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Endobronchial Ultrasound

Aug 21 | 10:30 AM

Join Dr. Viswesvaran as he talks about some highly effective procedures used to diagnose lung cancer, infections, and other diseases causing lymphadenopathy. EBUS allows physicians to perform Transbronchial Needle Aspiration (TBNA) to aspire fluid samples from lung without conventional procedures. Let's learn some interesting concepts and procedure hacks of EBUS.

[Music] so myself i am dr vishweshwaran i am currently working as a consultant interventional terminology and sleep medicine specialist attention hospitals malecrate in hyderabad i do not have any disclosures or any uh funding so today uh since we are going to have a mixed set of audience involving both physicians and permanent and even young budding students i'd like to cater to all the aspects of ebus which will keep you entertained so ebus as we all know is nothing but it's a bronchoscopy but it also contains an ultrasound that is why we call it as an endo bronchial ultrasound so we have got two types of fibers the one on your left side what you see is the radial levers and one what you see on the right side is the convex probe ebus the difference is the radial e-bus as you can see it's like a cylindrical structure and it can provide a 360 degree view of your uh airbase the structures that are surrounding your airways whereas the convex probe that is seen on your right will not provide the 360 degree view but however it has got a larger diameter and a higher um and has got a very good ultrasound characteristics which will help in identifying lesions that are adjacent to the major arteries so that you can see a lymph node you can see a cyst or you can even see a lung cancer with the help of your cornea probe so the real so the first thing is i will speak a few words about the radial levers so when you look at all these ct scan every one of us here know that probably we are dealing with a case of a cancer or we are dealing with a case of a pneumonia like a tuberculosis or nocardiosis or fungal infection but the problem comes here is how are we going to take a biopsy of this these are neither in the major airways for you to pass a bronchoscope and take a biopsy nor it is abutting your chest wall so that you can pass a ct guided biopsy or an ultrasound guided biopsy if you try to attempt a ct guided biopsy in such lesions where there is a distance between the chest wall and the lesion there is a very high chance that you might induce a pneumothorax and that might become a traumatic experience for the patient so here comes the real role of the radial ebus so what does this radius do it's nothing but a flexible catheter which has got a rotating ultrasound transducer which produces a 360 degree that is a radial ultrasound image so that this small cylindrical tube is passed into the bronchial subsequence until the characteristic ultrasound signal indicating the presence of a lesion is demonstrated so once you know that you are have seen the lesion localize the lesion with the help of the radial bus then you use a biopsy forceps or you use a cryobroke forceps to take cryopro to take a biopsy from these segments so let me make it explain you how does it how it really works so the picture on your left side so we have wedged a broncoscope in the sub segment of the subsequent bronchus and we are passing a guide sheet and through the guide sheet we will then pass a radial probe when the radial probe is inside a normal array as you can see from the left side the the black image the ultrasound image does not show anything but if your radial probe is passed into the lesion like into the or near the lesion as you can see from the right side image you can get some characteristic ultrasound images these ultrasound images suggest that probably you are near the tumor or you are you may be even inside the tumor once you get this image what you do is you remove the radial probe you leave the guide sheet there and through the guide sheet as you see on the left side you pass a brush and this brush is moved up and down so that you take some sample out of it and that might be a representative of your lung cancer if you don't want to use a brush and you want a biopsy space you can pass a forceps through this catheter and take a biopsy from this region so in all these cases once the radial evas was used with these characteristic ultrasound images that is found on a radial levers what you get is ultimately a malignancy so this radially bus primarily helps you in identifying lesions which are outside your major airways but which are difficult to be biopsied by either image guided biopsy that's when actually the role of the radius comes into practice now moving on to the major aspect which is the convex probe ebus this convex pro bus is nothing better it's a linear curved array transducer and it scans parallel to the insertion direction of the scope and right now it is considered to be both the e bus along with your us we call it as medical mediastinoscopic so it has now become the investigation