Endobronchial Ultrasound Bronchoscopy-Guided Biopsy for Lymphoma

CHAPTER 1

My name is Dr. Htwe. I'm the assistant professor of medicine, and I'm also an intervention pulmonologist. Today is a case about bronchoscopy and endobronchial ultrasound. My patient is a 70-years-old woman, with a sarcoma of the thigh, and she got treatment, and since 2019 she has been cancer free. So, for those kind of patient we do surveillance every year, and in one of the surveillance scans show there is a mediastinum lymphadenopathy, which means that there is a lymph node around the airway. They are big. That is concerning. Our differential diagnosis can be recurrence of sarcoma or lymphoma, or sometime it can go to the sarcoidosis changes. So, we need a tissue biopsy. The best way to do the biopsy of the lymph node around the airway is endobronchial ultrasound, because this is the least invasive and also the very safe procedure. We call it a very moderate risk procedure. The common risk can be bleeding, because we're using the needle, and then go through with the airway, and then do a lot of passages. And another one is infection, because all of the bronchoscopy procedure is not sterile, right? Even though we use the sterile technique, the airway is not sterile. So, whenever we touch the airway and airway mucosa, it's not sterile anymore. So, we can introduce the infection from the upper airway all the way down to the lower airway. Another one is injury to the nearby structure. By that means that I can accidentally poke into the lung parenchyma, and cause the pneumomediastinum or pneumothorax, or I can accidentally poke through the blood vessel. But that's why, when we do the biopsy, we need to see the needle all the time. However, this endobronchial ultrasound is very safe procedure, and it's very rare to develop those complication. Common indication for the endobronchial ultrasound is two things. One is that if patient develop a lung cancer or concern for lung cancer, they do need to find out what stage of the lung cancer it is. Then, endobronchial ultrasound are very important rule for staging, because the staging going to guide patient to get the treatment, whether patient is a surgery candidate or radiation, or combined chemo and radiation. So, we do that for those kind of lung cancer staging. The second one is if patient have a lymphadenopathy for unknown reason. Sometimes, sarcoidosis or infection, or sometimes it can be metastatic from different type of cancer. We need to have a tissue sample. Then with the endobronchial ultrasound also very important as well. There's similar process for both type of procedure, both a little bit different. For the lung cancer staging, which I did in this case, even though we don't necessarily need to, it's kind of a systematic staging, because we have to sample the lymph node serially. If we sample the lymph node without serial what can happen, it can cause a seedling, which is I can accidentally put the cancer cell to the non-spreading lymph node, and I can stage up the patient. So, that is important in the cancer staging. But this patient have a sarcoma and lymphoma, which is a generalized process. So, I don't necessarily need to stage like a cancer. When I scan for the lymph node, anything above five millimeter we consider large. But for lymphoma and sarcoidosis, I am expecting to see more than one centimeter, or a little bit larger lymph node. My patient is only level seven lymph node is significantly enlarged. 11R and 11L are borderline enlarged. But I sample all of them, because the diagnosis yield for those lymphomas, sarcoidosis from the EBUS is not very high. To perform the endobronchial ultrasound, you always have to start with the airway inspection, because sometime we can find some lesion in the airway. Then I can change my decision whether I gonna continue with the endobronchial ultrasound or not. So, I always start with the airway inspection and I then airway clearance. And then after that, I use the endobronchial ultrasound scope. It is like I explained that to you in the video. In the scope at the tip, there is a transducer that is attached to the balloon, and then whenever we inflate with the water, and there is a media that can contact the ultrasound wave. It's the same with like a simple ultrasound, that we use it in general ultrasound. We need to have a contact with the airway mucosa all the time. If we don't have any contact, we won't be seeing the images. And in the EBUS is if you look in the screen, there is a dot on the right corner of the images that where is the needle gonna come out, and then the needle gonna come out like 35-degree angle. And we, during the ultrasound procedure, we prefer to see our needle length all the time, so that we know where is our needle is, we know where our sampling is. Because of that advantage, the diagnosis yield of the EBUS is very good. If patient have a negative, especially for the lung cancer, the negative predict value is really high, and it's more than 95%. We usually, generally do the three passages. You can do one or two passages as well. However, based on a lot of the data published, we do it minimum three passages. And for lymphoma and sarcoidosis workup, we sometimes do it through four to five passages.

CHAPTER 2

So, this is called the endobronchial ultrasound. At the tip, you're gonna have this channel. The needle gonna come out with like a 30 degree. I can show you when the needle is in there. This is kind of the transducer. And then, there is a balloon that is made with the latex. So, if patient have a latex allergy, you cannot use it. And how we gonna do that conduction is we place a little bit of saline. So, the saline used like a lubricant, and when it contact with the airway mucosa, we can see it in the endobronchial ultrasound images. And then, if I turn it on, there is a light sources. And then, if you look at the camera, and if I put my finger at the tip of the scope, and you won't see it. But if I came from the anterior, and then you're seeing it. So, whenever we are doing the endobronchial ultrasound, you don't want a perfect view like a regular bronchoscope, because if you are seeing the perfect view, then your scope is kind of pointing to the backward. So, you can accidentally injure to the posterior wall of the bronchial wall. Did we loop? Let me loop it down. But then this endobronchial ultrasound scope is a little bit bigger than therapeutic scope. So, we have to use a lubricant. So, I'm using the mineral oil.

