Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (18)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Asahina, H.
Right arrow Articles by Nishimura, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Asahina, H.
Right arrow Articles by Nishimura, M.
(Chest. 2005;128:1761-1765.)
© 2005 American College of Chest Physicians

Transbronchial Biopsy Using Endobronchial Ultrasonography With a Guide Sheath and Virtual Bronchoscopic Navigation*

Hajime Asahina, MD; Koichi Yamazaki, MD, PhD; Yuya Onodera, MD; Eiki Kikuchi, MD; Naofumi Shinagawa, MD; Fumihiro Asano, MD and Masaharu Nishimura, MD, PhD

* From the First Department of Medicine (Drs. Asahina, Yamazaki, Kikuchi, Shinagawa, and Nishimura), and the Department of Radiology (Dr. Onodera), Hokkaido University School of Medicine, Sapporo, Japan; and the Department of Respiratory Medicine (Dr. Asano), Gifu Prefectural Gifu Hospital, Gifu, Japan.

Correspondence to: Koichi Yamazaki, MD, PhD, First Department of Medicine, Hokkaido University School of Medicine, North 15, West 7, Kitaku, Sapporo 060-8638, Japan; e-mail: kyamazak{at}med.hokudai.ac.jp


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: We evaluated the feasibility, safety, and efficacy of transbronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath (EBUS-GS) and virtual bronchoscopy (VB) navigation for small peripheral pulmonary lesions ≤ 30 mm in diameter.

Design: Pilot study.

Setting: A national university hospital.

Patients: We performed TBB using EBUS-GS with VB navigation for 29 patients with 30 small peripheral pulmonary lesions (average diameter, 18.6 mm) between January 1, 2004, and August 31, 2004.

Interventions: VB images were reconstructed from helical CT data. TBB was then performed using EBUS-GS with VB navigation.

Results: In all patients, TBB was performed safely with no complications. Bronchi seen on VB imaging were highly consistent with the actual structures confirmed using fiberoptic bronchoscopy. Following VB navigation, the endobronchial ultrasonography (EBUS) probe was inserted into third- to sixth-generation bronchi. Twenty-four lesions (80%) were visualized on EBUS images. Average durations of the initial EBUS examination of lesions, first biopsy, and the total procedure were 9.56 min, 11.99 min, and 25.72 min, respectively. Nineteen lesions (63.3%) were diagnosed from histopathologic or cytologic examination. Diagnostic sensitivities were 44.4% (8 of 18) for lesions < 20 mm in mean diameter and 91.7% (11 of 12) for lesions 20 to 30 mm in mean diameter.

Conclusions: In summary, TBB using EBUS-GS with VB navigation was safely performed and was effective in diagnosing small peripheral pulmonary lesions.

Key Words: endobronchial ultrasonography with a guide-sheath • navigation • primary lung cancer • small peripheral pulmonary lesion • transbronchial biopsy • virtual bronchoscopy


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Flexible fiberoptic bronchoscopy (FFB) has been used for > 30 years in the diagnosis of peripheral pulmonary lesions, with diagnostic accuracy reported at 20 to 84% for malignant lesions and at 35 to 56% for benign lesions.123456 FFB has a lower diagnostic yield in smaller lesions; detecting only 11 to 42% of those < 20 mm in diameter under radiographic fluoroscopic guidance.178

Several methodologic problems hinder the diagnosis of small peripheral pulmonary lesions using FFB9: (1) small peripheral pulmonary lesions may not be visible under fluoroscopic guidance; (2) while curettage for transbronchial cytology can reach small peripheral pulmonary lesions, transbronchial biopsy (TBB) forceps cannot do so, given the difficulty in maneuvering within the angles of the bronchi; and (3) identifying accessible bronchial routes to reach small peripheral pulmonary lesions is not always easy within the time limitations of the procedure. We previously reported a new procedure aimed at overcoming these problems: CT-guided TBB using an ultrathin bronchoscope with virtual bronchoscopy (VB) navigation.9 Using this method, diagnostic yield for lesions < 20 mm was as high as 65% (all diagnoses were confirmed pathologically).9 However, this procedure also had the disadvantages of excessive radiation exposure from CT and of occupying the CT room for approximately 1 h.