of choice for almost all the mediastinal lymph node sampling so previously prior to the advent of the ebus convex probiebus most of the patients who has got metastatic lymph nodes in the chest these patients are subjected to very laborious surgeries like in the form of a exploratory uh mediastinoscopy to take a lymph nodes these surgeries are really uh risky and it requires a lot of expertise and hospital care and it requires admission so that's when the concept of the convex probe ebus came where you just pass an broncoscope like instrument with an ultrasound you localize the lymph node and take a biopsy from there and then you confirm whether you are dealing with a cancer you are dealing with the tuberculosis you are dealing with any other sort of infections so the indications when we actually use these convex probes are mainly for staging of non-small cell lung carcinoma or in case if a patient comes to you with recurrence or you want to patient is on treatment and he still continues to develop new lymph nodes and you want to take a biopsy for re-staging then this convex pro vibus can be used it is also used for obtaining tissue for diagnosis on the large central large tumors for example if you have a tumor which is not inside your trachea but it is surrounding your trachea or the major airways you cannot use a bronchoscope and take a biopsy in such cases also you can use a convex group ebus it is also used in the evaluation of the mediastinal lymph lymphadenopathy of any etiology be it a benign like tuberculosis or sarcoidosis or it can be in the form of malignancy like lymphomas or metastatic lung diseases and it is also used in the sampling of mediastinal masses which may be in the form of a superior and anterior mediastinal tumors like a thyroid tumor or for that matter it can be even other sorts of metastatic tumors into the mediastinum so in at the nearing the end of the presentation i will be explaining a few cases with which you can better understand what we are really speaking about so the advantages of this convex probe is that it helps in the sampling of the lung and the mediastinal lesions the lung lesion should be adjacent to the average it is minimally invasive definitely the pain it is a daycare procedure where the patient comes in the morning do does the test and goes back from the same day unlike your mediastinoscopy or extensive surgeries which are used for no lymph node exploration of the mediastinum it is more cost effective than the surgical mediastinoscopy and the complications are relatively uncommon because you use a very small needle to take a uh efficiency sample and it is with and the complications are almost negligible it has got a good sensitivity and a specificity but however what would be the drawbacks of using such a procedure sometimes very rarely you may get a false negative result that means probably the patient is having a malignancy or tuberculosis but still you may get a negative report in case if you get a negative report upon an ebus that's when we subject these patients for mediastinoscopy if you are suspecting any sort of metastatic uh lymph nodes and few not all the nodes are going to be around your major airways like trachea or main brokers few of these nodes might be away from your address those nodes become the inaccessible targets because of their anatomical location and this slide really puts the perspective why we say that the ebs tbna has revolutionized the field of interventional terminology especially with respect to lung cancer staging this is because if you see the sensitivity and the specificity you see the ct pad you get an integrated pet city the media asthenoscopy which was considered to be the gold standard even there the media stenoscope has got a sensitivity of only 81 percentage but when you are combining e when you are using either e bus t b and a or you are combining the e bus t b n a plus u s t f t t e u s f n fna the sensitivity goes as high as 89 to 91 percentage that means it has got even a higher sensitivity than your conventional mediastinoscopy for identifying metastatic or malignant lymph nodes and the specificity is hundred percentage the positive predictive value is hundred percentage and the negative predictive value is almost 91 to 96 percentage now that is why now for all patients who present with the mediastinal lymphadenopathy of any cause for evaluation the first modality of approach should be an endo bronchial ultrasound tbm name if feasible so this is a clear image which shows that how the lymph stations which can be sampled by the ebus far exceeds the u.s and that's why the e-bus is now preferred as the modality of choice for staging the mediastinum and the same ebu scope can also be passed through the esophagus that is what we call this usb fna where we pass the same scope instead of an esophageal scope into the esophagus and we can access even those nodes which can be accessed by means of your us so the e-bus can be used both in the broncos as well as in the esophagus in certain cases so now moving on it's moving on to few aspects related