To begin, hold the endoscope in the left hand with the left thumb on the steering lever. Hold the distal end of the endoscope in the right hand. Enter the trachea through the nasal or oral cavity.
Once the vocal cords are visualized, press the appropriate button on the screen to administer two milliliters of 2%lidocaine twice, and pass the vocal cords with care. Administer an additional two milliliters of 2%lidocaine into the trachea and in both the right and left main bronchus respectively. After inspecting the bronchial tree, retract the bronchoscope and change to the EBUS scope.
Turn on the ultrasound transducer to locate the six anatomical EBUS landmarks. At landmark one, turn the endoscope counterclockwise in the trachea to locate station 4L, between the arch of the aorta and the left pulmonary artery. At landmark two, to locate station seven, place the scope in the right or left main bronchus and turn the endoscope facing medially.
Locate station seven between the right pulmonary artery and the left atrium below the carina. At landmark three, place the endoscope in the left main bronchus or the left upper lobe and direct the view upward. Locate station 10L, adjacent to the left main bronchus cranial to the left upper lobe.
At landmark four, place the endoscope in the right main bronchus or the right upper lobe bronchus and direct the view upward. Locate station 10R on the lateral wall of the right main bronchus. Just coddle to the inferior border of the azygos vein.
At landmark five, to find the azygos vein, retract the endoscope slightly cranially and turn the transducer clockwise in the trachea to visualize the azygos vein draining into the superior vena cava. At landmark six, to find station 4R, retract the endoscope further cranially from the azygos vein and turn the transducer clockwise in the trachea. Identify station 4R to the right or in front of the trachea above the lower border of the azygos vein, which marks the border between station 10R and 4R.
Once the relevant lymph node is visualized, get the biopsy equipment from the assistant and insert the needle into the working channel, ensuring to keep the steering lever in a neutral position to avoid damage to the endoscope. Then adjust the sheath so that it is visible at the end of the endoscope. Orient the transducer towards the bronchial wall so that the lymph node is visualized on the left side of the ultrasound picture.
After puncturing the lymph node with the needle, remove the stylet and press the appropriate button on the screen to apply suction to the needle. Ensure the needle moves back and forward several times. Release the suction and retract the needle tip while still inside the sheath, ensuring the distal end of the endoscope is not flexed and remains in a neutral position.
After the final biopsy, using the white light view, inspect the biopsy site for bleeding. If no bleeding is observed, retract the endoscope. Data comparing targeted EBUS by PET-CT and systemic EBUS TBNA approaches are shown here.
Comparison of systematic and targeted staging in 107 patients showed that systematic EBUS TBNA sampling provided additional important clinical information in 14 cases compared to targeted EBUS. Similar results were reported in another study, showing that systematic EBUS was superior to PET-CT targeted EBUS alone.