The recent development of small-caliber ultrasound probes has expanded the clinical applications of ultrasonography to tracheal, bronchial, and peripheral pulmonary lesions. Guided by a fiberoptic bronchoscope, a small-caliber ultrasonographic probe can be successfully introduced into peripheral lesions. Endobronchial ultrasonography (EBUS) is reported to be useful in confirming accurate insertion of the bronchoscope into lesions,10 and the technique of EBUS with a guide sheath (EBUS-GS) has been applied to the diagnosis of peripheral pulmonary lesions.1112 This method could possibly overcome the disadvantages of CT-guided TBB.

In the present study, TBB using EBUS-GS and VB navigation were combined in one procedure. The feasibility, safety, and efficacy of this procedure for diagnosing small peripheral pulmonary lesions were evaluated.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
Participating subjects were 29 patients with 30 peripheral pulmonary lesions (≤ 30 mm in mean diameter) who were referred to Hokkaido University Hospital for diagnostic bronchoscopy between January 1, 2004, and August 31, 2004. Nineteen patients were men, and 12 were women. Average age was 62.2 ± 11.6 (± SD) years (range, 43 to 84 years). Peripheral pulmonary lesions were defined as those that were surrounded by pulmonary parenchyma and not visible on bronchoscopy (no evidence of endobronchial lesion, extrinsic compression, submucosal tumor, or narrowing, inflammation, or bleeding of the bronchus). Mean diameter of peripheral pulmonary lesions was 18.9 ± 6.5 mm (range, 10.0 to 30.0 mm). Distribution of lesions was as follows: right upper lobe, n = 11 (36.7%); right middle lobe, n = 1 (3.3%); right lower lobe, n = 7 (23.3%); left upper lobe, n = 7 (23.3%); and left lower lobe, n = 4 (13.3%). Six lesions were not detected on chest radiographs. After providing written informed consent, patients underwent the procedures described below.

VB
All patients underwent chest CT in order to generate VB images to guide TBB. CT was performed using a multidetector CT scanner (Aquilion; Toshiba; Tokyo, Japan) with the following parameters: 0.5-mm collimation; four detectors; pitch, 5–7; and rotation time, 0.5 s. Helical volume data sets were acquired during single breath-hold inhalations. Images were reconstructed from helical CT data and transferred to a work site (Virtual Place; AZE; Tokyo, Japan). All VB images were constructed by one radiologist. The volume-rendering method was used for the VB algorithm, VB objects were constructed by autosegmentation, and a fly-through image was created. Reconstructed VB images were generated accurately to approximately the fifth generation of bronchi, as more peripheral branches were not visible. For more peripheral zones, VB images were therefore instead generated using pulmonary arterial branches.13

EBUS-GS–guided TBB and Bronchial Brushings
Each patient received premedication of 15 mg pentazocine hydrochloride and 0.5 mg atropine sulfate. Local anesthesia of the upper respiratory tract was achieved using 4% lidocaine. EBUS was performed using an endoscopic ultrasound system (EU-M30S; Olympus; Tokyo, Japan) equipped with a 20-MHz mechanical radial-type probe (XUM-S20–17R; Olympus) with an external diameter of 1.4 mm. Bronchoscopes had a 2.0-mm diameter working channel (BF-P-260F, 4.0-mm external diameter; and BF-P-240, 5.3-mm external diameter; Olympus). Following VB navigation, the bronchoscope was inserted as deeply as possible into the target bronchus under direct vision. An EBUS probe was inserted into the guide sheath, and the guide sheath-covered probe was then inserted through the bronchoscope working channel and advanced to the peripheral pulmonary lesion under VB guidance to obtain an EBUS image. EBUS imaging and radiograph fluoroscopy were used to confirm that the probe and guide sheath had reached the lesion. After localizing the lesion using EBUS imaging, the probe was removed to leave the guide sheath in the peripheral lesion. Biopsy forceps and a bronchial brush were introduced via the guide sheath to provide specimens for pathologic and cytologic examination. When the bronchus visualized on VB images could not be identified, a double-hinged curette was inserted into the guide sheath, and the bronchus demonstrated on VB was selected by manipulating the curette, as reported previously.11 Once the bronchus was identified, the curette was removed. The probe was then reinserted through the guide sheath, and reacquired EBUS images were examined to confirm the lesion had been reached. Bronchoscopy procedures were performed by seven pulmonary fellows, each with > 5 years of training and experience in bronchoscopy, who were directly supervised and assisted by the pulmonary faculty member in attendance.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
For all 29 patients (30 peripheral pulmonary lesions), EBUS-GS–guided TBB was performed safely with no complications such as pneumothorax, major bleeding, or pneumonia. The bronchi depicted on VB images were highly consistent with the actual structures, as confirmed on FFB. Following VB navigation, the bronchoscope was smoothly inserted into third- to sixth-generation bronchi (mean, 4.0 ± 0.9 generations). EBUS detected 24 of the peripheral pulmonary lesions (80.0%). All patients in whom peripheral pulmonary lesions were visible on EBUS imaging subsequently underwent EBUS-GS–guided TBB and bronchial brushing. Average time to first EBUS imaging of the lesion, including anesthesia of the tracheobronchial tree and insertion of the bronchoscope and echo probe into the lesion following VB, was 9.56 ± 6.57 min. Average time to first biopsy, including time to first EBUS imaging and adjustment of forceps position, was 11.99 ± 6.85 min. Average duration of the complete examination was 25.72 ± 9.13 min.

