Sedation Options for Endobronchial Ultrasound–guided Transbronchial Needle Aspiration

To the Editor:

As an early user of endobronchial ultrasound (EBUS) (1, 2), and the first physician in Pittsburgh, Pennsylvania, to perform the procedure, who does not have general anesthesia available for bronchoscopies, I found the study by Casal and colleagues very illuminating (3). As I taught many of the pulmonologists and thoracic surgeons currently using EBUS at the University of Pittsburgh Medical Center, I believe another important reason for using general anesthesia for advanced bronchoscopy procedures, including EBUS, is for teaching purposes. Although I also believe EBUS should only be taught to experienced bronchoscopists (not first-year fellows), I have found that much of the sedation time can be used up while trainees try to pass the EBUS bronchoscope through the vocal cords. This obviously leaves less time for the most important parts of the procedure: learning imaging and anatomical landmarks and tissue acquisition. This can be avoided with general anesthesia, leaving plenty of time in the lower airways for ultrasound and tissue acquisition. After reading the study of Casal and colleagues, I think that general anesthesia should be more widely available in bronchoscopy suites of teaching centers, and one of the major reasons to have it available is for these procedures. Ideally, bronchoscopy suites offering advanced procedures (such as EBUS and electromagnetic navigation bronchoscopy) should have the potential for both moderate sedation and general anesthesia.