Dear Editor,

We were delighted to receive the editorial on the learning curve for endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) [1]. Dr. Medford cites detailed literature that the physician skill acquisition rate is heterogeneous, and increasing experience with EBUS-TBNA results in increasing yields and accuracy. Continued experience with any procedure raises yields to expert levels, and physicians should aspire to life-long learning. Although we must continue to strive for procedural excellence, should we expect peak yields before competency can be achieved?

As we know, EBUS-TBNA is an effective diagnostic and staging tool, which is more cost effective and less invasive than mediastinoscopy [2]. We run the risk of subjecting patients to either delayed care or more mediastinoscopies if we restrict the practice of this minimally invasive procedure to a few select centers where large volumes are done. While mediastinoscopy is on the decline, it is still widely practiced in the community [3]. One survey of thoracic physicians found that while EBUS-TBNA was preferred for staging, few had access, and the result was a lack of a standardized approach to mediastinal staging [4]. Just as conventional TBNA advanced the ability of bronchoscopy to increase diagnostic yield so does EBUS-TBNA advance minimally invasive lung cancer diagnosis and staging. Just as every positive conventional TBNA spares a patient a more invasive procedure [5] such does each positive EBUS-TBNA. The literature laments how underutilized conventional TBNA is due to lack of training [5]. If we restrict EBUS-TBNA to large volume centers, we may find ourselves also lamenting how underutilized EBUS-TBNA is.

We advocate that adequate EBUS-TBNA yields (>90%) can be achieved at 25 procedures in pulmonary trainees with experienced attending supervision and guidance. In addition, ongoing learning and maintenance of skills is needed [6]. Intense, structured curricula may lower the number to achieve competency, as demonstrated by Wahidi et al. [7], and less structure may raise that number [8]. Higher required procedural numbers will reduce the number of physicians performing EBUS-TBNA. This raises concerns about limiting access resulting in delayed diagnosis and/or staging, or patients undergoing mediastinoscopy when a minimally invasive EBUS-TBNA would suffice.

1.
Medford AR: Learning curve for EBUS-TBNA: longer than we may think. Respiration 2015;90:173.
2.
Medford AR: Endobronchial ultrasound-guided transbronchial needle aspiration. Int J Clin Pract 2010;64:1773-1783.
3.
Vyas KS, Davenport DL, Ferraris VA, Saha SP: Mediastinoscopy: trends and practice patterns in the United States. South Med J 2013;105:539-544.
4.
Debscheck EJ, Steinfort DP, Irving LB, Hew M: Mediastinal staging of non-small cell lung cancer among Australasian thoracic physicians: clinical practice and constraints on minimally invasive techniques. Intern Med J 2012;42:627-633.
5.
Mehta AC, Wang KP: Teaching conventional transbronchial needle aspiration. A continuum. Ann Am Thorac Socc 2013;10:685-689.
6.
Bellinger CR, Chatterjee AB, Adair N, Houle T, Khan I, Haponik E: Training in and experience with endobronchial ultrasound. Respiration 2014;88:478-483.
7.
Wahidi MM, Hulett C, Pastis, et al: Learning experience of linear endobronchial ultrasound among pulmonary trainees. Chest 2014;145:574-578.
8.
Fernández-Villar A, Leiro-Fernández V, Botana-Rial M, Represas-Represas C, Núñez-Delgado M: The endobronchial ultrasound-guided transbronchial needle biopsy learning curve for mediastinal and hilar lymph node diagnosis. Chest 2012;141:278-279.
© 2012 S. Karger AG, Basel
2015
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.