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Endobronchial Ultrasound (EBUS) & ROSE

EBUS as a minimally invasive bronchoscopy procedure that is used to diagnose mediastinal lymph node enlargements, primarily used in the context of accurately diagnosing and staging of Lung cancers, EBUS can also help diagnose other cancers in the body spreading to mediastinal lymph nodes including from the bowel (Esophageal and Colonic etc), kidney and others tumors also rarely some gynecological tumors.

EBUS could equally also be useful in helping diagnoses of other benign causes of mediastinal lymph node enlargement i.e Sarcoidosis, Tuberculosis or any other infections like fungal infections. The accuracy (i.e sensitivity and specificity) of this relatively safe test is very high ranges between 92-100% respectively

The procedure involves the use of a flexible telescopic camera device, a pencil like tube which has a camera with an attached ultrasound processor tip that goes through the patient’s mouth and into the his/her windpipe and into smaller tubules in the lungs. Using this camera, the doctor can get two images one is the endoscopic view (inside the airways) and the other one being the ultrasound image (outside the airways view), after visualizing ultrasonic view of the lymph node or the lesion, the examiner collects tissue samples from lesion outside the airways, which is normally done with a small thin (the TBNA) needle. During the EBUS procedure, which we know is a very safe procedure and has relatively little or no complications, rarely the patient may experience some cough and soreness of throat which eventually goes away within few hours and does not last long.

Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a modern technique used for tissue sampling of lymph nodes or for lesions adjacent to the airways. Lymph Node enlargement in the chest wall can be seen in various conditions including any cancers spreading to the mediastinum i.e primarily Lung cancers, but also help other cancers like bowel, renal and gynecological cancers, Lymphomas could sometimes be diagnosed along with other benign conditions like Sarcoidosis, Tuberculosis and other infections like Fungal infections which can cause enlargement of the lymph gland adjacent to the airways.

Rapid on-site evaluation (ROSE) during the EBUS-TBNA procedure assesses the samples collected for a definitive pathological diagnosis and assures good sampling enhances and confirms the diagnostic yield from the procedure including reducing number of biopsy passes needed.

How the Procedure Works

While performing the Rapid on-site slide evaluation (ROSE) during an EBUS guided TBNA procedure, the patient lies in a supine position and the physician stands at the patient’s head end assisted usually by two nurses. An ultrasound image obtained by touching the walls of the airways endoscopically and a lymph node station is then targeted for biopsy. Patient usually given mild sedation, cough suppressants and local anesthesia normally but procedure can occasionally be performed in General Anesthesia.

Summary of the procedure

  • The ultrasound transducer gets coupled to the airway wall. After which the technician achieves coupling through direct contact between the tip of the bronchoscope and the airway wall or couple up with the saline-filled balloon within the airway wall
  • The bronchoscope position is adjusted carefully sometimes more saline is added to the balloon to correct the coupling. A neutral position is usually maintained, and the nurse holds the scope in position, the needle is then inserted. The needle is secured on the scope and the slider is pushed to the lock-in position. The sheath is then adjusted in order to be visualized in the endoscopic view.
  • As the target area is located on the ultrasound image, the needle is advanced into the target, guide wire removed. The prepared syringe is attached on the aspiration part and suction is applied. The needle is moved back and forth in the target area several times in order to collect a viable sample for diagnosis and staging. Rapid staining of some slides reviewed on a monitor and a microscope assures accurate sampling during the time of the procedure

Possible Risk Factors of Endobronchial Ultrasound

The EBUS procedure is considered a very safe procedure, but just like any medical procedure, there are rare possible complications may include:

  • Bleeding from the biopsy
  • Hoarseness of voice
  • Low oxygen level during the procedure
  • Small risk of collapse of the lung

Benefits of EBUS-TBNA

Some of the benefits of a patient choosing the EBUS-TBNA procedure include:

  • Reduction of diagnostic work-up time with quick safe and accurate diagnosis and staging if needed
  • Ability to accurately assess and restage mediastinal lymph nodes previously stated less accurately by other imaging techniques e.g. CT (Computerized Tomogram) scan or even PET (Positron Emission Tomography) scan
  • Prevents unnecessary futile surgeries on patients because of accurate staging
  • Successful surgical procedures can now be performed in Lung cancer resections on patients, previously ruled out by over staging by CT scan or PET scans.
  • Reduction in time and costing for adequate diagnosis for enlargement of mediastinal Lymph Nodes of significant size 

Post-op Guidelines

After the procedure, the patient is continuously monitored for at least one hour. This includes monitoring of the patient’s vital signs and parameters like Heart Rate, Blood Pressure, and oxygen saturation. And in cases where the patient undergoes the procedure under mild sedation, he/she can only be discharged after a few hours, or until the side effects of the sedative have lessened. Allowed to drink coffee or tea before being discharged home. Some family member or friend should drive the patient and accompany the patient home and ideally stay overnight to ensure good recovery from sedation.

Recovery

After the procedure, patients remain in recovery for a couple of hours while the numbing agent wears off to ensure that the gag reflex goes back to normal. The patient may experience a scratchy throat or some hoarseness for some hours and should be ok afterwards.

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