distal from the chest wall or with a bronchial sign. 10.1097/MD.0000000000007843
    Atypical cells in pathology of endobronchial ultrasound-guided transbronchial biopsy of peripheral pulmonary lesions: incidence and clinical significance. Huang Chun-Ta,Tsai Yi-Ju,Ho Chao-Chi,Yu Chong-Jen Surgical endoscopy BACKGROUND:Atypical cells may occasionally be the only pathologic finding in radial-probe endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) of peripheral pulmonary lesions (PPLs); however, it is uncertain how often we encounter such a situation and what clinical features can be used to identify these ambiguous PPLs, which are more likely to be malignant. METHODS:From 2009 to 2016, consecutive patients referred for EBUS-guided TBB of PPLs and with pathology reports indicating atypical cells alone were included. Medical records were reviewed to extract patient demographics, clinical characteristics, procedural details and complications. The primary outcome was the final diagnosis of the PPLs on subsequent investigation. Multivariate logistic regression analysis was used to identify independent factors associated with a final malignant diagnosis. RESULTS:One hundred sixty-five (7.2%) of 2291 patients had non-diagnostic TBB showing atypical cells. Benign and malignant diagnoses were subsequently obtained in 45 (27%) and 120 (73%) patients, respectively. The leading malignancy was lung adenocarcinoma; of note, a variety of benign lesions revealed cellular atypia on pathology, in particular, chronic inflammation, tuberculosis and pneumonia. Multivariate analysis indicated lesion appearance [solid vs. others; odds ratio (OR) 7.93; 95% confidence interval (CI) 2.94-21.40; P < 0.001] and probe position (adjacent to vs. within; OR 3.36; 95% CI 1.11-10.15; P = 0.032) were two significant factors predictive of a final diagnosis of malignancy. CONCLUSIONS:One out of 14 EBUS-guided TBB procedures for PPLs exhibited atypical cells on pathology. Meticulous management strategies should be formulated to deal with these instances after taking into consideration lesion appearance, probe position and patient preferences. 10.1007/s00464-018-6452-1
    Radial probe endobronchial ultrasound scanning assessing invasive depth of central lesions in tracheobronchial wall. Li Jing,Chen Ping-Ping,Huang Yu,Chen Zheng-Xian Chinese medical journal BACKGROUND:Patients with central tracheobronchial benign or malignant lesions who have not recieved surgical treatment can be treated by interventional techniques, such as laser, afterloading radiotherapy, cryotherapy, photodynamics treatment, radiofrequency ablation and stenting, etc. The accuracy of the invasive depth of central lesion in tracheobronchial wall plays an important role in making interventional treatment plan. This study used radial probe endobronchial ultrasound (RP-EBUS) scanning to evaluate the accuracy of the invasive depth of central lesions in tracheobronchial wall, and the influence of RP-EBUS scanning in treatment plan making and guidance. METHODS:This was a prospective study of consecutive patients with central tracheobronchial lesions found by CT or bronchoscopy. We performed EBUS scanning after common bronchoscopy under local anesthesia. A radial ultrasonic probe (2.0 mm in diameter with 20-MHz frequency) with a balloon sheath was introduced through the 2.8-mm-diameter channel of a flexible bronchoscope. The balloon at the tip of the probe was inflated with distilled water until coupling with the airway wall under endoscopic control. The circular image of EBUS, which revealed the layered structure of the tracheobronchial wall, could be achieved. RESULTS:Total of 125 patients were enrolled in the study. Thirty patients underwent surgical operation and pathologically proved the RP-EBUS diagnosis accuracy of tumor invasive depth in tracheobroncial wall was 90% (27/30), sensitivity and specificity were 88.89% (24/27) and 100% (3/3), respectively. In response to EBUS images, 40 approaches were altered or guided: lymph-node metastasis and compressive lesions was diagnosed by EBUS-guided transbronchial needle aspiration (TBNA) (n = 8); Lesions ablation with laser or electricity were stopped when EBUS demonstrated close range with vessels or perforation possibility (n = 13), stents size were changed (n = 14), operation was canceled (n = 3) and foreign body was removed (n = 2). No complication associated with the use of EBUS was observed. CONCLUSION:RP-EBUS can be a useful tool in assessing the central lesion invasive depth to the tracheobronchial wall.
