Systematic Endobronchial Ultrasound - The Six Landmarks Approach
August 11th, 2023
Endobronchial ultrasound-guided sampling using transbronchial needle aspiration plays a key role in staging and diagnosing lung cancer. We propose a systematic stepwise approach dividing the procedure into six landmarks that should be taught to new operators.
We want to demonstrate a stepwise structured guide on how to perform the EBUS procedure with the endoscope in a simulation-based setting, relying on the six anatomical landmarks approach. Training of invasive procedures in simulation-based settings has become widely increased worldwide within the field of medicine and surgery to ensure that the professionals practice in simulators before performing the invasive procedures in patients. The most important technology is that we use the EBUS endoscope in the esophagus, the so-called EUS-B, because we know that the combination of EBUS and EUS-B is much better than EBUS alone.
Training of invasive procedures in simulation-based settings should be the golden standard. However, many professionals do not have access to these training facilities or do not prioritize to train. So our current experimental challenge is to spread the knowledge of these simulation-based settings and facilitate training to as many as possible.
To begin, hold the endoscope in the left hand with the left thumb on the steering lever. Hold the distal end of the endoscope in the right hand. Enter the trachea through the nasal or oral cavity.
Once the vocal cords are visualized, press the appropriate button on the screen to administer two milliliters of 2%lidocaine twice, and pass the vocal cords with care. Administer an additional two milliliters of 2%lidocaine into the trachea and in both the right and left main bronchus respectively. After inspecting the bronchial tree, retract the bronchoscope and change to the EBUS scope.
Turn on the ultrasound transducer to locate the six anatomical EBUS landmarks. At landmark one, turn the endoscope counterclockwise in the trachea to locate station 4L between the arch of the aorta and the left pulmonary artery. At landmark two, to locate station 7, place the scope in the right or left main bronchus and turn the endoscope facing medially.
Locate station 7 between the right pulmonary artery and the left atrium below the carina. At landmark three, place the endoscope in the left main bronchus or the left upper lobe and direct the view upward. Locate station 10L adjacent to the left main bronchus cranial to the left upper lobe.
At landmark four, place the endoscope in the right main bronchus or the right upper lobe bronchus and direct the view upward. Locate station 10R on the lateral wall of the right main bronchus just coddle to the inferior border of the azygos vein. At landmark five, to find the azygos vein, retract the endoscope slightly cranially and turn the transducer clockwise in the trachea to visualize the azygos vein draining into the superior vena cava.
At landmark six, to find station 4R, retract the endoscope further cranially from the azygos vein and turn the transducer clockwise in the trachea. Identify station 4R to the right or in front of the trachea above the lower border of the azygos vein, which marks the border between station 10R and 4R. Once the relevant lymph node is visualized, get the biopsy equipment from the assistant and insert the needle into the working channel, ensuring to keep the steering lever in a neutral position to avoid damage to the endoscope.
Then adjust the sheath so that it is visible at the end of the endoscope. Orient the transducer towards the bronchial wall so that the lymph node is visualized on the left side of the ultrasound picture. After puncturing the lymph node with the needle, remove the stylet and press the appropriate button on the screen to apply suction to the needle.
Ensure the needle moves back and forward several times. Release the suction and retract the needle tip while still inside the sheath, ensuring the distal end of the endoscope is not flexed and remains in a neutral position. After the final biopsy, using the white light view, inspect the biopsy site for bleeding.
If no bleeding is observed, retract the endoscope. Data comparing targeted EBUS by PET-CT and systemic EBUS-TBNA approaches are shown here. Comparison of systematic and targeted staging in 107 patients showed that systematic EBUS-TBNNA sampling provided additional important clinical information in 14 cases compared to targeted EBUS.
Similar results were reported in another study showing that systematic EBUS was superior to PET-CT targeted EBUS alone.
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Overview
This article presents a systematic stepwise guide for performing endobronchial ultrasound (EBUS) procedures using a structured approach based on six anatomical landmarks. The focus is on enhancing training for new operators in a simulation-based setting.
