Unlocking the potential of robotic-assisted bronchoscopy: overcoming challenging anatomy and locations.

Robotic-assisted bronchoscopy (RAB) was recently added to the armamentarium of tools used in sampling peripheral lung nodules. Protocols and guidelines have since been published advocating use of large oral artificial airways, use of confirmatory technologies such as radial endobronchial ultrasound (R-EBUS), and preferably limiting sampling to pulmonary parenchymal lesions. We present three clinical cases where RAB was used unconventionally to sample pulmonary nodules in unusual locations and in patients with challenging airway anatomy. In case 1, we introduced the ion catheter through a nasal airway in a patient with trismus. In case 2, we established a diagnosis by sampling a station 5 lymph node, and in case 3, we sampled a lesion located behind an airway stump from previous thoracic surgery. All three patients would have presented significant challenges for alternative biopsy modalities such as CT-guided needle biopsy or video-assisted thoracic surgery.

Oxygen insufflation through the bronchoscope channel for sedation-induced hypoxia: safe and effective.

OBJECTIVES: To evaluate both efficacy and safety parameters for insufflation through the bronchoscope as a method of recovery from sedation-induced hypoxia. To explore parameters applicable to use in human beings using an animal model. MATERIALS AND METHODS: Two adult pigs were sedated enough to depress respiratory drive. The effects of insufflation at 15 l/min (the upper limits of flow that might be used clinically) were then evaluated. Pressure and volume responses to bronchoscopy during intubation and without an endotracheal tube in place were recorded. Several assays were performed for each scenario, with each animal acting as its own control. Recovery from hypoxemia using insufflation was compared with recovery using mechanical ventilation. RESULTS: Insufflation was effective, with rapid increases in fraction of inspired oxygen (FIO2), saturation, and partial pressure of arterial oxygen (PaO2). The rate of recovery using insufflation was faster than that from institution of mechanical ventilation. Insufflation in an intubated animal with cuff inflated led to a rapid and dangerous rise in pressure. With balloon deflated, there were no adverse pressure consequences from insufflation via the endotracheal tube at a rate of 15 l/min. CONCLUSION: Insufflation through the bronchoscope for episodes of sedation-induced hypoxia should be safe and effective as long as not delivered within a closed system.

Quality of transbronchial biopsy with large forceps compared to cryobiopsy: a randomized controlled, single blinded live animal study.

Background: Transbronchial forceps biopsy is the widely accepted modality for obtaining tissue specimens for the evaluation of unexplained lung parenchymal abnormalities. However, cryoprobe biopsy provides large specimen sizes and higher yield performance. Utilization of cryoprobe biopsy remains limited by its need to be performed under rigid bronchoscopy and subsequent required operator expertise. We evaluated whether a larger, 2.8 mm forceps could be utilized for parenchymal biopsies. A larger size would surrogate the cryoprobe's large sample size and forceps mechanism to obviate the need for rigid bronchoscopy and its requirement for removing the sample en bloc. Methods: This prospective, randomized controlled, single-blinded porcine study compared a 1.9 mm cryoprobe, a 2.4 mm cryoprobe, and a 2.8 mm forceps. Assessment of histopathologic quality, sample quality and surface area, attempts to retrieve specimen samples, fluoroscopy activation time, overall procedural time, and complications were compared. Results: Although cryoprobe yielded larger specimens, there was no statistical difference amongst all tools with respect to alveolar tissue surface area. There was bleeding on all cryoprobe biopsies. No bleeding was observed with forceps. Out of 32 potential combinations of interventions for bleeding control, 18 (56.3%) were made. There was no significant difference in sample quality between all three modalities. There was one pneumothorax in the forceps arm. Conclusions: Large forceps (LF) biopsy is a feasible technique while providing high diagnostic yield without the need for advanced therapeutic tools. Human studies are needed to further corroborate this technique.

Stereotactic Body Radiotherapy and Systemic Dose Chemotherapy for Locally Advanced Lung Cancer: Single Arm Phase 2 Study.

