Bronchoscopy with EBUS (Endobronchial Ultrasound)

This leaflet explains what a Bronchoscopy with EBUS (Endobronchial Ultrasound) is and how to prepare for it. The information here will help put your mind at ease about any worries you may have. Also, by helping you to prepare, this will make sure nothing stops you from having the procedure on the day.

If you are worried or concerned, please ask us any questions you have and we will do our best to help. Please remember that there are no “silly” questions.

This leaflet aims to cover as many different situations and problems you may have. Not all of the information may apply to you.

What is a Bronchoscopy with Endobronchial Ultrasound (EBUS)?

A Bronchoscopy is a procedure during which a flexible camera (known as a bronchoscope) is passed through your mouth and vocal cords into your windpipe and airways. This camera allows the team to look at your airways.

An Endobronchial Ultrasound (EBUS) is a specialised ultrasound probe (a type of camera which uses sound waves) which attaches to the bronchoscope to look through the walls of your airways to “see” the different structures next to them.

This test is used to take samples from your airways or the structures surrounding your airways.

Why do I need an EBUS?

You will have been offered an EBUS usually after you have gone through other tests by the chest team. Most commonly you will have had a CT scan of your chest (a detailed 3-dimensional X-ray scan).

The CT scan may have shown that the lymph glands next to your airways were larger than they should be.

It may also have shown a shadow in your lung which is lying close to one of your airways. An EBUS would be performed to take samples from these glands or shadows to work out what has caused these problems.

Much less commonly, an EBUS may be performed in a patient who has a lung cancer to make sure there was no sign of spread to the lymph glands before deciding what the right treatment would be.

Your team will talk to you to explain why they are doing the test.

What are lymph glands?

Lymph glands (also known as lymph ‘nodes’) are small glands located throughout the body. They form part of your body’s immune system.

They store your white blood cells and help to defend against harmful things such as bacteria and viruses. These glands can become swollen in a number of illnesses such as infections, inflammatory conditions and cancers.

How do I get ready for an EBUS?

It is important that you follow these simple instructions to avoid a delay or having to cancel the procedure. If there is anything you are unsure of, please feel free to ask any questions at any time.

The most important things to know are when to fast (go without food) and what adjustments you may need to make in taking your regular medicines.

Fasting

We ask you to fast before the procedure to make sure that your stomach is empty. This reduces the chance of you being sick during the procedure, which is very dangerous and could damage your lungs.

You should not eat anything for 6 hours before your appointment time. You can have clear fluid up until 2 hours before your appointment time.

Your procedure may be done in the morning or afternoon.

Morning appointments

If your appointment is in the morning, we ask you to fast from midnight on the day of your procedure. You can have morning medications (except diabetes medications and medications to thin the blood, we explain what to do with these below) providing they are taken with a small sip of water before 06:30am in the morning.

Afternoon appointments

If your appointment is in the afternoon, you can have a light breakfast, such as a slice of toast around 07:30am. You can have clear fluids up till 11:00am. You can take your morning medications (except diabetes medications and medications to thin the blood, we explain what to do with these below) with your breakfast.

Will you change any of my usual medicines?

We may need to change some of your medicines in the days leading up to your test or on the day of the test itself. These are the most common medicines we might change:

What should I do with my diabetes TABLETS before my test?

Acarbose

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning: omit morning dose if you have been told to fast from midnight.

If your test is in the afternoon: take your morning dose if eating breakfast. Do not take your lunchtime dose.

Repaglinide or Nateglinide

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning: omit morning dose if you have been told to fast from midnight.

If your test is in the afternoon: take your morning dose if eating breakfast. Do not take your lunchtime dose.

Pioglitazone

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning: take as normal.

If your test is in the afternoon: take as normal.

Sitagliptin, Saxagliptin, Vildagliptin

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning: omit your morning dose.

If your test is in the afternoon: omit your morning dose.

What should I do with INSULINS before my test?

Once daily (evening)

(Lantus® / Glargine or Levemir / Detemir® Insulatard® or Humulin®)

Day before going into hospital: no dose change.

Day of the test:

If your test is in the morning: no dose change.

If your test is in the afternoon: no dose change.

Once daily (morning)

(Lantus® / Glargine or Levemir / Detemir® Insulatard® or Humulin®)

Day before going into hospital: no dose change.