CHAPTER 3

Dr. Wallace is trying to intubate with the endobronchial ultrasound scope. That's good. Look forward. Stay in the center. So, this is a view we wanted with a therapeutic scope, but we don't want it with endobronchial ultrasound. If you're seeing that this is a perfect view. So, yeah. And down a little bit. No, I don't need a picture for that. Go forward, forward, forward. That's good. Now, he is already in the trachea. Now relax. When you're in the trachea, relax. Push it down. This is the view that we want. You don't want to see the whole trachea wall. If you see the wall, then your're kind of - your scope gonna, yeah, scrape the posterior wall of the trachea, which we don't want. So push it down. Relax. Relax. Push it down. Yes. Relax, push it down. Push it down. Push it down. So now, I'm gonna start focusing on this one, okay? So, right now, you are looking at the trachea. And, come back a little bit.

CHAPTER 4

So, there are two type of endobronchial ultrasound procedure. One is for mediastinal staging. For the mediastinal staging, we have to go with the systematically. For example, it's a cancer, it's a nodule that we're interested on the right side, we are gonna start very far away from the left side to the right. And this patient have a sarcoidosis, so we don't necessarily need to use that. But however, for the systematically staging, we will start with like, a mediastinum staging for the cancer process. So, you wanna start on the right or left? I'll start on the right. Right. Okay. So, now if you wanna go to the right, come back, face the scope toward the right main, forward. Uh-huh. Forward. Now, you're gonna go to the left. If you see the whole right main, then your tip is pointing to the left, which you don't want. Okay, so thumb down a little bit. Turn towards, yes, like at three o'clock. Good, you're good. Now, you're in the right upper and right lower. Okay, that is good. It is a carina of the BI. And then, you're gonna face it to the lateral wall, and thumb down. Thank you. Thumb down. So now, if you are seeing the airway, then you have no contact with the airway mucosa. Then, you have to inject a little bit of saline. And then, I like to lock it. Now, thumb down, and then this way. Okay, so we did not see anything. Do you know how to scan it? Let me show you how to scan it. I ask you to get back here. So, what you do is whenever you scan, your thumb's gonna be always down, and then here, like a ladder, go to the posterior up, anterior up, posterior. It's like, kind zig-zag pattern. Yeah. It's not up and down. It's like, lateral up, lateral up. Yeah. Yeah. So, go back to the right main again. Okay, you wanna do? Uh-huh. Click it. You wanna go back to the main carina? Yes, we gonna start with the 11R. Let's say, let's pretend that we have a nodule on the left side. Left side. Okay. So you wanted to start with the right, right? So the very first one is 11R. That is good. Forward. Now you're in the BI, so I would thumb down. You want all the way to the right middle lobe. So then, if you go deep down, that's gonna be station 12. 11RI. 11RI, and yeah. We don't want to scan the 11RI. Okay. You understand? 11RS? 11RS. So then, that is good. Thumb down. Then, you're seeing your airway, which means there is no contact with the mucosa. So then, what you have to do, you can... Oh, good. So, that's what we are seeing is the 11. Yeah. RS. Uh-huh. 11RS, yeah. So, when we measure the lymph node, anything above five millimeter is considered as large. We try to measure it from the inner border of the lymph node. Should I press diameter? Yeah. And then... I take pictures. Yes. Good, thank you. I will call that a homogeneous lymph node. So now, after you scan 11R, and then if you go up, but you're gonna see 10R. 10R. Yes. Good. Uh-huh. So, this is that right upper lobe. So, it's still coming up. That's good. That is a 10R. Yeah. It's okay. You don't need to take a picture. So then, above 10R, this is a blue dot, right? So, what is that? Azygos. That's the azygos vein. Okay. Above the azygos vein is? Is 4R. 4R. Okay. No, we're not doing anything yet. I'll let you know when things are happening. So then, it's a 4R stay all the way from the anterior wall of the trachea to the lateral wall. That's right. So, what I want you to scan is scan from like 11 o'clock to like four o'clock. Make sure I don't miss any. Yes. Good. This is just a kind of subcutaneous, but this is very small lymph node, so I'm not that... Yeah, that's fine. Not this one. Keep scanning. So, scan all the way to the lateral wall. Up. That's a very small lymph node that is flat. So, it looked like benign to me. Yes. Scan it again. Okay, that's airway? No, what is that? Did you went down to the right? No, I'm still on the... Because hat look like, okay. You went really too fast. Here we go. Okay, so this is a 4R. Yeah. Okay. So now, he is checking if this azygos vein is the right one. 4R? Yes. So, that is a common mistake that we do. If you found one lymph node, there is many, many lymph nodes in the 4R stage, so you have to scan all the way to the innominate vein. Okay. Up to 2R. Okay. So keep scanning. And mostly, we have on the air? Yeah, yeah. We can do all the way? If you have a LMA and you can scan all the way to the 2R, which is appropriate method. And we - okay. Then, you can give a little bit of balloon, because