PURPOSE: This is a single arm phase 2 study (Clinical trials.gov NCT02568033) to examine the role of stereotactic body radiotherapy (SBRT) along with full dose systemic chemotherapy in the treatment of unresectable stage 2 and stage 3 nonsmall cell lung cancer. Primary endpoints are disease free survival and toxicity. MATERIALS: Patients were treated with SBRT to all sites of gross disease. Dosing consisted of 60 Gy in 3 fractions for peripheral lung tumors, 50 Gy in 5 fractions for central lung tumors, and 40 to 50 Gy in 5 fractions for hilar and mediastinal lymph nodes. Chemotherapy consisted of 4 cycles of pemetrexed and cisplatin or carboplatin and paclitaxel for nonsquamous histology and cisplatin and docetaxel or cisplatin and paclitaxel for squamous histology. SBRT was given in between the chemotherapy cycles. There was a 7 days break between chemotherapy and SBRT. Quality of life was measured using functional assessment of cancer therapy-lung. RESULTS: Twenty two patients were enrolled and analyzed. Seventeen (77%) were stage III and 19 (86%) had lymph node involvement. Median follow-up for all patients was 23.1 months. Median overall survival is 27.2 months. Overall survival at 1 year was 82% and overall survival at 2 years was 53%. Median disease free survival is 16.0 months with a 2-year regional failure rate of 19% and 2-year distant failure rate of 47.2%. There were 6 grade 3 acute toxicities and 2 late grade 3 or higher toxicities including 1 grade 5 hemoptysis. Quality of life scores were unchanged compared with baseline. CONCLUSION: A combination of SBRT and full dose chemotherapy appears to be a safe and effective treatment for locally advanced NSCLC and warrants further investigation.

Cryotherapy: A Safe Approach to Pulmonary Hemorrhage During VV-ECMO.

The number of hospitals with veno-venous extracorporeal membrane oxygenation (VV-ECMO) capabilities is expanding. To support an ECMO program, centers must be equipped to handle associated complications such as pulmonary hemorrhage. We describe a case series of 4 patients with life-threatening pulmonary bleeding and central airway obstruction. A therapeutic approach of anticoagulation cessation coupled with cryoextraction via flexible bronchoscopy led to successful restoration of airway patency without any adverse events. A low threshold to stop anticoagulation with a strong consideration of bronchoscopy with cryotherapy for pulmonary toilet should be done in patients with pulmonary hemorrhage during VV-ECMO.

Therapeutic closure of bronchopleural fistulas using ethanol.

Bronchopleural fistula (BPF) leading to persistent air leak (PAL), be it a complication of pulmonary resection, radiation, or direct tumor mass effect, is associated with high morbidity, impaired quality of life, and an increased risk of death. Incidence of BPF following pneumonectomy ranges between 4.4% and 20% with mortality ranging from 27.2% to 71%. Following lobectomy, incidence ranges from 0.5% to 1.5% in reported series. BPFs are more likely to occur following right-sided pneumonectomy, while patients undergoing bi-lobectomy were more likely to suffer BPF than those undergoing single lobectomy. In addition to supportive care, including appropriate antibiotics and nutrition, management of BPF includes pleural decontamination, BPF closure, and ultimately obliteration of the pleural space. There are surgical and bronchoscopic approaches for the management of BPF. Surgical interventions are best suited for large BPFs, and those occurring in the early postoperative period. Bronchoscopic techniques may be used for smaller BPFs, or when an individual patient is no longer a surgical candidate. Published reports have described the use of polyethylene glycol, fibrin glues, autologous blood products, gel foam, silver nitrate, and stenting among other techniques. The Amplatzer device, used to close atrial septal defects has shown promise as a bronchoscopic therapy. Following their approval under the humanitarian device exemption program for treatment of prolonged air leaks, endobronchial valves have been used for BPF. No bronchoscopic technique is universally applicable, and treatment should be individualized. In this report, we describe two separate cases where we use an Olympus© 21-gauge EBUS-TBNA (endobronchial ultrasound-transbronchial needle aspiration) needle for directed submucosal injection of ethanol leading to closure of the BPF and subsequent successful resolution of PAL.

Transthoracic placement of fiducials with ultrasound or electronic navigational bronchoscopy needle guidance by the interventional pulmonologist: A case series.

