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3.6 Scanning by theProbe
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133
cause complications such as pleural perforation; thus, take
care when feeling resistance in your hands. Furthermore, the
ultrasound probe with the guide sheath is inserted into the
bronchus leading to the lesion, which is conrmed from the
chest X-ray plain image, CT images, and virtual bronchoscopic navigation.
3.6 Scanning by theProbe
An operator inserts the ultrasonic probe and the guide sheath
from the working channel of the bronchoscope to the periphery and stops it when senses any resistance. Do not push too
hard to puncture the visceral pleura. Try decreasing the time
to use X-ray uoroscopy as much as possible, and try using
the diaphragm of the uoroscopy. When the ultrasonic probe
is pushed to the periphery while scanning, the tip of the
probe exes and applies a load to the rotating probe, which
destroys the probe. Scanning when pulling back the probe
could decrease the burden on the probe and provide clear
EBUS images. Scanning the entire lesion from the distal site
to the proximal site of the lesion and observing the entire
lesion are essential. In particular, when the proximal bronchus is obstructed by the tumor and the peripheral lung has
obstructive pneumonia, a heterogeneous area (tumor) of the
internal echo on EBUS is determined as the lesion at the
proximal site of obstructive pneumonia; cells/tissues should
be collected from this heterogeneous area. Furthermore,
EBUS images are preserved to show the internal structures
of the lesion, including echo intensities, hyperechoic lines/
points, and blood vessels.
In recent years, we use the X-ray uoroscopic image
rotated 180°, the location on which coincides with the left
and right, the cranial and the caudal side of patients in the
supine position. In addition, bending the tip of the bronchoscope upward and downward, the movement of the tip of
the bronchoscope on uoroscopy correlates with that of the
thumb on the up/down-angle lever, making it easy for bronchoscopists to select the branch. In cases of the lesion hidden in the mediastinum or diaphragm, a ground-glass
shadow, a small lesion, or a lesion hidden by another
shadow that is challenging to establish the position by uoroscopy, EBUS effectively conrms the lesion location.
Before performing brushing cytology and biopsy, the probe
with the guide sheath is inserted to visualize the bronchus
involved in the lesion and from which bronchus tissue and
cells should be collected during the bronchoscopic
procedure.
Regarding terms signifying the positional correlation
between the probe and the lesion, “within” implies the state
the probe is surrounded circumferentially with the lesion
(the probe located in the lesion), and “adjacent to” implies
the state the probe is located just beside the lesion (the probe
is in contact with the lesion; Fig.3.9).
Previously, we reported the differential diagnosis of
benign or malignant and the differentiation degree of peripheral lung cancer using EBUS [
1] (see page 17–19). When the
internal echo of the peripheral pulmonary lesion is homogeneous, the lesion is classied as Type I; however, when the
internal echo of the peripheral pulmonary lesion is heterogeneous (heterogenous), the lesion is classied as Type III.In
the study, 92% of type I lesions were benign and 99% of
types II or III were malignant. Among type I, EBUS images
of pneumonia are categorized into type Ia when blood vessels are preserved in the lesion. When blood vessels are not
found in the typeIlesion, organized pneumonia is frequent,
and it is categorized as type Ib. Furthermore, type II image
without blood vessels is categorized into type IIa, which is
assumed to be the early stage of well-differentiated
adenocarcinoma.
Guidance to the peripheral bronchus using the bronchial
branch diagram (Fig.3.10).
Fig. 3.9 Terms of the
position between the
ultrasonic probe and the
lesion. The state where the
probe is surrounded in the
lesion (the probe is in the
lesion) is called as “within”
and the state where the probe
is just beside the lesion is
called as “adjacent to.” (a),
“within”. (b), “adjacent to”
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3 EBUS-GS forPeripheral Pulmonary Lesions
8
B
9
B
10
B
8
B
9
B
10
B
The truncus basalis branches
8
and B9+B10.
into B
The bronchoscope advances into B
without rotation.
8
B
9
branches into B9a and B9b.
B
9
aB9a
B
When entering into B
9
a
B
9
a
B
9
b
bronchoscopist rotates the
bronchoscope clockwise
about 30°.
