so this patient is a 32y old woman who've had mediastinal adenopathy enlargement of the lymph nodes and she also have been having Progressive shortness of breath and in the course of the workup of course we're concerned about possibilities of bad things such as malignancies which a young woman and even though she's a non-smoker could be lymphoma there are also other mediastino tumors but definitely high up in the differential not just the fact that she's africanamerican but just a whole clinical feature is that she may have Saro does a stage one Saro with medo adenopathy but we want to also look into Airways because very often we'll find mucosal thickening and that will be another way to diagnose sod dois and finally of course we always want to rule out infection and broncoscopy is an effective way to do that as well now in the course of our broncoscopy the main goal is to sampo those lymph nodes because they were the major pathology scene and again the most effective least invasive way would be to approach it first by trans bronchiole aspiration tbna if we come up here and look at the lymph node stations we will see enlarged lymph nodes in the preina and as we we go up to this next panel I have already flipped the film to help me look to fit with a bronchoscopic view of the right hila lymph node the subar lymph node and possibly even extending to the left higher lymph nodes so after the initial examination of the Airways we will then perform transbronchial needle aspiration of the lymph nodes probable endobronchial biopsy of the airway looking at the most abnormal segments and perhaps also perform trans Broncho biopsies so this is a 21 gauge tbna needle we open up the package and it consists of both a syringe which we shall use and also the needle catheter device we flatten this out bring this out hook the syringe on now we have ergonomically a fairly easy to pull out and it's held in a single hand to advance the needle we push on the blue button forward and it automatically locks I cannot pull this back to pull back I will have to depress the blue button single hand motion and pull back we always check to make sure the tip of the needle is not exposed this will damage the bronos scope scope and here's the tip of the needle catheter and that's all we need to show there are several techniques which I will show you the first one we're going to approach is the lymph node in the right highum and I will not extend the needle Elliot let's go towards the right highum here is the takeoff of the right upal and you can still suction if need be and as you approach to the right hm don't flex so much it's just right about like so Advance a little bit more and now start turning in okay go down a little bit more I want it to be in the right broncus in the medus here and as Elliot flexes up I push my needle out so it's anchored into the mucosa now Elliot go forward don't let the catheter come out too far are you flexed okay and Advance on three together go ahead you call it one two and we see the needle going through now it could be a little more 90° which we will do in the next time and here I will be pushing the needle in and out of the mucosa and you can see it coming in and out of the mucosa so far no Hemorrhage and when you push the catheter far out enough you see if you're in he so the first pass here I will use the no suction technique merely using capillary action after about four or five P now I push the needle down pulling it backwards and we will pull the whole cat to the back and Elliot will straighten out the bronos scope let's take a look in the airway a little bit of hemorrhage you can suction clean we take outside and do cytology okay so again not too much Hemorrhage so but we will try to get out more this is without [Music] suction like I said number one yes I don't think I work with you so far this we will go back with a different needle it's helpful to get a Core biopsy and hence we use a somewhat larger gauge needle catheter this is a 19 gauge but the rest of the setup is essentially identical so this one we'll do a somewhat different approach come back even a touch more Elliot I will bring out the needle first very often I find this to actually be a little more challenging in an awake patient but with the benefit of anesthesia of course there's very little movement this is ideal now go up towards the prear at 12:00 start flexing up now you really have to turn towards come back a little bit now start flexing up Flex up a little more yes there okay and on three maximally flexed Max Flex we'll go forward all right one two three Advance now suction so in fact she coughed us into it as you can tell suction keep the airway clean and again I'm doing it without any suctioning sometimes when we do it without suctioning I feel we can maybe get a better sample with less trauma and now I'll break suction by pulling this back straighten out the bronchoscope please we always check to make sure the tip of the needle is not exposed this will damage the bronos scope on three come back and again straighten out your scope okay and you can look at the site to make sure there's not too much hemorrage and that's a nice view of how it should look like after a tbna right you have a little Dart dot but certainly no excessive [Music] trauma the details of this particular case went pretty smoothly we first used a 21 gauge needle went into the right High lymph node and the first pass actually showed not just some Broncho cell cells almost always present but also lymphocytes and some granuloma like cells which would be pathic of sosis but also infection so we made sure we save some specimen and send it off for infectious workup primarily to look for fungal infections or microbacterial infections traditionally the gold standard would have been to perform a median sosc but that obviously is a more invasive procedure requires general anesthesia and again you know for ladies especially it would require making a cut up towards the neck and cosmetically it could be an issue so overall we just feel that tbna if it gives us an answer is a much less invasive approach depending on the circumstance but in the case of a benign condition such as cardosis where it does not make too much of a difference which lymph node we approach first I would go to the largest lymph node most easily accessible and also one that I think would cause less complications now on the other hand if I'm concerned about the lung cancer I would then approach The Highest Potential stage which in this case would be the one most Central in the preina so-call N2 and then go dist toly to the N1 in summary overall there are many different uses for Trans Broncho aspiration or Endor Broncho aspiration I like using it because it provides a mechanism for in the same bronchoscopic procedure not only in going after the primary lung Mass which is often in the periphery but of sampling Central Airway lymph nodes and providing a staging procedure all in one sitting