K 201

Two bronchoscopists (SB and TL) performed EBUS GS TBLB as previously described.^{[21 –23 (link)]} Firstly, a thin bronchoscope (outer diameter, 4.0–4.2 mm, BF-P260F or BF-P290, Olympus) was inserted as far into the bronchus nearest to the PLL as possible. Secondly, a radial EBUS probe (UM-S20–17S, Olympus) was inserted with GS (K-201, Olympus) through the working channel of bronchoscope; EBUS imaging confirmed that the probe reached the target lesion. Biopsy (TBLB) and brush were performed only when a lesion was confirmed by EBUS visualization (within or adjacent). Lastly, after the lesion was confirmed, the EBUS probe was removed leaving only the GS. Brush and biopsy forceps were introduced via the GS to obtain cytology and pathology samples. Following 1 brush, 2 biopsies were followed; this process was repeated ≥3 times until at least 4 biopsy specimens were obtained. After tissue acquisition, bronchoscopy was wedged for 2 to 5 minutes to confirm that there was no bleeding and the procedure was terminated. Most procedures were carried out with the help of fluoroscopy (69% [44/64] of VBN group and 73% [47/64] of NVBN group). All cases were performed with conscious sedation and under the guidance of anesthesiologists (SEP, IH, HK, and MA). A routine chest radiograph was done within 2 hours following the conclusion of the procedure.

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.

In EBUS-GS TBB, we used video bronchoscopes (BFp-260F, 4.0-mm outer diameter and BF1T-260, 5.9-mm outer diameter; Olympus, Tokyo, Japan) with an ultrasound scanner (EU-ME-1; Olympus) for the EBUS-GS biopsies. We used guide sheath kits with two sizes (K-201 and K-203 unit; Olympus). Each guide sheath kit consisted of a guide sheath, forceps, and a cytology brush. To detect the target lesion, we used radial endobronchial ultrasound probes (UM-S20-17S, 1.7-mm outer diameter and UM-S20-20R, 2.0-mm outer diameter; Olympus). In the CTBB group, we used several types of bronchoscopes for biopsy (BF260, BF6C260, BFp260F, and BF1T260; Olympus), disposable biopsy forceps (FB-231D; Olympus), and disposable cytology brushes (BC-202D-2010; Olympus).