Cleveland Clinic’s Respiratory Institute provides a full range of advanced diagnostic and interventional bronchoscopy techniques. The institute has some of the world’s most extensive experience with:

• Electromagnetic navigation

• Endobronchial ultrasound

• Lung transplant-related airway disease

• Airway stenting

• Management of airway complications due to histoplasmosis

• Benign airway diseases

• Metallic stent removal

Endobronchial Ultrasound

Endobronchial ultrasound (EBUS) procedures allow clinicians not only to sample enlarged nodes for diagnostic purposes but also to systematically stage the mediastinum of patients with known or suspected lung cancer. EBUS is routinely used for the concomitant diagnosis and staging of lung cancer in a single session, obviating the need for a second bronchoscopy or a mediastinoscopy.¹

In 2020, the average lymph node size biopsied during staging procedures was 9.64 mm; 69% of biopsied nodes were < 10 mm in size. In addition, 2.7 nodes on average per staging procedure were sampled. Again, these outperform standards published in the medical literature on EBUS staging. The ability to routinely and accurately access lymph nodes of < 10 mm is extremely important given that PET scanning is less sensitive for nodes < 7 to 10 mm. In addition, published guidelines call for invasive sampling of normal-sized nodes in instances where risk of nodal involvement is high.²

Size of Lymph Nodes Sampled During Lung Cancer Staging (N = 1,574)


Lymph Node SizeNumber of Lymph Nodes Sampled (%)
0.1–4.994 (6.0)
5.0–9.9989 (62.8)
10.0–19.9408 (25.9)
≥ 20.083 (5.3)


  1. Almeida FA, Casal RF, Jimenez CA, Eapen GA, Uzbeck M, Sarkiss M, Rice D, Morice RC, Ost DE. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013 Dec;144(6):1776-1782.
  2. Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, Harris LJ, Detterbeck FC. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e211S-e250S.
EBUS Sampling Adequacy

Sampling adequacy during staging and diagnostic procedures (defined as a final cytologic diagnosis of lymphoid or malignant cells, or granulomas) is 95.2% at the Respiratory Institute, exceeding benchmarks from published literature.¹⁻³ Of the 222 EBUS with transbronchial needle aspiration (EBUS-TBNA) nodal specimens demonstrating non-small cell carcinoma, a specific tumor histology could be determined in 85% of samples. Next generation sequencing testing was performed in 130 samples and results were considered adequate for analysis in 128 (98.5%); 147 (94.8%) of samples were adequate for PD-L1 expression analysis in the 5145 specimens in which it was analyzed.

EBUS Sampling Adequacy


EBUS Final Primary Diagnosis 2020
Primary lung cancer591
Nondiagnostic/no specific diagnosis276
Metastatic cancer83
Granulomas without a specific diagnosis24


  1. Yasufuku K, Pierre A, Darling G, de Perrot M, Waddell T, Johnston M, da Cunha Santos G, Geddie W, Boerner S, Le LW, Keshavjee S. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011 Dec;142(6):1393-1400.
  2. Liberman M, Sampalis J, Duranceau A, Thiffault V, Hadjeres R, Ferraro P. Endosonographic mediastinal lymph node staging of lung cancer. Chest. 2014 Aug;146(2):389-397.
  3. Ost DE, Ernst A, Lei X, Feller-Kopman D, Eapen GA, Kovitz KL, Herth FJF, Simoff M; AQuIRE Bronchoscopy Registry. Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry. Chest. 2011 Dec;140(6):1557-1566.
Bronchoscopy Complication Rate

The aggregate bronchoscopy major complication rate in 2020 was lower than expected compared with published data.¹⁻² With respect to 2 of the most commonly reported complications, the institute’s pneumothorax and major bleeding rates were either below or on par with published data.

Bronchoscopy Complication Rate (N = 3093)



  1. Asano F, Aoe M, Ohsaki Y, Okada Y, Sasada S, Sato S, Suzuki E, Senba H, Fujino S, Ohmori K. Deaths and complications associated with respiratory endoscopy: a survey by the Japan Society for Respiratory Endoscopy in 2010. Respirology. 2012 Apr;17(3):478-485.
  2. Ouellette DR. The safety of bronchoscopy in a pulmonary fellowship program. Chest. 2006 Oct;130(4):1185-1190.