When entering into B
assistant rotates the
bronchial branch diagram
counterclockwise
about 30°
B
B9b
9
B
b
9
b
B
10
B
8
B
9
B
a
9
B
b
10
B
8
B
9
a
B
9
b
B
10
B
9
9
a, the
9
a, the
9
ai
B
9
aii
B
8
B
9
B
b
10
B
9
ai
B
B
Fig. 3.10 Guidance to the peripheral bronchus using the bronchial branch diagram
Here, I describe our guiding method to the peripheral
bronchus using the bronchial branch diagram drawn by doctors currently.
3. The assistant holds the bronchial branch diagram drawn
on the paper beside the monitor of the bronchoscopic
image and highlights the bronchus resulting in the peripheral pulmonary lesion.
1. A bronchoscopist holding a bronchoscope stares at the
monitor of the bronchoscopic image.
2. An assistant stands beside the monitor of the bronchoscopic image while holding the bronchial branch diagram
drawn on the paper by the reading CT anatomy.
4. The bronchoscopist does not withdraw the bronchoscopist’s gaze from the monitor of the bronchoscopic image
and advance the tip of the bronchoscope to the pointed
bronchial branch.
9
aii
B9a branches into B
9
ai and B
9
3.6 Scanning by theProbe
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135
5. The bronchoscopist controls the bronchoscope while
bending the tip of the bronchoscope by the up/down- angle
lever of the bronchoscope and the bronchoscope rotation
itself. Here, the focus of the bronchoscopist should be to
avoid hitting the bronchial wall, making it as visible as
possible without rotating the bronchoscope. While the
bronchoscope is rotated substantially, the bronchial branch
diagram is rotated heavily, and the bronchoscopist also
tends to lose the location of the tip of the bronchoscope.
6. The bronchoscopist should focus on advancing by rotating the bronchoscope as less as possible but rotate the
bronchoscope to some extent to enter the bronchus for
proceeding. While looking at the monitor of the bronchoscopic image, the assistant rotates the bronchial branch
diagram in real-time based on the rotated bronchoscopic
image. Finally, the location of the tip of the bronchoscope
is not lost in the meanwhile.
7. Likewise, the assistant highlights the bronchial lumen
leading to the next-generation bronchus on the monitor of
the bronchoscopic image.
Repeat the steps mentioned above from 1 to 7; the tip of
the bronchoscope can advance to the peripheral bronchus
close to the lesion.
Virtual bronchoscopic navigation (VBN) guides the
peripheral bronchus while watching the virtual bronchoscopy. The advantages of the VBN are the accurate distance to
the next bronchial branch, the accurate direction of the
branch, and the accurate size of the branch. Conversely, the
disadvantage of the VBN includes the trouble that the assistant instructs the computer to rotate and advance the virtual
bronchoscopic image depending on the bronchoscopic
image. To avoid this trouble, we selected the guidance of
pointing by the assistant’s nger on the monitor of the bronchoscopic image while rotating the bronchial branch diagram on the paper.
Cases with blood vessels in the lesion are categorized as
typeIIb, most of whom are well-differentiated adenocarcinomas with less air content. In addition, type III is categorized
into type IIIa with hyperechoic lines–suspected lung cancer,
and type IIIb without hyperechoic lines–suspected poorly
differentiated adenocarcinoma. The major point of this classication is the internal echo (homogeneous or heterogeneous) and the patency of vessels in the lesion (Fig.3.11).
When the blood vessel in the lesion is evidently open, type Ia
or IIb is suspected. When the lesion internal echo is homogeneous, type I is suspected, and when the internal echo is heterogeneous, type III is suspected.
In recent years, several ground-glass nodules (GGN) have
been reported, and opportunities for biopsy by bronchoscopy
for GGNs have also witnessed an upsurge. GGNs are often
categorized as type IIa in the type classication of EBUS
described above, but the experience is essential to identify
the hyperechoic points in the lesion (Fig.
3.12). Before bron-
choscopy, if you invert the black/white of chest X-ray and
rotate 180°, we estimate whether we can observe the image
similarly on the uoroscopic image.