to the convex probe as you can see from the left side this is how a convex probe ever actually looks like the various parts of this probe are depicted on the image on the right side so the tip one is nothing but your ultrasound probe then you have got a working channel and through the working channel you pass a needle and you have a camera at the tip which help in visualizing what is exactly happening so the convex ebus is a real-time visualization of the node and you can take an fnac under real time assistant that's what makes it very special and with respect to the mediastinal lymph node staging this is very very important when you are dealing with a case of a suspected lung cancer the mediastinum has got a multiple of nodes which are divided into major stations just the superior mediastinal nodes the iotic nodes the inferior mediastinal nodes and the n1 nodes so the e bus can help you in accessing almost all of your n1 nodes and your more in the inferior media standard it can help you to access the subcarrinal node whereas it cannot be used for the para esophageal or for the pulmonary ligament even in the aortic the sub biotic and the parability cannot be accessed by means of your rebus but when it comes to the superior mediastinal nodes which is most commonly involved in cases of lung cancer almost all nodes right from upper particle prevascular and lower parametrical can be easily accessed by means of your tibus so if you are having a patient who has got a mediastinal lymphadenopathy in the superior mediastinal nodes section or in the subcalianal section or in the n1 node section then your e-bus becomes the modality of choice so if you see the picture on the right side that exactly depicts how the scope is passed into the trachea and into the bronchus and it is approximated against the wall to visualize the node and these fnases are taken under real-time guidance so now i will briefly since many of them might not have had an exposure to the e-bus i'm briefly explaining you what we really do in the e-bus the first step involves the introduction of the scope so we are introducing the scope ins inside the uh track here so when we do the one difference between the bronchoscope and the eva scopus that as you can see from the picture on the left side you are going to have an angulated view that is because of your uh ultrasound tip so the image will not be a linear view it will be an angulated view and so you may have to develop some skills to negotiate the scope through the vocal cord into the trachea so once i am inside the trachea i will use the tip of the ultrasound tip to localize the lymph node which is shown in the picture on your right side so once i do there is a balloon also present at the end of the near the ultrasound transducer so this balloon is generally filled with saline because ultrasound the air is a poor conductor of an ultrasound base and it can cause artifacts so to prevent the air from entering between the point of approximation of the ultrasound probe with the tracheal or the bronchial wall we introduce a balloon and through this balloon a s line is installed and it is approximated against the wall to get a clear image and once it is approximated as you can see from the right side we localize the lymph node the lymph node is seen on the ultrasound and with the help of the doppler you will also help localize the blood vessels so that when you pass the needle you don't hit these blood vessels and once it is done through the working channel we introduce a sheet and through the sheet we introduce a needle which exactly goes inside the node under real-time guidance and helps in taking us a sample and this sample is then sent for analysis as you can see which is called as a rows that is a rapid on-site evaluation so once the rapid onset evaluation is done there are very high chances that your pathologist will give the diagnosis on table probably you are dealing with the case of a cancer or you are dealing with the case of a infection in the form of a granulomatous inflammation like in tuberculosis in most of the indian settings so this is for those who have already been using the e bus so how do we really differentiate the lymph nodes so when you pass the scope when and the first node that you have to see is your subcarnal node so you place it at the left that is the station 7 so you place it at the level of the carrier and approximate it against the karena and the node that you see is the sub kerano node now bring your scope at least one centimeter above and rotate it against the right lateral wall the node that is present above the azagos vein becomes the four r and the node that is present below the segment's vein becomes the tenth r similarly on the left side the node that is present above the pulmonary artery is your 4l node and the node that is present below the pulmonary artery is your left hilar node so this is how we really visualize the lymph nodes and always search from foreign station 7 station 10 l 10r and then use the acycles and then go to the 4th r so whenever we use this ultrasound there