    Diagnostic yield of additional conventional transbronchial lung biopsy following radial endobronchial ultrasound lung biopsy for peripheral pulmonary lesions. Park Sojung,Yoon Hee-Young,Han Yeji,Wang Kyung Sook,Park So Young,Ryu Yon Ju,Lee Jin Hwa,Chang Jung Hyun Thoracic cancer BACKGROUND:Radial endobronchial ultrasound (R-EBUS) transbronchial lung biopsy (TBLB) improves the diagnostic yield from peripheral pulmonary lesions (PPLs). However, the small specimens obtained using small forceps through a guide sheath (GS) may impede diagnosis and molecular analysis. Here, we investigated the diagnostic significance of additional conventional TBLB with standard forceps after R-EBUS-GS-guided TBLB. METHODS:We retrospectively reviewed data from 55 patients who underwent conventional TBLB after R-EBUS-GS-guided TBLB for PPL diagnosis. Procedures were performed on single PPLs with no visible lesions on bronchoscopy. In cases with inconclusive pathologic confirmation, final diagnoses were made based on pathologic specimens or clinical observations. RESULTS:The median size of the target lesions was 28 mm. The appearances on computed tomography images were solid (n = 45, 81.8%), part-solid (n = 7, 12.7%), and cavitary nodules (n = 3, 5.5%). A computed tomography bronchus sign was present in 35 (63.6%) cases, and a radial probe was positioned within target lesion in 32 (58.2%) cases. R-EBUS-GS-guided TBLB was diagnostic in 30 (54.5%) patients, and subsequent conventional TBLB yielded additional diagnostic information in 8 (14.5%) patients. Probe positioning within target lesions and the outer margin of PPLs more than 1 cm from pleura were significantly associated with enhanced diagnostic yield from the combined procedures. In conventional TBLB, probe positioning within target lesions (75.0% vs. 11.8%, P = 0.004) and characteristic of nonsolid nodules (83.3% vs. 15.8%, P = 0.006) were significantly associated with additional diagnostic utility. CONCLUSIONS:Conventional TBLB following R-EBUS-GS-guided TBLB could be a useful procedure for diagnosing PPLs, especially for nonsolid nodules. KEY POINTS:Significant findings of the study: Additional conventional TBLB with standard forceps after R-EBUS-GS-guided TBLB yielded an additional 14.5% diagnostic utility for peripheral pulmonary lesions. For conventional TBLB, probe positioning within target lesions and nonsolid nodules were significantly associated with additional diagnostic utility. WHAT THIS STUDY ADDS:Conventional TBLB with standard forceps after R-EBUS-GS-guided TBLB is an effective and economically accessible diagnostic tool for peripheral pulmonary lesions. 10.1111/1759-7714.13446
    Radial Probe Endobronchial Ultrasound-guided Lung Biopsy for Histopathological Diagnosis of Cryptogenic Organizing Pneumonia. Ma Miao,Li Yan,Cai Hou-Rong,Ding Jing-Jing,Wang Yong-Sheng,Gao Yu-Juan,Dai Jing-Hong,Zhao Qi,Xiao Yong-Long,Meng Fan-Qing,Fan Xiang-Shan,Miao Li-Yun Chinese medical journal 10.4103/0366-6999.198015
    Diagnostic value of the combined use of radial probe endobronchial ultrasound and transbronchial biopsy in lung cancer. Lee Sang Chul,Kim Eun Young,Chang Joon,Lee Sang Hoon,Han Chang Hoon Thoracic cancer BACKGROUND:Although the use of radial endobronchial ultrasound (R-EBUS) with a guide sheath has shown improved diagnostic capability in peripheral pulmonary lesions, its utility is still low due to variable performance. To overcome its limitation, we evaluated the feasibility and efficacy of R-EBUS combined with transbronchial biopsy (TBB) under fluoroscopic guidance. METHODS:We retrospectively reviewed medical records of 74 patients with non-small cell lung cancer (NSCLC) who underwent R-EBUS combined with TBB or TBB alone as a diagnostic technique. Subjects were grouped according to the diagnostic modality used (R-EBUS combined with TBB vs. TBB alone). Each group was matched for age, sex, and location of the biopsy. The chi-square test and paired t-test were used to compare characteristics and identify factors that affected the diagnostic yield. RESULTS:The mean age of the study cohort was 67.4 ± 12.8 years, with 21 (56.8%) men and 16 (43.2%) women in each group. The lesion size was significantly smaller in the R-EBUS group (23.6 vs. 33.9, P < 0.001). The diagnostic yield with the combined use of R-EBUS and TBB (27/37, 72.9%) was significantly higher than that with standard TBB alone (22/37, 59.4%). Lung lesions with a positive bronchus sign were associated with a higher diagnostic yield (odds ratio = 3.52 [1.17-10.62]; P = 0.025). CONCLUSIONS:The combination of R-EBUS with TBB resulted in a higher diagnostic yield than either technique alone. Thus, the addition of R-EBUS biopsy would be helpful to improve the diagnostic yield of TBB. KEY POINTS:SIGNIFICANT FINDINGS OF THE STUDY: The combination of R-EBUS with TBB under fluoroscopic guidance improved the diagnostic yield of PPLs compared to TBB alone. A tissue diagnosis was more likely in pulmonary lesions with the air-bronchus sign. WHAT THIS STUDY ADDS:The use of R-EBUS could help improve the low diagnostic yield of TBB under fluoroscopic guidance without increasing the incidence of complications. 10.1111/1759-7714.13425
