Endobronchial ultrasound with a guide sheath during bronchoscopy for peripheral pulmonary lesions

ABSTRACT

Introduction

Radial probe endobronchial ultrasound (rEBUS) improves the diagnostic yield of peripheral pulmonary lesions (PPLs). A notable methodological limitation of rEBUS is that it does not provide real-time images during transbronchial biopsy (TBB) procedures. To overcome this limitation, a guide sheath (GS) method was developed.

Areas covered

This review covers the procedures and complications of rEBUS-guided TBB with a GS (EGS method). We also present the data from key randomized controlled trials (RCTs) of the EGS method and summarize the usefulness of combining the EGS method with various techniques. Finally, we discuss in which situations EGS should be used.

Expert opinion

A large RCT showed that the diagnostic yield of the EGS method for PPLs was significantly higher than that of rEBUS-guided TBB without a GS (non-GS method). However, since the EGS and non-GS methods each have their own advantages and disadvantages, they should be considered complementary and used flexibly in different cases. In some cases, a combination of the two may be an option. The appropriate combination of EGS with various techniques may enhance the diagnostic yield of PPLs and help prevent complications. The choice should be based on the location and texture of the target lesion, as well as operator skill, resource availability, safety, and accuracy.

KEYWORDS:

• Augmented fluoroscopy
• bronchoscopy
• CBCT
• EGS
• EBUS-TBB
• electromagnetic navigation bronchoscopy
• guide sheath
• transbronchial biopsy
• virtual bronchoscopic navigation

Article highlights

• The most important methodological limitation of radial probe endobronchial ultrasound (rEBUS)-guided transbronchial biopsy (EBUS-TBB) is that it does not provide real-time images during TBB procedures. To overcome this limitation, the EBUS-TBB with a guide sheath (EGS method) was developed.

• In a large randomized controlled trial, the diagnostic yield of the EGS method for peripheral pulmonary lesions (PPLs) was significantly higher than that of EBUS-TBB without a GS (non-GS method). The diagnostic superiority of EGS was particularly evident for upper lobe lesions.

• The EGS method is a safe procedure for PPLs, with very low reported complication rates.

• Although controversial, some studies have reported that the combination of the EGS method with various techniques, such as fluoroscopy, virtual bronchoscopic navigation, electromagnetic navigation bronchoscopy, cone-beam computed tomography, and rapid on-site evaluation, enhances the diagnostic yield of PPLs.

• Ultrathin bronchoscopy with rEBUS (EBUS-UT method) is another useful technique for the diagnosis of PPLs.

• The EGS method and non-GS methods, including the EBUS-UT method, should be considered complementary and used flexibly in different cases. In some cases, a combination of the two may be an option.

Abbreviations

AF	=	augmented fluoroscopy
CBCT	=	cone-beam computed tomography
EBUS	=	endobronchial ultrasound
EBUS-UT	=	endobronchial ultrasound-guided ultrathin bronchoscopy
EGS	=	endobronchial ultrasound with a guide sheath
ENB	=	electromagnetic navigation bronchoscopy
GS	=	guide sheath
PPL	=	peripheral pulmonary lesion
RCT	=	randomized controlled trial
rEBUS	=	radial probe endobronchial ultrasound
ROSE	=	rapid on-site evaluation
TBB	=	transbronchial biopsy
UTB	=	ultrathin bronchoscope
VBN	=	virtual bronchoscopic navigation

Declaration of interest

Y Takashima has received research funding from Olympus Corporation and Olympus Medical Systems Corporation. M Oki has received speaker fees from Olympus Corporation and AMCO as an invited guest speaker at academic medical meetings. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.