are few things which we can observe to exactly differentiate what sort of node we are dealing with whether we are dealing with a benign node or a malignant node when you have a small axis length these nodes are generally benign nodes but when the axis is big we probably are dealing with the malignant node when the shape is irregular generally it is a benign node when the shape is clearly wrong then probably you are dealing with the case of a malignant node and the when the margins are ill defined it generally indicates that that it is a lymph adenitis probably because of an infection but when the margins become well defined probably you are dealing with the case of a metastatic lymph node if you see a central hyla structure that is a presence of a vascular within the hilum of the node then probably you are dealing with a benign feature when you don't see a central hyaluronic structure probably you are dealing with a malignancy and when you see a central necrosis generally it is absent in case of your benign nodes whereas your central necrosis is present in case of a malignant nodes and when the nodes are heterogeneous probably you are dealing with a case of a malignant node and when they are homogeneous probably are dealing with the case of a benign but having said that in india we see a lot of tuberculosis lymph nodes and it becomes really difficult to differentiate a malignant node from a benign node because the heterogeneous architecture can be present even in a tubercular node as in the case of a malignant lymph node the central necrosis which is considered to be an attribute of the malignant lymph node in a western population might be seen even in case of a tubercular lymph node and even for that matter the characteristic feature that will help you to differentiate whether you are dealing with a tubercular node or a malignant node is the metastatic nodes you can see multiple nodes under real time ultrasound having with the capsules adhering to each other so these are the few features which you can use to differentiate in our routine clinical practice for differentiating a benign lesion like a tuberculosis node from a malignant known so another important aspect of the e-bus is what we refer to as the rapid on-site evaluation so what we do is as i said to you in the previous picture we take the limb sample and we immediately subjected to the pathologist who sits next to you in the operation theta and it gives the advantage of the rose is that that you have a preliminary information that means whether you have really hit a node or not and if you have hit a node probably is it a malignancy or it is a benign or it is a reactive node these details you will get let's say for example you have hit a node on the first path and it gives you the diagnosis of malignancy so now you can use the specimen triaging that means whatever the other passes you pass through the lymph node you take all these samples for additional studies like flow cytometry or microbiology studies or molecular testing or for cell block preparation so by doing this it will help you to improve the yield as well as it will help you to improve the technique because once you know that you have already attained the diagnosis you will not waste further passes on the same node and thereby it limits the operation timing and it will also help in better coordination between the pathologist and endoscopist which is very important because your pathologist is blinded he doesn't know about the case and when you give him the leading points then probably he may give you a diagnosis so this is how the rose happens so a e bus is done the you have confirmed there is a malignancy or infection then the samples are taken for ancillary testing and it is then processed and we get the final report in at a later stage so the rose helps in arriving at an immediate diagnosis it improves the confidence of the performer of the e-bus and it will also help you to save time thereby resources as well so now moving on since we have spoken a lot about the role of the e bus in a malignant lymph node this e bus does not confine itself only to the diagnosis of malignant lesions you can use this convex ebus even for benign conditions so the first benign condition what we commonly see is the sarcoidosis and a granuloma study which is a very big study showed that the e bus that is indoor sonographic which may be either in the form of an e best dbna or in the form of a usfna the diagnosis of lower stage one and two of sarcoidosis was higher when compared to your protein bropostopic biopsy and the diagnostic yield was as high as eighty percent in the endosomographic group while it is only 53 percentage in the standard bronchoscopy group so this clearly shows that your ebus is very helpful in diagnosing a case of sarcoidosis now moving on to the another important benign etiology which we see in indian scenario is tuberculosis why we have to use an e-bus for tuberculosis because your primary tb is seen in 40 percentage of adult cases and as high as 90 to 95 percentage of pediatric cases and the tb presents