Endobronchial ultrasound (EBUS)

What is EBUS?

An EBUS is a procedure that allows the doctor to look into your lungs (similar to bronchoscopy) then take samples of the glands in the centre of your chest (mediastinum) aided by the use of an ultrasound scanner.

A flexible tube (bronchoscope), which is about as thick as a pencil, is passed into your lungs via your mouth. A small camera at the end of the bronchoscope enables the doctor to look directly into your windpipe (trachea) and smaller airways (bronchi). A small ultrasound probe on the end of the camera allows the doctor to see the glands in the centre of the chest (mediastinum) and take samples under direct observation. Occasionally, it is useful to look down your gullet (oesophagus) at the same time with the same camera (the anaesthetic in your throat allows this), as sometimes the glands can be sampled from the gullet which often causes less coughing and is more comfortable for the patient with breathing difficulties.

Why am I having this procedure?

Most commonly, it is undertaken to collect samples from the central lymph glands in the centre of your chest (mediastinum) which may be enlarged for a variety of reasons. This procedure can be very helpful in supporting a diagnosis; in nine out of 10 interventions we would expect this to be the case. This will help improve the decision-making process regarding further treatment options.

Where is this procedure undertaken?

You will be informed of a time and date of your procedure.

Please come to the endoscopy department, which is on Level 3 of the Addenbrooke’s Treatment Centre (ATC).

Use ‘Car Park 2’. Take your parking ticket and appointment letter to the customer service desk in the car park to obtain discounted parking.

Please note that the appointment time is for your pre procedure check, not the time of your examination. The length of time you will be here will vary enormously but may be anything from two to four hours or more. Please ask your admitting nurse for further information during your admission check.

What should I do before the procedure?

• It is vital that you arrange transport to and from the hospital and have someone at home with you afterwards as you will be given sedation for the procedure.
• You should not eat four hours before the procedure, but you may have clear drinks for up to two hours beforehand.
• If you are taking, warfarin please read the ‘Alert for patients on Warfarin’ on page 2 as you might need to have an INR test seven days before the appointment.
• If you take any other blood thinning medication (anticoagulants) or antiplatelet (e.g. clopidogrel, aspirin) please contact your referring doctor for advice regarding when to stop taking this medication pre procedure.
• All other medication should be taken as normal with a small sip of water
• Wear clothing that is comfortable and not too tight fitting.
• You will be asked to remove all jewellery (except wedding bands), so it would be wise to leave valuables at home.
• You should inform the doctor if you take any medicines which ‘thin the blood’ such as: Aspirin, Warfarin, Rivaroxaban, Clopidogrel, Clexane or Dalteparin for example. It may be safer for you to not take these medicines before the procedure. The doctor will decide how long not to take them for.

For most patients, a period of 48 hours without the following medicines is required.

Warfarin: for patients advised to continue their medication

You must contact the referring doctor and the Pleural Team for Advice.

• You should have an INR test seven days before the endoscopy.
• If that INR result is 3.0 or less, continue with your usual daily warfarin dose.
• If that INR result is more than 3.0, ask your supervising anticoagulant service for advice to reduce your daily warfarin dose so that your INR is 3.0 or less when you have the endoscopy.

Warfarin: for patients advised to stop medication

• You should stop warfarin five days before the endoscopy. Ideally, your INR will be less than 1.5 when you have your procedure.
• After the endoscopy go back to your usual daily dose as soon as you are eating again (that will usually be the same evening).

You should have your INR checked one week later to ensure you are adequately anticoagulated again.

If you have:

• Metal mitral valve
• Metal valve + previous stroke / thrombosis
• Valvular heart disease you may need heparin injections instead of warfarin. Ask your local anticoagulant service for advice.

Clopidogrel: for patients advised to continue medication

• Continue with your usual dose.

Clopidogrel: for patients advised to stop medication

• You should stop clopidogrel seven days before the endoscopy.

Other anticoagulant medication

Acenocoumarol, sinthrome, phenindione, dindevan

If you are taking any of these please contact the endoscopy department 01223 216515.

Importantly, the operator on the day has the option not to perform the procedure if they perceive an elevated risk of major bleeding / haemorrhage.

Covid 19 testing requirements

If you are experiencing COVID symptoms (fever / persistent new cough / loss of taste / smell / flu like symptoms / new gastric disturbances) it is advised that you perform a LFT (lateral flow test) before you attend for the procedure and call the endoscopy department for advice on 01223 257080.

What happens during the procedure?

On arrival to the department we will explain the procedure to you and ask you to sign a consent form. You can change your mind about having the procedure at any time.

This procedure is carried out under sedation using anaesthetic spray that is applied to the back of the throat. During the procedure you may feel some slight discomfort as the bronchoscope is passed through your mouth into the airway, further anaesthetic is applied through the scoping device at the level of the voice box, this may make you cough but will settle down as the anaesthetic begins to work. The bronchoscope is then moved further down into an appropriate area for obtaining samples.

A plastic mouth guard will be placed between your teeth temporarily. This prevents your mouth from closing on the bronchoscope during the procedure. This will provide protection for your teeth and for the equipment.

Your oxygen levels will be monitored throughout and a small oxygen tube may be placed inside your nostril during the procedure. The sedation you have been administered can cause a need for some supplementary oxygen as you recover from the procedure. This is typically only for a short period of time.

The sedative will continue to have a mild sedative effect for up to 24 hours and may leave you unsteady on your feet for a while.

You must arrange for a responsible adult to come with you and wait to take you home. You will not be able to drive yourself. If you come without an escort, we will have to cancel the procedure. If you are entitled to use hospital transport, an escort is not required however; someone should be available to monitor you at home when you return there and stay with you overnight ideally. This applies to all patients receiving sedation medication.

What are the risks or complications?

It is common to have a minor sore throat which settles down quickly, you may also cough up a little blood after the procedure and this should not alarm you. However, if you cough up large amounts, feel unwell, or develop a fever, please contact your GP or your accident and emergency department if out of hours.

There is a small chance that this procedure may cause a pneumothorax (Air escaping from your lung into the chest cavity). The chances of this are approximately 1/1000. To resolve this you may need to have a small drain inserted into the space where the air has collected. It may be necessary for you to be admitted into the hospital in this circumstance.

Extremely rarely, infection can occur following the procedure but this is usually easily treated with antibiotics.

Following EBUS there is a very small risk of air or blood leaking into the centre of the chest. These conditions are characterised by chest pain and shortness of breath. Any concerns within five days’ post procedure please contact the pleural service team between 09:00 - 17:00 (Monday to Friday) or if out of hours please contact the respiratory specialist registrar via the hospital switchboard. Please find the contact numbers below.

When will I know the results of the procedure?

You will receive an appointment to discuss the results of the samples taken; this is approximately two weeks after the procedure.

Contacts / further information

Pleural service: 01223 349189

Respiratory specialist registrar (out of hours): 01223 245151

References / sources of evidence

National Institute for Health and Care Excellence. 2008. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal masses (IPG254). Available on the NICE website (opens in a new tab) [Last Accessed 21/05/2013].

North Bristol NHS Trust. 2010. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

Available on the North Bristol NHS Trust website (opens in a new tab) [Accessed 21/05/2013].

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and / or specialist one to one care is required.