Endobronchial ultrasound (EBUS) has long been a common diagnostic tool used in the diagnosis of pulmonary pathologies. In the last decade, increased interest has been shown in its usage via the oesophagus for sampling lesions inaccessible via the airways. We describe three cases in which we used this modality to biopsy lesions not visualised via conventional EBUS and which would be too risky to be attempted via a CT-guided biopsy with a high likelihood of complications. More focused education on using EBUS via the oesophagus for respiratory trainees could greatly improve overall clinical practice. It improves the diagnostic yield of lesions and prevents subsequent referral to gastrointestinal colleagues which may delay diagnosis especially during the COVID-19 pandemic as was the case in our patient cohort where services are already limited. EBUS, due to its smaller size, is less irritant to the upper airways and requires less sedation than endoscopic ultrasound (EUS) scopes. It is also shorter than an EUS scope improving manoeuvrability. Each of our cases resulted in early histological diagnosis and subsequent appropriate treatment.

Pulmonary lymphangitis carcinomatosis is a complication of malignancy with a poor prognosis. We describe an unusual case in which it caused ventilatory failure and unfortunately death in a previously well male in his 70s. Abnormal chest imaging led to a wide differential diagnosis with Bronchoscopy confirming malignant cells. MRI of his pelvis and biopsy was done diagnosis of metastatic leiomyosarcoma, a particularly aggressive malignancy. Sarcoma-related lymphangitis carcinomatosis is rarely described in the literature and this is the first case to our knowledge of its association with leiomyosarcoma.

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Use of non‐invasive ventilation (NIV) in patients with hypercapnic respiratory failure has clear benefits over invasive ventilation. Existing risk prediction models are complex and difficult to apply in the acute setting. We developed the Midland NIV score comprising only five parameters for use to predict NIV failure (in‐hospital death or intubation) at initiation. Individuals with Midland NIV score of ≤11 (average 13% NIV failure) may be suitable for general ward care, compared to intensive care for those with Midland NIV score ≥12 (average 66% NIV failure rate). Prospective external validation is required.