only like a thoracic lymphadenopathy and when you use an e bus to diagnose this lymphadenopathy the overall sensitivity goes as high as 87 percentage and the specificity is hundred percentage this means if you are having if you are going to have hundred people who present you with the media lymphadenopathy with tuberculosis in as high as 87 days of cases you can arrive at the diagnosis of tuberculosis and if you can demonstrate afb then it is 100 specific yes it is a tubercular lymph node this is very very important because most of the time we see that the patients getting referred to us patient has got a mediastinal lymphadenopathy and some referral doctor starts these patients on empirical att and the patient does not respond the patient worsen and then they come to us we do a bus and it turns out to be a lymphoma there are cases where the patients present to us with after treatment from a referring physician not improving and it turns out to be a drug resistant mycobacterium so what in our practice we routinely do is when we take these ebus samples we always subject them for gene expert analysis and afb culture analysis this is because even as per the national guidelines all samples for mycobacterium should be sent for first line cultures as well as you have to rule out reference resistance because we have a problem of drug resistant mycobacterium so an empirical atp should be started one only when you have tried all your means and you are not able to diagnose a case of tuberculosis if not you need to subject these patients for diagnostic testing and you need to find out whether you are dealing with a drug sensitive or a drug resistant mycobacterium in addition to this we may see a cation granuloma and when you see such cases in granulomas it can also be seen in histoplasmosis or blastomystosis and even in hiv patients where the problem of drug resistance is very high your ebus tbna can give a diagnostic yield of 60.5 percentage and the diagnostic accuracy goes as high as 97.7 percentage when you combine a transfer lung biopsy along with your best tb so this definitely makes ebus a modality of choice when you are dealing a case of tuberculosis in addition to this you can also have many uncommon conditions which can be diagnosed with the help of your ebus it may be in the form of nocardiosis it may be in the form of a non-tubercular mycobacterium you can see an esophageal duplication cyst you can see a bronchogenic cyst sometimes even when you because an ultrasound can also see the blood vessel when you see a clot in the blood vessel probably you are dealing with a case of a pulmonary embolism and even there are cases where the pericardial effusion is on the posterior aspect so you pass the e bus and people have even removed pericardial effusion from the posterior aspect of the pericardium so in addition to this the most important point is before you take a patient for ebus always see the ct scan because if you see the cd scan which is depicted here you can clearly say that this is probably not a lymph node because the horns will this looks very homogeneous and the horns field unit is as equivalent to that of a blood or a liquid so this was a case of an esophageal duplication cyst so this is how your ebus can also help in diagnosis of very uncommon conditions now moving on to newer aspects of convex ebus one of the most exciting thing that is extrapolated from the gastro side is the anastography so what is allosterography is it shows the consistency of the lymph node by using this elastographic technique so for example if you see the node on the right side when you look just through the e bus that is the black color image you see that it looks like a homogeneous node but actually when you put an elastography you get varying shades of color the blue indicates the harder part of it and the green indicates that the softer part part of it so in case if you are planning an e-bus and you are trying multiple times you are not getting a diagnosis probably you may be hitting the greener portion which is just a necrotic component ideally you need to hit the blue portion so that you get a evidence of malignancy so it is a very promising tool for differentiating between a benign and a malignant lymph node and the strain elastography is a real time technique used with that ultrasound transcutaneous ultrasound and endoscopic ultrasound which is also extrapolated to the e bus the point is most of the inflammatory process do not change the anaesthetic characteristic of the lymph node so your analystography becomes primarily important when you want to either differentiate a benign from malignant node or you are getting repeated passes so you want to use this elastography to find out the target of site of needle function so the animation is not working so this is a another new technology which has come into the play by which we called as the usb fna so previously we used to send the patients for adrenal metastasis uh sampling to the gastrocyte but what people have observed is you can use the same eboscope into the esophagus and go even