When the lesion cannot be found on uoroscopy, we
determine the location of the lesion where hyperechoic
points are unevenly distributed around the probe, pulling the
probe inside the guide sheath and pushing the probe out of
the guide sheath. In cases of ground-glass nodules, the pul-
Fig. 3.11 Key point of the type classication on EBUS images. The
EBUS image is classied as type Ia or type IIb when the vessel in the
lesion is clearly present. The EBUS image is classied as type I when
the internal echo is homogeneous. The EBUS image is classied as type
III when the internal echo heterogeneous. (a), blood vessels inside the
lesion are cleanly opened, the internal echo of the lesion is homogeneous, and it is classied as type Ia. (b), a blood vessel in the lesion is
not found, the internal echo is heterogeneous, and it is classied as type
IIIa
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Fig. 3.12 The EBUS image
of the pure ground-glass
nodule (GGN). A slightly
dense pure GGN has
hyperechoic points (←)
around the probe on the
EBUS image
3 EBUS-GS forPeripheral Pulmonary Lesions
monary artery accompanying the bronchus is not affected by
the lesion, suggesting that a biopsy of the pulmonary artery
could be performed during the transbronchial biopsy.
Recently, we tried avoiding a biopsy of the pulmonary artery
by the following method. Focus on the presence or absence
of a blood vessel in contact with the probe on the EBUS
image and move the tip of the bronchoscope using the upand down-angle lever. Next, operate the up/down-angle lever
to move the probe in a direction away from the pulmonary
vessel, followed by pulling out the probe and inserting the
biopsy forceps into the guide sheath and performing a biopsy
at pinpoint in the direction opposite to the vessel.
3.7 Solutions When theProbe Does Not
Enter WithintheLesion
Brushing cytology and biopsy are performed when the probe
is within the lesion (“within”) using EBUS-GS.If the probe
cannot be guided into the lesion, try guiding the probe into
the lesion using the following procedure:
3.7.1 Re-select theAppropriate Bronchus
UndertheBronchoscopic Image
Inserting the ultrasonic probe into the bronchus selected
under the reading CT anatomy, the probe is either far from
the lesion or adjacent to the lesion. In these conditions, you
can pull back the ultrasonic probe and GS (probe/GS), select
another bronchus under the bronchoscopic images, and
position the probe/GS within the lesion. For this procedure,
it is essential to determine branches to be inserted at the second and third attack on the reading CT anatomy and VBN
before the bronchoscopic examination. As the rst, second,
and third branches in the bronchial branch diagram by the
reading CT anatomy are close to each other, it is easy to
understand because these branches enter the same lesion.
The tip to guide another bronchus successfully is not to
pull out the ultrasonic probe at a burst but to pull it slowly
under the bronchoscopic images. The angle of the tip of the
bronchoscope should be adjusted as soon as the tip of the
ultrasonic probe is visible, and insert the ultrasonic probe in
the intended branch because when the ultrasonic probe is
entirely removed from the bronchoscope and, then, reinserted, the bronchial lumen is often difcult to observe
because of sputum.
3.7.2 Re-select theAppropriate Bronchus
UnderX-Ray Fluoroscopy (Fig.3.13)
The ultrasonic probe is guided to the vicinity of the lesion and
is not in the lesion rst. We bend the tip of the bronchoscope
using the up/down-angle lever of the bronchoscope under
X-ray uoroscopy and move the probe/GS toward the lesion.
While keeping the bent bronchoscope, pull the probe/GS
under X-ray uoroscopy. The tip of the probe/GS might move
to the lesion marginally if there is a bronchial bifurcation.
Upon determining the position of the bronchial bifurcation by
this movement (even if it is unknown), the probe/GS is
inserted with the up/down-angle lever of the bronchoscope
toward the lesion and the probe/GS might be reached within
the lesion.
3.7.3 Re-select theAppropriate Bronchus
UndertheEBUS (Fig.3.14)
The bronchoscope is advanced up to the vicinity of the
lesion, and the ultrasonic probe is in contact with the lesion
(“adjacent to”). After pulling back and pushing the ultrasonic
3.7 Solutions When theProbe Does Not Enter WithintheLesion
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AB C
137
Fig. 3.13 Re-select the appropriate bronchus under X-ray uoroscopy.
