Endobronchial Ultrasound (EBUS) Uses and What to Expect

Endobronchial ultrasound (EBUS) is used for diagnosing lung cancer and certain inflammatory lung diseases that cannot be confirmed with standard imaging tests. The procedure can also help determine the stage of lung cancer.

EBUS is a minimally invasive procedure in which a flexible scope is inserted through the mouth and into the larger airways of the lungs (called the bronchi) to image tissues using high-frequency sound waves. Endobronchial ultrasound is typically performed on an outpatient basis.

Uses and Purpose of Endobronchial Ultrasound

After a lung cancer diagnosis (or if initial tests suggest it is lung cancer), endobronchial ultrasonography may be ordered alongside traditional bronchoscopy. Unlike bronchoscopy, which directly visualizes the airways through a viewing scope, EBUS can help healthcare providers see beyond the airway tissues using refracted sound waves.

Endobronchial ultrasound can be used to determine the extent of tumor invasion in the central airways.

The two primary indications for EBUS include:

• Staging of lung cancer: Staging is used to determine the severity of lung cancer so that the appropriate treatment is delivered. Endobronchial ultrasound allows healthcare providers to obtain tissue from within the lung or mediastinal lymph nodes in the chest using a technique called transbronchial needle aspiration (TBNA). The biopsied cells can then be sent to the lab for analysis to help determine how early or advanced the cancer may be.
• Evaluation of abnormal lesions: If an abnormal lesion is found on a chest X-ray or computed tomography (CT) scan, EBUS with TBNA can be used to obtain a sample of the affected tissues. Doing so can help confirm if swollen lymph nodes are caused by cancer or an inflammatory lung disease like sarcoidosis. EBUS can also be used to sample lymph nodes in people suspected of having pulmonary lymphoma, a form of blood cancer.

Endobronchial ultrasound is usually not the first tool a practitioner will turn to diagnose lung cancer. It is typically ordered when initial imaging tests and lab tests are strongly suggestive of the disease. EBUS is particularly useful in accessing a mass or nodule situated near a major airway, saving your healthcare provider from having to go through the chest wall.

EBUS is most commonly used to stage non-small cell lung cancers (NSCLC) but is being increasingly used to stage small cell lung cancers (SCLC), a less common form of the disease.

Limitations

As effective a tool as endobronchial ultrasound is, there is only a limited amount of lung tissue that it can visualize. While it is good at visualizing the upper and front portions of the mediastinum (a space between the membrane lining the two lungs), it may not be able to see if the lung cancer has spread (metastasized) to other parts of the mediastinum.

EBUS is also sometimes used to diagnose lung infections, although its efficacy can vary. With tuberculosis, endobronchial ultrasound can access hard-to-reach lymph nodes and establish whether the bacterial strain is resistant to available antibiotics. Even so, with a sensitivity of roughly 55% in people with tuberculosis, EBUS is prone to false-negative results in five of every 10 procedures.

Similar Tests

Prior to the introduction of endobronchial ultrasonography, the accurate staging of lung cancer required invasive procedures that accessed the lungs via the thorax (chest). These include such procedures as:

• Mediastinoscopy, in which a scope is inserted through an incision at the top of the sternum (breastbone)
• Thoracoscopy, in which small incisions are made between the ribs of the chest to access the lungs using narrow, specialized tools and a viewing scope
• Thoracotomy, an open lung surgery

Endobronchial ultrasonography can provide healthcare providers with the information needed without the risks associated with surgery.

Types

Depending on what your healthcare provider is evaluating, you may receive one of two different types of EBUS tests. Your healthcare provider may also want to perform a biopsy during your EBUS test.

• Convex probe (CP-EBUS): This type is used to image the larger airways. If your healthcare provider needs to do a biopsy during the procedure, it can be done with EBUS-transbronchial needle aspiration (EBUS-TBNA).
• Radial probe (RP-EBUS): This type gives your provider a 360-degree view of your airways. It can produce more detailed images than a convex probe EBUS. If your healthcare provider needs to do a biopsy, they will need to use separate equipment.

Risks and Contraindications

The risks and contraindications for endobronchial ultrasonography are similar to those of bronchoscopy. Some are mild and transient, resolving without treatment, while others require medical intervention.

The most common risks of endobronchial ultrasound include:

• Laryngospasm: Spasms of the vocal cords characterized by cough, difficulty swallowing, and sore throat
• Bronchospasm: Spasms of the airways characterized by shortness of breath, cough, and wheezing
• Hypoxemia: Low blood oxygen
• Infection, often related to bleeding at the biopsy site or accidental injury to the airways
• Cardiac complications ranging from irregular heartbeat to heart attack, typically in those with a pre-existing heart condition
• Pneumothorax: A collapsed lung (considered a medical emergency)

Because anesthesia is required, people may also experience nausea, vomiting, muscle pain, blood pressure changes, and bradycardia (slowed heart rate).

Ultrasound is contraindicated in people with the following health conditions:

Before the Procedure

Like bronchoscopy, endobronchial ultrasonography is generally considered safe with a relatively low risk of complications. Knowing what to expect can help you prepare.

Timing

Even though the EBUS procedure takes only around 20 to 30 minutes to perform, it can take up to four hours to prepare for the procedure and recover from the anesthesia. It is best to clear your schedule on the day of your procedure and arrange for one more day off so you can rest and recuperate.

Location

Endobronchial ultrasound is performed in an operating room or special procedure suite of a hospital. The room is equipped with an electrocardiogram (ECG) machine to monitor your heart rate and a ventilator to deliver supplemental oxygen if needed.