below the diaphragm to look to the sites like left adrenal gland even subcarnal gland and even liver meds and you can take biopsy from these sites to confirm the metastasis in addition to this the other new advancements that are coming are as you can see from the left side this is nothing but a pro core needle it gives you a biopsy instead of an fnac and in addition to this through your ebus you can pass a forceps into the node and you can take a biopsy and this helps in increasing the yield this is very important because these days we are moving from just diagnosing as lung cancer we wanted to diagnose it as adino we wanted to do the molecular analysis and then we have to say whether it is a egf or positive or egf or negative so tissue really becomes a very important thing so before i finish the presentation i will show you a few of the interesting cases which i had in my practice so she's a 45 year old female tobacco chewier diaptic hypertensive she had a post myocardial infarction she had a carcinoma of the town four years back and post radiotherapy and she presented to us with complaints of breathlessness and cough and cities showed collapse of a suspicion of an endoluminal mass so here we know that we are dealing with a cancer now comes the point we need to stage this cancer so when we did this staging of n2 so we always start from a higher stage so we move from n3 node that means a contralateral node or a superconductive node then move to the n2 node and then we move to the n1 node which are the ipsilateral nodes so in this case the station uh staging it was showed that station 7 was negative that is n2 was negative but station 4 l was positive so the patient had an n1 node so this helps in downstaging the tumor and she can go for a curative internet and the eber's tbn is showed at malignancy so this is that is how your e-bus can help in staging of your cancer this is another interesting case she was a 60 year old female post hysterectomy she had a bleeding per vagina and an fdg pet showed abid lesions in the mediastinum as well as fdg avid lesions in the wall of the vagina so this case was referred to us by our oncologist she had a ca cervix and she had got a pet avoid mediastinal lymph node so the oncologist was of the opinions yes this is a case of a metastatic disease and so we want to just provide her with palliative therapy and not surgical treatment so that is when we took this patient for an ebus dbna and we did the sampling of this node and it turned out to be a granuloma so this patient has got two disease one sca cervix and the pet avid node which was there in the mediastinum is a tuberculosis so this patient who was deemed just for palliative care and who could have died from metastasis later was now taken for a curative treatment with surgical resection and her tb was treated with the help of att so in india if you get a pet positive lymph node it does not always mean its metastasis and two diseases can coexist and definitely you need to sample these nodes despite having a pet positivity as in this case where a treatment was changed based upon your ebus from just a palliative care to a curative index so this changed the course of the treatment in a patient with a ca cervix similarly we had a 68 year old male who was a non-smoker diabetic hypertensive post ptc on dual antiplatelets he had a history of renal cell carcinoma on sitigated biopsy pet city was done that showed mediastinal lymphadenopathy suggestive of metastasis so again can you hear me yeah so this patient was planned for the palliative care by the medical oncologist and he was referred to us for mediastinal lymph node sampling as you can see from the pet city here the patient has got a renal mass which is a renal cell cancer and an isolated right paratrooking lymph node which in most of our mind and with respectability we will think it is just a metastatic node so we took this patient for e bus we did the e bus sampling of the lymph node and what we could see was again a granuloma this is another case where the patient was doomed as a metastatic disease for a palliative care we did an abuse we showed a granuloma and it was suggestive of tuberculosis so the patient was starting on att and now the patient underwent nephrectomy which is a curative intern so this is how your e-bus can really make a difference in your treatment management a 50 year old male diabetic he presented to us with complaints of dry cough and breathlessness and ct was successful of mediastinal lymphadenopathy with perilymphatic distribution of nodules and it was done there was petabyte deletion localized only to the lung and this is something new that is coming up which is called as a ebus intra-nodal cryobiopsy so this was the pet image which showed lots of pet avoid lymph nodes and we kept on doing an uh ebus for almost 10 to 15 passes but we couldn't arrive at a diagnosis that is when we did something called as a cryo intra nodal cryobiopsy so what we did was instead of the needle we passed the cryoprobe we tunnel through the airways into the lymph node with the help of