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Endobronchial Ultrasound and Extended RolesEndobronchial Ultrasound Extended Roles: Know Thy Limitations FREE TO VIEW

A. R. L. Medford, MD, FCCP
Author and Funding Information

From the North Bristol Lung Centre, Southmead Hospital.

Correspondence to: Andrew R. L. Medford, MBChB, MD, Dip(CRM), PGCert(TUS), North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, England; e-mail: andrewmedford@hotmail.com


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(5):1516. doi:10.1378/chest.13-0111
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Published online
To the Editor:

In the December 2012 issue of CHEST, Kennedy et al1 raise an important point about acknowledging the boundaries of endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-TBNA), citing infectious complications after sampling a nonsubsternal thyroid nodule. There are a number of issues to consider.

The first is infection. Proximity to the vocal cords is likely to be an issue with oropharyngeal contamination. Substernal thyroid nodules, and avoidance of more invasive surgical excision or mediastinoscopy, may well be a better indication for an extended role of EBUS-TBNA, but more data are needed to clarify this.2 The risks for infection in this scenario may be reduced by greater distance from the vocal cords (although the EBUS-TBNA needle is not sterile), and this might better justify EBUS-TBNA over surgical exploration.

Second, what is the best test in this situation, and who is the best trained person to do it? Radiologists (especially those with a subspecialist interest in head and neck) are very adept at sampling thyroid nodules accessible via ultrasound-guided fine-needle aspiration under asepsis. Moreover, it is somewhat harder to justify complications when doing a procedure that someone else is more optimally trained for.

The third issue is training. The learning curve for EBUS-TBNA is notoriously idiosyncratic and longer than previously thought, even for experienced bronchoscopists.3 Adding in extended roles for EBUS-TBNA introduces a need to consider this in curriculum requirements and training standards. Such roles have not been addressed currently in the UK national guidelines for EBUS-TBNA.4 As another example, a few EBUS-TBNA operators perform transesophageal endoscopic ultrasound (EUS) with bronchoscope-guided fine-needle aspiration (EUS-B-FNA)5-7 using the endobronchial ultrasound scope when full-blown EUS is not available. This also requires competency with esophageal intubation, is not covered in the EBUS-TBNA curriculum, and is not a substitute for complete EUS-guided fine-needle aspiration (EUS-FNA). Moreover, it has been suggested by some that such a procedure might be better performed by experienced EUS operators.8 Again, it might be harder to justify complications when doing EUS-B-FNA as opposed to EUS-FNA by a trained EUS operator. As a counter argument, however, there may be occasions where EUS-FNA is not available (given its considerable cost) and a trained EUS-B-FNA operator could perform this as an alternative if only endobroncial ultrasound equipment is available.

In summary, there is a natural inclination, as with any innovative technology, to extend the roles of EBUS-TBNA with time, but this needs to be recognized in EBUS-TBNA curricula and training programs. Careful consideration in the light of existing and new data is required as to what extended roles are reasonable and which of these roles are perhaps better performed by other specialist operators; that is, know thy limitations.

References

Kennedy MP, Breen M, O’Regan K, McCarthy J, Horgan M, Henry MT. Endobronchial ultrasound-guided transbronchial needle aspiration of thyroid nodules: pushing the boundary too far? Chest. 2012;142(6):1690-1691. [CrossRef] [PubMed]
 
Chalhoub M, Harris K. The use of endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule. Chest. 2010;137(6):1435-1436. [CrossRef] [PubMed]
 
Kemp SV, El Batrawy SH, Harrison RN, et al. Learning curves for endobronchial ultrasound using cusum analysis. Thorax. 2010;65(6):534-538. [CrossRef] [PubMed]
 
Du Rand IA, Barber PV, Goldring J, et al;; British Thoracic Society Interventional Bronchoscopy Guideline Group British Thoracic Society Interventional Bronchoscopy Guideline Group. British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax. 2011;66(suppl 3):iii1-iii21. [CrossRef] [PubMed]
 
Hwangbo B, Lee GK, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;138(4):795-802. [CrossRef] [PubMed]
 
Medford AR, Agrawal S. Single bronchoscope combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration for tuberculous mediastinal nodes. Chest. 2010;138(5):1274. [CrossRef] [PubMed]
 
Nicol LM, Skwarski KM. Role of transoesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging and diagnosis of lung cancer. Thorax. 2012;67(suppl 2):A13. [CrossRef]
 
Sharma M. Combined imaging for benign mediastinal lymphadenopathy: endoscopic ultrasonography first or endobronchial ultrasonography first? Chest. 2011;140(2):558-559. [CrossRef] [PubMed]
 

Figures

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References

Kennedy MP, Breen M, O’Regan K, McCarthy J, Horgan M, Henry MT. Endobronchial ultrasound-guided transbronchial needle aspiration of thyroid nodules: pushing the boundary too far? Chest. 2012;142(6):1690-1691. [CrossRef] [PubMed]
 
Chalhoub M, Harris K. The use of endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule. Chest. 2010;137(6):1435-1436. [CrossRef] [PubMed]
 
Kemp SV, El Batrawy SH, Harrison RN, et al. Learning curves for endobronchial ultrasound using cusum analysis. Thorax. 2010;65(6):534-538. [CrossRef] [PubMed]
 
Du Rand IA, Barber PV, Goldring J, et al;; British Thoracic Society Interventional Bronchoscopy Guideline Group British Thoracic Society Interventional Bronchoscopy Guideline Group. British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax. 2011;66(suppl 3):iii1-iii21. [CrossRef] [PubMed]
 
Hwangbo B, Lee GK, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;138(4):795-802. [CrossRef] [PubMed]
 
Medford AR, Agrawal S. Single bronchoscope combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration for tuberculous mediastinal nodes. Chest. 2010;138(5):1274. [CrossRef] [PubMed]
 
Nicol LM, Skwarski KM. Role of transoesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging and diagnosis of lung cancer. Thorax. 2012;67(suppl 2):A13. [CrossRef]
 
Sharma M. Combined imaging for benign mediastinal lymphadenopathy: endoscopic ultrasonography first or endobronchial ultrasonography first? Chest. 2011;140(2):558-559. [CrossRef] [PubMed]
 
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