This document provides information on endobronchial ultrasound (EBUS) procedures, including the pre-procedure, technique, and post-procedure aspects. It describes the two types of EBUS probes and discusses how they are used to visualize airway walls and surrounding structures. The document outlines the indications for EBUS, including staging of lung cancer and evaluating mediastinal lesions. It also reviews the preparation, anesthesia, equipment, positioning, and techniques used for radial probe EBUS and curved probe EBUS.

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Endobronchial Ultrasound
Author: Narayan Neupane, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Updated: Dec 16, 2015
Pre­Procedure
Background
Endobronchial ultrasound (EBUS) is a technique that uses ultrasound along with
bronchoscope to visualize airway wall and structures adjacent to it. The clinical
application and diagnostic benefit of EBUS have been established in many studies.
EBUS has been incorporated into routine practice in many centers because of its
high diagnostic informative value and low risk. It may replace more invasive
methods for staging lung cancer or for evaluating mediastinal lymphadenopathy and
lesions in the future.[1, 2, 3, 4] EBUS and guided sampling is gaining popularity
rapidly.
Two types of EBUS exist: radial probe EBUS (RP­EBUS) and convex probe EBUS
(CP­EBUS). Radial probe EBUS was commercially available in 1992, which
increased the yield of TBNA of mediastinal lymph nodes. The first CP­EBUS
bronchoscope with "Echo camera" and "Aloka" ultrasonic probe was introduced in
1992. Another CP­EBUS device (Olympus XBF­UC40P) was introduced in 2002,
but Olympus BF­UC160F­OL8 is the currently available CP­EBUS bronchoscope in
the United States.
Physicians should have knowledge of mediastinal lymph node stations and
sonographic anatomy of airway wall. The endobronchial ultrasound image visualize
distinct layers of the bronchial wall with mucosa, submucosa, endochondrium,
cartilage, perichondrium, connective tissue and adventitia. Mucosa, endochondrium,
perichondrial layer, adventitia are hyperechoic while submucosa, cartilage and
connective tissue appear hypoechoic.
Indications
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Staging of non­small cell lung cancer (NSCLC)
EBUS­guided transbronchial needle aspiration (TBNA) has higher diagnostic yield
than conventional TBNA in all lymph node stations except subcarinal lymph nodes
in determining the lymph node involvement in NSCLC.[5] Its ability to precisely
visualize the airway wall invasion helps to categorize the tumor (T) component of
staging and surgical resection planning.[6] It can be combined with endoscopic
ultrasound­guided fine­needle aspiration to near complete sampling of mediastinum
using a single endobronchial ultrasound bronchoscope.[7] It can also be used to
restage the lung cancer in mediastinum.[8]
Evaluation of mediastinal lesions, intrapulmonary pulmonary nodules, and
endobronchial lesions
EBUS can visualize and allow physicians to sample and diagnose various
mediastinal abnormalities,[9] including sarcoidosis[10, 11, 12, 13] and mediastinal
lymphoma.[14, 15] It can characterize the intraparenchymal and endobronchial
lesions and help to determine the likelihood of malignancy based on appearance.
EBUS­TBNA can visualize and allow sampling of pulmonary nodules that are not
visualized by fluoroscopy and may avert the need for surgical procedures.[16] RP­
EBUS is relatively accurate tool in the investigation of peripheral pulmonary lesions.
[17]
Guidance of endobronchial therapy
EBUS provides useful additional information during various interventions including
resection of endobronchial lesion, stricture dilatation, stenting, laser therapy, and
argon plasma coagulation.[18]
Contraindications
Contraindications to endobronchial ultrasound (EBUS) are similar to
contraindications to flexible bronchoscopy and include following:
Life­threatening cardiac arrhythmias
Current or recent myocardial ischemia
Poorly controlled heart failure
Severe hypoxemia
Uncooperative patient
Additional contraindications to EBUS­TBNA are related to bleeding risk and include
following:
Current anti­platelet agents [19]
Current anticoagulant therapy
Coagulopathy
Thrombocytopenia
Elevated blood urea nitrogen or serum creatinine
Preparation
Anesthesia
EBUS is usually performed under procedural sedation and local anesthesia. Local
anesthesia on airways is done by nebulizing 1% or 2% lidocaine and spraying
lidocaine spray in the posterior pharynx. A 1­2 mL of 1% to 2% lidocaine can be
installed through the working channel of bronchoscope during insertion and
procedure, if needed. EBUS can be done in general anesthesia. The use of a
laryngeal mask airway allows access to upper paratracheal nodes, which may not be
accessible with endotracheal tube in place. The size of endotracheal tube should be
at least No. 8 or larger, to accommodate the CP­EBUS bronchoscope. Patient
should be NPO for at least 6 hours.
