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122

cranial

caudal

Left

2 Actual Identication ofBronchial Branch

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B9b

truncus

ventral

B8+B

basalis

B9b

mediallateral

B8+B

dorsal

bii

B9bi

B9b

B9bii

B9bi

bia

B9bii

biayy

bib

biay

biayx

biax

bii

B9bii

B9biax

B9biay

B9biayy

biayx

B9biayx

Fig. 2.188 CT, bronchial branch diagram and bronchoscopic ndings

B9a

(medial)

B9bia

(lateral)

B9bib

bib

bia

B9biay

biax

B9biay

2 Actual Identication ofBronchial Branch

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123

Fig. 2.189 Fluoroscopy (1)

Fig. 2.190 EBUS

Fig. 2.191 Fluoroscopy (2)

124

cranial

caudal

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Left B10b

2 Actual Identication ofBronchial Branch

ventral

B9+B

truncus basalis

9+10

B9+B

lateral

B10b+B10c

dorsal

b+B10c

medial

B9+B

B10a

B10b

B10c

B10b+B10c

B10b

B10bii

B10biib

biia

B10biiay

biiax

B10biiax

Fig. 2.192 CT, bronchial branch diagram and bronchoscopic ndings

B10bii b

bii ax

B10b

B10bii

biib

biia

2 Actual Identication ofBronchial Branch

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Fig. 2.193 EBUS

125

Fig. 2.194 Fluoroscopy

References

1. Yamashita H.Roentgenologic anatomy of the lung. Tokyo: IgakuShoin, Ltd.; 1978.

2. Arai T, Shiozawa M. Pulmonary resections: anatomy and surgical technique. Tokyo: Asakura Publishing; 1983. (in Japanese)

EBUS-GS forPeripheral Pulmonary

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Lesions

Queries raised regarding bronchoscopy to bronchoscopists dealing with respiratory diseases remain partially elucidated. With the rapid development of several new technologies, bronchoscopy has become easy for patients, taking less time and offering a high diagnostic yield to treat bronchial and pulmonary lesions precisely.

Considering the ideal bronchoscopic procedure, I started endobronchial ultrasonography (EBUS) in 1994. The procedure involved inserting a small ultrasonic probe that reached the peripheral pulmonary lesion through the bronchial lumen and visualizing the peripheral pulmonary lesion by EBUS.Initially, performing a biopsy at the same position visualized by EBUS was challenging because we pulled the ultrasonic probe out from the lesion. Since 1996, I started using the ultrasonic probe covered with a guide sheath. After conrming that the lesion has been reached by EBUS, the probe is removed from the GS, which, in turn, is left in situ. Then, the brush or biopsy forceps are inserted into the GS, enabling biopsy at the same position (Fig. Currently, the GS has two types of outer diameters—2.5 and

2.0mm—and reaches up to just below the pleura. When an ultrasonic probe inserted into the bronchus reaches the lesion, the ultrasonic waves from the transducer of the ultrasonic probe enter and reect the lesion, thereby clearly depicting the lesion.

The performance of individuals in daily life, including sports, comprises an outstanding procedure in either area. Even in medical care, surgery is a representative procedure that involves “using the body” with excellent techniques, similar to endoscopic procedures. Each facility has numerous tips for performing a bronchoscopic procedure, which should be shared among facilities. In addition, the fundamental basis for outstanding procedures should be accepted extensively, and not remain limited to each facility. In our opinion, professional bronchoscopists should follow “a ow and tricks of basic techniques.” Perhaps, the outstanding technique is a compilation of small particularities that are, otherwise, insignicant individually. Performing each particularity sequentially might not exhibit a noticeable change,

3.1).

but, I believe, their accumulation will result in enormous differences.

“Establishing and acquiring outstanding procedures” and “seeking higher-level procedures every day” are proverbs that can be considered a “master” to raise the spirit and pursue a way of living.

This book focuses on the identication of the bronchus leading to the peripheral pulmonary lesion. I will elucidate “EBUS-GS procedure using bronchial branch diagram by the reading CT anatomy in 2015.”