you see this: there is no contact right here. Here we go, here we go. Good. That's a node. So then, what is the innominate vessel? Three. Can you tell me the differences between the 4R and 2R? 2R, the apex is the intersection of the innominate artery with the trachea. Yeah. So, now can you tell me the innominate artery over it? It has to be below, right? Yeah, I think it's gonna... I'm going down slightly. Okay, that's good. Okay, so that is the innominate vessel. So that is a 2R. Okay, good. That's a 2R. Okay. That's 2R. 2R? 2R, yeah. But I'm not taking sample. They are not very big. Mhmm. Mhmm. So, if you want to scan seven, you have to scan it from both sides. Seven does not have a right or left. Left. We are gonna go from the right middle lobe, and scan just above the right middle lobe. So, that is a big seven. Yeah. A seven. Yeah, seven. Okay. We find that guy. Have you ever done the EBUS before? Do what? Have you ever done a EBUS before? You let me do it. That should be easy. No, no, you do one pass too, if you're around. I can do a pass or two. But yeah, we're not... We gonna sample seven. Are we gonna start with seven? Seven. Yeah. Again, again, you see? Once you find it, your job is not done yet. You have to scan the whole area. Yes, because there can be more than one lymph node, right? Yeah. I'm gonna go from the left also. But did you scan it all the way to the top? I didn't do it from the right. Yeah. You did it already? No, I did not do it. Yeah, right. Yeah, do it the proper way. Okay, good. So now, you went to the left main. Okay. I'm turning because it's supposed to have the RA below. Uh-huh. So scan. For the seven, if you want to... Supposed to have three, right? Yeah. Huh? Sometimes, we can have two or three. Yes. But do you see this is a conglomerate, right? There's a one node, right there. So, if you want to scan seven, you have to scan it like, from the kind of seven-o'clock position to 11-o'clock position, okay? Now, when you're at the carina, you gonna move your body. And go back to the left main. All the way to the distal left main, and then scan it again. Now, you are seeing the seven from the left side. Uh-huh. So, what is that? You see the peristalsis? Then the air coming in, this is esophagus. Oh. So, when you scan the EBUS, there is two station that you can see esophagus, 4L Well, eight and nine is true, but we can't get it with the EBUS scope. Seven from the left, and 4L that you're gonna see the esophagus. Okay. So, from the seven from the left side, you're gonna scan it from one-o'clock to five-o'clock position. Scan up. That's the esophagus. Uh-huh. I'm not ready yet. That's okay. My job is to be ready, so... Whenever you're doing, I feel like I have to grab it. No, no, sorry, I'll stay back. All right. Okay. Uh huh. Now, you keep scanning until you are at the carina. That is what? Is that the... Your cardiac. I think it look like a cardiac shadow that you're seeing. Yeah. Right? Yeah. So now, when you get to the carina, I think you are. And then, you turn it toward the lateral wall. We gonna scan for the...? 11L. 4L. 4L. Right there. Yeah, uh-huh. So, this is the carina, right? So 4L is in the lateral wall, like kind of around nine o'clock, eight- to 10-o'clock position. So, what vessel are you seeing? We're supposed to have aorta. Okay. Above it, and then PA below. Okay. That one looks like aorta to us. Yeah, because it's huge. It's huge, and its wall is very thick. So then, you find the PA. This is a very little 4L, but I do want to see the triangle for the 4L. Okay then hold on, let me change up my scope. Uh-huh. Uh-huh. Yeah, I would thumb down right here, because yeah. Go down a little bit. Another way of scanning the 4L is you go down to the left main, and then you sweep up. Okay. You don't need to scan it for 4L and then you sweep up. And you're gonna still see in the pulmonary artery. And then if you sweep more, you're gonna still see in the aorta, and between that is the 4L. Okay. Now, show me that triangle. Okay, let me do that again. If you push it too much, then you're gonna have air, and then it won't be good. So, go all the way to the left main. Okay, good. Forward. Forward a little bit. Okay. Go up? Yes, now thumb down. You're... Okay, good. I think that's the PA. You see? Yeah. So, turn toward a little bit. So this is the 4L. Yeah. So, this is the PA, this is the aorta, this is a 4L. Yeah. So, we can take a picture. Yeah, thank you. Right there? Uh-huh. Yeah. You see that little thing? Yeah, it's very small. 1-2 millimeters. It's like this little guy? No. So, this is the cartilages. What is that? This is airway cartilage. Oh. So, this one. Do you see it's not only one? You got like, kind of one here, one here, one there? Okay. Is that a good place to start? Yeah. Yeah. And... No, no, no. Just that little..? That's it, yeah. Okay. It's so tiny. It takes practice to understand. Yeah. Get those other 4L. So then, you can keep scanning all the way up and then find 2L. Yeah. Then, we have the... Aorta. And past that is the, yeah. 4L. Above is the 2L. Yeah, 2L. You're right. Sometimes you can't find it. Do you see it, Alex? you see it all the time. So, those are cartilages. Yeah, there will be there. Cartilage. Cartilage. Yes. Okay. One, two. Do you see, those are like... Yeah, so those are not lymph node. You won't see it in 11, because they're very deep, and probably not prominent anymore. But in the trachea, you will see that. It's okay. If you don't see it, then that's fine. I think you're pretty too far high up, right? Yeah. So now, the next one you're gonna scan is? 11L. 11. 