Equipment
RP­EBUS probe
The system has ultrasound processor and balloon catheter that are attached to the
probe. The balloon is fixed at the tip of the probe. If overinflation or excessive
pressure occurs, the balloon slips from the tip and small amount of water is
released from the balloon to prevent balloon rupture. The 20 MHz miniature radial
probe is the standard probe. The 30 MHz miniature radial probe provides a more
detailed image of the airway wall and surrounding structures. These probes have
diameter of 2.5 mm so, a flexible bronchoscope with working channel of 2.8 mm is
required to use it. The 20 MHz ultra­miniature radial probe is smaller than either
miniature radial probe, so it can be inserted through the 2 mm working channel of a
bronchoscope and can extend further into subsegmental bronchi than the miniature
radial probe.
CP­EBUS bronchoscope
Currently available CP­EBUS bronchoscope (Olympus BF­UC160F­0L8) has linear
curved array ultrasonic transducer of 7.5 MHz at the distal tip, which has capability
of displaying B­mode and color Doppler mode.
The field of view is 80 º, and the direction of view is 35 º forward oblique. The outer
diameter of the bronchoscope is 6.2 mm and inner channel diameter is 2 mm. The
dedicated 22­gauge needle (NA­201SX­4022 single use) has echogenic dimpled tip
to enhance visibility by ultrasound. The maximum extruding stroke is 40 mm with
safety mechanism that stop at 20 mm. The needle has internal sheath which
prevents contamination of sample by bronchial wall tissue.
Positioning
EBUS is usually performed on supine position with operator standing on head end
of bed. The bronchoscopist should have clear view of monitor.

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Technique
Approach
The monitoring devices are placed onto the patient, supplemental oxygen is
administered by nasal cannula, and intravenous access is established before
starting the procedure. Eyes should be covered to prevent splashing the normal
saline, secretion, or blood into the eyes.
RP­EBUS
Conventional bronchoscopy with working channel of at least 2.8 mm is required for
RP­EBUS. When the bronchoscope is in the airway and around the target lesion,
the radial probe is placed in a catheter sheath and inserted through the working
channel of the bronchoscope. The probe is positioned at the target level and the
balloon is filled with water till it has firm contact with the airway. Complete circular
image of airway wall and surrounding structures is obtained when the balloon has
firm contact with the airway wall. RP­EBUS gives 360 º image of the airway wall
and surrounding structures.
If patient does not tolerate complete obstruction of airway, the balloon can be filled
partially and applied to the airway wall in semicircular manner.
Sequential TBNA
Sequential TBNA is defined as localization of lesion first and subsequent sampling
of the lesion. When the ultrasound identify the target lesion, the radial probe is
removed from the working channel of bronchoscope and TBNA needle is introduced
through it. TBNA of the lesion is performed using technique similar to conventional
TBNA. Sequential TBNA can also be used to localize and sample intraparenchymal
lesion. The probe should be introduced using catheter with extended working
channel and placed exactly on the lesion. With guide sheath in position, the radial
probe is removed and biopsy forceps or brush is used to sample the lesion through
the guide sheath. It can also be combined with virtual bronchoscopic navigation
system.[20]
CP­EBUS
A regular fiberoptic bronchoscopy should be done first to determine anatomy and
exclude endobronchial lesion. CP­EBUS is usually performed orally, as ultrasound
probe in it prevents using nasal route. The image quality is lower to that of a regular
bronchoscope. A disposable latex balloon is attached to the ultrasound probe. The
tip of the bronchoscope should be positioned more anteriorly while passing through
the vocal cords to avoid sticking the EBUS bronchoscope on the posterior part of
vocal cords. Once in the airways, a syringe filled with sterile water is attached to the
balloon channel of the scope and the balloon is filled with water to achieve contact
with the airways. Lymph nodes are identified with its typical sonographic
appearance.
Lymph nodes should be differentiated from vascular structures, which are also
hypoechoic. Doppler accurately differentiates lymph nodes and vascular structures.
All mediastinal lymph node stations should be evaluated systematically. Subcarinal
lymph node can be visualized either from right main or left main bronchus. The
bronchoscopic and ultrasonic views can be toggled alternatively or two­screen
display of both views can be used in the monitor. The tip should be flexed up for
ultrasound image and down for endoscopic image. The ultrasound image can be
frozen, allowing the size of lesions to be measured.
Real­time TBNA
Real­time TBNA is defined as simultaneous sonographic visualization and sampling
of the lesion. Once the target lesion is identified, the dedicated 22­gauge needle is
inserted through the working channel of the bronchoscope and fastened to it. The
tip of bronchoscope should be in neutral position to allow the sheath to come out of
the distal end of working channel. The needle should remain within the catheter
during passage through the working channel in order to prevent injury to the
bronchoscope. Once the catheter emerges out of the bronchoscope, the needle is
advanced from the catheter and locked into position. The insertion point of needle is
localized and it is then pushed through the bronchial wall into the target lymph node
under direct ultrasound visualization.
With the needle in the target lymph node, the internal sheath is removed. This
cleans the lumen of the needle system, which usually becomes contaminated with
bronchial cells. Suction is applied using a 20­mL syringe, and the catheter is moved
back and forth. Suction is released and the needle is pulled back into the flexible
catheter. The entire transbronchial needle system is then removed from the
bronchoscope in a single, smooth motion. The tissue core is removed from the
needle lumen by reinserting the internal sheath.