Mean number of specimens obtained using EBUS-GS–guided TBB with VB navigation was 2.8 ± 2.4. Diagnosis was possible in 19 cases (63.3%) [Table 1 ]: primary lung cancer, n = 14 (adenocarcinoma, n = 8; squamous cell carcinoma, n = 2; non-small cell carcinoma, n = 2; and small cell carcinoma, n = 2); metastatic lung cancer, n = 2 (the primary lesion was laryngeal in one patient, and uterine in the other); diffuse large B-cell lymphoma, n = 1; and nontuberculous mycobacteriosis, n = 2. Pathologic diagnosis was performed for 14 lesions (46.7%), and a cytologic diagnosis was made for 16 lesions (53.3%).


View this table:
[in this window]
[in a new window]

  		Table 1.. Diagnosis and Treatment of Examined Lesions Found by EBUS-GS–Guided TBB

 
A representative case is shown in Figure 1 . A 55-year-old man was admitted to our hospital with an abnormal opacity on chest radiograph. Chest radiography and CT showed a pulmonary nodule measuring 17 mm in mean diameter in the right S2b, surrounded by a low attenuation area. The EBUS probe was advanced into the B2biß bronchus following VB navigation, demonstrating a low-echoic nodule surrounded by a highly reflective interface produced between the aerated lung and the lesion. Small cell carcinoma of the lung was diagnosed from EBUS-GS–guided TBB.



View larger version (86K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1.. A 55-year-old man was admitted to our hospital with an abnormal opacity on chest radiograph. Chest radiography (top left, A) and CT (top right, B) showed a pulmonary nodule measuring 17 mm in mean diameter in the right (rt.) S2b. VB demonstrated a precise route to the peripheral nodule (center left, C, and center right, D). EBUS showed a low-echoic nodule surrounded by a highly reflective interface produced between the aerated lung and the lesion (bottom, E). Small cell carcinoma of the lung was diagnosed from EBUS-GS–guided TBB.

 
In 11 lesions, EBUS-GS–guided TBB with VB navigation was nondiagnostic. These included two lesions in which atypical cells suspicious for malignancy were obtained and four nodules that were visible on EBUS but yielded insufficient biopsy and brushing samples. Of these 11 lesions, 6 lesions were diagnosed as malignant: 4 primary lung cancers (3 adenocarcinomas, 1 squamous cell carcinoma) were diagnosed on surgical resection; 1 primary lung cancer (adenocarcinoma) was diagnosed on repeat EBUS-GS-guided TBB, and 1 pulmonary metastasis of uterine cancer was diagnosed using a percutaneous approach. The remaining five masses were designated as benign. These comprised four lesions that shrank during follow-up and one nontuberculous mycobacterial nodule diagnosed from sputum culture and clinical course. Accordingly, of the 30 lesions in which a final diagnosis was made, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 63.3% (19 of 30 lesions), 100.0% (7 of 7 lesions), 100.0% (17 of 17 lesions), 53.9% (7 of 13 lesions), and 76.7% (23 of 30 lesions), respectively.