the cryoprobe and we use the cryoprobe to take a sample and as you can see the picture on the right side that is an intranodal cryo biopsy and this was then sent for analysis and as you can see from this picture the cryo biopsy of the node was suggestive of granuloma and this and it was cd4 by cd8 ratio was increased and this turned out to be a case of your sarcoidosis so this is another innovation which has been done in recent times in the utility of ebus and this is a one last case a patient was a 24 year old male non-smoker no comorbidity he presented to us with complaints of hostness of voice breathlessness loss of weight and appetite there was a collapse of the left upper lobe with mediastinal lymphadenopathy and prior fob was done ball was suggested of gene expert endo bronchial biopsy was inconclusive so this patient had a bronchoscopy done which was done by us and it suggested tuberculosis but look at the pet city we weren't convinced that this is probably a case of just tuberculosis so we took this patient for ebus because the patient was having excessive bleeding even upon touching the mucosa and in ebus what we got was a nut cell carcinoma a nut are the midline tumors which are extremely aggressive and there is no definitive treatment for this case and this is a very very rare case and one of the first reported cases of nut carcinoma along with tuberculosis but however we lost the patient within three months of diagnosis because of the aggressive nature of the tumor so i will end my presentation here and here is my mail id if you got any queries you can drop me your mail and if there are any further queries you can take it was really great so uh everyone if you have any questions you can put it in comment box i will wait for two minutes and so can take that up asap right now and explain you all that but uh if you don't have anything you can drop a mail to search id so anything will do but right now uh we are live and we can answer your questions right away can you please repeat the procedure that's not possible right now because it was really beautiful so you have an ultrasound tip you go and approximate against the wall and there will be a sheet coming out through the sheet you will pass a needle you will see the node and you take a biopsy and then come out that's the simple way to explain the procedure okay okay but if you want to uh watch it again the recording will be made available really soon uh in cases of medicine and you can watch there the biopsy forcep is a bit blunt uh how is it inserted into the node across the airway in the wall i hope it must be a permanent uh so like what we do is um uh you can take an electrocautery knife and you can make a small nick at the region where you want to insert your forceps that means you are you are making a small hole and through that hole you will pass the forceps and take a biopsy and come out okay so basically you are creating a cat before you pass the forceps and then you will take out the normal biopsy great okay so and the needle size is 19 8 or 22 what is the preferable one see to be very honest with you like we have tried all the needles we have tried 22 we have tried 21 we have tried 19 to be very honest like if your skill is good and if you have a rose and you have an experienced pathologist then most of the time whatever needle you get you will get a diagnosis in 95 percentage of cases there is no difference between a 21 gauge and a 22 gauge but when you go to 19 watch yes the 19 watch gives you a bigger material because it is of a bigger luminal size but the problem with the bigger material is it is also blood contaminated so when you take it for a cytopathological analysis probably your pathologist will say that more of a bloody sample is coming but however in few cases when we had repeated negativity on 21 or 22 gauche we have used the 19 gauge and in such cases we have got a diagnosis so we use 19 watts not as a routine only when we have repeated passes which comes negative in such cases we use either 19 gauge or we use a forceps biopsy or we use the intra nodal correct so but for most cases even a simple 21 and 22 should be sufficient okay so i hope that answers your question uh sakshi okay so with this we'll wrap up the session thanks a lot sir for joining us today it was really great and thank you everyone for joining us and please get back to us with some amazing suggestions and speakers suggestions too we'll try our best to arrange this session with those recommended speakers thank you have a great weekend eyes up

BEING ATTENDED BY

Dr. Nilesh Charel & 699 others

SPEAKERS

dr. Viswesvaran Balasubramanian

Dr. Viswesvaran Balasubramanian

Renowned Interventional Pulmonology and Sleep medicine specialist | Consultant - Yashoda hospitals Hyderabad | Credits more than 25 publications in indexed national and international journals

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dr. Viswesvaran Balasubramanian

Dr. Viswesvaran Balasubramanian

Renowned Interventional Pulmonology and Sleep...

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