The number of needle aspirations per site can impact the yield and range from 3­7
depending on the study, but the first pass has the highest yield.[21, 22] If the TBNA
is being done for staging of NSCLC, the sampling should be started from N3
followed by N2 and N1 lymph nodes to avoid contamination and upstaging.
Pearls
Pearls include the following:
Knowledge of mediastinal anatomy and lymph node stations is essential for
EBUS and EBUS­TBNA.
EBUS is generally safe procedure with high diagnostic accuracy.
It can be performed with local anesthesia and procedural sedation as an
outpatient basis.

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EBUS­TBNA of mediastinal and hilar lymph nodes can be performed real­
time using CP­EBUS or sequentially using RP­EBUS.
Transbronchial biopsy of peripheral pulmonary nodules can only be done
sequentially using RP­EBUS.
Clinical application of EBUS­TBNA may avert the use of more invasive
interventions for staging and restaging the lung cancer and diagnosis of
mediastinal pathology.
EBUS is gaining popularity rapidly and can be learned through training.
Post­Procedure
Complications
EBUS and EBUS­TBNA are usually safe procedures. No serious complications
were found on a systematic review of effectiveness and safety of CP­EBUS­TBNA
of regional lymph nodes.[23] Reported complications are agitation, cough, hypoxia,
laryngeal injury, fever, bacteremia and infection, bleeding, pneumothorax, and
broken equipment becoming stuck in the airway. Mediastinal abscess has been
reported as a case report. Complications related to upper airway local anesthesia
are laryngospasm, laryngeal edema, bronchospasm, methemoglobinemia, and
cardiac arrhythmias.[24] Complications attributable to procedural sedation are
respiratory depression, cardiovascular instability, vomiting, and aspiration.
Specimen Preparation
Aspirated specimen is smeared onto glass slides and air dried so that an on­site
cytopathologist can evaluate the specimen. The use of rapid on­site evaluation
significantly improves the diagnostic yield of transbronchial aspiration[25] , and it is a
cost­effective approach.[26] It leads to avoidance of additional biopsies without loss
in diagnostic yield and also reduces the complication rate of bronchoscopy.[27, 28]
Histological cores are fixed with formalin and sent to the pathology department. The
samples can be used for molecular analysis.
Monitoring
Continuous monitoring of cardiac rhythm, heart rate, respiratory rate,
oxyhemoglobin saturation, and blood pressure is usually done after the procedure
until the effects of sedation and upper airway anesthesia have been resolved.
Eating and drinking can be resumed once the gag reflex returns. A chest radiograph
should be performed following the procedure to evaluate complications, such as
pneumothorax. Outpatients must have stable vital signs, be alert and oriented with
baseline ambulation status before discharge.
Cleaning the Bronchoscope
The bronchoscope should be disinfected and hung upright to prevent the
accumulation of moisture.
EBUS Training
As EBUS­TBNA is a new technique, a large number of pulmonologists need
training on this as it can be learned with appropriate training only. Evidence­based
protocols for teaching EBUS­guided TBNA are necessary.[29] No accepted method
exists of assessing EBUS technical skill or competency. An EBUS computer
simulator can accurately discriminate between operators with different levels of
clinical EBUS experience and help in assessing training and evaluating competency.
[30]
Patient Education
You should not eat or drink at least 6 hrs before the procedure. You may be asked
to discontinue blood thinning medications several days prior to the procedure. A thin
tube called a bronchoscope is placed in the mouth. It is difficult to speak once the
bronchoscope is in the airways. You will be monitored closely for two to four hours
after the test. Chest x­ray will be performed. You must not drive an automobile on
the same day. A family member or friend must be available to drive or accompany
you home. You may have a mild sore throat, hoarseness, cough or fever. If the lung
is punctured, it can cause an air leak (pneumothorax), which results in lung collapse.
If you have increasing chest pain or shortness of breath, or if you cough up more
than a few tablespoons of blood, you should contact your doctor. Result of the test
may take few days.
Contributor Information and Disclosures
Author
Narayan Neupane, MD Pulmonologist, UPMC Horizon
Narayan Neupane, MD is a member of the following medical societies: American College of Chest Physicians,
American Thoracic Society
Disclosure: Nothing to disclose.
Coauthor(s)
M Frances J Schmidt, MD Chief of Pulmonary Medicine, Pulmonary Fellowship Program, Teaching Attending
Physician, Department of Medicine, Interfaith Medical Center
M Frances J Schmidt, MD is a member of the following medical societies: American College of Chest
Physicians, American College of Physicians
Disclosure: Nothing to disclose.
Chief Editor

7. 9/23/2016 Endobronchial Ultrasound: Pre­Procedure, Technique, Post­Procedure
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Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine,
Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung
Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine
Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest
Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic
Society
Disclosure: Nothing to disclose.
Acknowledgements
The authors wish to thank Dr. Sonali Sethi, Director of Interventional Pulmonary, New York Methodist Hospital,
Brooklyn, NY, for his assistance with this article.
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