    Endobronchial Ultrasound Reliably Quantifies Airway Smooth Muscle Remodeling in an Equine Asthma Model. Bullone Michela,Beauchamp Guy,Godbout Mireille,Martin James G,Lavoie Jean-Pierre PloS one Endobronchial ultrasonography (EBUS) revealed differences in the thickness of the layer representing subepithelial tissues (L2) between human asthmatics and controls, but whether this measurement correlates with airway smooth muscle (ASM) remodeling in asthma is unknown. In this study, we sought to determine the ability of EBUS to predict histological ASM remodeling in normal and equine asthmatic airways. We studied 109 isolated bronchi from the lungs of 13 horses. They underwent EBUS examination using a 30 MHz radial probe before being processed for histology. ASM remodeling parameters were evaluated in EBUS images (L2 thickness, L2 area, L2 area/internal perimeter [Pi] and L2 area/Pi2) and histological cuts (ASM area/Pi2), and compared. EBUS was then performed ex vivo on the lungs of 4 horses with heaves, an asthma-like condition of horses, and 7 controls to determine whether central bronchial remodeling could be detected with this technique. An optimized approach was developed based on data variability within airways, subjects, and groups, and then validated in 7 horses (3 controls, 4 with heaves) that underwent EBUS in vivo. L2 area was significantly associated to ASM area in isolated lungs (p<0.0001), in the absence of significant bias related to the airway size. Bronchial size significantly affected EBUS ASM-related parameters, except for L2 area/Pi2. L2 area/Pi2 was increased in the airways of asthmatic horses compared to controls, both ex vivo and in vivo (p<0.05). Bronchial histology confirmed our findings (AASM/Pi2 was increased in asthmatic horses compared to controls, p<0.05). In both horses with heaves and controls, L2 was composed of ASM for the outer 75% of its thickness and by ECM for the remaining inner 25%. In conclusion, EBUS reliably allows assessment of asthma-associated ASM remodeling of central airways in a non-invasive way. 10.1371/journal.pone.0136284
    A retrospective study comparing the ultrathin versus conventional bronchoscope for performing radial endobronchial ultrasound in the evaluation of peripheral pulmonary lesions. Sehgal Inderpaul Singh,Dhooria Sahajal,Bal Amanjit,Gupta Nalini,Ram Babu,Aggarwal Ashutosh N,Agarwal Ritesh Lung India : official organ of Indian Chest Society BACKGROUND:Few studies have reported on the utility of ultrathin bronchoscopes (UTBs) for performing radial probe endobronchial ultrasound (EBUS). Herein, we describe our experience with UTB and conventional bronchoscope (CB) for performing radial EBUS. MATERIALS AND METHODS:This was a retrospective study comparing the diagnostic yield of a prototype UTB (external diameter 3 mm, working channel diameter 1.7 mm) versus CBs (external diameter ≥4.9 mm) in performing radial EBUS for the evaluation of peripheral pulmonary lesions (PPLs). Fluoroscopic guidance was not available. RESULTS:A total of 121 subjects (34, UTB; 87, CB; 69.4% males) with a mean (standard deviation [SD]) age of 55.2 (14.8) years underwent radial EBUS. The mean (SD) size of PPLs on computed tomography of the thorax was 22.2 (13.7) mm. The lesions were significantly smaller in the UTB group (16.4 vs 24.7 mm, P = 0.006). Eight lesions could be visualized within the lumen of the peripheral smaller bronchi with the UTB. The overall yield of radial EBUS was 52.9% and was similar in the two groups (UTB vs. CB, 55.9% vs. 51.7%; P = 0.7). The procedure time was significantly shorter in the UTB group. On multivariate logistic regression, the yield was similar in the two groups after adjusting for the size and location of the lesion and position of the radial probe in relation to the lesion. CONCLUSION:Despite smaller lesions, radial EBUS performed with the UTB was found to have similar efficacy to that performed with the CB. More lesions could be visualized endobronchially using the UTB making it an attractive alternative for performing radial EBUS. 10.4103/lungindia.lungindia_115_18
