How is real-time TBNA performed during endobronchial ultrasound (EBUS)?

Updated: Apr 24, 2019
  • Author: Narayan Neupane, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Real-time TBNA is defined as simultaneous sonographic visualization and sampling of the lesion. Once the target lesion is identified, the dedicated needle is inserted through the working channel of the bronchoscope and fastened to it. The tip of the bronchoscope should be in neutral position to allow the sheath to come out of the distal end of the working channel. The needle should remain within the catheter during passage through the working channel in order to prevent damaging the bronchoscope. Once the catheter emerges from the bronchoscope, the needle is advanced from the catheter and locked into position. The insertion point of the needle is localized and then pushed through the bronchial wall into the target lymph node under direct ultrasound visualization.

With the needle in the target lymph node, the internal sheath is removed. This cleans the lumen of the needle system, which usually becomes contaminated with bronchial cells. Suction is applied using a 20-mL syringe, and the catheter is moved back and forth. Suction is released, and the needle is pulled back into the flexible catheter. The entire transbronchial needle system is then removed from the bronchoscope in a single, smooth motion. The tissue core is then removed from the needle lumen by reinserting the internal sheath.

The number of needle aspirations per site can impact the yield and can range from 3 to 7 aspirations, depending on the study, but the first pass has the highest yield. [31, 32] If the TBNA is being done for staging of NSCLC, the sampling should be started from N3, followed by N2 and N1 lymph nodes, to avoid contamination and upstaging.

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