(a), EBUS cannot visualize the lesion. (b), under X-ray uoroscopy,
use the up/down-angle lever of the bronchoscope to direct the ultrasonic
probe toward the lesion. Using the up/down-angle lever of the broncho-
scope, the bronchoscopist keeps the ultrasonic probe facing the direction of the lesion, pull back the ultrasonic probe on the uoroscopic
screen. (c), re-insert the ultrasonic probe into the bronchus heading to
the lesion
ABCD
tumor
tumor
probe
probe
EBUS
Fig. 3.14 Re-select the appropriate bronchus under the EBUS. (a), the
bronchoscope is advanced up to the vicinity of the lesion and the ultrasonic probe is in contact with the lesion (“adjacent to”). (b), when
applying the up-angle lever of the bronchoscope, the ultrasonic probe
approaches the lesion. In addition, when applying the down-angle lever
of the bronchoscope, the ultrasonic probe moves away from the lesion.
tumor
EBUS
tumor
(c), in this case, the up-angle lever of the bronchoscope is maintained,
the ultrasonic probe is kept close to the lesion, and the probe/GS is
pulled back while looking at the ultrasonic image. (d), if there is a bronchial branch leading to the lesion on the way, the probe/GS might enter
the bronchus leading to the lesion while inserting the ultrasonic probe
again
tumor
probe
tumor
tumor
EBUS
probe and GS several times, the ultrasonic probe is still adjacent to the lesion.
To resolve this situation, let us move the probe/GS with
the up/down-angle lever of the bronchoscope on the ultrasound image. For instance, when applying the up-angle lever
of the bronchoscope and moving the tip of the bronchoscope,
the probe/GS approaches the lesion, but when applying the
down-angle lever of the bronchoscope and moving the probe/
GS, probe/GS moves far from the lesion. In this example, the
up-angle lever of the bronchoscope is maintained, the ultrasonic probe is kept close to the lesion, and the probe/GS is
pulled back while examining the ultrasonic image. If a
branch of the bronchi is heading to the lesion on the way, reinsert the probe/GS, which may enter the bronchus heading
to the lesion.
The movement of the ultrasonic probe with the up/downangle lever of the bronchoscope could move tangentially to
the margin of the lesion. Herein, we straighten the broncho-
scope itself (it is challenging to rotate the bronchoscope if
the bronchoscope was curved) and rotate the bronchoscope
and apply the up/down-angle lever of the bronchoscope to
alter the direction of the ultrasonic probe again. After the
bronchoscope rotation, if the ultrasonic probe approaches the
lesion by using the up/down-angle lever, the probe/GS is
pulled back and pushed while maintaining the angle, the
probe/GS might be inserted in the lesion.
3.7.4 Re-select theAppropriate Bronchus
Using theGuiding Device UnderX-Ray
Fluoroscopy (Fig.3.15)
In rare cases, the ultrasonic probe cannot be reached after
the procedures mentioned above. In this condition, leave
the guide sheath in situ with the extraction of the ultrasonic
probe, insert the guiding device into the guide sheath, and
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3 EBUS-GS forPeripheral Pulmonary Lesions
BA C
Fig. 3.15 Re-select the appropriate bronchus using the guiding device
under X-ray uoroscopy. (a), the ultrasonic probe cannot reach the
lesion. (b), after bending the tip of the inserted guiding device in the
direction of the lesion slightly on the uoroscopic screen, pull back the
guiding device slowly. While pulling back the guiding device, the tip of
the guiding device might enter the bronchial branch leading to the
lesion. When the tip of the guiding device enters the bronchial branch
locate the tip just out of the guide sheath. After bending the
tip of the guiding device in the direction of the lesion marginally, pull back the guiding device and GS slowly. The tip
here is to keep bending the guiding device marginally
(severe bending could damage the bronchus). While pulling
back the guiding device and GS, the tip of the guiding
device could enter the branch of the bronchi leading to the
lesion.
