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.

IntroductionCentral airway obstruction (CAO) is a life-threatening complication of lung cancer. The prevalence of CAO in lung cancer patients is unknown. We audited CAO burden to inform our local cancer service.MethodsThis is a cohort review of all new lung cancer diagnoses between 1 November 2014 and 30 November 2015. CAO was defined by CT appearance. CT scans and routine patient records were followed up to 30 November 2018 to determine the prevalence of CAO at diagnosis; the characteristics of patients with prevalent CAO; mortality (using survival analysis); and incident CAO over follow-up.ResultsOf 342 new lung cancer diagnoses, CAO prevalence was 13% (95% CI 10% to 17%; n=45/342). Dedicated CT scan review identified missed CAO in 14/45 (31%) cases. In patients with prevalent CAO, 27/44 (61%) had a performance status of ≤2, 23/45 (51%) were diagnosed during an acute admission and 36/44 (82%) reported symptoms. Treatments were offered to 32/45 (71%); therapeutic bronchoscopy was performed in only 8/31 (26%) eligible patients. Median survival of patients with prevalent CAO was 94 (IQR 33–274) days. Multivariate analysis, adjusting for age, gender and disease stage, found CAO on index CT scan was independently associated with an increased hazard of death (adjusted HR 1.78 (95% CI 1.27 to 2.48); p=0.001). In total, 15/297 (5%) developed CAO during follow-up (median onset 340 (IQR 114–551) days). Over the audit period, 60/342 (18%; 95% CI 14% to 22%) had or developed CAO.DiscussionsThis is the first description of CAO prevalence in 40 years. Patients with prevalent CAO had a higher mortality. Our data provide a benchmark for service planning.

IntroductionCervical lymphadenopathy in lung cancer indicates advanced disease. The presence of mediastinal lymphadenopathy is commonly associated with involvement of neck lymph nodes and some studies suggest routine neck ultrasound (NUS) in this group of patients. We conducted a two-phase study looking at training a respiratory physician to perform ultrasound-guided neck lymph node aspiration in patients with suspected lung cancer.MethodsIn the first phase of the study, one of the authors underwent training in NUS according to predetermined criteria. The adequacy of sampling was prospectively recorded. In the second phase, consecutive patients with suspected lung cancer and mediastinal lymphadenopathy underwent NUS and sampling of abnormal lymph nodes. The outcomes were the adequacy of samples for pathological analysis and molecular analysis, prevalence of cervical lymphadenopathy, and change in stage.ResultsFollowing the period of training, 35 patients underwent neck node sampling with an overall adequacy of 88.6% (95% CI 78.1–99.1%). Cervical lymph node involvement was confirmed in 13 out of 30 patients with lung cancer (43.3%, 95% CI 25.5–62.6%). Further immunohistochemistry and molecular studies were possible in all patients when it was required (nine cases). NUS led to nodal upstaging in four out of 30 (13.3%) cases.ConclusionTraining a respiratory physician to perform NUS and needle sampling to an acceptable level is feasible. Benefits of embedding this procedure in lung cancer diagnosis and pathway staging need to be explored in further studies.

Background: A variety of disease processes investigated by respiratory physicians can lead to cervical lymphadenopathy. Ultrasound (US) has revolutionised respiratory investigations, and neck ultrasound (NUS) is increasingly recognised as an additional important skill for respiratory physicians. Objectives: We aimed to assess the feasibility of NUS performed by respiratory physicians in the workup of patients with mediastinal lymphadenopathy. Methods: This is a single-centre retrospective cohort study. All patients that underwent US-guided cervical lymph node sampling were included. The diagnostic yield is reported, and specimen adequacy is compared for respiratory physicians and radiologists. Results: Over 5 years, 106 patients underwent NUS-guided lymph node sampling by respiratory physicians compared to 35 cases performed by radiologists. There was no significant difference in the adequacy of sampling between the two groups (respiratory physicians 91.5% [95% CI 84.5–96%] compared to 82.9% [95% CI 66.4–93.4%] for radiologists [p = 0.2]). In the respiratory physician group, a diagnosis was achieved based on lymph node sampling in 89 cases (84%). Neck lymph node sampling was the only procedure performed to obtain tissue in 48 cases (45.3%). Conclusion: NUS and sampling performed by respiratory physicians are feasible and associated with an adequacy rate comparable to that of radiologists. It can reduce the number of invasive procedures performed in a selected group of patients. Guidelines for training and competency assessment are required.