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Armin Ernst, MD, FCCP; Felix Herth, MD, FCCP; Ralf Eberhardt, MD; Mark Krasnik, MD
Author and Funding Information

Affiliations: Boston, MA,  Heidelberg, Germany,  Copenhagen, Denmark

Correspondence to: Armin Ernst, MD, FCCP, Chief, Interventional Pulmonology, BIDMC, 330 Brookline, Ave, Boston, MA 02215; e-mail: aernst@bidmc.harvard.edu


The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2008;134(6):1351. doi:10.1378/chest.08-2022
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To the Editor:

We thank Dr. Kennedy and his colleagues1 for their comments regarding the level of sedation during endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA).2 The use of propofol and a laryngeal mask airway is certainly an additional option available to the bronchoscopist. It is important to remember, though, that there is currently no proof that any level of anesthesia deeper than moderate sedation is required for performing the procedure. This applies for the goal of the procedure (full staging vs targeted biopsy) as much as for the level of experience. Even though we agree that general anesthesia may make it easier especially for the relatively inexperienced operator, some issues require consideration before asking the anesthesiologist to provide deep sedation or general anesthesia for a patient.

Part of the advantage of EBUS TBNA is the ease and minimal patient impact compared with surgical staging, as well as the potential economic advantage. Deeper levels of sedation may partially negate these advantages by adding additional personnel and requiring operating room-type facilities in some institutions. An additional drawback to adding more resources that really are probably not required is the recent severe reimbursement cutback on the facility-based reimbursement (Hospital Outpatient Prospective Payment System) for EBUS TBNA procedures by the Centers for Medicare and Medicaid Services in January 2008.3 We need to choose the best approach for our patients but need to manage and minimize the resource use at the same time.

Kennedy MP, Shweiwat Y, Sarkiss M, et al. Complete mediastinal and hilar lymph node staging of primary lung cancer by endobronchial ultrasound: moderate sedation or general anesthesia? Chest. 2008;134:1350-1351. [PubMed] [CrossRef]
 
Herth FJF, Eberhardt R, Krasnik M, et al. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography- normal mediastinum in patients with lung cancer. Chest. 2008;133:887-891. [PubMed]
 
Centers for Medicare and Medicaid Services. Federal Register. 2007;:72
 

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References

Kennedy MP, Shweiwat Y, Sarkiss M, et al. Complete mediastinal and hilar lymph node staging of primary lung cancer by endobronchial ultrasound: moderate sedation or general anesthesia? Chest. 2008;134:1350-1351. [PubMed] [CrossRef]
 
Herth FJF, Eberhardt R, Krasnik M, et al. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography- normal mediastinum in patients with lung cancer. Chest. 2008;133:887-891. [PubMed]
 
Centers for Medicare and Medicaid Services. Federal Register. 2007;:72
 
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