On the uoroscopic image, if the tip of the guiding device
enters the bronchial branch leading to the lesion, you might
notice that the tip of the guiding device moves marginally
toward the lesion. Now, push the bent guiding device toward
that branch slightly, push and straighten the guiding device,
and let it insert into the lesion. At that position, push the
guide sheath to be along the guiding device and place the
guide sheath inside the peripheral lesion. Subsequently, the
guiding device is removed, the ultrasonic probe is reinserted,
and the ultrasonic image shows whether the guide sheath is
inside the lesion or not.
The best point of this procedure is to rotate the C-arm or
turn patients so that the distance between the guiding
device and the lesion is the longest on the X-ray uoroscopic screen. In addition, ensure that the tip of the bending guiding device is facing the direction of the lesion, pull
back the guiding device gently, and hook the tip of the
guiding device into the bronchus that is not visible on the
uoroscopic image.
As the tip of the guiding device is thin, the guiding device
should be moved when feeling some resistance. Of note,
both pushing and pulling the guiding device forcibly could
cause bronchial injuries.
leading to the lesion, you might notice that the tip of the guiding device
moves slightly toward the lesion. (c), push the exed guiding device
into that branch slightly, push and straighten the guiding device, and
insert the guiding device into the lesion. At that position, the guide
sheath is pushed over the guiding device, and the guide sheath may be
placed inside the peripheral pulmonary lesion
3.7.5 Countermeasure Taken When
theBronchus Is Obstructed
attheMargin oftheLesion
When the ultrasonic probe is guided to the lesion margin, the
lesion is hard and the bronchus could be markedly obstructed
at the lesion margin. Where the ultrasonic probe is pushed at
the bronchial obstruction, EBUS visualizes just only the
proximal margin of the lesion. The bronchus is established to
be obstructed on the bronchial branch diagram or the navigation. Then, the probe is pulled out, and the guide sheath is
left. Next, the brush or the guiding device is inserted into the
bronchus. The brush or guiding device could enable making
a little hole at the obstructed bronchus. After removing the
brush or guiding device, the probe is reinserted through the
guide sheath, the probe enters inside the lesion, and a biopsy
is successfully performed when it becomes possible to visualize the EBUS image.
In some cases, the probe could not be pushed because the
tip of the ultrasonic probe is not at the margin of the lesion
and the probe reaches just under the visceral pleura. When
the probe has reached beneath the visceral pleura, there is a
risk of pleural perforation in this procedure; thus, the brush
or the guiding device should not be inserted.
3.7.6 Pinpoint Biopsy (Fig.3.16)
By scanning the bronchus with a radial-type ultrasonic
probe, we can observe the short-axis image of the peribronchial lesion.
biopsy forceps
tumor
tumor
3.8 Leave theGuide Sheath InSitu
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Fig. 3.16 Pinpoint biopsy.
(a), the ultrasonic probe is
adjacent to the lesion. (b), for
example, when you apply the
up-angle lever of the
bronchoscope, the ultrasonic
probe approaches the lesion.
However, when you apply the
down-angle lever, the
ultrasound probe moves away
from the lesion. (c), in this
situation, keep the up-angle
lever of the bronchoscope and
position the tip of the probe/
GS close to the lesion. It
becomes possible to perform
the pinpoint biopsy of the
lesion
probe
ABC
vessel
tumor
139
bio
When the ultrasonic probe is in contact with the lesion,
observe the direction in which the probe is in contact with
the lesion, the normal lung tissue, and vessels. Of note, vessels around the probe should not be biopsied. For instance,
when you apply the up-angle lever of the bronchoscope and
move the tip of the bronchoscope, the ultrasonic probe
approaches the lesion. Conversely, when you apply the
down-angle lever, the ultrasound probe moves away from the
lesion. In this condition, you should keep the up-angle lever
of the bronchoscope and position the tip of the ultrasonic
probe and guide sheath close to the lesion. Notably, these
procedures are described in Sect. 3.7.3. Re-select the appropriate bronchus under the EBUS described previously.
