Bronchoscopy with Virtual Bronchoscopic Navigation (VBN) and Radial Endobronchial Ultrasound (EBUS)

This leaflet explains what a Bronchoscopy with Virtual Bronchoscopic Navigation (VBN) and Radial Endobronchial Ultrasound (EBUS) 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 Virtual Bronchoscopic Navigation (VBN) and radial 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.

Virtual Bronchoscopic Navigation is special computer software which helps build a detailed roadmap of the very small airways of your lungs.

Radial Endobronchial Ultrasound (EBUS) is a small, flexible specialised ultrasound probe (a type of camera which uses sound waves to make pictures) which is passed down through a bronchoscope.

This is then used to examine your lungs to try to find small abnormal areas. The use of these different techniques together is called a Bronchoscopy with Virtual Bronchoscopic Navigation (VBN) and radial Endobronchial Ultrasound (EBUS).

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

We will refer to this procedure as VBN-EBUS for the rest of this information leaflet.

Why do I need a VBN-EBUS?

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

The CT scan will have shown small abnormal spots or patches very deep in your lung tissue. These may be in, or very near the small airways of your lungs.

These spots or patches can be caused by many things including infections, inflammation, scars and cancers.

It’s usually not possible to tell exactly what these things are from the CT scan alone.

The most important thing is to check if these areas are cancer by getting a sample or “biopsy” of them.

When spots are as small and deep within the lungs as these, it takes the very specialised equipment and testing of VBN-EBUS to potentially find and sample them.

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

How do I get ready for a VBN-EBUS?

Don’t worry, it isn’t complicated. However, it is important that you follow these instructions carefully and ask us any questions you may have regarding preparation as problems could lead to a delay or even cancellation of your procedure.

The most important things to know about are when to fast and what adjustments to your medicines you may need.

Fasting

We ask you to fast or not eat 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 for VBN-EBUS 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 then you can have a light breakfast, such as a slice of toast around 07:30am in the morning. You can have clear fluids up till 11:00am in the morning. 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:

Diabetes medicine

If you take insulin or diabetic tablets you will have received advice from the doctor who arranged your Bronchoscopy so that appropriate arrangements can be made, and advice given about your preparations. Some patients will not be suitable for the procedure to be done as a day case and an overnight stay may be necessary. The following are the guidelines for each of the different medications.

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

If you are taking Byetta® (exenatide) or Victoza® (liraglutide) by injection, these medications should not be taken on the day of your test and should be restarted once you are eating and drinking normally.

What should I do with my INSULINS before my test?

If you have not received advice about your diabetes, please ring the respiratory secretaries on 01642 624296, 01642 624936 or 01642 624615.

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

If you continue to take blood thinning medicine before you have an EBUS, this will increase the chance of serious bleeding during the test. This would put your health at serious risk and make it much 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 VBN-EBUS. 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 VBN-EBUS.

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 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 steroids

The treatment for Addison’s disease is daily steroid treatment. 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 a VBN-EBUS 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 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 you may have, as we use this 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 VBN-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 throat spray (local anaesthetic). 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 give you sedation through the drip. This is usually a combination of two medicines (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.

A large X-ray camera will be put into position over your bed and chest. This can look and feel quite frightening, but it will never cover your head.

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 pass the camera into your airways. The team will use a roadmap which has been produced by the VBN software in advance of your test. This will let the team guide the camera down into your lungs to as close to the abnormal areas as possible.

The EBUS probe will pass down through the camera and into your lung. The X-ray camera will take pictures of your chest so that the team can guide the EBUS probe into the right position in your lungs. The EBUS probe produces pictures of your lung and airways which tell the team if they have found the abnormal area.

When the team have found the abnormal area and it is safe to do so, biopsies will then be taken by passing a tool through the camera, into the area of interest.

To give the best chance of working out what the abnormal spot or patch is, multiple biopsies or samples may be taken. If there is more than one abnormal area the team will may 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 VBN-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 VBN-EBUS?

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

After the VBN-EBUS, you will be monitored in the recovery area for up to 2 hours while the sedation and the local anaesthetic wears off. When the nurses looking after you are happy, you will usually 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’s important to remember that having a VBN-EBUS is a common and safe procedure. If you have been asked to have a VBN-EBUS, 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’s 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 a VBN/EBUS?

This test is usually performed on very small abnormal areas in your lungs. These are not usually other ways to carry out these biopsies.

It may be possible to biopsy these areas using a CT scan to help guide a needle through your chest wall into them. However, this usually more difficult than this test and carries more risks.

Another possibility would be to have an operation to biopsy or remove the area under a general anaesthetic. This is the most invasive option and is usually considered last. This may not be an option for your abnormality.

If you don’t wish to have a biopsy, then a “watch and wait” approach could be considered. This would involve monitoring the areas with another CT often 2 – 3 months later to see if it grows. If it does grow, then the options could be reconsidered at this point.

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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Leaflet Reference: PIL1291
Date for review: 10/02/2024