Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Advancements In Endobronchial Ultrasound-Guided Needle Aspiration

  Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a central technique in modern respiratory medicine. By combining bronchoscopy with real-time ultrasound, clinicians can examine lymph nodes and peribronchial lesions that are difficult to reach through conventional airway inspection.

  The procedure has changed how suspected lung cancer, sarcoidosis, tuberculosis and selected metastatic cancers are diagnosed and staged. A minimally invasive needle sample can often provide both cytological material and tissue for molecular testing, reducing the need for surgical mediastinoscopy or repeated investigations.

  Recent progress involves more than improved ultrasound processors. Advances in needle design, elastography, rapid on-site evaluation, artificial intelligence and specimen handling are helping teams obtain more useful samples with fewer passes. These developments are particularly important when a biopsy must support targeted therapy or immunotherapy decisions.

  In Australia, EBUS services are concentrated in major respiratory centres in Sydney, Melbourne, Brisbane, Perth and Adelaide, while regional patients may travel considerable distances for assessment. Public hospital capacity, private referrals, Medicare funding arrangements, equipment procurement and the availability of trained bronchoscopists all influence access.

  Why EBUS-TBNA Matters

  EBUS-TBNA allows systematic sampling of mediastinal and hilar lymph node stations under direct ultrasound guidance. Compared with blind transbronchial aspiration, real-time imaging improves target selection and helps the operator avoid major vessels and adjacent structures.

  For patients with suspected non-small cell lung cancer, the technique can combine diagnosis and staging during a single bronchoscopy. Sampling a mediastinal node may establish malignancy and reveal whether disease has spread beyond the primary lesion, helping a multidisciplinary team decide between surgery, radiotherapy, systemic treatment or surveillance.

  The method is also useful in non-malignant disease. Enlarged lymph nodes caused by granulomatous disease, infection or inflammatory conditions can be assessed without an open surgical procedure. Interpretation still depends on clinical history, imaging, microbiology and pathology rather than on the ultrasound appearance alone.

  Better Imaging And Sampling

  Modern EBUS systems provide higher-resolution images, improved Doppler assessment and more precise control of the needle within a lymph node. Elastography can display tissue stiffness, offering an additional clue when selecting viable or suspicious areas, although it should support rather than replace conventional ultrasound and cytological assessment.

  Newer aspiration needles are designed to collect larger or better-preserved specimens. Some have modified tip geometries, different gauges or cutting features intended to increase histological yield. Larger tissue fragments can be valuable when architecture is needed, especially for lymphoma or complex molecular profiling.

  Specimen adequacy has become a major measure of procedural quality. A small sample may confirm cancer but fail to provide enough material for epidermal growth factor receptor, ALK, ROS1, BRAF, KRAS or PD-L1 testing. Close communication between the bronchoscopist, cytopathologist and laboratory helps determine how many passes should be reserved for cell blocks, histology, flow cytometry and genomic analysis.

  Smarter Needle Strategies

  Experienced operators increasingly use a structured nodal assessment rather than sampling only the largest lymph node. The examination may begin with stations most likely to change the clinical stage, followed by targeted sampling of abnormal nodes identified on computed tomography or positron emission tomography.

  Rapid on-site evaluation can provide immediate feedback about cellularity and specimen quality. A cytologist or trained pathology professional assesses material during the procedure and advises whether additional passes are required. This approach may reduce inadequate samples, although access to on-site expertise varies between Australian hospitals.

  Emerging approaches include three-dimensional ultrasound reconstruction, contrast-enhanced imaging and computer-assisted interpretation. Artificial intelligence may eventually help classify lymph nodes or identify suspicious regions, but these tools require validation across different machines, patient groups and disease patterns before they can guide routine decisions independently.

  Safety And Workflow

  EBUS-TBNA is generally performed with conscious sedation or general anaesthesia, depending on patient factors, local expertise and the complexity of the examination. Common short-term effects include sore throat, cough, transient fever or minor bleeding. Serious complications such as significant haemorrhage, infection or pneumothorax are uncommon but require appropriate monitoring and emergency capability.

  Safe practice begins before the bronchoscope enters the airway. Teams review anticoagulants, antiplatelet medicines, oxygen requirements, allergies, sleep apnoea, airway anatomy and coexisting cardiovascular disease. Clear consent should cover the purpose of sampling, possible nondiagnostic results and alternative procedures.

  Australian services must also manage infection prevention, privacy and documentation requirements under local hospital policy and relevant state or territory frameworks. Equipment reprocessing, staff competency and laboratory accreditation are practical components of quality assurance, not administrative details separate from patient care.

  Australian Practice Considerations

  Geography is a significant factor in respiratory diagnostics. A patient from regional New South Wales, northern Queensland or Western Australia may need coordinated transport and accommodation for a procedure in Sydney, Brisbane or Perth. Telehealth can support pre-procedure review and follow-up, but it cannot replace local anaesthetic, bronchoscopy or pathology services.

  The Australian market includes public hospitals, private day-procedure facilities and specialist respiratory practices with different purchasing models. Decisions about EBUS platforms, needles and cytology support often involve capital budgets, tender processes, servicing arrangements and the ability to maintain a reliable supply of compatible consumables.

  Medicare arrangements and local referral pathways influence whether patients receive investigation through a public respiratory clinic or a private specialist. Clinicians must also consider the Therapeutic Goods Administration framework for medical devices, state-based consent requirements and the Australian Privacy Principles when transferring imaging, pathology or genomic information.

  Smoking remains a major respiratory health concern, while vaping has added a newer counselling and diagnostic consideration, particularly among younger adults. In metropolitan centres, multidisciplinary lung cancer meetings may review EBUS findings quickly; rural services may depend on scheduled virtual conferences and courier transport for pathology specimens.

  What The Evidence Means

  The strongest benefit of contemporary EBUS-TBNA is diagnostic efficiency. When imaging, procedural technique and pathology are integrated, one well-planned bronchoscopy can answer several clinical questions: Is malignancy present? Which nodal stations are involved? Is there enough tissue for biomarker testing? Could a non-malignant condition explain the radiological findings?

  No technique is universally sufficient. Very small, necrotic or technically inaccessible nodes may produce an inadequate result, and a negative sample does not always exclude disease when clinical suspicion remains high. Further biopsy, repeat sampling or surgical staging may be appropriate after a multidisciplinary review.

  Aspect	Established Practice	Developing Direction
  Imaging	High-resolution B-mode and Doppler ultrasound	Elastography, contrast enhancement and 3D reconstruction
  Sampling	Fine-needle aspiration with cell-block preparation	Needles designed for larger histological cores
  Adequacy	Visual assessment and pathology review	Rapid on-site evaluation with digital support
  Cancer testing	Cytology, immunohistochemistry and selected biomarkers	Broader next-generation sequencing from limited tissue
  Service delivery	Metropolitan hospital-based procedures	Regional coordination, telehealth and shared pathology networks

  The central lesson is that better outcomes depend on the whole diagnostic pathway rather than a single device. Careful staging, appropriate needle selection, disciplined specimen allocation and rapid communication with pathology determine whether EBUS provides a result that genuinely changes treatment.

  Clinicians and patients should remember that endobronchial ultrasound-guided needle aspiration is most powerful when technology is matched with expertise, safety systems and thoughtful clinical interpretation. A high-quality sample is not merely a diagnosis; it is the foundation for accurate staging and personalised respiratory care.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)