Subsequently, the ultrasonic probe is pulled back slightly
into the guide sheath and pushed out into the lesion while
maintaining the up-angle lever of the bronchoscope. When the
transducer of the ultrasonic probe is pulled back into the guide
sheath completely, the brightness of the EBUS image suddenly becomes dark. However, when the ultrasonic probe is
pushed out of the tip of the guide sheath, the EBUS image of
the lesion suddenly becomes bright. Assumedly, the ultrasonic
wave emitted from the transducer is completely weakened by
the guide sheath, and when the transducer comes out even
slightly from the guide sheath, the ultrasonic wave reaches the
lesion, and the EBUS image becomes bright. Thus, by adjusting the point where the EBUS image becomes bright just at the
proximal site of the lesion, performing a biopsy is feasible
with the biopsy forceps facing the bronchial wall beside the
lesion. This technique of biopsy is termed as “pinpoint biopsy”
because we perform the biopsy at the “pinpoint” area.
In addition, “pinpoint biopsy” can avoid the biopsy of the
pulmonary artery or vein (vessel). When the pulmonary vessel
is in contact with the probe, we try applying the up- and downangle lever of the bronchoscope and move the tip of the bronchoscope and the ultrasonic probe. Imagine the case that the
probe approaches the pulmonary vessel after applying the upangle lever, and the probe moves away from the pulmonary
vessel after applying the down-angle lever. In this case, when
the tip of the probe and the guide sheath are oriented away
from the pulmonary vessel after applying the down-angle
lever, the guide sheath is left facing the bronchial wall beside
the lesion and the pinpoint biopsy is performed. We expect this
“pinpoint biopsy” avoids the biopsy of the pulmonary vessel
and could decrease the risk of major bleeding by the biopsy.
3.8 Leave theGuide Sheath InSitu
We remove the ultrasonic probe and leave the guide sheath at
the proximal site from the center of the lesion. The proximal
site from the center of the lesion is selected because the
biopsy forceps close at the position approximately 4 mm
away from the tip of the guide sheath because of the structure
of the biopsy forceps, and the guide sheath moves to the
periphery with inspiration. When the tip of the guide sheath
goes through the lesion, it becomes impossible to collect the
cells and tissues for diagnosis.
Observe the attenuation by the reection of the guide
sheath on the EBUS image (Fig.3.17).
As mentioned in “pinpoint biopsy,” one of the ways to
place the guide sheath inside the peripheral pulmonary lesion
precisely is to check the attenuation by the reection of the
guide sheath on the EBUS image. After visualizing the
peripheral lesion with EBUS, the assistant slowly pulls back
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Fig. 3.17 Image attenuation
by the guide sheath. This
phenomenon is to place the
sheath inside the peripheral
pulmonary lesion accurately.
(a), visualize the peripheral
lesion with EBUS. (b),
thereafter, the assistant pulls
back the ultrasonic probe
2–3mm without moving the
position of the guide sheath,
and the transducer of the
ultrasonic probe goes into the
guide sheath. When the whole
of the transducer is covered
by the guide sheath, the
ultrasonic image suddenly
becomes dark. After
conrming this phenomenon,
it is possible to place the
guide sheath inside the
peripheral pulmonary lesion
accurately. (F.Asano,
T.Miyazawa: The Best
Techniques for Performing
Bronchoscopy, Chugai
Igakusha, 2012)
3 EBUS-GS forPeripheral Pulmonary Lesions
the ultrasonic probe about 5mm into the guide sheath without moving the position of the guide sheath, and the transducer of the ultrasonic probe enters the guide sheath. When
the complete transducer is covered by the guide sheath, the
ultrasonic waves emitted from the transducer are reected by
the guide sheath, and the brightness of the ultrasonic image
suddenly becomes dark. Following this procedure, the assistant pushes the ultrasonic probe into the bronchus in the
lesion. When the ultrasonic probe is pushed slightly and the
transducer comes out of the guide sheath even marginally,
the brightness of the ultrasonic image abruptly increases. By
conrming this phenomenon, it is possible to place the distal
end of the guide sheath at the intended place accurately.
