Increased mortality in patients without ventilator-associated pneumonia.

We fully support the use of a single linear endobronchial ultrasound (EBUS) bronchoscope for both endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fi ne-needle aspiration (EUS-FNA) of mediastinal lymph nodes, as reported in the recent CHEST article by Herth et al. 1 Having initially established and reported our own results with EBUS-TBNA for both malignant and benign disease, 2 , 3 we have more recently moved to performing EUS-FNA and EBUS-TBNA with a single linear EBUS bronchoscope for benign and malignant nodes. We would like to add the particular utility of EUS-FNA in nonmalignant disease as well as the more common utility in malignant disease. In our fi rst fi ve combined EBUS-TBNA EUS-FNA procedures via a single EBUS bronchoscope, three patients with suspected TB (enlarged subcarinal and hilar nodes but no parenchymal lung disease) had TB diagnosed (caseous granulomatous histologic results with positive TB culture) from the EUS-FNA only (with only one positive histologic examination and culture from EBUS-TBNA, and all negative on BAL). In addition, the antibiotic sensitivities from mediastinal lymph node culture are helpful to ongoing management of the TB. (The remaining two cases were for suspected malignancy, metastatic renal cell carcinoma and non-small cell lung cancer, which were confi rmed at EBUS-TBNA and EUS-FNA of subcarinal nodes). We have also found EUS-FNA more tolerable to some patients than EBUS-TBNA, particularly those with pronounced cough despite adequate conscious sedation and those with poor lung function and signifi cant comorbid lung disease. This can be particularly helpful if Station 7 is a target or there is a paraesophageal lymph node. Obviously, the cost savings of another EUS scope are also welcome in resource-rationed health-care systems. In summary, combined EUS-FNA EBUS-TBNA is likely to become more commonplace for all the above reasons but should not be overlooked in the diagnosis of benign disease accessible by this technique.