Day of the test:

If your test is in the morning: Take your normal dose. Your blood glucose will be checked on admission.

If your test is in the afternoon: Take your normal dose. Your blood glucose will be checked on admission.

Twice daily

(Novomix 30® / Humulin M3® / Humalog Mix 25® / Humalog Mix 30®)

Day before going into hospital: no dose change.

Day of the test:

If your test is in the morning:

• Halve the usual dose
• Your blood glucose will be checked on admission
• Resume your normal insulin with your evening meal.

If your test is in the afternoon:

• Halve the usual dose
• Your blood glucose will be checked on admission
• Resume your normal insulin with your evening meal.

3, 4 or 5 injections daily

Day before going into hospital: no dose change.

Day of the test:

If your test is in the morning:

• Do not take your morning dose of short acting insulin if no breakfast is eaten
• If you normally take a long acting basal insulin in the morning you should take your normal dose
• If you normally take a pre-mixed insulin the dose should be halved
• Do not take your lunchtime dose. Resume your normal insulin with your evening meal.

If your test is in the afternoon:

• Take your usual morning insulin dose(s)
• Do not take lunchtime dose
• Your blood glucose will be checked on admission
• Resume your normal insulin with your evening meal.

If you are using a continuous insulin pump, this will continue to run at its normal setting. Your blood sugar will be checked before and during the procedure. If your blood sugar falls, we will turn your insulin pump off until you have completed the procedure and are able to eat and drink.

Blood thinning medications

It is important to stop your blood thinning medicine before your test. Failure to do so may increase the chance of you having serious bleeding during the test. This would put your health at serious risk and make it harder to make a diagnosis.

If you are using Warfarin, you should have been told exactly when to stop it and when to have a blood test prior to the test. If not please ring the respiratory secretaries.

If you are using Apixiban (Eliquis), Dabigatran (Pradaxa) or Rivaroxaban (Xerelto) you should have been given a stop date by the Consultant referring you for the procedure. If not please ring the respiratory secretaries.

The following is a guide to how long each different blood thinner needs to be stopped before the EBUS.

Warfarin

Stop 5 days prior to Bronchoscopy. You will need an INR test the day before the Bronchoscopy to make sure your INR is below 1.5. Please check with us to see if you need injections to thin the blood whilst your INR is low.

Aspirin

Do not take on the morning of the procedure.

Clopidogrel (Plavix) / Dipyridamole (Persantin) / Prasugrel (Effient) / Ticagrelor (Brilique)

Stop 7 days before the Bronchoscopy. Please contact us and check if your Cardiologist has advised you not to stop these medications as we may need to discuss the risk versus benefit with them.

Daltaparin / Tinzaparin / Enoxaparin

Stop one full day before the procedure.

Apixaban (Eliquis) / Dabigatran (Pradaxa) / Rivaroxaban (Xerelto)

Usually stopped 2 to 4 full days before the procedure but please check with us as your kidney function (determined by blood test) will determine when this should be stopped.

Medication for Parkinson’s Disease

Medicines for Parkinson’s disease need to be taken at very precise times. We advise you to take your normal medicine with a small sip of water up to two hours before the test. We will normally make sure you are first on the list for the test.

We may ask you to bring a supply of your medicine to hospital so that you can take it as soon as you are able to eat and drink, if your next dose is at this time. If you have a very complicated combination of medicines, we may discuss your case with your supervising consultant before you have the test.

Addison’s Disease and other conditions needing long-term steroid use

The treatment for Addison’s disease is daily use of steroids. Some patients with other conditions such as asthma, rheumatoid arthritis and bowel problems may also take long term steroid treatment (specifically 5mg or more of prednisolone a day).

If this applies to you, we will give you an injection of Hydrocortisone into a muscle before you have the test. We will also ask you to double your normal dose of Hydrocortisone or Prednisolone tablets for 24 hours after the test. After this, providing you are well, you can go back to your normal dose.

How exactly is an EBUS test done?

You may have had relatives or friends who have had other types of camera test done and this has made you worried. This is a simple and safe test and by telling you exactly how it is carried out, we hope that it puts you at ease.

On the day

You will need a friend or relative to bring you, collect you and stay with you overnight after you’ve been discharged. If nobody is available to do this, then you will be admitted to hospital overnight.

