Complications

While CP-EBUS and RP-EBUS are associated with the same procedural and sedation complications as exible bronchoscopy, they add a few specifc complications but remain an extremely safe procedure overall. In a systematic review of 20 publications including 14 original research studies, performing CP-EBUS-TBNA of regional lymph nodes was reported to only cause minor complications including cough, agitation, and puncture site bleeding without any serious complications [83]. Similarly, RP-EBUS does not directly contribute to any signifcant complications, but the coupling of TBBx of peripheral pulmonary lesions to the procedure as a whole increases the risk for complications. Serious complications of RP-EBUS-guided TBBx include bleeding (<1%) and pneumothorax (<4%) [16, 84, 85]. Overall, the use of EBUS is safe with low morbidity.

Summary

Since the introduction of EBUS, it has become one of the most versatile and powerful tools available to the bronchoscopist. The application of EBUS for sampling peripheral lung nodules, diagnosing diseases of the mediastinum, and its most widespread use in staging NSCLC has reshaped the feld by ultimately outperforming the previous technically diffcult and ineffective approaches. As the role of EBUS continues to grow, additional applications are likely to emerge and play an in uential role in pulmonology.

References

1.\DiMagno EP, Buxton JL, Regan PT, Hattery RR, Wilson DA, Suarez JR, et al. Ultrasonic endoscope. Lancet. 1980;1(8169):629–31.

2.\Hurter T, Hanrath P. Endobronchial sonography: feasibility and preliminary results. Thorax. 1992;47(7):565–7.

3.\Herth FJ, Ernst A, Becker HD. Endobronchial ultrasound-­guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions. Eur Respir J. 2002;20(4):972–4.

4.\Yang H, Zhang Y, Wang KP, Ma Y. Transbronchial needle aspiration: development history, current status and future perspective. J Thorac Dis. 2015;7(Suppl 4):S279–86.

5.\Vyas KS, Davenport DL, Ferraris VA, Saha SP. Mediastinoscopy: trends and practice patterns in the United States. South Med J. 2013;106(10):539–44.

6.\Yasufuku K, Chiyo M, Sekine Y, Chhajed PN, Shibuya K, Iizasa T, et al. Real-time endobronchial ultrasound-­guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest. 2004;126(1):122–8.

7.\Chao TY, Lie CH, Chung YH, Wang JL, Wang YH, Lin MC. Differentiating peripheral pulmonary lesions based on images of endobronchial ultrasonography. Chest. 2006;130(4):1191–7.

8.\Yasufuku K, T. F. Endobronchial ultrasound: indications, advantages, and complications. Waltham: UpToDate; 2012.

9.\Kurimoto N, Murayama M, Yoshioka S, Nishisaka T. Analysis of the internal structure of peripheral pulmonary lesions using endobronchial ultrasonography. Chest. 2002;122(6):1887–94.

10.\Kuo CH, Lin SM, Chen HC, Chou CL, Yu CT, Kuo HP. Diagnosis of peripheral lung cancer with three echoic features via endobronchial ultrasound. Chest. 2007;132(3):922–9.

11.\Zhang HF, Zeng XT, Xing F, Fan N, Liao MY. The diagnostic accuracy of CT-guided percutaneous core needle biopsy and fne needle aspiration in pulmonary lesions: a meta-analysis. Clin Radiol. 2016;71(1):1–10.

12.\Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155(3):137–44.

13.\Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):142S–65S.

14.\Paone G, Nicastri E, Lucantoni G, Dello Iacono R, Battistoni P, D’Angeli AL, et al. Endobronchial ultrasound-­driven biopsy in the diagnosis of peripheral lung lesions. Chest. 2005;128(5):3551–7.

15.\Kikuchi E, Yamazaki K, Sukoh N, Kikuchi J, Asahina H, Imura M, et al. Endobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions. Eur Respir J. 2004;24(4):533–7.

16.\Kurimoto N, Miyazawa T, Okimasa S, Maeda A, Oiwa H, Miyazu Y, et al. Endobronchial ultrasonography using a guide sheath increases the ability to diagnose peripheral pulmonary lesions endoscopically. Chest. 2004;126(3):959–65.

17.\Chao TY, Chien MT, Lie CH, Chung YH, Wang JL, Lin MC. Endobronchial ultrasonography-guided transbronchial needle aspiration increases the diagnostic yield of peripheral pulmonary lesions: a randomized trial. Chest. 2009;136(1):229–36.

18.\Yamada N, Yamazaki K, Kurimoto N, Asahina H, Kikuchi E, Shinagawa N, et al. Factors related to diagnostic yield of transbronchial biopsy using endobronchial ultrasonography with a guide sheath in small peripheral pulmonary lesions. Chest. 2007;132(2):603–8.

19.\Huang CT, Ho CC, Tsai YJ, Yu CJ, Yang PC. Factors in uencing visibility and diagnostic yield of transbronchial biopsy using endobronchial ultrasound in peripheral pulmonary lesions. Respirology. 2009;14(6):859–64.

20.\Tay JH, Irving L, Antippa P, Steinfort DP. Radial probe endobronchial ultrasound: factors in uencing visualization yield of peripheral pulmonary lesions. Respirology. 2013;18(1):185–90.

21.\Steinfort DP, Khor YH, Manser RL, Irving LB. Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-­ analysis. Eur Respir J. 2011;37(4):902–10.

22.\Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-­ analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. 2012;142(2):385–93.

23.\Asahina H, Yamazaki K, Onodera Y, Kikuchi E, Shinagawa N, Asano F, et al. Transbronchial biopsy using endobronchial ultrasonography with a guide sheath and virtual bronchoscopic navigation. Chest. 2005;128(3):1761–5.

24.\Ishida T, Asano F, Yamazaki K, Shinagawa N, Oizumi S, Moriya H, et al. Virtual bronchoscopic navigation combined with endobronchial ultrasound to diagnose small peripheral pulmonary lesions: a randomised trial. Thorax. 2011;66(12):1072–7.

25.\Eberhardt R, Anantham D, Ernst A, Feller-Kopman D, Herth F. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176(1):36–41.

26.\Harley DP, Krimsky WS, Sarkar S, Highfeld D, Aygun C, Gurses B. Fiducial marker placement using endobronchial ultrasound and navigational bronchoscopy for stereotactic radiosurgery: an alternative strategy. Ann Thorac Surg. 2010;89(2):368–73; discussion 73–4.

27.\Herth F, Ernst A, Schulz M, Becker H. Endobronchial ultrasound reliably differentiates between airway infltration and compression by tumor. Chest. 2003;123(2):458–62.

28.\Irani S, Hess T, Hofer M, Gaspert A, Bachmann LM, Russi EW, et al. Endobronchial ultrasonography for the quantitative assessment of bronchial mural structures in lung transplant recipients. Chest. 2006;129(2):349–55.

29.\Soja J, Grzanka P, Sladek K, Okon K, Cmiel A, Mikos M, et al. The use of endobronchial ultrasonography in assessment of bronchial wall remodeling in patients with asthma. Chest. 2009;136(3):797–804.

30.\Sarkiss M. Anesthesia for bronchoscopy and interventional pulmonology: from moderate sedation to jet ventilation. Curr Opin Pulm Med. 2011;17(4):274–8.

31.\Rusch VW, Asamura H, Watanabe H, Giroux DJ, Rami-Porta R, Goldstraw P, et al. The IASLC lung

cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classifcation for lung cancer. J Thorac Oncol. 2009;4(5):568–77.

32.\Fujiwara T, Yasufuku K, Nakajima T, Chiyo M, Yoshida S, Suzuki M, et al. The utility of sonographic features during endobronchial ultrasound-guided transbronchial needle aspiration for lymph node staging in patients with lung cancer: a standard endobronchial ultrasound image classifcation system. Chest. 2010;138(3):641–7.

33.\Herth F, Becker HD, Ernst A. Conventional vs

copy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial. JAMA. 2013;309(23):2457–64.

35.\Tremblay A, Stather DR, Maceachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest. 2009;136(2):340–6.

36.\Agarwal R, Srinivasan A, Aggarwal AN, Gupta D. Effcacy and safety of convex probe EBUS-TBNA in sarcoidosis: a systematic review and meta-analysis. Respir Med. 2012;106(6):883–92.

37.\Wahidi MM, Herth F, Yasufuku K, Shepherd RW, Yarmus L, Chawla M, et al. Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration: CHEST guideline and expert panel report. Chest. 2016;149(3):816–35.

38.\Madan K, Mohan A, Ayub II, Jain D, Hadda V, Khilnani GC, et al. Initial experience with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) from a tuberculosis endemic population. J Bronchol Interv Pulmonol. 2014;21(3):208–14.

in suspected tuberculosis: a minimally invasive technique with a high diagnostic yield. J Infect. 2009;58(4):309–11.

40.\Casal RF, Adachi R, Jimenez CA, Sarkiss M, Morice RC, Eapen GA. Diagnosis of invasive aspergillus tracheobronchitis facilitated by endobronchial ultrasound-­guided transbronchial needle aspiration: a case report. J Med Case Rep. 2009;3:9290.

41.\Steinfort DP, Irving LB. Endobronchial ultrasound staging of thyroid lesion in small cell lung carcinoma. Thorac Cardiovasc Surg. 2010;58(2):128–9.

42.\Casal RF, Phan MN, Keshava K, Garcia JM, Grosu H, Lazarus DR, et al. The use of endobronchial ultrasound-­guided transbronchial needle aspiration in the diagnosis of thyroid lesions. BMC Endocr Disord. 2014;14:88.

43.\Casal RF, Jimenez CA, Mehran RJ, Eapen GA, Ost D, Sarkiss M, et al. Infected mediastinal bronchogenic cyst successfully treated by endobronchial ultrasound-guided fne-needle aspiration. Ann Thorac Surg. 2010;90(4):52–3.

44.\Anantham D, Phua GC, Low SY, Koh MS. Role of endobronchial ultrasound in the diagnosis of bronchogenic cysts. Diagn Ther Endosc. 2011;2011:468237.

45.\Moonim MT, Breen R, Gill-Barman B, Santis G. Diagnosis and subclassifcation of thymoma by minimally invasive fne needle aspiration directed by endobronchial ultrasound: a review and discussion of four cases. Cytopathology. 2012;23(4):220–8.

46.\Yoshida Y, Singyoji M, Ashinuma H, Itakura M, Iizasa T, Tatsumi K. Successful diagnosis of a thymoma by endobronchial ultrasound-guided transbronchial needle aspiration: a report of two cases. Intern Med. 2015;54(21):2735–9.

47.\Sanz-Santos J, Cirauqui B, Sanchez E, Andreo F, Serra P, Monso E, et al. Endobronchial ultrasound-­ guided transbronchial needle aspiration in the diagnosis of intrathoracic lymph node metastases from extrathoracic malignancies. Clin Exp Metastasis. 2013;30(4):521–8.

48.\Navani N, Nankivell M, Woolhouse I, Harrison RN, Munavvar M, Oltmanns U, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrathoracic lymphadenopathy in patients with extrathoracic malignancy: a multicenter study. J Thorac Oncol. 2011;6(9):1505–9.

49.\Tournoy KG, Govaerts E, Malfait T, Dooms C. Endobronchial ultrasound-guided transbronchial needle biopsy for M1 staging of extrathoracic malignancies. Ann Oncol. 2011;22(1):127–31.

50.\Grosu HB, Iliesiu M, Caraway NP, Medeiros LJ, Lei X, Jimenez CA, et al. Endobronchial ultrasound-­ guided transbronchial needle aspiration for the diagnosis and subtyping of lymphoma. Ann Am Thorac Soc. 2015;12(9):1336–44.

51.\Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-­ Harris D,Alberts WM. Executive Summary: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5):7–37.

52.\Romano M, Libshitz HI. Hodgkin disease and non-­ Hodgkin lymphoma: plain chest radiographs and chest computed tomography of thoracic involvement in previously untreated patients. Radiol Med. 1998;95(1-2):49–53.

53.\Steinfort DP, Conron M, Tsui A, Pasricha SR, Renwick WE, Antippa P, et al. Endobronchial ultrasound-­guided transbronchial needle aspiration for the evaluation of suspected lymphoma. J Thorac Oncol. 2010;5(6):804–9.

54.\Kennedy MP, Jimenez CA, Bruzzi JF, Mhatre AD, Lei X, Giles FJ, et al. Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lymphoma. Thorax. 2008;63(4):360–5.

55.\Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65(2):87–108.

56.\Barta JA, Powell CA, Wisnivesky JP. Global epidemiology of lung cancer. Ann Glob Health. 2019;85(1):8.

57.\Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395–409.

58.\Horeweg N, Scholten ET, de Jong PA, van der Aalst CM, Weenink C, Lammers JW, et al. Detection of lung cancer through low-dose CT screening (NELSON): a prespecifed analysis of screening test performance and interval cancers. Lancet Oncol. 2014;15(12):1342–50.

59.\Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e211S–e50S.

60.\Goldstraw P, Chansky K, Crowley J, Rami-Porta R, Asamura H, Eberhardt WE, et al. The IASLC lung cancer staging project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classifcation for lung cancer. J Thorac Oncol. 2016;11(1):39–51.

61.\Memoli JS, El-Bayoumi E, Pastis NJ, Tanner NT, Gomez M, Huggins JT, et al. Using endobronchial ultrasound features to predict lymph node metastasis in patients with lung cancer. Chest. 2011;140(6):1550–6.

62.\Yasufuku K, Chiyo M, Koh E, Moriya Y, Iyoda A, Sekine Y, et al. Endobronchial ultrasound guided transbronchial needle aspiration for staging of lung cancer. Lung Cancer. 2005;50(3):347–54.

63.\Yasufuku K, Nakajima T, Motoori K, Sekine Y, Shibuya K, Hiroshima K, et al. Comparison of endobronchial ultrasound, positron emission tomography, and CT for lymph node staging of lung cancer. Chest.

chial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer. Chest. 2008;133(4):887–91.

65.\Hwangbo B, Kim SK, Lee HS, Lee HS, Kim MS, Lee JM, et al. Application of endobronchial ultrasound-­ guided transbronchial needle aspiration following integrated PET/CT in mediastinal staging of potentially operable non-small cell lung cancer. Chest. 2009;135(5):1280–7.

66.\Ernst A, Anantham D, Eberhardt R, Krasnik M, Herth FJ. Diagnosis of mediastinal adenopathy- real-­time endobronchial ultrasound guided needle aspiration versus mediastinoscopy. J Thorac Oncol. 2008;3(6):577–82.

67.\Annema JT, van Meerbeeck JP, Rintoul RC, Dooms C, Deschepper E, Dekkers OM, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245–52.

68.\Yasufuku K, PierreA, Darling G, de Perrot M, Waddell T, Johnston M, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393–400.

69.\Rintoul RC, Skwarski KM, Murchison JT, Wallace WA, Walker WS, Penman ID. Endobronchial and endoscopic ultrasound-guided real-time fne-needle aspiration for mediastinal staging. Eur Respir J. 2005;25(3):416–21.

70.\Vilmann P, Krasnik M, Larsen SS, Jacobsen GK, Clementsen P. Transesophageal endoscopic ultrasound-­guided fne-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy: a combined approach in the evaluation of mediastinal lesions. Endoscopy. 2005;37(9):833–9.

71.\Herth FJ, Krasnik M, Kahn N, Eberhardt R, Ernst A. Combined endoscopic-endobronchial ultrasound-­ guided fne-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest. 2010;138(4):790–4.

72.\Hwangbo B, Lee GK, Lee HS, Lim KY, Lee SH, Kim HY, et al. Transbronchial and transesophageal fne-­ needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;138(4):795–802.

73.\Daly ME, Singh N, Ismaila N, Antonoff MB, Arenberg DA, Bradley J, et al. Management of stage III non-­ small-­cell lung cancer: ASCO guideline. J Clin Oncol. 2021;40(12):1356–84.

74.\Koshy M, Fedewa SA, Malik R, Ferguson MK, Vigneswaran WT, Feldman L, et al. Improved survival associated with neoadjuvant chemoradiation in patients with clinical stage IIIA(N2) non-small-cell lung cancer. J Thorac Oncol. 2013;8(7):915–22.

75.\Eberhardt WE, Pöttgen C, Gauler TC, Friedel G, Veit S, Heinrich V, et al. Phase III study of surgery versus defnitive concurrent chemoradiotherapy boost in patients with resectable stage IIIA(N2) and selected IIIB non-small-cell lung cancer after induction chemotherapy and concurrent chemoradiotherapy (ESPATUE). J Clin Oncol. 2015;33(35):4194–201.

76.\Herth FJ, Annema JT, Eberhardt R, Yasufuku K, Ernst A, Krasnik M, et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol. 2008;26(20):3346–50.

77.\Lindeman NI, Cagle PT, Aisner DL, Arcila ME, Beasley MB, Bernicker EH, et al. Updated molecular testing guideline for the selection of lung cancer patients for treatment with targeted tyrosine kinase inhibitors: guideline from the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology. J Mol Diagn. 2018;20(2):129–59.

78.\Kalemkerian GP, Narula N, Kennedy EB. Molecular testing guideline for the selection of lung cancer patients for treatment with targeted tyrosine kinase inhibitors: American Society of Clinical Oncology Endorsement Summary of the College of American Pathologists/International Association for the Study of Lung Cancer/Association for Molecular Pathology clinical practice guideline update. J Oncol Pract. 2018;14(5):323–7.

79.\Martin-Deleon R, Teixido C, Lucena CM, Martinez D, Fontana A, Reyes R, et al. EBUS-TBNA cytological samples for comprehensive molecular testing in non-small cell lung cancer. Cancer. 2021;13(9):2084.

80.\Righi L, Franzi F, Montarolo F, Gatti G, Bongiovanni M, Sessa F, et al. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)- from morphology to molecular testing. J Thorac Dis. 2017;9(5):395–404.

81.\Casadio C, Guarize J, Donghi S, Di Tonno C, Fumagalli C, Vacirca D, et al. Molecular testing for targeted therapy in advanced non-small cell lung cancer: suitability of endobronchial ultrasound transbronchial needle aspiration. Am J Clin Pathol. 2015;144(4):629–34.

82.\Faber E, Grosu H, Sabir S, San Lucas FA, Barkoh BA, Bassett RL, et al. Adequacy of small biopsy and cytology specimens for comprehensive genomic profling of patients with non-small-cell lung cancer to determine eligibility for immune checkpoint inhibitor and targeted therapy. J Clin Pathol. 2021;75(9):612–9.

83.\Varela-Lema L, Fernández-Villar A, Ruano-Ravina A. Effectiveness and safety of endobronchial ultrasound-­transbronchial needle aspiration: a systematic review. Eur Respir J. 2009;33(5):1156–64.

84.\Hayama M, Izumo T, Matsumoto Y, Chavez C, Tsuchida T, Sasada S. Complications with endobronchial ultrasound with a guide sheath for the diagnosis of peripheral pulmonary lesions. Respiration. 2015;90(2):129–35.

85.\Chen A, Chenna P, Loiselle A, Massoni J, Mayse M, Misselhorn D. Radial probe endobronchial ultrasound for peripheral pulmonary lesions. A 5-year institutional experience. Ann Am Thorac Soc. 2014;11(4):578–82.