10L and 11L. But that's how you have to scan it. Can we pick up the... Yeah. Balloon up. Okay. Can we pick up the air? No. Oh, he doens't have any. So, what I have been seeing there, you go a little bit too deep, but you try to push it down. You're gonna be injuring the carina. Yeah. So, I would thumb down and push it. You don't want to relying on the white light. Yeah. Now, you're in the left main. You should try to focus relying on this view. Okay, that is good. I will push it down, but you can't go farther anymore. There is no other way it's gonna go to left lower lobe, right. I have it make to the... You're in the left main. Yeah. Yeah. I would just push it down. I would not focus on the view. Because what you are doing, you are doing thumb up. So, you are kind of rubbing the wall. That is good. I would relax your thumb and push it down. Yes. Push it down, that you can't go farther anymore. Yeah. Go, go, go, go. More, more, more. So now, this is the upper lobe. Now you're in 11. 11L. 11L. Yeah. Okay, we are gonna sample 11L. Yeah. 11L. That looks big also. 11L, seven, and what else? And then kind of, we need to look for 10L. Yeah. No, I'm thinking which one is... The big one, 11R. RS, would be... 11L, 7, and 11R. Yes. Okay, we are gonna start with 11L then. We're gonna start here? Mhmm. Okay. Start with 11L? Uh-huh. Okay. Have you ever tried two-person technique? The jabbing technique? Two person. Two people? Two people. Yeah, we did two people or by ourselves. Okay, so now, where are you now? Let me get my scope again. Okay, your glove on. I think because 11L is a little bit bigger. So, I will let you try one too. 11L. Show me again. Okay, good, that's good, okay. So, here. So I will start with two-people technique. So for the two people, one person bronchoscopy, you have to keep on the steady pressure. And then the needle usually gonna come out from the blue dot. Yeah. So, I am kind of introducing the needle. And I have to be careful I should not bend. If I bend it, then I have to use a new different needle. Yeah, I'll put my finger... And then after that, I'm gonna lock my needle. And then, this is the sheath. This is a sheath that gonna, yeah. To prevent that my needle tip gonna be accidentally injuring the scope. So, you wanna do the proper way, so can you come back and show me the white light? So then, if I push it down, do you see that? You see that kind of, yes, protective sheath came out. So, you might want to just see it. So, this like a good... Yeah, not long enough. Yeah. So I lock it, and then I won't move it again anymore. And you're still seeing that 11L. So now, this is the needle kind of girth. Let me give a good... Good. That's okay. Can you go down a little bit more deeper? That's perfect. So now, I'm gonna hold the scope, and then I'm kind of advancing my needle. And then, now... I lost the view, but it's okay. No, it's okay. It's good. I'm already in it. There you go. You see? There you go. Okay, good. So now, Paula, would you be able to do the slow pull? So, this is a slow-pull method. Yes, you can do it. Okay, yep, you have your side? Slow pull? So this is a slow... Sorry, I'm in your face. That's okay. This is the slow pull method. What it does is it apply the steady negative pressure. And while I'm doing the needle passage. When I do the needle passage, it just kind of slow, backward all the way to the end of the node. Fast forward. Slow fast, what? Fast forward. Uh-huh. Yes. You don't like pressure, you don't use pressure, negative pressure? I don't like to using the suction, because that can cause a bloody sample. So, I always try it without using the suction. Oh, okay. And then, when I want to come out, I pull all the way back really quick. And this is 11L, right? This is 11L, correct. Just making sure. Now, they are processing the sample. So, how we are processing is, here, Paula is doing, the needle is out. Can you grab the syringe? Okay. Mhmm. This is a saline, and then they try to flush it. Now, when it's clear, it's stop, and they put the stylus back. So now, I want you to try one person. Okay, so now, I am showing a one-person technique. So, I will be assisting, and Dr. Wallace, Dr. Thomas? Yes. Dr. Thomas gonna do the whole procedure by himself. They said there was a little bit. Yeah. Okay, I'll try it. He lock it? The sheath is already set, and then you want a guide or you don't want it? I'll take that. Okay. So now, this is not a good view. I would come back more. That's good. Pull back a little bit more. You go when your needle is up, then it's gonna be, good. I think that's good. That's perfect. Yeah. So, you're already in it. That's good. I know I'm like, this is kind of awkward. I know, we do the... We do it while you take it out. One sec. Yeah. I see. Be careful. Okay? Yeah. I don't wanna like knock everything off though. Like, there's like so much that can go. I think we might have to use suction. Hey Ian, is everything okay? Jen, done with the procedure? Yes. Good. You wanna come up? Come up. I think I'll use the suction next time. Still 11L? 11L. I will tell you if I move the station. You can do flow for lymphoma