3.9 Cells andTissue Collection
ThroughtheGuide Sheath
The tip of the guide sheath is placed on the proximal side of the
bronchus in the peripheral pulmonary lesion and a brush, or
biopsy forceps, is passed through the guide sheath. The brush
or the forceps is inserted into the guide sheath until where the
stopper on the brush or the biopsy forceps attaches at the proximal end of the sheath. The assistant xes the stopper and the
proximal edge of the guide sheath using the left hand. Then, the
assistant pushes the brush into the lesion while feeling resistance. Especially in cases of lesions close to the visceral pleura,
the focus should be on the length of the extruded brush to avoid
penetrating the visceral pleura with a brush. Remember the
length of the extruded brush with X-ray uoroscopic screen
and the feeling of the hand; move the brush to not push it
beyond the memorized length of the extended brush.
Subsequently, change to insert the biopsy forceps into the
guide sheath and place it up to the position where the stopper
of the forceps attaches to the proximal end of the guide
sheath. It is best to perform the biopsy just out of the tip of
the guide sheath, using the opened forceps without moving
the guide sheath. However, it is challenging to open the cups
without moving the guide sheath, and the tissue that can be
retrieved through the thin guide sheath constitutes small
specimens in many cases. Then, the bronchoscopist is jabbing the biopsy forceps about 2–3 mm, opening the cups
wide, and pushing cups toward the lesion.
The point for biopsy at the accurate position is to establish
the position of the rotating transducer on the X-ray uoroscopic screen when the probe scanning the lesion locates at
the proximal site a little away from the center of the lesion.
Remember the position on the uoroscopic screen. As the
guide sheath moves easily because of the respiratory movement and cough, try marking the location of the transducer
by sticking a tag on the uoroscopic screen.
Furthermore, the best way to collect as large biopsy tissue
as possible is (1) the bronchoscopist grasps the biopsy forceps adequately opened by cups through the guide sheath
and pushes the biopsy forceps toward the lesion; (2) the
assistant grips strongly and xes the exit part of the guide
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sheath and the stopper of the biopsy forceps together; (3) the
assistant slowly closes the cups of the biopsy forceps for
about 5s. You should feel the hardness of the lesion when
you close the cups of the biopsy forceps. In particular, when
you close the cups completely, you close more slowly.
3.10 Removing theGuide Sheath
Typically, after biopsy, leave the guide sheath at the biopsy site
for 2–3 min, then pull out the guide sheath, and check the
hemostasis. By waiting for 2–3min to hold the guide sheath at
the biopsy site, bleeding from the biopsy site would be stopped,
and after the guide sheath is pulled out, the blood will not come
out in the bronchus in most cases. In some cases, I have experienced that bleeding with setting the GS for about 1min 30s
could not stop. In rare cases, the guide sheath is left for about
4–5min because we suspect bleeding might come up in the
guide sheath after the biopsy. In cases we suspect the occurrence of more bleeding than usual after biopsy, we pull back
the guide sheath about half of the length exiting from the tip of
the bronchoscope after about 2-min waiting, and leave the
guide sheath about from 30s to 1min. Perhaps, coagulation of
the blood in the bronchus from the biopsy site to the tip of the
guide sheath would work for hemostasis advantageously.
3.11 Complications andCountermeasures
3.11.1 Bleeding
As the bleeding from the biopsy site comes into the guide
sheath, it rarely comes out into the respiratory tract. In
cases of severe bleeding, bleeding might come up to the
opening of the guide sheath, but by waiting for the guide
sheath to set at the biopsy site for about 4–5 min, most
bleeding stops, and then the guide sheath can be pulled out.
I experienced a case of intrapulmonary hemorrhage on
X-ray uoroscopy after the biopsy. However, after setting
the guide sheath at the biopsy site for about 10min, I pulled
out the guide sheath, and almost no bleeding returned in the
airway.
3.11.2 Pneumothorax
Using the guide sheath, it is less likely to experience pneumothorax after the bronchoscopic procedure. However, a
risk of pneumothorax occurs when a brush for brushing
cytology exceeds the position of the lesion. In addition, with
the guide sheath, the biopsy can be performed at the accurate
location of the lesion, but we should focus on the procedure
for the lesion beneath the visceral pleura.
3.11.3 The Bending oftheGuide Sheath
The guide sheath might bend at the point where the guide
sheath comes out from the tip of the bronchoscope. I
encountered this phenomenon mostly at the right upper lobe
bronchus; the cause is that the bending angle of the tip of the
bronchoscope changes after inserting the guide sheath into
the periphery, the angle between the guide sheath and the tip
of the bronchoscope does not coincide, and then the guide
sheath is bent. Once the guide sheath is bent, it is often challenging to attempt to pull back the guide sheath out of the
bronchoscope, and it is sometimes necessary to pull the
bronchoscope with the guide sheath together.
References
1. Kurimoto N, Murayama M, Yoshioka S, etal. Analysis of the internal
structure of peripheral pulmonary lesions using endobronchial ultrasonography. Chest. 2002;122:1887–94.
Comparison ofEndobronchial
https://t.me/medicina_free
Ultrasonography Images andResected
Specimens
4
The objectives of performing endobronchial ultrasonography (EBUS) with a guide sheath (EBUS-GS) to examine pulmonary peripheral lesions can be broadly divided into
“conrming the presence of a lesion” and “understanding its
internal properties.” Since sampling lesion tissue is essential
for pathological diagnosis, concerns have been raised that
EBUS tends to be used solely to conrm whether or not a
lesion is present.
The basic pattern of the vascular structure of the peripheral lungs consists of the “bronchovascular bundles,” in
which pulmonary arteries running parallel to the bronchi are
communicating with the central vascular system and the pulmonary veins are running between the bronchovascular bundles that appear to spread like a fan shape when they are
viewed two-dimensionally. In the process of lesion growth,
even small lesions may involve multiple bronchi if the mechanisms of brosis and cicatricial contraction come into
effect. If lesions grow expansively, however, even large
lesions may involve only a single bronchus.
Although the location from which tissue is sampled is an
important factor affecting diagnosis, when taking biopsies of
pulmonary peripheral lesions, the area to be sampled cannot
be freely chosen. This is because the area of the lesion
involved with the bronchus or bronchi itself determines which
tissue can be sampled. Depending on the size of the lesion,
one or two bronchi may be involved. When deciding on biopsy
location, the only factors we can take into account are the
choices of whether to take the sample in the proximal side or
distal side of the involved bronchus on the longitudinal axis
and, at best, of whether the angle of approach of the bronchoscope tip should be from above or below the bronchus and to
its right or left. Even in this restricted situation, however,
every effort must be taken to avoid damaging the accompanying pulmonary artery as a result of the biopsy. Clinical observations have practically conrmed that, in EBUS-GS, the
guide sheath itself exerts a tamponade effect at hemorrhage
sites; however, it is important not to cause arterial injury,
because airway hemorrhage is a serious complication.
EBUS-GS may provide an effective means of understanding the three-dimensional structure of lesions and
sampling tissue from the location most likely to provide the
most suitable tissue while avoiding blood vessels. In this
paper, case studies and our usual method of comparing
EBUS images with resected specimens are described. In
the latter part, cases are described as reference examples of
the courses of blood vessels that can be identied on EBUS
when choosing which peripheral bronchi to enter. This
assumes that EBUS images are saved as videos, as well as
still images. With the exception of high-resolution images,
we have found that it is possible to store approximately
4years’ worth of bronchoscopy (including EBUS images)
and uoroscopy videos on a 1 terabyte external hard drive.
Our method is as follows.
4.1 Ination-Fixation ofExcised
Specimens
4.1.1 Things toDo BeforeInation-Fixation
toEnable aProper Comparison
Photograph both the hilar side and the opposite side of the
excised specimen. If the bronchial stump is open, macrophotographs can be taken, and the branching morphology identied by bronchoscopy can be reconrmed. If it has been
stapled closed, the course of the staple line should also be
identied. If there is no pleural indentation or other clues to
the lesion location on the surface of the visceral pleura, generally identify its location by palpating the specimen in its
collapsed state, and make a photographic record to enable it
to be reidentied after ination from pleural patterns such as
the distribution of anthracosis (Fig.4.1).
© Springer Nature Singapore Pte Ltd. 2020
N. Kurimoto, K. Morita, Bronchial Branch Tracing, https://doi.org/10.1007/978-981-13-9905-3_4
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