Please wear comfortable clothing and ensure you remove nail varnish as this can interfere with the monitor used to read your oxygen levels. If you smoke, please try to avoid doing so on the day of the procedure as it can lower your oxygen levels during the procedure.

Bring all your medication (including over the counter remedies) and a list of any allergies.

You must tell us of any Latex allergy as this is used during the procedure. We can still do the procedure without latex, but it requires special arrangements to be made in advance of your test.

Please come to the Endoscopy department located on the lower ground floor of the South Wing at North Tees Hospital.

After booking in at reception, you will be taken through to the Endoscopy department to go through a checklist with a nurse. A relative or friend may be able to sit with you during this conversation, but they won’t be able to accompany you into the procedure room while you are having your test.

The nurse will ask you questions about your medical history, which medicines you take and what allergies you have. They will also do some simple checks of your pulse, blood pressure, oxygen levels and temperature.

You may have answered some of these questions before you came for the test, but these questions are to make sure that the test is carried out as safely as possible.

You will then be offered a seat in the Endoscopy waiting area so you may wish to bring a book or some music and headphones to keep yourself relaxed.

You will be given an appointment time, but the procedure may not take place at this exact time, depending on the number and type of cases we have.

We know it is worrying to sit and wait for a procedure, but sometimes cases take longer than expected. We will do our best to keep you informed on the day.

The Doctor will go through a consent form to ensure you understand the risks and benefits of having the procedure. You will have the chance to ask any questions you have at this time.

Having the EBUS

When you are ready you will be taken through to the EBUS room where you will be made comfortable on a patient trolley.

The Nurses will go through some simple checks, including checking your name and allergies. You will then be attached to different monitors to allow the team to read your pulse, blood pressure and oxygen levels during the procedure.

A thick needle (cannula) will be inserted into your arm/hand so that we can give you sedation.

The Doctor will give you a numbing local anaesthetic (throat spray). This can taste a little unpleasant, but this passes quickly. It is common to feel a lump in your throat as it is numbing, your mouth and throat will then go completely numb and feel strange. These are all normal sensations and nothing to worry about.

The team will then give you sedation through the drip. This is usually a combination of two different medicines called Midazolam and Fentanyl. This is to relax you and make you feel sleepy.

You will usually receive oxygen through a soft sponge into one of your nostrils.

When the team are happy that you are ready they will lie you flat. The Doctor performing the test will stand behind you at the head of the bed. The other team members will stand around the bed to assist.

The camera is then passed through your mouth and your vocal cords (voice box). At this point, the team will spray more local anaesthetic on your vocal cords, windpipe and airways through the camera. This is to numb them and make you much more comfortable.

It is normal to cough and to have a sensation of narrowing of your throat while this is happening. It passes and the team will be there to reassure you. There is always plenty of room to breathe.

The Doctor will use the EBUS camera to find the abnormal area seen on your previous CT scan. If it is safe to do so, biopsies will then be taken by passing a needle through the camera and wall of your airway into the gland or shadow.

To give the best chance of working out why a gland has swollen or what a shadow is, multiple biopsies or samples are taken. If there is more than one abnormal gland or shadow, the team will take biopsies from these as well. The biopsies should not cause you any pain, but you will probably cough while they are being taken.

You might hear or remember lots of numbers and letters being spoken during the test. This is the team noting exactly where they are taking samples from.

The procedure will be performed by a Consultant, possibly with help from a senior Doctor. There will be a minimum of 2 nurses to look after you during this time. The procedure usually takes 20 to 30 minutes.

When the EBUS is finished you will be taken to the recovery area.

Will I be awake during the procedure?

As mentioned previously, we will give you sedation before and during the procedure. This will usually make you more relaxed and sleepy.

This isn’t a general anaesthetic, so you will not be unconscious. You may remember some or all of the procedure.

Will I be able to go home on the same day of the EBUS?

Yes, as long as you have someone to take care of you that night.

After the EBUS you will be monitored in the recovery area for up to 2 hours while the local anaesthetic wears off. When the Nurses are happy, you will be offered a drink and something to eat.

Important: The sedation medication can affect your judgement and behaviour for up to 24 hours after the procedure. Therefore, for the first 24 hours you must not:

• Drive
• Drink alcohol
• Sign any legal documents
• Work
• Operate machinery
• Be responsible for small children.