3.1 Pharyngeal/Laryngeal Anesthesia

Smooth execution of bronchoscopic examination depends on the condition of pharyngeal/laryngeal anesthesia. At present, a small-diameter bronchoscope is commonly used with an external diameter of about 4mm; bronchoscopy through the nasal cavity can also be performed by spreading the local anesthetic agent around the vocal cord and administering the sedative such as midazolam. However, when the bronchoscope cannot be inserted through the narrow nasal cavity and the convex-type ultrasonic bronchoscope used has an approximately 7-mm outer diameter, the bronchoscope should be inserted through the oral cavity. Performing pharyngeal/laryngeal anesthesia properly could help patients and bronchoscopists alike.

Furthermore, I would like to discuss performing pharynx/ laryngeal anesthesia as learned from our seniors. Equipment involves a mirror of the forehead (some are integrated with light) to reect light for the pharynx/larynx, a reection mirror for observation, anti-fogging of the reection mirror, and the Jackson-type sprayer. The procedure is as follows:

A patient is made to sit on the posterior of the chair. The patient sits upright as the lower jaw is lifted marginally,

while the upper part of the body bends forward. The patient grips the tip of the tongue using the gauze in his

right hand and pulls down the tongue.

127

128

ABC

sheath

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3 EBUS-GS forPeripheral Pulmonary Lesions

tumor

guide

Fig. 3.1 EBUS-GS. (a), to visualize the lesion by the ultrasonic probe

covered with a guide sheath (probe/GS). (b), to conrm that the probe/ GS has reached the lesion, remove the ultrasonic probe, and leave the guide sheath in the lesion. (c), insert biopsy forceps and a brush into the

A doctor sitting in front of the patient sprays 4% xylocaine

several times at the entrance of the pharynx with a Jackson- type sprayer while synchronizing the inspiration of breathing.

Then, grasp and insert the reecting mirror by the left hand.

Reect light at the reecting mirror pushing the uvula by the left hand and observe the pharyngeal entrance

(Fig.3.2). Grasp and insert the Jackson-type sprayer by the right hand. While visualizing the pharynx/larynx with the reection mirror,

spray 4% xylocaine from the front of the pharynx to the lar-

ynx with synchronizing the inspiration of breathing slowly. Typically, the spray is performed during one inspiration.

Continue this procedure in accordance with four inspi-

rations and repeat this operation after a rest for about

20–30s. After spraying 1–2mL of 4% xylocaine, hook the Jackson-

type sprayer at the dorsal wall of the epiglottis by the right

hand and pull the epiglottis toward the side of the doctor.

After that, spray the vocal cord directly from the tip of the

Jackson-type sprayer (Figs.3.2 and 3.3). Finally, spray 4–5mL of 4% xylocaine. When the vocal cord cannot be seen with a mirror because of

a narrow pharynx, or the patient exhibits strong reexes,

we ask the patient to say “Ah” to open the pharynx and

spray the pharynx/larynx. If anesthesia is inadequate,

consider inserting the bronchoscope through the nose.

transducer

guide sheath and collect the cells and tissue from the lesion. (F.Asano, T. Miyazawa: The Best Techniques for Performing Bronchoscopy, Chugai Igakusha, 2012)

sonic probe of UM-S20-17S (outer diameter, 1.7 mm; 20MHz; radial-type; Olympus), BF-P260F (outer diameter, 4.0mm; Olympus) with the working channel diameter of 2.0 mm, and a thin guide sheath kit (K-201, K-202; Olympus) is used; however, for collecting large tissue, we use UM-S20- 20R (outer diameter, 2.0 mm; 20 MHz; radial-type; Olympus), a bronchoscope with the working channel diameter of 2.8mm, and a thick guide sheath kit (K-203, K-204; Olympus).

First, insert brush/biopsy forceps with the stopper into the guide sheath and adjust the position so that the cups of the biopsy forceps and the brush appear precisely at the end of the sheath when stopped by the stopper; this enables brushing and performing a biopsy at just out of the guide sheath. Then, push out the tip of the biopsy forceps markedly from the guide sheath, pull back the opened cups of the forceps toward the end of the sheath, and x the position of the stopper on the biopsy forceps at this point. Of note, cups of the biopsy forceps can be opened where they come out of the end of the sheath.

Next, insert the ultrasonic probe into the guide sheath so that the entire transducer at the tip of the probe exits just out the tip of the guide sheath. As the biopsy forceps can open and close, they can biopsy the tissue 4mm away from the tip of the guide sheath. Thus, the position of the transducer that provides the EBUS image should be located 4 mm away from the tip of the guide sheath (Fig.3.4).

