© 2008 American Thoracic Society
Modalities for Diagnosis of Peripheral Lung DiseasesTo the Editor:I read with interest the article by Dr. Eberhardt and colleagues (1), which demonstrates that a combination of endobronchial ultrasound (EBUS) and electromagnetic navigation bronchoscopy (ENB) improves the diagnostic yield of flexible bronchoscopy in peripheral lung lesions compared with either of the procedures individually. Furthermore, the combination does not compromise safety. Their primary outcome was the diagnostic yield and secondary outcomes included analysis of yield by lesion size, lobar location, and lesion pathology. The more important comparison relevant for the clinician, however, is whether the EBUS and ENB combination procedure is superior to or of the same value as computed tomography (CT)–guided transthoracic needle aspiration and/or biopsy (TTNA/B) in diagnosing peripheral lung lesions. Several aspects of the TTNA/B procedure offer special advantages over the EBUS and ENB combination procedure. The TTNA/B procedure offers a higher diagnostic yield of up to 90% of those tested (2), and the suspected nodule may be smaller than 10 mm (3). The TTNA/B procedure is done under local anesthesia, whereas the combined procedure is done under general anesthesia or moderate sedation. In addition, the cost of TTNA/B is much lower than the combined EBUS and ENB procedure. Two aspects of the EBUS and ENB procedure, nevertheless, are worth noting. First, Eberhardt and coworkers reported that pneumothorax occurred in only about 10% of those tested, compared with a 20% rate in transthoracic biopsies. However, the incidence of pneumothorax also relates to the degree of obstructive airway disease (3); the authors didn't report the FEV1 level or chronic obstructive pulmonary disease (COPD) status of their patients. Furthermore, following pneumothorax, EBUS and ENB cannot be repeated due to anatomical changes after partial collapse of the lung, while with CT-guided needle aspiration, biopsy is still possible. A second aspect relevant in the United States is that bronchoscopy-based procedures are usually done by pulmonologists, while CT-based procedures are done by radiologists. In other countries, however, pulmonologists perform the CT-guided transthoracic biopsy as well. Table 1 tabulates our last 3 years of cumulative experience with TTNA/B. The overall diagnostic rate was 83%, and the pneumothorax rate 19%. Only 4% of patients required treatment with chest tube, and no fatality occurred.
In summary, TTNA/B is superior to EBUS and ENB for diagnostic purposes, and less expensive. A comparison of the complication rates between the two approaches awaits the presentation of valuable data on the degree of COPD in their patients.
Assaf Horafeh Medical Center FOOTNOTES Conflict of Interest Statement: D.S. has no financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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