It will be necessary for someone to collect you from the Endoscopy Unit and stay with you for 24 hours following the procedure.

If we have had to adjust or stop your normal medicines before the procedure, we will tell you and the person collecting you when to restart them before you leave the department.

What risks or side effects should I know about?

It is important to remember that having an EBUS is a common procedure. It is safe. If you have been asked to have an EBUS then your team feel that the possible benefits outweigh any risks. The following are the risks which you should be aware of:

• Sore throat and hoarse voice
• Cough: it is common to cough during the procedure. We try to reduce this as much as possible by using local anaesthetic spray as we are inserting the camera. You may cough more often than normal for you for a few days after the test.
• Bruising in your eye: very rarely, the cough can result in a bruising to the white of your eye. This is known as a subconjunctival haemorrhage. It can look worrying but is harmless and does not affect your eyesight. It gets better usually in 7 to 14 days.
• Damage to existing teeth or any dental work: this is rare and minimised by the removal of any dentures before the test and the use of a mouth guard.
• Breathing problems: rarely, the airways can be irritated by the test and go into spasm. This is more likely in patients with pre-existing lung disease, such as asthma or COPD. You may require a nebuliser. Some patients may take a longer time to recover after the procedure and you may need to be admitted to hospital for observation or further treatment.
• Heart Problems: in up to 5 out of every 100 patients, this procedure may put a brief minor strain on the heart. This can cause abnormal beating of the heart. It can very rarely cause fluid to collect in the lungs or a heart attack.
• Fever: fever after this procedure is common. It usually settles within 24 to 48 hours and paracetamol can be taken to treat this. Always stick to the recommended daily dose advice on the packet.
• Infection: less than 1 in 500 patients develop an infection in their chest. Please contact your GP or Specialist Nurse if you have symptoms such as breathlessness, a cough that isn’t going away or is getting worse and new sputum (phlegm), or if you simply just don’t “feel right.”
• Bleeding: usually any bleeding is minor and settles quickly. About 1 in 1000 patients may develop significant bleeding. This may require the team to give medicine into your airways to control the bleeding. It is very rare for any bleeding to be life threatening.
• Allergic reactions to sedative medicine or local anaesthetic spray.
• Failure to achieve a diagnosis: in about 1 in 10 patients, the samples don’t give enough information to be confident about the diagnosis. This may mean that the team ask you either to undergo another EBUS or an alternative biopsy test.
• Death: less than 1 in 1000 patients will not survive the procedure. The risks are higher in patients who have very severe heart or breathing problems. Your team will have carefully weightless up the risk to your health before recommending this test to you.

It is normal to feel quite anxious about the test after reading all of the possible risks and side effects. However, please be assured that the vast majority of patients who have this test have no problems during or after the test.

When will I get my test results?

The team will tell you on the day if they have been able to get the samples they needed. They won’t be able to tell you the results of these samples on the day of the test.

The samples will then go to the laboratory. The results are usually available within 7 days. However, it can take longer for complex biopsies, or if extra tests are needed.

When the results are available, you will be contacted to arrange a consultation.

If you have come from another hospital to have the test, you will receive the results from the team at the referral hospital. If you are worried about lack of follow up arrangements, please let us know.

Is there any alternative to having an EBUS?

This depends on why you are having the EBUS. If the test was to investigate lumps or shadows in your lungs that also had swollen glands near them, alternative tests are possible, such as using a CT scanner to guide a needle through your chest wall into the area of concern.

If the test was to investigate swollen glands in your chest without any additional lung shadows or lumps, another type of biopsy might be possible. This involves an operation where a small incision is made at the bottom of your neck with a camera passed in through your skin, underneath your breastbone.

This can then be used to find the glands in this area and take samples. The advantage of this test is that whole glands can be taken rather than just samples.

The disadvantage with this procedure is that a much smaller number of glands can be found compared to EBUS, which limits its ability to get glands which are deeper in the chest.

The team will have carefully considered which test they feel will give the most information and is the safest for you. They will be happy to explain any other possibilities and the final decision will be yours.

References

British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults, Du Rand IA, Blaikley J, Booton R, et al. Thorax 2013; 68: i1–i44.

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