Performing measurements during the preparation is time- consuming. Considering that the distance from the

3.2 Preparing theGuide Sheath

tip of the guide sheath to the metal as the marker of the guide sheath is 2.5mm, we xed the probe 2.5mm away from the tip of the guide sheath to the proximal end of the

An ultrasonic processor (Olympus such as EU-ME 2, EU-ME 1, EU-M 2000, EU-M 30, or EU-M 30S) is necessary to perform EBUS-GS (Fig.3.5). Typically, the ultra-

transducer. Then, the center of the transducer can correspond to the site where the cups of the biopsy forceps open and close (4mm away from the tip of the guide sheath). By

Closing the mouth

Pushing the soft palate,

Opening the mouth

3.3 Setting oftheUltrasonic Processor

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129

Pulling down the tongue

soft palate

tongue

Tips of mirror and spray

④

Hooking the Jackson-type Sprayer at the epiglottis

epiglottis

vocal cord

Open the mouth

①

and pull down the tongue

Moving the tongue

②

ventrally,the space of pharynx is widened

②

③

the space is widened

The mirror image

⑤

of the epiglottis and larynx

Fig. 3.2 The procedure of pharyngeal and laryngeal anesthesia

wrapping the probe surface and the proximal end of the guide sheath along with a tape, the transducer position can be xed to the tip of the guide sheath. The guide sheath kit comprises the Ultrasound Stopper xing the probe with the guide sheath. Of note, considerable resistance exists when passing or pulling the probe on this stopper; hence, the probe should be xed with the end of the guide sheath using the tape.

3.3 Setting oftheUltrasonic Processor

There are several points in the setting of the ultrasonic processor (Fig.3.5).

Owing to normal and inverse images in the image direction

of the radial-type ultrasonic probe, keep it inverse. Initially, the radial-type ultrasonic probe was used in hepatobiliary diseases. In addition, it was imperative to compare the normal image scanned from the duodenum inserted from the cranial site with the CT images observed from the caudal side. Hence, the image observed from the tip of the probe to the proximal site is considered normal. Finally, performing EBUS under the bronchoscope, the EBUS image should be inversed.

Always observe and record with the same gain, same con-

trast, same image quality (1 or N: normal), and the same sensitivity time control (STC). At present. we are performing EBUS with gain 9/19 and contrast 4/8.

130

region

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Fig. 3.3 The location of the

tip of the Jackson-type sprayer. The operator hooks the dorsal wall of the epiglottis with the tip of the Jackson-type sprayer and pulls the epiglottis toward the operator. You can spray the vocal cords directly from the tip of the Jackson-type sprayer

3 EBUS-GS forPeripheral Pulmonary Lesions

vocal cord

the tip of the epiglottis

right

arytenoid

region

left

arytenoid

the edge of

the mirror

Fig. 3.4 Preparing the guide sheath (GS). Position the stopper where

the sheath of the brush and the cups of the biopsy forceps exit just out of the tip of the GS.Insert the ultrasonic probe through the GS so that the transducer of the probe exits out of the GS and secure the guide sheath and the probe with the tape. As the biopsy forceps will be opened and closed at the tissue 4mm away from the tip of the GS, the position of the center of the transducer should be located at 4mm away from the

tip of the guide sheath. It is challenging to measure when preparing the GS.As the distance from the tip to the metal of the GS to the end of GS is 2.5mm, keep the edge of the transducer 2.5mm away from the tip of the GS so that the center of the transducer positions at 4mm away from the tip of the guide sheath. (F.Asano, T.Miyazawa: The Best Techniques for Performing Bronchoscopy, Chugai Igakusha, 2012)

3.4 Insertion ofaBronchoscope

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Fig. 3.5 Setting of the

ultrasonic processor. Set the image direction of EBUS using the radial-type ultrasonic probe to be INVERSE.Always observe and record with the same gain, contrast, image quality (1 or N: normal), and sensitivity time control (STC). Before starting the examination, press the freeze release button on the keyboard and rotate the transducer of the probe once to check multiple circles around the probe on the EBUS screen

131

Press the freeze release button on the keyboard before start-

ing bronchoscopy and rotate the transducer of the probe once to check multiple circles around the probe on the screen.