also, right? Yeah. So, for the flow cytometry, what I do is I do the combined mediastinum flow. So, I try to get the one passage from every lymph node. Why do you slowly take the stylus out while you... So, this is called capillary pressure. So, I'm applying steady negative pressure so that the sample gonna come out. That happened less bloody. If you pull it out, then a lot of people have a lot of different technique. I've seen it over the... No, I think it... What we have so far. Oh no, I will use suction then. Right now, our sample is not very good, so we gonna try suction this time. Good. Okay. So, this is kind of cleaning the channel. Yeah. And then... Yeah. One second. Wait for me. Can I put pressure now? One sec, I'm pulling the suction. Okay, good. And then, when you apply the negative suction, I have to keep an eye on the syringes, because if there is a blood come out, then we have to stop immediately. Okay. Okay. Mhmm. Mhmm. Okay, good. And let me do one pass, okay? Yeah, yeah. Is it good? Yeah, it all looks good. It's nice. You're good. Thank you. You will be better. Okay, okay, okay. I try not to bend the needle. The needle. So, did you see the sheath is a bit too long? It can come out. Yeah. It can come out. So then, you can adjust the sheath. I like this. Okay. So, I want you to pull, and you do very slow pull. Slow. So when I'm doing it, yeah. Oh. I manipulate my thumb a little bit. So you see now, I'm in the different part of the node. Yeah, yeah, yeah. Hey Alex. Yeah. You ready for the next pass? Is this good enough now? Is it a good one? Kind of. Huh? So, the last one is just a blood. We have a little bit. Okay. Let her do one more pass. That's good. So what I do. You wanna do, uh huh. That's perfect. Yeah. Still 11L? This is still 11L. You are still... I'm still not good. That's fine. Go there, and then you lock it. Good. And then, that's perfect. So, hey, you want to do all the way, girl, or you want to go... I'll do like three. No, do you see the one? Yeah. So, which is when however, you come in like 30, 35 degrees. So then, you can set your sheath around like one and a half. Okay. If you do three then you're gonna go all the way down here. Okay. Yeah. Good. Good. That's perfect. So now, you poke the needle slowly, which is anchor and poke it. Poke it really hard. Good. Now, you see you're in the node, but you can go a little bit deeper. Now you change your... Yeah. Weak angle. Okay, good. That's good. No, no. One second. Okay. Is that okay? Yeah. We gonna use the suction. So, you're gonna hold off for a minute. Okay. I apply the negative pressure, and then when I tell stop, then you stop, okay? Good. Come back more. Like fast forward, slow backward, fast forward, slow. Yeah. Good, good. It's really good. Keep doing. Are you looking at the blood, right? Yeah. That's good. You got a good control. That's very good. So, in the EBUS procedure, we have to see the needle all the time to avoid the injury. Higher. It's getting the motion. Oh, I haven't been counting. I'm at 10-ish. I always tell them 30. Okay, now you're done, right? Yeah. Before you come out. Yeah. Suction off, and then come out. Okay. You bring it down? Yeah. No, got it. The sample is not very good yet. Oh, that is a good sample. Can I suggest you something? Absolutely. If you put the needle down, then sometimes you can accidentally bend it. Oh, okay. So then, it's better to do it this way. That's okay. If the needle bended, then we can't use it anymore. Understood. No, I'm up for whatever tips and tricks. Yeah. It's good. So, we gonna still do one more pass. You wanna do it? You wanna do it? You do it. Keep doing it. You do it and then you do seven pass first. And then we gonna go back to... Okay. Maybe pull back a little bit more, because yeah, that's good. Thumb down. Yeah. Is that okay? That's good. Perfect. Yeah. Okay, good. Yeah. Do you see what is behind right? The heart? Uh-huh. I don't want to do have that much. One and a half. That's good. That's good. Yeah. Poke it. Did you? Yeah. You're in it. Good. That might be too, uh huh, good. So, you see this is the tip, right? Yeah. Okay, good. One second. Let us do this. If we don't remove the stylus, no matter how much you're doing... So wait. No suction? I'm using suction. Thank you. Yes. And now, you go higher. Can you go a little bit deeper? Oh, you didn't go... No. Come back more. Good. Move forward. Good. Come back more. Come. Good? We did already? 15. More? You could do a little bit more. Yeah. I don't want to pit again anymore. Higher. Ah, get my workout in. Yeah. This is already a theory today. I work out my thumbs more than anything else, as a pulmonologist, yes. Now, if you wanna to stop, you can stop. And now what you... No. Oh shoot. The suction. You see? That's what happened. You don't want that. It's okay to be slow and be patient. I like fast, but I don't rush for the new thing. So now, you go to seven. Suction, then pull out. Yes. So, come back. Come back. Now thumb up. Push it down. Thumb up and point it towards me. Push it down. Push it down. Yeah. Good, good. You gonna be... On the right? Yes, you will be. There's no other way. Go. Right there. That's a big boy. We are moving on to the seven. Here. All right, you don't want to bend the needle. Okay. So, that's why, be patient. I have to keep ask about patience, I didn't know