    Predicting the Risk of Malignancy of Lung Nodules Diagnosed as Indeterminate on Radial Endobronchial Ultrasound-Guided Biopsy. Zo Sungmin,Woo Sook-Young,Kim Seonwoo,Lee Jung Eun,Jeong Byeong-Ho,Um Sang-Won,Kim Hojoong,Kwon O Jung,Lee Ho Yun,Lee Kyungjong Journal of clinical medicine The next diagnostic step in cases of indeterminate radial probe endobronchial ultrasound (radial EBUS)-guided biopsy results remains uncertain. This study aimed to identify risk factors for malignancy based on clinical findings, chest computed tomography (CT), and radial EBUS images, and to estimate the risk of malignancy in lung nodules that showed indeterminate radial EBUS-guided biopsy results by constructing a nomogram. This retrospective study included 157 patients with indeterminate results on an initial radial EBUS biopsy performed at the Samsung Medical Center from January 2017 to December 2018, but with a definitive final diagnosis. Medical records, chest CT, radial EBUS images, and the final diagnoses were reviewed. Patients were randomly divided into training and validation sets. Factors related to malignancy were identified through logistic regression analysis, and a nomogram was constructed using the training set and subsequently applied to the validation set. Six factors in univariable and multivariable analyses, including upper lobe location, spiculation, satellite nodules, echogenicity, presence of dots or linear arcs, and patency of vessels and bronchi predicted malignancy. A nomogram was constructed based on these predictors. The area under the curve (AUC) value of the nomogram was 0.858 using the chest CT factors, which improved to 0.952 when radial EBUS factors were added. The calibration curve showed good agreement between the actual and nomogram-predicted malignancy outcomes. The utility of radial EBUS images for revealing risk factors of malignancy was confirmed. Furthermore, our nomogram was able to predict the probability of malignancy in lung nodules with indeterminate radial EBUS-guided biopsy results. 10.3390/jcm9113652
    Radial Endobronchial Ultrasound Greyscale Texture Analysis Using Whole-Lesion Analysis Can Characterise Benign and Malignant Lesions without Region-of-Interest Selection Bias. Badiei Arash,Nguyen Phan,Jersmann Hubertus,Wong Michelle Respiration; international review of thoracic diseases BACKGROUND:Radial-probe endobronchial ultrasound (RP-EBUS) is predominantly used clinically for the localisation of peripheral pulmonary lesions prior to biopsy. However, the RP-EBUS image itself contains information that can characterise the aetiology of lesions. OBJECTIVES:The aim of this study was to show the utility of RP-EBUS image analysis using unconstrained regions of interest (ROIs) that utilise more image information and eliminate ROI selection bias. METHODS:We developed custom software to analyse RP-EBUS images digitally captured during clinical procedures. Unconstrained ROIs were mapped onto lesions. We computed first-order greyscale image statistics of minimum, maximum, mean, standard deviation and range of pixel intensities, and entropy. We also computed second-order greyscale texture features of contrast, correlation, energy and homogeneity. The results of image analysis were compared to gold-standard tissue diagnosis. Features from expert- and non-expert-defined ROIs were also compared. RESULTS:Eighty-five images were analysed (38 benign and 47 malignant). Five greyscale features were significantly different between benign and malignant lesions. Benign lesions had higher mean (p < 0.01) and maximal (p < 0.001) intensity, greater range (p < 0.001) of pixel intensities and greater entropy (p < 0.01). The highest positive predictive values were associated with maximal (87.8%) and range of pixel (83.8%) intensities. There were no significant differences between expert- and non-expert-defined ROIs. CONCLUSION:RP-EBUS image analysis using unconstrained ROIs eliminates ROI selection bias and can characterise benign and malignant lesions with an accuracy of up to 85%. 10.1159/000492752
