Bill (not his real name), a 30-year-old attorney and golfer, was on the eighth tee about to pull out his No. 2 iron when he started to cough up small amounts of blood and began to complain about pain in his chest and shortness of breath. Bill was brought to the emergency department of a nearby hospital and was examined by the ED physician. Blood work, a chest X-ray and a CT scan of his chest were done. His vital signs remained stable while in the ED.
After reviewing both the chest X-ray and the CT scan, the ED doctor immediately consulted a thoracic surgeon who recommended an endobronchial ultrasound-guided transbronchial needle aspiration (EBUS) for a suspicious mediastinal lesion.
EBUS is a procedure typically performed in an operating room to help with diagnosis, staging and treatment of lung cancer involving mediastinal lymph nodes, some mediastinal masses, and evaluation of enlarged non-specific mediastinal nodes.
It is a safe and accurate procedure usually done in an outpatient setting under either local sedation or general anesthesia.
SEE ALSO: Lung Cancer Overview
A thoracic surgeon performs the EBUS procedure in the OR; however, a trained pulmonologist can do this procedure in a bronchoscopy lab. If an unexpected complication should arise, the thoracic surgeon’s training and expertise is preferred.
“EBUS is a minimally-invasive, relatively new tool used to assess the mediastinum and enlarged lymph nodes in the chest. It is about 45-60 minutes in duration and has minimal reported complications,” explained Dr. Lawrence Glassman, MD, FACS, Chief of Thoracic Surgery, North Shore-LIJ Health System, Manhasset, N.Y.
“[EBUS] is complimentary to other more invasive procedures, such as video-assisted thoracic surgery [V.A.T.S.] and mediastinoscopy,” Glassman said. “Its use is best in well-practiced hands and requires a team of doctors, nurses and technicians with experience to maintain quality and patient satisfaction.”
When performed in the OR, general anesthesia under laryngeal mask airway or oral intubation with at least a No. 8 ET tube is used to accommodate thebronchoscope. To easily access the proximal paratracheal lymph nodes, the laryngeal mask airway is preferred.
A flexible bronchoscope with an ultrasound probe is inserted into the patient’s airway passing first into the trachea, next to the right main bronchus, then on to the carina, passing towards the anterior wall of the main bronchus in order to view the mediastinal nodes.
The paratrachael nodes can all be biopsied as well as some hilar nodes. A No. 21 or No. 22 gauge aspiration needle biopsy is passed through a biopsy channel in the bronchoscope to obtain samples of tissue outside the bronchial tree using the “quick jab” technique.
Suction is applied to the biopsy needle by using a 20cc syringe and passing the needle in and out for about 10 times then releasing the suction and the biopsy needle. The needle is released out of the sheath and the specimen is obtained.
Cytology brushes and glass slides are used to obtain smears for histology. It is not unusual to have the cytology lab tech present in the OR during the procedure in order to expedite the histological findings.
In Bill’s case, Reed-Sternberg cells were seen under the microscope to confirm the suspected diagnosis: Hodgkin’s lymphoma.
The nursing care of the patient intra-operatively is important to ensure that the procedure proceeds as planned.
The circulating nurse and scrub nurse are vital to the OR team so that the surgeon and his assistant have the necessary equipment and sterile supplies needed for the procedure. Documentation of the procedure is done by the circulating nurse.
Postop nursing care of the patient includes assessing the patient’s vital signs and oxygen saturation in order to monitor for a pneumothorax. A chest X-ray is done to rule out any hemorrhage, pneumothorax and pleural effusion. Assessing for laryngeal nerve injury can be done by monitoring the EKG for any cardiac arrhythmias. Fever, leukocytosis and pleural effusion can indicate an esophageal perforation.