3.4 Insertion ofaBronchoscope

While inserting a 4-mm bronchoscope, when no disease is present in the nasal cavity, try inserting it through the nasal cavity rst. A right-handed bronchoscopist would select the right nasal cavity because the right-hand gripping of the bronchoscope is easy to x with the right cheek of patients, and the scope could be advanced straight to the glottis (when inserting the scope from the left nasal cavity, the glottis could be reached through the marginally curved route). If the right nasal cavity is narrow and difcult to insert, the left nose or oral cavity should be selected. In the nasal cavity, the scope advances to the ventral space of the inferior nasal turbinate or between the middle nasal turbinate and the inferior turbinate. When reaching in front of the vocal cord, 1mL of 1% xylocaine should be sprayed one or two times to the vocal cords from the working channel of the bronchoscope.

Advancing into the trachea, 1 mL of 1% xylocaine is sprayed one to two times in the lower part of the trachea. At this point, observe from the healthy side of the bronchus. At the healthy right side, spray 1-mL of 1% xylocaine once each at the entrance of the right upper lobe bronchus, right middle lobe bronchus, and right lower lobe bronchus, and observe from the right main bronchus to each subsegmental bronchus. Similarly, on the left side, spray 1mL of 1% xylocaine once each at the entrance of the left superior segment bron-

chus, lingual segment bronchus, and left lower lobe bronchus, and then from the left main bronchus to each subsegment bronchus. Of note, xylocaine is used <400mg overall, combined ten times of 1% xylocaine (100 mg in total) in the bronchus with about 200mg of pharyngolaryngeal anesthesia. Focus on decreasing the amount of xylocaine considering the patients’ physique and age to avoid xylocaine overdose.

When observing the bronchial lumen by bronchoscopy, the following points should be considered: (1) do not create an unobserved blind spot in the bronchial lumen; (2) do not touch the bronchial wall; (3) take photos of the spur of the bronchus at the edge of the screen (Fig.3.6); (4) move the tip of the bronchoscope at a uniform speed with no waste. To attain (1) and (2), controlling is imperative so that the tip of the bronchoscope moves at the center of the bronchial lumen. To attain (4), the skillful procedure of seniors should be analyzed. The time to observe the left and right bronchi taken by most doctors at our hospital was approximately 6min.

After observing the bronchial lumen, the steps that should be performed when advancing the bronchoscope to the bronchi leading to the peripheral lesion are as follows: (1) advancing the bronchoscope through the center of the bronchial lumen until it approaches the spur of the bronchial branch; (2) pushing the bronchial wall on the opposite side of the spur and pass through the bifurcation subsequently (spurs are obstacle to pass through the bifurcation; Fig. 3.7); (3) wait at the site that is difcult to advance, changing the angle of the tip of the bronchoscope marginally. Finally, the tip of the bronchoscope sometimes passes the bifurcation.

When reaching the site that does not go further, 1mL of physiological saline is recurrently administered from the

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3 EBUS-GS forPeripheral Pulmonary Lesions

Fig. 3.6 Points to be noticed in the bronchial lumen observation. Take

pictures that have the spur at the edge of the screen

Fig. 3.8 The saline injection

method. Where the bronchoscope ts the bronchus snugly, repeat the ush of 1mL of physiological saline from the working channel into the bronchial lumen. By injecting 5–10mL overall and lling the inside of the bronchi, the sputum is moved, and the lumen becomes visible clearly

Fig. 3.7 Points for advancing the bronchoscope. While pushing the

opposite site of the spur of the bronchial bifurcation, we could pass through the spur (→)

working channel to a total of approximately 5–10mL and lling the inside of the bronchus, sputum is moved, and the bronchial lumen is visible (Fig.3.8). In this scenario, insert the ultrasonic probe from the working channel into the bronchus. The physiological saline administration is used in most cases when the peripheral pulmonary lesion is solid. When the ground-glass attenuation on CT images constitutes the primary part of the lesion, and the physiological saline administration produces hyperechoic points in the vicinity of the probe on the EBUS image, determining the position of the ground-glass nodule is challenging; thus, physiological saline is not injected for the ground-glass nodule.

3.5 Guiding theUltrasonic Probe/Guide

Sheath tothePeripheral Bronchus

In the peripheral bronchus distal from the sub-subsegmental bronchus, the guide sheath with the outer diameter of 2.5 or

2.0mm is in contact with the bronchial surface. Hardly any air exists between the guide sheath and the bronchial surface, and the balloon is not essential. Moreover, the guide sheath can be guided to just under the visceral pleura unless an obstruction occurs in the bronchus. Strong pushing when encountering resistance in the guidance to the lesion could

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