    Diagnosis of peripheral pulmonary lesions with radial probe endobronchial ultrasound-guided bronchoscopy. Boonsarngsuk Viboon,Kanoksil Wasana,Laungdamerongchai Sarangrat Archivos de bronconeumologia INTRODUCTION:The diagnosis of peripheral pulmonary lesions (PPLs) is a challenging task for pulmonologists. Radial probe endobronchial ultrasound (R-EBUS) has been developed to enhance diagnostic yield. The objective of this study was to evaluate the effectiveness of R-EBUS in the diagnosis of PPLs. METHODS:A retrospective study was conducted on 174 patients diagnosed with PPLs who underwent EBUS-guided bronchoscopy. Histological examination of specimens obtained by transbronchial lung biopsy (TBLB) and cytological examinations of brushing smear, brush rinse fluid and bronchoalveolar lavage fluid (BALF) were evaluated for the diagnosis. RESULTS:The mean diameter of the PPLs was 25.1 ± 10.7 mm. The final diagnoses included 129 malignancies and 45 benign lesions. The overall diagnostic yield of EBUS-guided bronchoscopy was 79.9%. Neither size nor etiology of the PPLs influenced the diagnostic performance of EBUS-guided bronchoscopy (82.9% vs. 74.6% for PPLs>20mm and PPLs≤20mm; p=0.19, and 82.9% vs. 71.1% for malignancy and benign diseases; p=0.09). TBLB rendered the highest yield among these specimens (69.0%, 50.6%, 42.0%, and 44.3% for TBLB, brushing smear, brush rinse fluid, and BALF, respectively; p<0.001). The combination of TBLB, brush smear, and BALF provided the greatest diagnostic yield, while brush rinse fluid did not add benefits to the outcomes. CONCLUSION:R-EBUS-guided bronchoscopy is a useful technique in the diagnosis of PPLs. To achieve the highest diagnostic performance, TBLB, brushing smear and bronchoalveolar lavage should be performed together. 10.1016/j.arbres.2014.02.018
    Use of radial probe endobronchial ultrasound for the diagnosis of peripheral pulmonary lesion: First report from India. Sehgal Inderpaul Singh,Dhooria Sahajal,Aggarwal Ashutosh N,Behera Digambar,Agarwal Ritesh Lung India : official organ of Indian Chest Society Radial probe endobronchial ultrasound (EBUS) helps in the evaluation and sampling of peripheral pulmonary lesions (nodules, masses, consolidation), and has been demonstrated a safer alternative to computed tomography guided procedure, especially in lesions that are away from the chest wall. Although radial probe EBUS has been available for more than two decades, there is no report from the Indian subcontinent. Herein, we describe two cases of peripheral lung lesions that were successfully sampled with the use of radial probe EBUS. 10.4103/0970-2113.177446
    Diagnostic Value of Non-Real-Time Radial Probe Endobronchial Ultrasound (RP-EBUS) Guided Positioning Method for Peripheral Pulmonary Lesions. Li Ning,Peng Yong,Chen Ying,Lv Yantian,Xu Guopeng,Ruan Ting Medical science monitor : international medical journal of experimental and clinical research BACKGROUND The aim of this study was to analyze the diagnostic value of thin bronchoscopy lung biopsy for peripheral pulmonary lesions under non-real-time guidance of radial ultrasound (RP-EBUS). MATERIAL AND METHODS We used a retrospective analysis of ultrasound images of 165 patients with peripheral pulmonary disease admitted to Suzhou Municipal Hospital Affiliated to Nanjing Medical University from February 2016 to December 2018 who were given RP-EBUS examination. Ultrasound images were obtained for all patients. There were 76 patients treated using traditional positioning method as the control group; 89 patients were treated by probe combined with bronchoscopy positioning method as the research group where the biopsy of the lesion along the path of the ultrasound probe was taken. The positive rate of the 2 methods was observed, and the factors affecting the quality of ultra-thin bronchoscopy under RP-EBUS non-real-time guidance were analyzed. RESULTS The detection rate of the study group was 77.64%, which was significantly higher than that in control group, which was 63.16% (χ²=5.238, P<0.05). The number of biopsies in the study group was 6±1.25, which was significantly lower than that of the control group which was 9±1.87 (t=4.116, P<0.05). The diagnostic positive rate of the RP-EBUS probe was significantly higher than that of the RP-EBUS probe (χ²=5.081, P<0.05). CONCLUSIONS The diagnostic positive rate of RP-EBUS non-real-time guided subtotal bronchoscopy lung biopsy for peripheral lung disease using probe combined with bronchoscopy positioning method was higher than the traditional positioning method, and the number of biopsies in the study group was significantly lower than that in the control group, which was related to the size, location, whether the probe was wrapped, or the characteristics of the ultrasound image. 10.12659/MSM.918888