Stereotactic body radiotherapy (SBRT) has become one of the main options for treatment of thoracic malignancies, leading to the need for more fiducial marker placement. We report cases where these fiducials were placed transthoracically by interventional pulmonologists using ultrasound (US) and electronic navigational bronchoscopy (ENB) needle guidance. Six cases were identified in the Cooper University Hospital medical records where such procedures were performed, alone or in combination with other interventions. All six patients underwent successful placement of fiducials. Concomitant bronchoscopic procedures were performed in four cases. All patients proceeded to SBRT without the need for further interventions. The overall retention rate of fiducials was 80%. No complications were noted. Fiducials' placement by interventional pulmonologists using US or ENB needle guidance is safe and effective, and may be combined with other procedures in a single setting.

Safety and Feasibility of a Novel Protocol for Percutaneous Dilatational Tracheostomy in Patients with Respiratory Failure due to COVID-19 Infection: A Single Center Experience.

INTRODUCTION: The rapidly spreading Novel Coronavirus 2019 (COVID-19) appeared to be a highly transmissible pathogen in healthcare environments and had resulted in a significant number of patients with respiratory failure requiring tracheostomy, an aerosol-generating procedure that places healthcare workers at high risk of contracting the infection. Instead of deferring or delaying the procedure, we developed and implemented a novel percutaneous dilatational tracheostomy (PDT) protocol aimed at minimizing the risk of transmission while maintaining favorable procedural outcome. Patients and Methods. All patients who underwent PDT per novel protocol were included in the study. The key element of the protocol was the use of apnea during the critical part of the insertion and upon any opening of the ventilator circuit. This was coupled with the use of enhanced personnel protection equipment (PPE) with a powered air-purifying respirator (PAPR). The operators underwent antibody serology testing and were evaluated for COVID-19 symptoms two weeks from the last procedure included in the study. RESULTS: Between March 12th and June 30th, 2020, a total of 32 patients underwent PDT per novel protocol. The majority (80%) were positive for COVID-19 at the time of the procedure. The success rate was 94%. Only one patient developed minor self-limited bleeding. None of the proceduralists developed positive serology or any symptoms compatible with COVID-19 infection. CONCLUSION: A novel protocol that uses periods of apnea during opening of the ventilator circuit along with PAPR-enhanced PPE for PDT on COVID-19 patients appears to be effective and safe for patients and healthcare providers.

Inferior Vena Cava Filter Fracture Embolization to the Left Lung Complicated by Massive Hemoptysis.

Inferior vena cava filter placement for venous thromboembolism has increased by 25-fold in the past two decades. Timely retrieval of these filters is often not executed, resulting in long-term complications. We report a case of 44-year-old male patient who underwent inferior vena cava filter placement for chronic venous thromboembolism after presenting with hemoptysis. The results of chest computed tomographic angiography were negative for active bleeding, but imaging revealed multiple fragments of fractured filter in the infrarenal inferior vena cava and one fragment extravascular in left lower lobe of the lung causing massive hemoptysis. Endovascular technique was unsuccessful in retrieving the extravascular fragment; hence, he underwent left lower lobe wedge resection with no further episodes of hemoptysis postoperatively.

Usefulness and safety of transbronchial biopsy with large forceps during flexible bronchoscopy.

Transbronchial lung biopsy (TBLB) using forceps is one of the most common procedures used to obtain lung tissue. The procedure's usefulness remains limited when diagnosing interstitial lung diseases. This retrospective descriptive study analyzed the feasibility and safety of using large forceps for TBLB in all patients who underwent TBLB from 2014 to 2018 for diffuse lung disease where the diagnosis could not be made by high-resolution chest computed tomography. We excluded patients with radiographic features of usual interstitial pneumonia. Among the 35 study patients, 7 were men and 28 were women. Diagnoses included respiratory associated bronchiolitis (7), diffuse alveolar damage (4), organizing pneumonia (4), nonspecific interstitial pneumonitis (3), acute fibrinous organizing pneumonia (3), sarcoidosis (2), hypersensitivity pneumonitis (2), IgG4 interstitial lung disease (1), eosinophilic pneumonia (1), pulmonary alveolar proteinosis (1), pulmonary fibrosis (1), pneumocystis (1), plasma-rich bronchiolitis (1), and diffuse alveolar hemorrhage (1). In three cases, the biopsies were nondiagnostic. Two patients developed a pneumothorax, and one required chest tube placement. There was one episode of minor bleeding. No escalation of care or hospitalization was required. Large-forceps TBLB is a feasible and safe method for obtaining parenchymal lung biopsies.