you... Now, here. So this is like two, right? Yeah. So you can set it up to three. Good. That's perfect. Thumb down. You are in the... You have to push it down a little bit. Good. Now, good. Okay, good? Uh-huh. Okay, good. Perfect. Okay. Now wait for us. Wait for us. Okay, now I do very slow pull, okay? Okay. You know how to do slow pull? Yeah. Very slow pull. Slow pull. Good. Good. That is really fast. It's really fast. I show you how to do slow. I'll show you a slow pull. Everyone makes fun of me 'cause I pull it so slowly. But, I'm just saying we get the best samples. Oh, okay. Yeah. You are slow. Yeah, I'll show you the slowest pull. No, I do not like suction that much. Now you see, if you look at the RPMI, look at how bloody it is. If you're bloody then some pathologist... Yeah. I'll be honest guys, I forgot to count again. It's okay. Although we're probably around 15. The 30. You're good. You just need to be patient. I'm impatient? You rush. In what sense? In the EBUS, because I'm like, "Oh my God". Oh. Now you drift. Do you see that? Good. Good. Come back. Okay. Did you see that your hand drift? Because your EBUS image different from the beginning. Yeah. Yeah. Which means because you drifted. Yeah. And this is seven. Yeah, seven. You can give it back to... And then I show you how to do slow pull. And I want this one too. I got the slow pull here. Yeah, if you don't drift, and you have a better chance of getting that longer. You got a good sample? No, nothing? What do you need? It's a good sample? I don't know. It was hard to push the saline through so... Yeah, I saw that. I don't see anything. Oh no. So, this is one node. Another node. I want both of them. So, when you introduce the needle, you don't want to be too rushed. Do slowly. Like in a very, because you bend it. Okay. Yeah. No, it's okay. My job is to observe and tell you what I see, not what I do. So, I have a suggestion for you, Wallace. What you do is, I don't know who, well... Your needle is halfway out, but you don't have a view. But then, you're trying to manipulate it. What's gonna happen? You are gonna make the hole bigger, and that going to high chance of having the air in the mediastinum. Okay. This is the needle is all the way halfway out. You don't have a view right, but come up. Come up and try. Yeah. If your needle is halfway in there, you'll try to push it down, what happen is the hole gonna, needle entrance hole gonna be bigger, and the air can go in, and that can cause the air in the mediastinum. I thought, like, push a little bit so you could see. So, no. Go thumb down. And then find another bad one. That looks good. Good. Uh-huh. So now, I want you to anchor. Do you know how the anchor mean? Anchor mean you don't poke it right away. You kind of teeter with your wall of the airway. And then once you have a good contact, like poke it. Yeah. Yeah, I see what you mean. Then, you don't have to go through that problem again. So now, go slow. This is good. Now it's already anchored. Now poke it, poke it. Yeah. Now, you look. Yeah. Yeah. You see? Okay. Good. Now, I will show you slow pull, okay? No, I do that. Can you go longer path all the way down? Come back more. So, I coordinate with your speed. If you fast, I do a little bit faster. If you slow, I pull a little bit slower. Okay. So, like I know my stylus gonna be out after you do the 15, 20 pass. Okay. Thank you. Thank you. Now you also drift. You see? I did. Did you notice? Yeah. Yeah. Everybody drifts. So, you just have to undrift it. If you drift it, then you're kind of on the border of the node. Yeah, I... If that is your intention, that's fine. Yeah. Yeah. Oh, that's good. That's a good one. Wallace, you got a good sample. Here. I think what happened is you went too deep. I would come toward me. Keep thumb down. Pull up. Pull up more. I think so. I might be wrong. I don't know. But also good. If you wanna look into it, look into it again. That looks... Okay. Forward. Forward. Look at me. Yeah, slow. Be slow. That's where you are. Yeah. Then, pull back a little bit. Yeah. That should be good. So, uh-huh. Uh-huh. I do slow pull. Uh-huh. Mhmm. Okay. Can we sent this to RPMI? RPMI for this one? Yeah. Let me do one pass, okay? I want you to practice slow pull this time. Yes. That's why. Okay. Was it a good sample? No, we don't know? No. So, I show you what is the anchor mean, and then what is that thing mean? But they're a different way of doing it. I want this part, right? Because this one is kind of heterogeneous. So, I want this part. Can you hold it right here? So now, my needle came out. You see the image is going away like a curtain. Which means that, you see, my needle is not in the wall, but it's very poking the wall. Now I steady and I just poke it. And then now, after this, I don't move. So this is my node. So, my needle is bent a little bit. So, I have to adjust it later. I will adjust it. But do slow pull. Very slow pull. Okay? Now, do you see that my needle is moved a little bit? I see. I am intentionally kind of going back. What's the name of that thing? Trying to get different areas to get more samples. You move. You should have pulled a little bit slower. Okay, I'm not done yet. That is fast. Still fast. I'm in trouble. No, it's okay. It's okay. Do it until you finish? Yeah, that's why I... Yeah. Which one are we sending this for? No, sample first. Okay. So, I always keep an eye on what is come out. Sometimes, it's relying on them. Sometimes you cannot. You gave us a good one. I just wanted to show you how it is. We gonna do more in seven? Huh? Gonna do more in seven? Yeah, more in seven. Because I think seven is where the money is. Where the money is. Yeah. So needle bent to the anterior. Seven. Oh, it's really good. Yeah. Okay. So, one more and we'd be good. So, needle bent to the anterior. Needle bent. So then, when you aim it, you aim it to the little bit posterior. You got it? You know what I mean? Because when I do it, I do it a little bit posterior. So, I want do the heterogeneous view. Go back. This one, right? And then, but when I get this view, the needle go to anterior. So then, with here, you're gonna get it. Okay. Now go. With this view, you will get it to the area that you want. Oh, I see. Because needle bent to anterior. So, you have to kind of overshoot to posterior. Posterior. Yeah. Yeah. You got it, right? You understand, right? Yeah. Okay. And then, you show me. So here. You can move your body, and I don't want you to get the injury all the time. So we're just very anterior now. Go back to posterior. This way I want. So now, overshoot a little bit. So what you do, you move your body. Here. Yeah. Here, your arm. If you look at it, I don't want you to do like this all the time. You're gonna have a plantar fasciitis right here. Okay. So, your arm have to be like this. Better to move my body instead of... Move your body. Yeah. Okay. That look good. Okay, now go, and then I will show you. Your needle gonna be the right one. So this is the anchor. Go, go, go. Slowly, go, go. Now the image is going away. Go slowly. You're not anchoring yet. Go slowly. Yeah, I can see that. So now poke. Yeah, good. Now find your needle. Yeah. It's much better than before. Yes. Now slow poke. Thank you. This is a good area. RPMI? No, the same seven, because I really want to have a sample from here. I'm doing what you were doing. That's good. You see? When you come out, come out really fast. Yeah. Go to 11R. Seven? Going to 11R. 11R, right? That's what we want. Yeah, that was kind of weak. There we go. Kind of winced out on that one. You got it. It looks like you got something. Oh, it's good enough. Yeah. Is this 11? Can I do the first pass? Yeah, yeah. Yeah. So here, I am kind of... Kevin, is patient doing okay? What's that? Is she doing okay? Because you know, the... Her pressure. No, the LMA is kind of off... Oh really? Okay. Yeah, she's on a ACE inhibitor. She didn't take it this morning, but pressure is kind of off, but... I'm still getting an end tidal, so... Okay, good. But her LMA is really crooked. Can you hold it right here? Can you do slow pull? Very slow pull? Slowly? Mhmm. So this one is, I don't think we can use suction. I'm gonna just do it, okay? It's just on the pressure, and then I don't like her LMA position. So, I just want to be done really quick. Yeah. So, it's 10 minutes. It's good now. Okay, 10 minutes. Uh-huh. 10 more minutes. We move onto the 11R. Just take your time because I do that dental case. Oh, okay. Okay. By the way, we're doing airway precautions. So, you have to clean the room for like how many? They haven't moved it yet. Okay, now that's good. That's 11R. 11R. Yes. Okay. I'm still in. So sorry. Oh yeah. Yeah. So, what I did is I was doing between the node. Yeah. Oh, we got a big chunk on that one. I know. Can you slow pull? Yeah, yeah. You said it is a good chunk? Yeah. Can I see? Can I see? Oh, okay. So, we are good. I'm gonna send this to RPMI. Oh this is RPMI? Yes. All right, so would you sweep out here? Yes. And then I might do one more passing. Okay. But I'll send this to RPMI. So, did you see? 10R was big. You see, that's a clean, good sample. Yeah. I want this. That's why I tried to avoid using the suction. That also good. That one looked like a good one. Okay. Let me just do it this one. So, yeah, I don't know that you're looking at me or not. I don't poke it from very far, but I poke it. Yeah. But I need that anchoring. So, what is does, if you don't anchor, what's gonna happen is then you are gonna slide down and all the way to the deep, yeah. Because sometimes, I hit the cartilage, and it's not gonna go anywhere. Yeah. So, if you use suction, then it's gonna be bleeding. So then, you don't get that kind of good sample anymore, and then you... The anchoring, you can feel it, but... Yeah. So then, I think towards... Where is my needle? Okay. Okay. So, my needle is pretty messed up. But look at my hand. I don't do this, I don't do that. I change my body. Yeah. This is gonna be your hand all your life so you don't want it, okay? You don't wanna mess it up. So, I try to go for the whole path. This is the last one. Okay, 11R. Because you pull really good. That's why I also got a good sample. The one you pulled fast, I'm not gonna be good anymore. Okay. Remember last time, I had to ask you to... Okay, here. Balloon down, and clean it. We're done. So, if you look at that. I don't know here, can you check it from the bottom? You see? This 'cause we got a really good core. And it's not that bloody. Everything that you see in the sample, this is a good sample, and so you have to check. As a proceduralist, you also have to check if your sample is good or not. We're not surgeons, so we're getting very small pieces.