    Multiple guided technologies based on radial probe endobronchial ultrasound for the diagnosis of solitary peripheral pulmonary lesions: a single-center study. Haidong Huang,Yunye Ning,Wei Zhang,Zarogoulidis Paul,Hohenforst-Schmidt Wolfgang,Man Yan-Gao,Yuguang Yang,Yuchao Dong,Chong Bai Journal of Cancer To evaluate the value of multiple guided technologies based on radial probe endobronchial ultrasound (R-EBUS) in the application of the diagnosis of solitary pulmonary peripheral lesions (PPLs). Analysis of diagnostic yield in 4 groups patients with different combined multiple guided technologies based on R-EBUS, 94 patients with 94 solitary PPLs from Mar, 2013 to Nov, 2014 in Changhai Hospital. The overall diagnostic yield was 75% (70/94), the diagnostic yield of Group A (R-EBUS) was 62%(16/26), Group B (R-EBUS with guided sheath, EBUS-GS) was 76% (34/45), Group C (EBUS-GS with fluoroscopy) was 82% (9/11), Group D (virtual bronchoscopic navigation guided EBUS-GS with fluoroscopy) was 92% (11/12). The overall histopathological diagnostic yield was 56% (53/94. Better histopathological diagnostic yield was associated with application of multiple guided technologies based on EBUS-GS, lesions located in non-lower lobes, lesion's diameter > 2cm, radial probe within the lesions and lidocaine nebulization combined with intravenous anesthesia. There were no severe complications in all the 94 cases. A ultrasonic radial probe was broken when exploring a lesion located in the apical-posterior segment of left upper lobe. Multiple guided technologies based on R-EBUS were safe and effective in the diagnosis of solitary PPLs. In practice, the diagnosis yield improved with the application of forcep biopsies combined with bronchial brushing and washing. 10.7150/jca.20035
    Molecular analysis of small tissue samples obtained via transbronchial lung biopsy using radial probe endobronchial ultrasound. Kim Insu,Eom Jung Seop,Kim Ah Rong,Lee Chang Hun,Lee Geewon,Jo Eun Jung,Kim Mi-Hyun,Mok Jeong Ha,Lee Kwangha,Kim Ki Uk,Park Hye-Kyung,Lee Min Ki PloS one BACKGROUND:Radial probe endobronchial ultrasound using a guide sheath (EBUS-GS) is used to diagnose peripheral lung cancer. The aim was to identify the accuracy of molecular analysis that were performed with EBUS-GS specimens in patients with non-small cell lung cancer (NSCLC). METHOD:From December 2015 to September 2017, we retrospectively studied 91 patients with peripheral NSCLC who underwent surgery after EBUS-GS. Epidermal growth factor receptor (EGFR) mutational and anaplastic lymphoma kinase (ALK) translocation status obtained from surgical specimens served as the references. RESULTS:Compared to the reference data, EGFR mutational testing of EBUS-GS specimens was in 97% agreement, and the κ coefficient was 0.931 (P< 0.001). In addition, on ALK translocation testing, the results of all 91 patients were in agreement with the reference data (concordance rate of 100%, κ coefficient 1.000; P< 0.001). CONCLUSION:We found that EBUS-GS could be used for molecular diagnosis, such as EGFR mutational and ALK translocation status, in patients with peripheral NSCLC. 10.1371/journal.pone.0212672
    Radial endobronchial ultrasound with a guide sheath for diagnosis of peripheral cavitary lung lesions: a retrospective study. Hayama Manabu,Okamoto Norio,Suzuki Hidekazu,Tamiya Motohiro,Shiroyama Takayuki,Tanaka Ayako,Nishida Takuji,Nishihara Takashi,Uehara Nobuko,Morishita Naoko,Kawahara Kunimitsu,Hirashima Tomonori BMC pulmonary medicine BACKGROUND:Radial endobronchial ultrasound with a guide sheath (EBUS-GS) has improved the diagnostic outcomes of peripheral lung lesions. However, to our knowledge, reports on the use of EBUS-GS for diagnosis of cavitary lesions are unavailable. Therefore, this study aimed to assess the effectiveness and safety of EBUS-GS for diagnosis of peripheral cavitary lung lesions (PCLLs). METHODS:This study was a single-institution retrospective review of PCLLs examined by using EBUS-GS between July 2013 and October 2015. The diagnostic results of different EBUS-GS samples, including cytologic, histopathologic, and microbiologic samples, were analysed separately. RESULTS:Of 696 radial EBUS procedures performed during the study period, 50 were performed for examination of PCLLs. The overall diagnostic yield for EBUS-GS was 80 % (40/50). Regarding 27 malignant lesions, the diagnostic yields for cytologic and histopathologic samples were 63.0 % (17/27) and 74.1 % (20/27), respectively. Regarding 23 benign lesions, the diagnostic yields for histopathologic and microbiologic samples were 69.6 % (16/23) and 47.8 % (11/23), respectively. Uni- and multivariate analyses indicated that the EBUS probe being within the lesion was the only factor significantly associated with increased diagnostic yield (odds ratio, 7.04; P = 0.03). Although pulmonary infection occurred after the procedure in 1 patient (2.0 %), no other complications, including pneumothorax or significant haemorrhage, were reported. CONCLUSION:EBUS-GS was found to be an effective and safe procedure for diagnosis of PCLLs. 10.1186/s12890-016-0244-y