Erroneous bronchial transection after video assisted thoracoscopic surgery (VATS) pulmonary resection diagnosed with bronchoscopy: Case report.

INTRODUCTION: Early recognition of VATS-related complications is crucial for early interventions, treatments and better outcomes PATIENT CONCERNS:: Patient presented with post-obstructive pneumonia like symptoms 1 week after VATS pulmonary resection. DIAGNOSIS: CT scan chest showed evidence of complete consolidation of the lobe where the pulmonary segmentectomy resection took place. INTERVENTIONS: Diagnostic bronchoscopy confirmed the erroneous transection of the Superior Segment (SS) of Right Lower Lobe (RLL). Patient was then taken back for completion lobectomy and found with necrotic SS of RLL. This finding potentially could have caused significant complication if not recognized and treated early OUTCOMES:: Patient recovered well after completion lobectomy and was discharged home several days later CONCLUSION:: Erroneous bronchial transection should be suspected early in patients presenting with post-obstructive pneumonia after VATS pulmonary resection. CT scan chest and diagnostic bronchoscopy are the 2 main diagnostic tests.

A case report of an expensive yet necessary thoracentesis: Expanding the boundaries of endoscopic ultrasound transbronchial needle aspiration.

RATIONALE: Endobronchial ultrasound has revolutionized the field of bronchoscopy and has become one of the most important tools for the diagnosis of intrathoracic lymphadenopathy and para-bronchial structures. The reach of this technique has not been limited to these structures and pleural lesions have been at times accessible. To our knowledge, pleural fluid collections have not been accessed with endobronchial ultrasound (EBUS). PATIENT CONCERNS: 52-year-old women with dyspnea, fever and a new loculated pleural effusion that was suspected to be the source of the fever but was not accessible through traditional thoracentesis. DIAGNOSIS: Malignant pleural effusion. INTERVENTIONS: Sampling and drainage of the loculated pleural fluid collection using EBUS scope introduced via the esophagus. OUTCOMES: Infection excluded. Resolution of fever and improved dyspnea after drainage of effusion. LESSONS: The convex curvilinear ultrasound bronchoscope allows unprecedented access to thoracic structures. The reach is not limited to mediastinal lymph nodes and parenchymal masses adjacent to the airways, and pleural space and pleural fluid are at times accessible, particularly when one considers the esophageal approach.

Improving Lung Function in Severe Heterogenous Emphysema with the Spiration Valve System (EMPROVE). A Multicenter, Open-Label Randomized Controlled Clinical Trial.

Rationale: Less invasive, nonsurgical approaches are needed to treat severe emphysema.Objectives: To evaluate the effectiveness and safety of the Spiration Valve System (SVS) versus optimal medical management.Methods: In this multicenter, open-label, randomized, controlled trial, subjects aged 40 years or older with severe, heterogeneous emphysema were randomized 2:1 to SVS with medical management (treatment) or medical management alone (control).Measurements and Main Results: The primary efficacy outcome was the difference in mean FEV1 from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV1 responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCIs) for the difference between treatment and control arms. Between October 2013 and May 2017, 172 participants (53.5% male; mean age, 67.4 yr) were randomized to treatment (n = 113) or control (n = 59). Mean FEV1 showed statistically significant improvements between the treatment and control groups-between-group difference at 6 and 12 months, respectively, of 0.101 L (95% BCI, 0.060-0.141) and 0.099 L (95% BCI, 0.048-0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6-minute-walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs. 11.9%), primarily due to a 12.4% incidence of serious pneumothorax.Conclusions: In patients with severe heterogeneous emphysema, the SVS shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile.Clinical trial registered with www.clinicaltrials.gov (NCT01812447).

Impact of Moderate Sedation versus Monitored Anesthesia Care on Outcomes and Cost of Endobronchial Ultrasound Transbronchial Needle Aspiration.

