K 203

Patient underwent flexible bronchoscopy (BF-1T260, Olympus, Japan) 5.8 mm in external diameter for complete inspection of airways before echo endoscopy. The EBUS (EU-M30 S, Olympus, Japan) was integrated with a 20 MHz radial probe (UM-S30-20 R, Olympus, Japan) 2.0 mm in external diameter and guide sheath kit (K-203, Olympus, Japan). For ROSE, the Diff-Quick staining method (American Scientific Products, McGaw Park, IL) was used and cytological evaluation was processed with microscope (DM500, Lycra, Germany)

All bronchoscopic procedures were performed under local anesthesia at the pharynx by nebulized lidocaine and conscious sedation by intravenous midazolam.^{8 (link)} During EBUS-GS TBB, we obtained ultrasound images of peripheral pulmonary lesions by a radial EBUS probe under fluoroscopic X-ray guidance. An EBUS probe was inserted through a guide sheath (K201 or K203; Olympus). When a suitable ultrasound image of the target lesion was obtained, we inserted a biopsy forceps followed by a cytological brush through the guide sheath. After performing biopsies and cytological brushing, 20 ml of saline was injected and retrieved as a bronchial washing. The biopsy forceps were rinsed in saline after each biopsy, and the rinsed saline was used for cytological examination. During each CTBB procedure, we inserted a biopsy forceps and cytological brush into a corresponding bronchus. The biopsies, forceps rinse, brushing cytology, and bronchial washing were performed in the same order as in EBUS-GS. For both periods (July 2009–March 2011, when CTBB had been performed; and April 2011–June 2012, when EBUS-GS-TBB had been performed), years of bronchoscopy experience of operator were equivalent (range: 7–15 years) in our institution.

Bronchoscopy was performed with a flexible bronchoscope of an EB-580T, EB-580S (Fujifilm, Tokyo, Japan), BF-1T290, BF1T-260, or BF-260 (Olympus, Tokyo, Japan). Patients underwent intravenous deep anaesthesia with pethidine, midazolam, or fentanyl, and 2% lidocaine was administered intratracheally. A flexible endotracheal tube (SACETT suction above cuff endotracheal tube 8.0–8.5 mm; Smiths Medical International Ltd., Minneapolis, MN, USA) was inserted for airway control. An endobronchial balloon (Fogarty® catheter, E-080-4F; Edwards Life-sciences, Irvine, CA, USA) was used for bronchial blockade and for haemostasis in all patients. If necessary, forceps (FB-15C-1, FB-231D; Olympus, Tokyo, Japan) and a guide sheath (K-201, K-203; Olympus, Tokyo, Japan) were used. A 1.4-mm 20-MHz radial probe (PB2020-M; Fujifilm or UM-S20-17S; Olympus) was also used in some patients for visualisation of lesions and blood vessels during determination of biopsy sites. All anticoagulant drugs were discontinued prior to the procedure as per guidelines [12 (link)].