    Fluoroscopic-Guided Radial Endobronchial Ultrasound Without Guide Sheath For Peripheral Pulmonary Lesions: A Safe And Efficient Combination. Casutt Alessio,Prella Maura,Beigelman-Aubry Catherine,Fitting Jean-William,Nicod Laurent,Koutsokera Angela,Lovis Alban Archivos de bronconeumologia BACKGROUND:Several guidelines recommend computed tomography scans for populations with high-risk for lung cancer. The number of individuals evaluated for peripheral pulmonary lesions (PPL) will probably increase, and with it non-surgical biopsies. Associating a guidance method with a target confirmation technique has been shown to achieve the highest diagnostic yield, but the utility of bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy as guidance without a guide sheath has not been reported. METHODS:We conducted a retrospective analysis of bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy procedures for the investigation of PPL performed by experienced bronchoscopists with no specific previous training in this particular technique. Operator learning curves and radiological predictors were assessed for all consecutive patients examined during the first year of application of the technique. RESULTS:Fifty-one PPL were investigated. Diagnostic yield and visualization yield were 72.5 and 82.3% respectively. The diagnostic yield was 64.0% for PPL ≤20mm, and 80.8% for PPL>20mm. No false-positive results were recorded. The learning curve of all diagnostic tools showed a DY of 72.7% for the first sub-group of patients, 81.8% for the second, 72.7% for the third, and 81.8% for the last. CONCLUSION:Bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy as guidance is safe and simple to perform, even without specific prior training, and diagnostic yield is high for PPL>and ≤20mm. Based on these findings, this method could be introduced as a first-line procedure for the investigation of PPL, particularly in centers with limited resources. 10.1016/j.arbres.2014.09.017
    Radial probe endobronchial ultrasound assisted conventional transbronchial needle aspiration in the diagnosis of solitary peribronchial pulmonary lesion located in the segmental bronchi. Huang Zhiang,Huang Haidong,Ning Yunye,Han Jin,Shen Yibo,Shi Hui,Wang Qin,Bai Chong,Li Qiang,Michael Simoff,Zarogoulidis Paul,Hohenforst-Schmidt Wolfgang,Konstantinou Fotis,Turner J Francis,Koulouris Charilaos,Katsaounis Athanasios,Amaniti Aikaterini,Mantalovas Stylianos,Pavlidis Efstathios,Giannakidis Dimitrios,Passos Ioannis,Michalopoulos Nikolaos,Kosmidis Christoforos,Mogoantă Stelian Ştefăniţă,Sapalidis Konstantinos Journal of Cancer The diagnosis of peribronchial pulmonary lesions located in the tertiary bronchi, also known as segmental bronchi, as well as, the 4th order and 5th order segmental bronchi is very difficult. Histopathological specimens cannot be easily obtained by endobronchial biopsies (EBBX) due to the patent but small segmental bronchial lumen. The aim of the present study was to evaluate the diagnostic accuracy and safety of the novel technique with radial probe endobronchial ultrasound (R-EBUS) assisted conventional transbronchial needle aspiration (C-TBNA) in the diagnosis of solitary peribronchial pulmonary lesions located in segmental bronchi from 3th to 5th order. From December 2014 to December 2015, 16 patients with solitary peribronchial pulmonary lesions in the segmental bronchi from 3th to 5th order confirmed by computed tomography (CT) were enrolled. The lesions were located using radial probe endobronchial ultrasound (R-EBUS) to determine the sites of conventional transbronchial needle aspiration (C-TBNA), then, histopathological specimens were obtained using the technique of C-TBNA. The final pathological diagnosis was made based on the findings from the surgical specimens. Statistical analyses were performed for specimen results and complications. On pathological evaluation, 14 of the 16 specimens were malignant, including 8 adenocarcinomas, 