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LETTER TO EDITOR
Year : 2018  |  Volume : 35  |  Issue : 6  |  Page : 539-540  

Ambidexterity: A useful addition to the skillset of an endobronchial ultrasound operator?


Department of Medicine, AIIMS, New Delhi, India

Date of Web Publication30-Oct-2018

Correspondence Address:
Dr. Animesh Ray
Department of Medicine, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_250_18

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How to cite this article:
Ray A, Kalum SJ, Sinha S. Ambidexterity: A useful addition to the skillset of an endobronchial ultrasound operator?. Lung India 2018;35:539-40

How to cite this URL:
Ray A, Kalum SJ, Sinha S. Ambidexterity: A useful addition to the skillset of an endobronchial ultrasound operator?. Lung India [serial online] 2018 [cited 2018 Dec 14];35:539-40. Available from: http://www.lungindia.com/text.asp?2018/35/6/539/244500



Sir,

Convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a commonly done procedure to sample lymph nodes and masses adjacent to the central airway.[1] Usually, the lymph node stations 1, 2, 4, 7, 10, and 11 are accessible by this relatively novel technique.[2] The EBUS scope (Olympus BF-UC180F), like other bronchoscopes, can be used by both the right- and left-handed person, facilitated by the midline position of the working channel through which the TBNA needle is inserted and maneuvered. The right-handed person usually holds the scope with his left hand and uses his left hand to manipulate the needle, while the left-handed person does the opposite.

A 58-year-old male patient with a history of smoking (40 pack-years) presented to us with complaints of shortness of breath, loss of weight, and appetite for the past 2 months. Chest X-ray and a subsequent computed tomography of the thorax [Figure 1] revealed a mass in the left hilar region, infiltrating the left main pulmonary artery, and abutting the left main bronchus. As the mass was central in location with diffuse emphysematous changes affecting the surrounding lung parenchyma, transthoracic biopsy was ruled out. An EBUS-guided TBNA was planned, but as the mass was located posteriorly and to the left, access to the mass was found to be very difficult [Figure 2]. The EBUS scope had to be angled posteriorly and to the left [Figure 3] and [Figure 4]. Since the operator was right-handed, positioning the scope was difficult holding it in the left hand. The operator had to change hand-holding scope with the right hand and angling it so to access the mass. The TBNA needle had to be held with the left hand, the wall of the left main bronchus was penetrated, and the needle advanced into the mass. Then, 6-7 to-and-fro motions made without application of suction. Altogether, three passes were made and a rapid on-site evaluation was done which showed neoplastic changes with suggestion of adenocarcinoma.
Figure 1: Computed tomography of the thorax showing a mass in the left hilar region, infiltrating the left main pulmonary artery, and abutting the left main bronchus

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Figure 2: A cartoon showing intratracheal view with the mass lying in the segment subtended by the angle between 270° and 370°

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Figure 3: The scope and the needle position while sampling the 4R lymph node station. The right-handed endobronchial ultrasound operator is holding the scope with the left hand and TBNA needle with the right hand

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Figure 4: The scope and the needle position while sampling the mass lying posteriorly and to the left. The right-handed endobronchial ultrasound operator is holding the scope with the right hand and TBNA needle with the left hand

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To the best of our knowledge, this is the first report of an EBUS procedure where the operator had to switch hands to complete the TBNA procedure. With evolution of EBUS-related technology and possible decrease in size of scope diameter in the future, more and more of mediastinal lesions can be accessed by it, mandating improvisation in the sampling technique. This report highlights the need for EBUS operator to be able to develop skills of TBNA aspiration with both the hands so that similar difficult-to-access lesions can be also sampled.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wahidi MM, Herth F, Yasufuku K, Shepherd RW, Yarmus L, Chawla M, et al. Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration: CHEST guideline and expert panel report. Chest 2016;149:816-35.  Back to cited text no. 1
    
2.
Gomez M, Silvestri GA. Endobronchial ultrasound for the diagnosis and staging of lung cancer. Proc Am Thorac Soc 2009;6:180-6.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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