1% versus 2% lignocaine for airway anesthesia in endobronchial ultrasound-guided transbronchial needle aspiration: A pilot, double-blind, randomized controlled trial

Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations

Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.

The cricothyroid versus Spray-As-You-Go method for topical anesthesia during Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA): The CRISPEN randomized clinical trial

Background:

Guidelines for flexible bronchoscopy in adults recommend both Cricothyroid and Spray-as-you-go method as the acceptable techniques for lignocaine administration. No studies have compared these two methods for topical anesthesia during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

Objectives:

Co-primary outcomes were the comparison of cough count and operator-rated overall procedure satisfaction on a Visual Analog Scale (VAS) between the groups. The secondary outcomes were cumulative lignocaine dose, time from bronchoscope introduction to crossing the vocal cords, procedure duration, and complications between the groups.

Methods:

Consecutive participants (age >18 years) undergoing EBUS-TBNA were randomized (1:1) to either cricothyroid or spray-as-you-go methods for lignocaine administration.

Results:

Three hundred and sixty-five participants were randomized (183: Cricothyroid and 182: Spray-as-you-go). Cough count till reaching carina (median [interquartile range]) was significantly lower (cricothyroid, 1 [0–2] vs. spray-as-you-go, 4 [2–6], P < 0.001) and operator rated overall procedure satisfaction, on VAS (mean ± standard deviation) (cricothyroid, 7.96 ± 1.48 vs. spray-as-you-go, 7.29 ± 1.48, P < 0.001) significantly greater in the cricothyroid group. Cumulative lignocaine dose (163.28 ± 31.50 mg vs. 177.0 ± 30.12 mg, P < 0.0001) and time from bronchoscope introduction to crossing the vocal cords (20.80 ± 11.21 s vs. 38.08 ± 15.26 s, P < 0.001) was significantly lower in the cricothyroid group. Procedure duration was similar in both the groups. Minor complications occurred in three patients in cricothyroid and six patients in the spray-as-you-go group (P = 0.31).

Conclusions:

Cricothyroid lignocaine administration is associated with less cough and superior operator-rated procedure satisfaction during EBUS-TBNA, at a lower cumulative lignocaine dose administered.

Trial Registration:

www.clinicaltrials.gov NCT02981264

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.