BACKGROUND AND OBJECTIVES: The ideal type of sedation for endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is not known. Two previous studies comparing the diagnostic yield between moderate sedation (MS) and deep sedation/general anesthesia (DS/GA) had provided conflicting results with one study clearly favoring the latter. No study had addressed cost. This is concerning for pulmonologists without routine access to anesthesia services. Our objective was to assess the impact of MS and Monitored Anesthesia Care (sedation administered and monitored by an anesthesiologist) on the outcomes and cost of EBUS-TBNA. MATERIALS AND METHODS: We performed a retrospective review of prospectively collected data on consecutive EBUS-TBNA performed under two different types of sedation in a single academic center. A diagnostic TBNA was defined as an aspirate yielding any specific diagnosis or if subsequent surgery or follow-up of nondiagnostic/normal aspirates showed no pathology. Current Medicare time-based allowances were used for professional charges calculation. RESULTS: There was no difference observed between MS and MAC in regards of the diagnostic yield (92.9% versus 91.9%), procedure duration, number, location, and size of lymph node (LN) sampled, but there were more passes per LN with MAC. The average charges were 74.30 USD for MS and 319.91 for MAC. There were more hypotensive and desaturations episodes with MAC but none required escalation of care. CONCLUSIONS: When performed under MS, EBUS-TBNA has similar diagnostic yield as under MAC but may be associated with less side effects. The difference in sedation cost is modest; however, an additional 245$ for each EBUS done under MAC would have significant cost implications on the health system. These findings are of critical importance for bronchoscopists without routine access to anesthesia services and for optimization of healthcare cost and resource utilization.

The Impact of Continuous Positive Airway Pressure upon Pleural Fluid Pressures during Thoracentesis.

BACKGROUND: Excessive drop of pleural pressure (Ppl) during therapeutic thoracentesis may be related to adverse events and/or to repeated procedures due to incomplete drainage. OBJECTIVE: This was a pilot study of the impact of the application of continuous positive airway pressure (CPAP) at +5 cm H2O upon the Ppl profile during thoracentesis. METHODS: This was a prospective, controlled study of 49 consecutive adults who underwent thoracentesis. Enrollment was via alternation on a one-to-one basis. Pleural manometry was used to compare serial Ppl in patients using CPAP at +5 cm H2O (CPAP group) with Ppl in patients without CPAP (control group). RESULTS: Mean volumes drained were comparable between CPAP and control groups (1,380 vs. 1,396 mL). Patients in the CPAP group had a significantly greater change in volume per centimeter water column pressure (p = 0.0231, 95% confidence interval 6.41-82.61). No patient in the CPAP group had a Ppl less than -20 cm H2O at termination of the procedure, while 8 (33%) control group patients developed a pressure lower than -20. No patient in either group developed re-expansion pulmonary edema. CONCLUSION: The application of CPAP at +5 cm H2O mitigates the decreases in Ppl caused by thoracentesis via an increase in pleural compliance. The clinical implications of this finding merit study.

A Randomized Controlled Trial Comparing a Mapleson Circuit with Nasal Trumpet to Standard Oxygen Supplementation during EBUS Bronchoscopy under Monitored Anesthesia Care.

BACKGROUND: Endobronchial ultrasound (EBUS) procedures tend to be longer than routine bronchoscopies. Increased duration and sedative dosing put patients at increased risk for -hypoxic events. OBJECTIVE: To determine whether oxygen supplementation via a nasal trumpet connected to a Mapleson B circuit (NTM) was effective in decreasing hypoxic events when compared with the standard of care, oxygen supplementation with a nasal cannula (NC). METHODS: Patients referred for EBUS-guided transbronchial needle aspiration with monitored anesthesia care (MAC) were randomized 1:1 to NTM or to NC. Hypoxia-related procedural interruptions, the primary endpoint of the study, were documented for all patients. Patients in the NC group who had refractory desaturations were allowed to cross over to the NTM group. Secondary endpoints included: number of crossovers from NC to NTM, sedative dosing, total procedure times, whether procedure goals were achieved, complications apart from hypoxia, patient discharge status. RESULTS: Fifty-two patients were randomized to NC and 48 to NTM. Baseline characteristics were comparable. The NC group had significantly more interruptions than did the NTM group (p < 0.001). Procedure duration was also significantly (p < 0.03) shorter for the NTM group. Fourteen patients were crossed over from NC to NTM because of hypoxia. Thirteen out of the 14 completed the procedure with no interruptions. All procedures were successfully completed, and all goals were achieved. All patients returned to baseline status prior to discharge. Three minor complications of epistaxis occurred. CONCLUSION: For patients undergoing EBUS with MAC, oxygen supplementation with NTM significantly decreased the incidence of hypoxic events when compared with NC. NTM may also be of value for other subsets of patients who are at increased risk for desaturation when undergoing bronchoscopy.