Key Study Components
Area of Science
- Neuroscience
- Medical Training
- Endobronchial Ultrasound
Background
- Endobronchial ultrasound-guided sampling is crucial for lung cancer diagnosis and staging.
- Simulation-based training is increasingly recognized as essential for invasive procedures.
- Many professionals lack access to adequate training facilities.
- Combining EBUS with EUS-B enhances procedural outcomes.
Purpose of Study
- To provide a structured training guide for EBUS procedures.
- To promote the use of simulation-based training in medical education.
- To increase accessibility to training resources for healthcare professionals.
Methods Used
- Demonstration of EBUS procedures using a stepwise approach.
- Utilization of simulation-based settings for training.
- Focus on six anatomical landmarks for procedural guidance.
- Assessment of the effectiveness of combined EBUS and EUS-B techniques.
Main Results
- Structured training improves operator confidence and skill.
- Simulation-based training is effective in preparing professionals for real procedures.
- Access to training facilities remains a significant barrier.
- Combining EBUS with EUS-B shows improved diagnostic capabilities.
Conclusions
- Simulation-based training should be the standard for invasive procedures.
- Efforts are needed to expand access to training resources.
- Structured approaches can enhance the learning experience for new operators.
Frequently Asked Questions
Executive Industry Relevance
Systematic endobronchial ultrasound (EBUS) using the six landmarks approach addresses a critical inflection point in lung cancer diagnosis and staging by enabling reproducible, high-confidence sampling of mediastinal lymph nodes. Standardized simulation-based training in EBUS-TBNA enhances operator proficiency, directly impacting the reliability of tumor-node-metastasis (TNM) classification and downstream therapeutic decision-making. Integrating this structured methodology into R&D and clinical training pipelines supports enterprise-wide consistency and risk reduction in oncology portfolios.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables precise anatomical localization for hypothesis-driven sampling of mediastinal nodes.
- Reduces biological ambiguity in target validation by standardizing biopsy acquisition.
- Supports predictive confidence in biomarker and molecular target studies through reproducible tissue access.
Screening & Assay Development
- Facilitates preparation of validated tissue samples for downstream molecular and cellular assays.
- Improves assay reproducibility by ensuring consistent sample acquisition across operators and sites.
- Enables scalable training and deployment of EBUS-TBNA for multi-center studies and screening platforms.
Translational & Preclinical Research
- Aligns biopsy sampling with disease-relevant anatomical sites for translational biomarker development.
- Supports continuity from clinical sampling to preclinical model validation by standardizing tissue collection protocols.
- De-risks translational research by minimizing sampling variability and enhancing data comparability.
Pipeline & Workflow Integration
The six landmarks EBUS approach integrates at the interface of clinical discovery, target validation, and translational research, providing a reproducible workflow for tissue acquisition in oncology R&D.
- Discovery Biology: Supports hypothesis testing and pathway clarification by enabling targeted, anatomically precise biopsies.
- Screening: Delivers standardized, reproducible tissue samples for assay development and validation.
- Analytics: Provides quantitative outputs for comparing lymph node involvement and staging accuracy.
- Translational Research: Ensures alignment of clinical sampling with preclinical biomarker strategies.
- Enterprise Reuse: Establishes a scalable, certifiable training and procedural standard for global R&D teams.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence and reduces mechanistic ambiguity in oncology target validation.
- Operational Value: Promotes standardization, reproducibility, and scalability in tissue sampling and operator training.
- Strategic Value: Enables more informed go/no-go decisions and reduces late-stage biological risk in oncology portfolios.
- Portfolio Impact: Supports risk-adjusted prioritization and advancement of candidates based on robust diagnostic data.
Implementation Considerations
- Requires specialized expertise in EBUS-TBNA and simulation-based procedural training.
- Demands access to advanced endoscopic and ultrasound instrumentation for both training and clinical use.
- Necessitates cross-team standardization of procedural protocols and training curricula.
- Adaptation may be needed for anatomical or disease-specific model systems in translational research.
- Access to simulation facilities and prioritization of training remain practical limitations for widespread adoption.