CHAPTER 5

So this case went pretty well, as I expected, and I did not encounter any unexpected complications such as bleeding. Or sometime, it can cause a kind of airway trauma, or sometime injury to the other area, which I did not encounter any of those. So, post-op care for this type procedure is very simple, because we dont go - we - our procedure is only around the central main airway, even though the risk for pneumothoraces there is very low. So, we don't necessarily need to monitor with the chest x-ray or anything like that. And there is no post-procedure restriction. So, once they wake up, and if they can swallow, they can start resuming the daily activities. We generally recommend not to drink alcohol product and not to drive within 24 hours. That's about it. There are different method of doing the endobronchial ultrasound, different procedure and different proceduralists, and there is a different preference. Some people like to do a two-person technique. Some people like to do it the kind of how the capillary negative pressure application, which I use it in the video, that I take the stylet out slowly. And I generally prefer that method, because that is causing the less bloody sample. So, that sample is cleaner. And then, I think we took a picture of that as well, so that it's gonna help pathologist to find out what it is. Some bronchoscopists like to use a negative pressure, which is kind of there is a 60-cc syringe which we can hook it up to apply the negative pressure, and then, with that negative pressure if you hook it up to the EBUS syringes, they're gonna apply the negative pressure, and they're gonna collect the sample as well with the blood. So, this is some of the proceduralists prefer that way. And again, there's are many other ways to do the EBUS procedure. There is a multiple lymph node in the thoracic cavity and majority of them can be accessible by the EBUS bronchoscope, but not all. So generally, they say 2R and 2L, and also the 4R and 4L, and also 10, 11R and L. You can also get to the 12R and L, and level seven. So, R is the lymph node on the right side of the mediastinum, we call it the R. The left side, that is L. But the seven is the only lymph node that does not have a right or left. Those are the lymph node that we can access with the EBUS scope. There is a level five and level six, which is the preaorta, and the perivascular. They can be accessible, but you have to go through the transvascular system. So, most of our bronchoscopists avoid to sample that level five and level six lymph node. There is a level eight and level nine can be accessed by the EUS, but not with endobronchial ultrasound. And generally, the lymph node demarcation between the right and left is a little bit different. So, for the 4R, the demarcation between 4L and 4R is the lateral wall of the trachea. 2R and 2L exactly the same thing, lateral wall of the trachea. So, if the lymph node is in front of the trachea, that is a R lymph node, it is not the L lymph node. But on the level one, which is above the chest wall, and the demarcation is between the midline, which we cannot access. In the ultrasound images, we can look at the architecture of the lymph node. It can be homogeneous, heterogeneous, and vascularity. Sometimes, there is a central fatty hylum. If you see the central fatty hylum, then there is a most likely gonna be the benign lymph node. And if there is a homogeneous, then it can be the benign lymph node. If there is a heterogeneous lymph node, then it is concerned for either cancer, or sometimes it's a necrosis can also cause the heterogeneous lymph node. And if the lymph node have a high vascularity, then it can be a sign for the high risk for malignancy. But none of those data very strongly suggest to support that. That's why we have to have a tissue sample. We cannot decide by just looking with the ultrasound image. There is a differentiation of the lymphadenopathy between the ultrasound procedure and CT scan. In the CT scan, we call it the enlarged lymph node if it is more than one centimeter, but in the EBUS there is a more than five millimeter, we call it an enlarged lymph node. So sometime, we see the lymph node in our endobronchial ultrasound, but in the CT scan there is not that much significant, because they usually don't use a contrast. And then the lymph node in the mediastinum can be confused with the blood vessel, and so mediastinal tissue. So, in the CT scan sometime it is not easy to differentiate. That's why endobronchial ultrasound is important, especially for the lung cancer staging. One of the tip that I wanna give out the bronchoscopy is that for the endobronchial ultrasound images, there is a white light and there is a ultrasound view. As a bronchoscopy, we need to memorize by looking at the ultrasound view and realizing where we are. Especially with the cancer staging, if you sample the wrong lymph node, you are telling the patient the wrong diagnosis. In the meantime, you're high risk of giving the seedling of the cancer cell to the non-involving lymph node. So, my tip is that try to memorize anatomy of the lymph node. Kind of, let's say, if seven have kind of esophagus besides the level seven, and then the 4R is between the triangle of the pulmonary artery and the aorta. So, by looking at those anatomy, and we should know where we are. If we don't know where we are after we do the biopsy, then I recommend it to find out where is your needle site is because after the bronchoscopy, after you clean out the bleeding, and you can see where is your lymph node site is, and you can justify, "Is this the right station that you sample or not?" Some of the lymph node can be very challenging. But then I don't stick with one method all the time. I have different method. Sometime, I go with a kind of very hard poke. Sometime, I go with a very slowly and adjusting my needle position all the time. Sometime, I ask for help, because if another person is holding your scope, there is a more stability, and then you have a higher chance of getting a better tissue. So, I don't stick with one method. If I try with one method, if I don't get it or if I don't get a good tissue, then I might try different method. And we should always check our sample quality, because patients go through the whole procedure. But we're getting very small core - sometimes we don't even call it the core biopsy. We got a very small tissue. And for us, pathologists, the non-diagnosis and patient have to go through the procedure again. So, we always have to check what our sample quality is. Even though you did three passages, there is nothing in your sample, or there is not enough, then try to do more. Bleeding is real. Sometimes it can bleed. If there is a bleeding happen, the best thing that I suggest is you press down your thumb with the EBUS scope, because at the tip of the EBUS scope is kind of rounded, and then you can balloon up. And by using that balloon up, you can use a tourniquet technique by putting the constant pressure. And I found with this is the most effective method of controlling the bleeding from the EBUS. Most common complication that I have seen from my procedure, I've never experienced air in the mediastinum. I hope I keep it that way. I've never experienced pneumothorax, but I saw a few pneumonia after my procedure. And then, I've seen quite a lot of bleeding. But, all of my bleeding are controlled with that technique, majority of them. And then that's, another technique that I use is I can give the ice saline, epi, go through the needle site that I give.