To begin, position the patient in a supine and apply monitoring equipment. Continuously monitor 3-lead telemetry, oxygen saturation, pulse, and intermittent blood pressure. While standing behind the patient's head, hold the handle of the echo endobronchoscope with the left hand, thumb in the lever, and distal end in the right hand.
Apply local anesthetic gel on the tip of the endoscope, then orally or through the nostril, introduce the endoscope into the oropharynx of the anesthetized patient. Advance the endoscope into the laryngopharynx while the epiglottis in front of the scope. Visualize the vocal cords using the bronchoscopic view.
Next, turn the scope left or right to direct it lateral to the adenoids. Ask the patient to swallow and slowly bend the endoscope posteriorly, introducing it into the esophagus following the patient's swallowing movement. If required, spray two milliliters of topical lidocaine in the oropharynx.
To identify six endoscopic ultrasound landmarks, shift to the ultrasonic image and introduce the endoscope into the stomach. At landmark one, turn the endoscope slightly counterclockwise to visualize the left liver lobe. At landmark two, turn the scope clockwise to visualize the abdominal aorta with the celiac trunk in superior mesenteric artery.
Turn the scope further clockwise at landmark three to visualize the left adrenal gland. At landmark four, retract the endoscope to the mediastinum to locate the mediastinal lymph station 7. Next, retract the endoscope a few centimeters and observe the reflections from the trachea.
Now turn the endoscope counterclockwise and at landmark five find mediastinal lymph node station 4L between the aortic arch and the left pulmonary artery. At landmark six, turn the endoscope clockwise and pass the trachea to find the azygos vein and mediastinal lymph node station 4R. Insert the sheath in the endoscope and adjust the length such that the tip is one millimeter outside the endoscope.
Then lock the sheath in place. Move the FNA needle with the stylet forward and retract the stylet a few millimeters to sharpen the needle. Under realtime ultrasonographic guidance, hit the target lesions.
Then retract the stylet and apply suction to the needle. Move the needle back and forth. Remove the suction and lock the needle in the upper position before removing the equipment from the endoscope.
The transesophageal ultrasound tissue sampling technique shows that diagnostic hit rates vary according to location with slightly higher diagnostic success rates of intrathoracic lesions.