We subsequently evaluated lesions according to size (Table 2 ). Of 18 lesions < 20 mm in mean diameter, 12 lesions (66.7%) were visible on EBUS and 8 lesions (44.4%) were diagnosed from this procedure (6 lesions from histopathologic analysis and 8 lesions from cytology). All 12 lesions measuring 20 to 30 mm in mean diameter were visible on EBUS, 11 of which (91.7%) were diagnosed using this procedure (8 lesions with histopathologic analysis, and 8 lesions with cytology).


View this table:
[in this window]
[in a new window]

  		Table 2.. Diagnostic Yield of EBUS-GS–Guided TBB With VB Navigation*

 
Diagnostic sensitivities of EBUS-GS–guided TBB with VB navigation in malignant and benign lesions were 73.9% and 28.6%, respectively. For malignant lesions alone, diagnostic sensitivity was 53.8% for lesions < 20 mm in mean diameter and 100% for lesions 20 to 30 mm in mean diameter.

Significant differences were found in diagnostic sensitivity of this procedure with regard to lesion size, number of samples taken, and total examination time. However, no significant differences were evident with regard to age, sex, or lesion location (Table 3 ). No significant differences in the diagnostic sensitivity were identified among the seven operators.


View this table:
[in this window]
[in a new window]

  		Table 3.. Characterization of Diagnosed Lesions and Nondiagnosed Lesions*

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
VB is a novel CT-based imaging technique that allows a noninvasive intraluminal evaluation of the tracheobronchial tree.131415161718 A few groups have reported its usefulness as a guide for TBB in diagnosing peripheral pulmonary lesions.1920 In particular, VB navigation was extremely useful for CT-guided TBB using an ultrathin bronchoscope.919 An ultrathin bronchoscope can be inserted into fifth- to sixth-generation bronchi, which are numerous. Hence, selecting an appropriate bronchial route to reach small peripheral lesions is occasionally difficult without VB navigation, considering the time limitations of the examination. In the present investigation of EBUS-GS–guided TBB, bronchoscopes with an external diameter of 4.0 to 5.3 mm could be inserted into fourth-generation bronchi on average. In addition, we attempted to select appropriate fifth- to sixth-generation bronchi using a double-hinged curette. In these situations, VB navigation provided useful information that facilitated three-dimensional understanding of the complicated bronchial routes to peripheral lesions and thereby saved time and unnecessary radiation exposure.

In addition, EBUS-GS–guided TBB has advantages in the following areas: (1) confirming the precise location of peripheral pulmonary lesions by EBUS imaging; (2) facilitating obtaining multiple biopsy and brushing specimens; and (3) obtaining biopsy specimens from peripheral pulmonary lesions accessible only through the use of a curette via the guide sheath.1011122122 EBUS-GS–guided TBB could therefore replace CT-guided TBB in most small peripheral lesions.

With regard to the effectiveness of EBUS-guided TBB in relation to tumor size, we previously reported the diagnostic yield to be 53.3% (8 of 15 lesions) for lesions < 20 mm and 66.7% (6 of 9 lesions) for lesions 20 to 30 mm in mean diameter.11 Herth et al10 reported yields of 80% (17 of 21 lesions) for lesions < 30 mm and 79% (23 of 29 lesions) for lesions > 30 mm. In the present study, diagnostic yields were 44.4% (8 of 18 lesions) for lesions < 20 mm and 91.7% (11 of 12 lesions) for lesions 20 to 30 mm. These studies are all retrospective, and each differed in design. Since diagnostic yield often depends on the ratio of benign disease to malignancy for the lesions included, it is difficult to compare the yield reported in the present study with that of others. However, EBUS-GS–guided TBB with VB navigation would appear slightly inferior to CT-guided TBB for diagnosis of lesions < 20 mm and similar or better than EBUS-guided TBB under radiograph fluoroscopy. From these results, EBUS-GS–guided TBB with VB navigation has the possibility to overcome the disadvantages of CT-guided TBB: excessive radiation exposure from CT and lengthy occupation of the CT room.