What to Wear

As you will be asked to change into a hospital gown, dress comfortably in clothes that can be easily removed and put back on. It is best to leave any jewelry or valuables at home.

Also be prepared to remove any dentures, hearing aids, contact lenses, or eyeglasses before the procedure. You will be given a secure place to store these along with your clothing and other belongings.

Food and Drink

In most cases, you will be asked to stop eating at midnight the day before the procedure. Most EBUS procedures are scheduled in the morning so that you don’t get excessively hungry. If the procedure is scheduled later in the day, the healthcare provider may advise you to stop eating six hours beforehand.

Your healthcare provider will also advise you about which drugs you need to stop prior to endobronchial ultrasound. Some medications can interfere with coagulation (blood clotting), leading to excessive bleeding and poor wound healing. Others may cause the excessive and harmful build-up of lactic acid in the blood.

Some of the drugs of concern include:

Some of these medications may need to be stopped a week in advance, while others only need to be discontinued on the day of the procedure. Advise your healthcare provider about any and all drugs you take to avoid potential harm.

EBUS Test Cost and Health Insurance

In the United States, the cost of an EBUS test can range from around $3,250 to $8,500 depending on where you live and which facility you choose. This includes payments made by both the insurer and the patient.

Prior authorization is required from your medical insurer before EBUS can be covered. To estimate your out-of-pocket expense, check the copay or coinsurance provisions in your policy before or after the deductible.

To reduce costs, ensure that the pulmonologist, anesthesiologist, and facility are all in-network providers with your health insurer. Out-of-network providers almost invariably cost more and, in some cases, may not even be covered by your insurance plan.

What to Bring

Be sure to bring your insurance card, an official form of identification (such as your driver’s license), and an approved form of payment if copay/coinsurance fees are required upfront. Because there may be waiting time, think about bringing something to read or occupy yourself with.

Other Considerations

Because anesthesia is involved, you will need to bring someone with you to drive you home. Some facilities will not allow you to leave unless you have organized transport, ideally with a friend or family member who can escort you inside your house and stay with you overnight.

EBUS Procedure

Endobronchial ultrasonography is performed by a pulmonologist along with an anesthesiologist and surgical nurse.

Pre-Test

You will need to complete a consent form and disclose any medications you’re taking and adverse reactions you’ve experienced. Your anesthesiologist will ask you about any allergies you have or adverse reactions you’ve experienced with anesthesia. The healthcare provider should also advise about the type of anesthesia being used and what to expect afterward.

Shortly before the procedure, the nurse will insert an intravenous (IV) line into a vein in your arm through which anesthesia and other medications can be delivered. You will also have adhesive probes attached to your chest to monitor your heartbeat on the ECG machine. A pulse oximeter will be placed on your finger to monitor your blood oxygen levels.

Throughout the Test

Endobronchial ultrasound is usually performed under procedural anesthesia, meaning that you will experience a “twilight sleep” but not sleep as deeply as you would with a general anesthetic (although one can be used, if needed).

Before the endobronchial ultrasound begins, the healthcare provider will first perform a regular bronchoscopy to visually examine the airways. The device will then be removed and replaced with an EBUS bronchoscope.

Unlike a regular bronchoscope, an EBUS bronchoscope can help a practitioner differentiate between normal and cancerous tissues because of the visual patterns it can project on the video monitor.

If an abnormal mass, lesion, or lymph node is found, the healthcare provider can obtain a tissue sample with the transbronchial aspiration needle.

After the Procedure

Most people tolerate endobronchial ultrasound well and are able to leave the hospital on the same day. Even so, it is not uncommon to experience nausea and feel unsteady due to the anesthesia.

Sore throat, hoarseness, and coughing are also common, although they tend to be mild and resolve in a day or so. You may also have pinkish or reddish phlegm if a biopsy was performed, but this is normal and usually of little concern.

After returning home, it is best to relax and take it easy for a day or so. You should not drive or operate heavy machinery for at least 24 hours following the procedure.

If you experience any unusual, persistent, or worsening symptoms—including fever, chills, coughing up blood, or trouble breathing—call your healthcare provider immediately. These may be signs of an infection.

Interpreting Results

Following an endobronchial ultrasound, your practitioner will schedule an appointment to discuss your results. If a biopsy was performed, the results are usually returned within two to five days.

If the procedure was used to stage lung cancer, your healthcare provider will discuss the results of the transbronchial biopsy with you. The information may include:

• The cancer type, such as lung adenocarcinoma, squamous cell carcinoma, large cell carcinoma
• The histological findings: Cellular characteristics seen under the microscope that can determine how aggressive or invasive a tumor may be
• The molecular test results: A report of the genetic profile of your cancer, which can determine if you are a candidate for certain therapies

These pieces of information can be used to stage and grade the disease, as well as ensure appropriate treatment.

If used for diagnostic purposes, EBUS results would detail what, if any, abnormalities were found in the histology.

Generally speaking, if a visible lesion is situated within the airways, there is between an 85% and 90% chance that it is cancer. The risk is lower if the lesion is situated beneath mucosal tissues and may be explained by other conditions like sarcoidosis.

Summary

Endobronchial ultrasound is used to diagnose or stage lung cancer or to diagnose certain inflammatory lung conditions. It is a minimally invasive procedure that can be done on an outpatient basis.

EBUS involves inserting a flexible tube into the airways to obtain images of them that your healthcare provider can use to identify lesions in the lungs. They may also take a biopsy during the procedure.