4 squamous cell carcinomas, and 2 small cell carcinomas, while 2 were non-malignant diseases. The diagnostic accuracy rate, sensitivity and missed diagnosis rates were 87.5%, 87.5% and 12.5%, respectively. When Combined the results of cytology with histologic samples obtained from C-TBNA the total diagnostic accuracy rate, sensitivity and missed diagnosis rate were 93.75%, 93.75% and 6.25%, respectively. There were 2 cases of bleeding complications >5 mL after C-TBNA, and both were resolved with endobronchial management. The combination of R-EBUS with C-TBNA was advantageous and safe for the diagnosis of solitary peribronchial pulmonary lesions located in the segmental bronchi. However, possible bleeding complications should be anticipated with needle aspiration. Further verification of this combined application should be investigated in larger clinical trials. 10.7150/jca.28755
    Radial probe endobronchial ultrasound using a guide sheath for peripheral lung lesions in beginners. Eom Jung Seop,Mok Jeong Ha,Kim Insu,Lee Min Ki,Lee Geewon,Park Hyemi,Lee Ji Won,Jeong Yeon Joo,Kim Won-Young,Jo Eun Jung,Kim Mi Hyun,Lee Kwangha,Kim Ki Uk,Park Hye-Kyung BMC pulmonary medicine BACKGROUND:The diagnostic yields and safety profiles of transbronchial lung biopsy have not been evaluated in inexperienced physicians using the combined modality of radial probe endobronchial ultrasound and a guide sheath (EBUS-GS). This study assessed the utility and safety of EBUS-GS during the learning phase by referring to a database of performed EBUS-GS procedures. METHODS:From December 2015 to January 2017, all of the consecutive patients who underwent EBUS-GS were registered. During the study period, two physicians with no previous experience performed the procedure. To assess the diagnostic yields, learning curve, and safety profile of EBUS-GS performed by these inexperienced physicians, the first 100 consecutive EBUS-GS procedures were included in the evaluation. RESULTS:The overall diagnostic yield of EBUS-GS performed by two physicans in 200 patients with a peripheral lung lesion was 73.0%. Learning curve analyses showed that the diagnostic yields were stable, even when the procedure was performed by beginners. Complications related to EBUS-GS occurred in three patients (1.5%): pneumothorax developed in two patients (1%) and resolved spontaneously without chest tube drainage; another patient (0.5%) developed a pulmonary infection after EBUS-GS. There were no cases of pneumothorax requiring chest tube drainage, severe hemorrhage, respiratory failure, premature termination of the procedure, or procedure-related mortality. CONCLUSIONS:EBUS-GS is a safe and stable procedure with an acceptable diagnostic yield, even when performed by physicians with no previous experience. 10.1186/s12890-018-0704-7
    [Diagnostic Utility of Electromagnetic Navigation Bronchoscopy Combined with 
Radial Probe Endobronchial Ultrasound in Peripheral Pulmonary Lesions]. Huang Haitao,Chen Shaomu,Pan Liangbin,Chen Ke,Yao Feirong,Ma Haitao Zhongguo fei ai za zhi = Chinese journal of lung cancer BACKGROUND:With the application of high resolution computed tomography (CT), a large number of peripheral lung lesions were found. It put forward new challenge on clinical diagnosis and treatment for these peripheral lung lesions. Electromagnetic navigation bronchoscopy (ENB) and radial endobronchial ultrasound probe (R-EBUS) are new technologies used for the diagnosis of peripheral lung lesions. The aim of this study is to explore the application value of ENB combined with R-EBUS in the diagnosis of peripheral pulmonary lesions. METHODS:From September 2016 to November 2017, eighteen patients with thirty peripheral pulmonary lesions in the First Affiliated Hospital of Soochow University were enrolled. The ENB was performed on these patients who were detected peripheral lung lesions by chest HR-CT. After successful navigation, the lesion's location was confirmed by R-EBUS, and specimens were acquired by needle aspiration, endoscopic cell brush and biopsy forceps. RESULTS:A total of eighteen patients with thirty lesions were enrolled in this study, the navigation success rate was 100%, the positive rate was 90%. The mean operation time was (95.61±28.74) min, and navigation time for each lesion was (25.90±11.29) min, and pneumothorax was observed in 1 case. CONCLUSIONS:ENB combined with R-EBUS for the diagnosis of peripheral pulmonary lesions is safe and effective. This technique is worth promoting. 10.3779/j.issn.1009-3419.2017.12.12