Several improvements may be necessary in order to increase the diagnostic yield of this procedure. First, in the present study, smaller nondiagnosed lesions received significantly fewer biopsies and longer examination time. In these smaller lesions, it is difficult and time consuming to select the appropriate bronchus and retain the guide sheath until sufficient numbers of samples can be obtained. For such lesions, curettage cytology should be considered as an additional measure. Moreover, bronchial washing may improve the diagnostic yield in some cases. Second, four lesions in the present study could not be diagnosed because specimens were insufficient. Since TBB and brush cytology are performed through the bronchial tree, it is difficult to obtain adequate samples from lesions beyond the bronchial wall. To overcome this problem, it may be necessary to consider using transbronchial needle aspiration. In addition, VB images were constructed by one radiologist in the present study. Development of new software and strategies is anticipated in the near future, enabling respiratory physicians to easily create VB images from information obtained by high-resolution CT scanning, hence making the procedure more accessible.

In summary, EBUS-GS–guided TBB with VB navigation was performed safely and was effective for diagnosing small peripheral pulmonary lesions. To clarify the efficacy and cost/benefit ratio of this procedure, randomized trials must be performed.


   Footnotes
 
Abbreviations: EBUS = endobronchial ultrasonography; EBUS-GS = endobronchial ultrasonography with a guide sheath; FFB = flexible fiberoptic bronchoscope; TBB = transbronchial biopsy; VB = virtual bronchoscopy

Received for publication December 2, 2004. Accepted for publication March 16, 2005.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Baaklini, WA, Reinoso, MA, Gorin, AB, et al (2000) Diagnostic yield of fiberoptic bronchoscopy in evaluating solitary pulmonary nodules. Chest 117,1049-1054[Abstract/Free Full Text]
  2. Shiner, RJ, Rosenman, J, Kaz, I, et al Bronchoscopic evaluation of peripheral lung tumours. Thorax 1988;43,887-889[Abstract/Free Full Text]
  3. Chechani, V Bronchoscopic diagnosis of solitary pulmonary nodules and lung masses in the absence of endobronchial abnormality. Chest 1996;109,620-625[Abstract/Free Full Text]
  4. Zavala, DC Diagnostic fiberoptic bronchoscopy: techniques and results of biopsy in 600 patients. Chest 1975;68,12-19[Abstract/Free Full Text]
  5. Cortese, DA, McDougall, JC Biopsy and brushing of peripheral lung cancer with fluoroscopic guidance. Chest 1979;75,141-145[Abstract/Free Full Text]
  6. Mori, K, Yanase, N, Kaneko, M, et al Diagnosis of peripheral lung cancer in cases of tumors 2 cm or less in size. Chest 1989;95,304-308[Abstract/Free Full Text]
  7. Schreiber, G, McCrory, DC Performance characteristics of different modalities of suspected lung cancer: summary of published evidence. Chest 2003;123,115s-128s
  8. Gasparini, S, Ferretti, M, Secchi, EB, et al Integration of transbronchial and percutaneous approach in the diagnosis of peripheral pulmonary nodules or masses: experience with 1027 consecutive cases. Chest 1995;108,131-137[Abstract/Free Full Text]
  9. Shinagawa, N, Yamazaki, K, Onodera, Y, et al CT-guided transbronchial biopsy using an ultrathin bronchoscope with virtual bronchoscopic navigation. Chest 2004;125,1138-1143[Abstract/Free Full Text]
  10. Herth, FJ, Ernst, A, Becker, HD Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions. Eur Respir J 2002;20,972-974[Abstract/Free Full Text]
  11. Kikuchi, E, Yamazaki, K, Sukoh, N, et al Endobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions. Eur Respir J 2004;24,533-537[Abstract/Free Full Text]
  12. Shirakawa, T, Imamura, F, Hamamoto, J, et al Usefulness of endobronchial ultrasonography for transbronchial lung biopsies of peripheral lung lesions. Respiration 2004;71,260-268[CrossRef][ISI][Medline]
  13. Onodera, Y, Omatsu, T, Takeuchi, S, et al Enhanced virtual bronchoscopy using the pulmonary artery: improvement in route mapping for ultra-selective transbronchial lung biopsy. AJR Am J Roentgenol 2004;183,1103-1110[Abstract/Free Full Text]
  14. Wever, WD, Vandecaveye, V, Lanciotti, S, et al Multidetector CT-generated virtual bronchoscopy: an illustrated review of the potential clinical indications. Eur Respir J 2004;23,776-782[Abstract/Free Full Text]
  15. Lacasse, Y, Martel, S, Hebert, A, et al Accuracy of virtual bronchoscopy to detect endobronchial lesions. Ann Thorac Surg 2004;77,1774-1780[Abstract/Free Full Text]
  16. Finkelstein, SE, Schrump, DS, Nguyen, DM, et al Comparative evaluation of super high-resolution CT scan and virtual bronchoscopy for the detection of tracheobronchial malignancies. Chest 2003;124,1834-1840[Abstract/Free Full Text]
  17. Hoppe, H, Dinkel, HP, Walder, B, et al Grading airway stenosis down to the segmental level using virtual bronchoscopy. Chest 2004;125,704-711[Abstract/Free Full Text]
  18. Hopper, KD, Lucas, TA, Gleeson, K, et al Transbronchial biopsy with virtual CT bronchoscopy and nodal highlighting. Radiology 2001;221,531-536[Abstract/Free Full Text]
  19. Asano, F, Matsuno, Y, Matsushita, T, et al Transbronchial diagnosis of a small peripheral pulmonary lesion using an ultrathin bronchoscope with virtual bronchoscopic navigation. J Bronchol 2002;9,108-111[CrossRef]
  20. Moriya, H, Koyama, M, Honjo, H, et al Interactive virtual bronchoscopy as a guide for transbronchial biopsy in two cases. J Jpn Soc Bronchol 1998;20,610-613
  21. Hurter, T, Hanrath, P Endobronchial sonography: feasibility and preliminary results. Thorax 1992;47,565-567[Abstract/Free Full Text]
  22. Kurimoto, N, Murayama, M, Yoshioka, S, et al Analysis of the internal structure of peripheral pulmonary lesions using endobronchial ultrasonography. Chest 2002;122,1887-1894[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 ChestHome page
S. A. Merritt, J. D. Gibbs, K.-C. Yu, V. Patel, L. Rai, D. C. Cornish, R. Bascom, and W. E. Higgins
Image-Guided Bronchoscopy for Peripheral Lung Lesions: A Phantom Study
Chest, November 1, 2008; 134(5): 1017 - 1026.
[Abstract] [Full Text] [PDF]

