Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been widely implemented in evaluating mediastinal disease. EBUS-TBNA is performed with low flow oxygen systems or general anesthesia. Little data exist on use of high flow nasal cannula (HFNC) in EBUS-TBNA. Methods: This was a single center parallel group randomized controlled trial comparing oxygenation through HFNC (Optiflow) against nasal prongs during EBUS. The primary end-point was the drop in oxygen saturations from procedure commencement, recorded by pulse oximetry, to the lowest level during EBUS-TBNA. Secondary end-points included changes in venous blood carbon dioxide, lowest oxygen saturation, changes in end-tidal CO2 during the procedure, intubation within 8 hours of the procedure and patient experience reported on a visual analog scale. Results: We randomized 20 patients to each study arm. The primary outcome of oxygen desaturation during the procedure was statistically significant with a difference of 7.7 percentage points (95% confidence interval, 4.91-10.49, P<0.001). The secondary outcome measure of lowest oxygen saturation was also statistically significant with a difference of −9.2 (95% confidence interval, −11.96 to −6.44, P<0.001). There was no difference in safety outcomes, visual analog scale score or in their willingness to return for repeat procedure. Conclusion: This single institution study in a university, tertiary referral center confirms that EBUS-TBNA performed with HFNC is associated with a statistically significant lower drop in oxygen saturation. Additional studies are needed to assess if this translates into improved clinical outcomes postprocedure.

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We read with interest the article by JI et al. [1] regarding the epidemiology of malignant pleural mesothelioma (MPM) in Sweden and familial clustering. The data in the study show the incidence of MPM in Sweden peaked in 2000 and has sharply declined since 2005. Data from other countries suggest a more delayed peak [2-4]. The highest annual incidence of MPM in the world has been reported to occur in the UK and Australia [5]. The incidence of MPM was predicted to peak in UK between 2011 and 2015; this was based on the known associated high latency period and the ban in using asbestos-containing products [6]. This variability in incidence trends across Europe can be explained by the different dates of asbestos bans in Europe, but Ireland migration trends also potentially play a role. Data from our institute indicates that the incidence of malignant mesothelioma has been increasing over the last decade (20 new cases diagnosed in 2002-2008 versus 26 cases in 2009-2013, an increase of 30% (95% CI 11.9-54.2%)). These findings are consistent with the statistics from the National Cancer Registry Ireland (figure 1) [7].