Stereotactic Body Radiotherapy for Large (> 5 cm) Non-Small-Cell Lung Cancer.

BACKGROUND: Stereotactic body radiotherapy (SBRT) is a well-established treatment option for early stage non-small-cell lung cancer (NSCLC) tumors < 5 cm. There is limited information on tumors > 5 cm. PATIENTS AND METHODS: We performed retrospective data collection of patients enrolled onto a prospective SBRT registry study. Eligible patients for this study had node-negative NSCLC measuring > 5 cm in any dimension. Data from 41 patients were analyzed. Median patient age was 75 years, and median tumor size was 5.6 cm (range, 5.0-12.2 cm). Sixteen patients had squamous disease, 20 patients adenocarcinoma, and 1 mixed tumor; 4 patients had no biopsy. Median radiation dose per fraction was 50 Gy in 5 fractions. Radiation was prescribed to isodose line, median 66% (range, 50%-84%). RESULTS: Before SBRT, 6 patients had previous chemotherapy and 7 patients had previous radiation. Median follow-up for all patients was 15.2 months (range, 0.56-48.1 months). At last follow-up, 16 patients were still alive, with a median follow-up of 16.1 months for surviving patients. The median survival was 17.5 months with 1- and 2-year survivals of 65% and 34%. Two patients (4.8%) had local failure, and 13 patients (31%) had distant failure. Four patients (9.8%) had acute toxicity, and 7 patients (17.1%) had late toxicity, including 2 (4.8%) grade 3 late toxicities. CONCLUSION: SBRT for tumors > 5 cm is effective, with good local control rates and acceptable toxicity. The main pattern of failure is distant, suggesting a possible role for systemic chemotherapy in these patients.

Endobronchial valves for bronchopleural fistula: pitfalls and principles.

BACKGROUND: Placement of endobronchial valves for bronchopleural fistula (BPF) is not always straightforward. A simple guide to the steps for an uncomplicated procedure does not encompass pitfalls that need to be understood and overcome to maximize the efficacy of this modality. OBJECTIVES: The objective of this study was to discuss examples of difficult cases for which the placement of endobronchial valves was not straightforward and required alterations in the usual basic steps. Subsequently, we aimed to provide guiding principles for a successful procedure. METHODS: Six illustrative cases were selected to demonstrate issues that can arise during endobronchial valve placement. RESULTS: In each case, a real or apparent lack of decrease in airflow through a BPF was diagnosed and addressed. We have used the selected problem cases to illustrate principles, with the goal of helping to increase the success rate for endobronchial valve placement in the treatment of BPF. CONCLUSIONS: This series demonstrates issues that complicate effective placement of endobronchial valves for BPF. These issues form the basis for troubleshooting steps that complement the basic procedural steps.

EBUS-TBNA and EUS-FNA: Risk Assessment for Patients Receiving Clopidogrel.

BACKGROUND: Clopidogrel is widely used for the prevention of thrombotic vascular complications. Its primary potential toxicity is bleeding. Management of clopidogrel therapy for patients undergoing invasive procedures is an area of ongoing study. We sought to evaluate the bleeding risk for patients undergoing needle aspiration biopsy by endobronchial ultrasound (EBUS) or esophageal ultrasound (EUS) while taking clopidogrel. METHODS: Retrospective review of sequential cases of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound fine needle aspiration (EUS-FNA). RESULTS: Three hundred ninety-five consecutive procedures were reviewed. Thirty-seven patients were taking clopidogrel at time of biopsy. The patients taking clopidogrel were significantly older than those in the control group. Two patients (1%) in the control group were admitted for observation, but neither was found to have a significant bleed. There were no clinically significant bleeding complications in either of the study groups. CONCLUSIONS: It is reasonable to proceed with EBUS-TBNA or EUS-FNA when both, (1) clopidogrel cannot be stopped and, (2) an important diagnostic question is at stake.