Home page
 ChestHome page
N. Yamada, K. Yamazaki, N. Kurimoto, H. Asahina, E. Kikuchi, N. Shinagawa, S. Oizumi, and M. Nishimura
Factors Related to Diagnostic Yield of Transbronchial Biopsy Using Endobronchial Ultrasonography With a Guide Sheath in Small Peripheral Pulmonary Lesions
Chest, August 1, 2007; 132(2): 603 - 608.
[Abstract] [Full Text] [PDF]

Home page
 ChestHome page
M. Yoshikawa, N. Sukoh, K. Yamazaki, K. Kanazawa, S.-i. Fukumoto, M. Harada, E. Kikuchi, M. Munakata, M. Nishimura, and H. Isobe
Diagnostic Value of Endobronchial Ultrasonography With a Guide Sheath for Peripheral Pulmonary Lesions Without X-Ray Fluoroscopy
Chest, June 1, 2007; 131(6): 1788 - 1793.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Respir. Crit. Care Med.Home page
T. R. Gildea, P. J. Mazzone, D. Karnak, M. Meziane, and A. C. Mehta
Electromagnetic Navigation Diagnostic Bronchoscopy: A Prospective Study
Am. J. Respir. Crit. Care Med., November 1, 2006; 174(9): 982 - 989.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Respir. Crit. Care Med.Home page
M. Hasegawa, Y. Nasuhara, Y. Onodera, H. Makita, K. Nagai, S. Fuke, Y. Ito, T. Betsuyaku, and M. Nishimura
Airflow Limitation and Airway Dimensions in Chronic Obstructive Pulmonary Disease
Am. J. Respir. Crit. Care Med., June 15, 2006; 173(12): 1309 - 1315.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (18)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Asahina, H.
Right arrow Articles by Nishimura, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Asahina, H.
Right arrow Articles by Nishimura, M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS