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EBUS Treatment Details - Dr. Nishtha Singh

EBUS Treatment Details - Dr. Nishtha Singh

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EBUS Treatment Details - Dr. Nishtha Singh

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  1. Endo-bronchial ultrasound (EBUS) Bronchoscopy- from basics and beyond Dr Nishtha Singh Executive Director & Pulmonary Consultant Asthma Bhawan, Jaipur Dr Nishtha Singh

  2. Over 30 years proven performance The EBUS Timeline 1992 Radial EBUS was introduced Convex probe EBUS introduced 2003 First publication with description Of EBUS-TBNA principle 2008 EBUS First came in India 2013 International guidelines recommend EBUS-TBNA as first testing method for lung cancer Rajasthan gets its First EBUS at Asthma Bhawan 2016

  3. Point Should Endobronchial Ultrasound Guide Every Transbronchial Needle Aspiration of Lymph Nodes? Dr Nishtha Singh

  4. Can we drive our cars on the road with headlights off at night? Dr Nishtha Singh

  5. “NO, We would not drive our cars at night without using the headlights, even on a familiar road or even after having studied images of that road carefully.” Dr Nishtha Singh

  6. Sample by conventional TBNA Sample by EBUS Dr Nishtha Singh

  7. “It is time to turn on the lights and be confident that our chances of safe arrival at the next destination is 90%” Dr Nishtha Singh

  8. Point Should Endobronchial Ultrasound Guide Every Transbronchial Needle Aspiration of Lymph Nodes? Yes Dr Nishtha Singh

  9. Moving away from the era of Imagining Dr Nishtha Singh

  10. Who are the right candidates for EBUS? Dr Nishtha Singh

  11. Case 1 • 50-year-old female presented with headache and chronic non-productive cough • Transbronchial lung biopsy = adenocarcinoma Dr Nishtha Singh

  12. Case 2 • 68-year-old man presented with chronic cough LUL mass 3.5 cm Subcentimeter 4R node • Transbronchial lung biopsy = adenocarcinoma Dr Nishtha Singh

  13. Case 3 • 45-year-old female with abnormal chest X-ray • Transbronchial lung biopsy = adenocarcinoma • Negative MLN on PET-CT Dr Nishtha Singh

  14. MLN staging? Not required Case 1 EBUS-TBNA Case 2 Case 3 Not required Dr Nishtha Singh

  15. Dr Nishtha Singh

  16. Mediastinal staging N1 N2 N3 T Dr Nishtha Singh

  17. TNM classification 5-year survival Rami-Porta R, et al. The IASLC lung cancer staging project: 8th edition of TNM classification. J Thorac Oncol 2014. Dr Nishtha Singh

  18. Staging and treatment Dr Nishtha Singh

  19. EBUS Procedure Dr Nishtha Singh

  20. EBUS Scope

  21. Balloon ApplicationAir is enemy Water is Friend Dr Nishtha Singh

  22. Ultrasound processor • Adjustable Gain and Depth • Gain is the degree of brightness with which given signal intensity is displayed. Analogous to a volume control knob on a stereo. • Depth- allows optimal display of an area of interest on the screen. • B mode and Doppler capabilities • B-mode (brightness mode) uses an array of transducers to scan a place through the tissue to produce a two-dimensional image on the screen. • Doppler mode measures the velocity of moving tissue. It detects blood flow in vessels and subsequently superimposes the display over the 2-D image. Dr Nishtha Singh

  23. Needle Gauge 19G/21G/22G Compatible Channel 2mm Aspiration port Scale Handle section Insertion portion Dr Nishtha Singh Dimple shape for high echogenic reflection

  24. Dr Nishtha Singh

  25. Preparation of EBUS- Patients Dr Nishtha Singh

  26. Anaesthesia • EBUS-TBNA is performed on an OPD basis under LA only or midazolam-induced conscious sedation. • LA is achieved with 5ml nebulized 2% lidocaine solution in the pharynx. • Oral route preferred. • ECG, Pulse oximetry, and BP monitoring is required with/without the presence of an anesthesiologist. Dr Nishtha Singh

  27. Anaesthesia and peri-operative care • General Anaesthesia with LMA • LMA mask size 4 or 5 required • Total IV anesthesia with propofol is commonly used. • General Anaethesia with ET tube • Size 8.5 in women and 9.0 in men • More difficult to visualize higher nodes • Indications may include difficult LMA placement, obesity Dr Nishtha Singh

  28. Subcarina (Station7): Definition based on IASLC map Upper border: • the carina of the trachea Lower border: • The upper border of the lower lobe bronchus on the left • The lower border of the bronchus intermedius on the right Dr Nishtha Singh

  29. Dr Nishtha Singh

  30. Dr Nishtha Singh

  31. LN Characteristics- Dr Nishtha Singh

  32. Anatomical landmarks during EBUS Dr Nishtha Singh

  33. Dr Nishtha Singh

  34. Dr Nishtha Singh

  35. Insertion of EBUS • Insertion • Ballooning • Searching Target • Applying needle set • Needle insertion • Negative pressure Dr Nishtha Singh

  36. How to take biopsies • When the target structure is identified, a biopsy can be taken. • Insert the sheet in the operative channel of the endoscope and lock it • Adjust the sheet with the tip a few millimeters outside the endoscope • Move the needle with the stylet a few millimeters forward • Retract the stylet 1 cm to make the needle sharp • Hit the target • Reinsert the stylet and then remove it • Connect the suction to the needle and move it back and forth • Stop moving needle and cease suction • Retract the needle and make sure the needle is in the upper position • Lock the needle and remove the equipment from the endoscope. Dr Nishtha Singh

  37. Dr Nishtha Singh

  38. EBUS-TBNA is a boon for mediastinal diagnosis • Access lymph node stations 1,2,4,7,10,11,12 • Minimal invasive SAFE technique • Real time procedure • Doppler mode helps differentiate LN from vessel • Used for diagnosis and staging Dr Nishtha Singh

  39. Dr Nishtha Singh

  40. Experience in our Institute Asthma Bhawan Dr Nishtha Singh

  41. Diagnosis of the 82 patients Dr Nishtha Singh

  42. Our experience so far! Learning Curve We took consecutive patients of MediastinalAdenopathy Dr Nishtha Singh

  43. Diagnosis changed Dr Nishtha Singh

  44. Case 1- 27 yr female with fever intermittent since 1 yr PUO? Dr Nishtha Singh

  45. CT was suggestive of mediastinallymphadenopathy Dr Nishtha Singh

  46. Dr Nishtha Singh

  47. Bronchoscopy done before was normal. • The diagnosis of treating physician was of Tuberculosis or Sarcoidosis. And he started patient on ATT. • After 1 month, patient came to us. Dr Nishtha Singh

  48. EBUS was done. Results???? Dr Nishtha Singh

  49. EBUS-TBNA s/o Reed sternberg like cells Cytology showed Hodgkins lymphoma. Dr Nishtha Singh

  50. Is there a role of EBUS-TBNA in Lymphoma? Dr Nishtha Singh

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