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      The role of sedation in endobronchial ultrasound-guided transbronchial needle aspiration: Systematic review

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          Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in diagnosis and staging of mediastinal lymph node (LN) lesions in lung cancer. Adequate sedation is an important part of the procedure since it provides patient's comfort and potentially increases diagnostic yield. We aimed to compare deep sedation (DS) versus moderate sedation (MS) in patients undergoing EBUS-TBNA procedure.


          PubMed, EMBASE, MEDLINE, and Cochrane Library were searched for English studies of clinical trials comparing the two different methods of sedations in EBUS-TBNA until December 2015. The overall diagnostic yield, LN size sampling, procedural time, complication, and safety were evaluated.


          Six studies with 3000 patients which compared two different modalities of sedation in patients performing EBUS-TBNA were included in the study. The overall diagnostic yield of DS method was 52.3%–100% and MS method was 46.1%–85.7%. The overall sensitivity of EBUS-TBNA of DS method was 98.15%–100% as compared with 80%–98.08% in MS method. The overall procedural times were 27.2–50.9 min and 20.6-44.1 min in DS and MS groups, respectively. The numbers of LN sampled were between 1.33–3.20 nodes and 1.36–2.80 nodes in DS and MS groups, respectively. The numbers of passes per LN were 3.21–3.70 passes in DS group as compared to 2.73–3.00 passes in MS group. The mean of LN size was indifferent between two groups. None of the studies included reported serious adverse events.


          Using MS in EBUS-TBNA has comparable diagnostic yield and safety profile to DS. The decision on the method of sedation for EBUS-TBNA should be individually selected based on operator experience, patient preference, as well as duration of the anticipated procedure.

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          Most cited references 28

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          GRADE guidelines: 3. Rating the quality of evidence.

          This article introduces the approach of GRADE to rating quality of evidence. GRADE specifies four categories-high, moderate, low, and very low-that are applied to a body of evidence, not to individual studies. In the context of a systematic review, quality reflects our confidence that the estimates of the effect are correct. In the context of recommendations, quality reflects our confidence that the effect estimates are adequate to support a particular recommendation. Randomized trials begin as high-quality evidence, observational studies as low quality. "Quality" as used in GRADE means more than risk of bias and so may also be compromised by imprecision, inconsistency, indirectness of study results, and publication bias. In addition, several factors can increase our confidence in an estimate of effect. GRADE provides a systematic approach for considering and reporting each of these factors. GRADE separates the process of assessing quality of evidence from the process of making recommendations. Judgments about the strength of a recommendation depend on more than just the quality of evidence. Copyright © 2011 Elsevier Inc. All rights reserved.
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            Practice guidelines for sedation and analgesia by non-anesthesiologists.

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              Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes.

              Although various techniques are available for obtaining pathology specimens from the mediastinal lymph nodes, including conventional bronchoscopic transbronchial needle aspiration (TBNA), transesophageal ultrasonography-guided needle aspiration, and mediastinoscopy, there are limitations to these techniques, which include low yield, poor access, need for general anesthesia, or complications. To overcome these problems, we undertook the current study to evaluate the clinical utility of the newly developed ultrasound puncture bronchoscope to visualize and perform real-time TBNA of the mediastinal and hilar lymph nodes under direct endobronchial ultrasonography (EBUS) guidance. Prospective patient enrollment. University teaching hospital. From March 2002 to September 2003, 70 patients were included in the study. The new convex probe (CP) EBUS is integrated with a convex scanning probe on its tip with a separate working channel, thus permitting real-time EBUS-guided TBNA. The indications for CP-EBUS were the diagnosis of mediastinal and/or hilar lymphadenopathy for known or suspected malignancy. Lymph nodes and the surrounding vessels were first visualized with CP-EBUS using the Doppler mode. The dimensions of the lymph nodes were recorded, followed by real-time TBNA under direct EBUS guidance. Final diagnosis was based on cytology, surgical results, and/or clinical follow-up. All lymph nodes that were detected on the chest CT scan could be visualized using CP-EBUS. In 70 patients, CP-EBUS-guided TBNA was performed to obtain samples from mediastinal lymph nodes (58 nodes) and hilar lymph nodes (12 nodes). The sensitivity, specificity, and accuracy of CP-EBUS-guided TBNA in distinguishing benign from malignant lymph nodes were 95.7%, 100%, and 97.1%, respectively. The procedure was uneventful, and there were no complications. Real-time CP-EBUS-guided TBNA of mediastinal and hilar lymph nodes is a novel approach that is safe and has a good diagnostic yield. This new ultrasound puncture bronchoscope has an excellent potential for assisting in safe and accurate diagnostic interventional bronchoscopy.

                Author and article information

                Endosc Ultrasound
                Endosc Ultrasound
                Endoscopic Ultrasound
                Medknow Publications & Media Pvt Ltd (India )
                Sep-Oct 2016
                : 5
                : 5
                : 300-306
                Tulane University Health Sciences Center, Section of Pulmonary Diseases, Critical Care and Environmental Medicine, New Orleans, Louisiana, USA
                [1 ]University of Miami Miller School of Medicine, Palm Beach Regional Campus, Florida, USA
                [2 ]Department of Medicine, Interventional Pulmonary Section, Roswell Park Cancer Institute, Buffalo, New York, USA
                [3 ]Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University at Buffalo, State University of New York, Buffalo, New York, USA
                Author notes
                Address for correspondence Dr. Fayez Kheir, Department of Medicine, Section of Pulmonary Diseases, Critical Care and Environmental Medicine, 1430 Tulane Avenue, Box 8509, New Orleans, Louisiana, USA. E-mail: fkheir@
                Copyright: © 2016 Spring Media Publishing Co. Ltd

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

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