***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: INTRODUCTION Fluoroscopy-guided bronchoscopy is usually performed for the diagnosis of peripheral pulmonary lesions ( PPL ) , but the diagnostic yield varies widely among studies . Endobronchial ultrasound ( EBUS ) can increase the diagnostic yield of bronchoscopic diagnosis of PPL . OBJECTIVE To compare the diagnostic yield of fluoroscopy-guided bronchoscopy and EBUS with fluoroscopy-guided bronchoscopy in the study of PPL . METHODS All patients who underwent bronchoscopy to study PPL from January 2009 to December 2012 were prospect ively included . 145 consecutive patients were r and omly distributed in two groups : EBUS and fluoroscopy ( 50 patients , 71.3 ± 8.2 years ) or fluoroscopy alone ( 95 patients , 68 ± 10.5 years ) . The mean diameter of the lesions was 41.97 ± 19.22 mm . Cytological brushing and transbronchial biopsies were obtained . All procedures were performed under fluoroscopic guidance with intravenous conscious sedation . EBUS was performed using an endoscopic ultrasound system equipped with a 20-MHz radial miniprobe introduced via a guide-sheath . Bronchoscopist , cytologist , study protocol , techniques and tools were the same throughout the whole study . RESULTS 129 ( 89 % ) patients had malignant disease . A diagnosis with bronchoscopy was established in 105 ( 72.4 % ) patients . EBUS plus fluoroscopy obtained a diagnostic yield in 78 % of patients and fluoroscopy alone in 69.5 % ( non-significant ) . In contrast , for lesions smaller than 30 mm , EBUS plus fluoroscopy guidance provided significantly greater diagnostic performance than fluoroscopy alone ( 90 vs. 52 % ; P=.05 ) . CONCLUSIONS Bronchoscopy under EBUS plus fluoroscopy guidance is a technique that has become useful for the diagnostic of LPPs , especially those smaller than 30 mm in diameter STUDY OBJECTIVE To assess the ability of endobronchial ultrasonography ( EBUS ) using a guide sheath ( EBUS-GS ) to diagnose peripheral pulmonary lesions . METHOD We devised a technique for EBUS-GS covering a miniature probe , and 150 lesions were evaluated in a prospect i ve open study . In this procedure , the probe covered by a guide sheath is introduced into the lesion via the working channel of a bronchoscope . The probe is withdrawn , while the guide sheath is left in situ . A brush or biopsy forceps is introduced through the guide sheath into the lesion . RESULTS One hundred sixteen of 150 EBUS-GS procedures ( 77 % ) were diagnostic . Cases in which the probe was located within the lesion had a significantly higher diagnostic yield ( 105 of 121 cases , 87 % ) than when the probe was located adjacent to it ( 8 of 19 cases , 42 % ) [ p < 0.0001 , chi(2 ) ] . The diagnostic yield from EBUS-GS in lesions < /= 10 mm ( 16 of 21 lesions , 76 % ) , > 10 to < /= 15 mm ( 19 of 25 lesions , 76 % ; p = 0.99 , chi(2 ) ) , > 15 to < /= 20 mm ( 23 of 35 lesions , 66 % ; p = 0.41 , chi(2 ) ) , and > 20 to < /= 30 mm ( 33 of 43 lesions , 77 % ; p = 0.96 , chi(2 ) ) were similar , demonstrating the efficacy of EBUS-GS even in lesions < /= 10 mm in diameter . In 54 of 81 lesions < /= 20 mm , fluoroscopy was not able to confirm whether the forceps reached the lesion . However , the yield was the same with ( 67 % , 18 of 27 lesions ) and without ( 74 % , 40 of 54 lesions ) successful fluoroscopy ( p = 0.96 , chi(2 ) ) . Moderate bleeding occurred in two patients ( 1 % ) ; there were no other complications . CONCLUSIONS EBUS-GS is a useful method for collecting sample s from peripheral pulmonary lesions , even those too small to be visualized under fluoroscopy Transbronchial biopsy ( TBBX ) for peripheral lung lesions is usually performed with the help of fluoroscopy , but the yield varies widely . This feasibility study aim ed to assess the ability of endobronchial ultrasound ( EBUS ) to provide imaging guidance for TBBX . In a prospect i ve study , 50 consecutive patients referred for TBBX for peripheral lesions underwent fluoroscopy-guided and EBUS-guided TBBX in r and om order . Diagnostic yields were compared for both modalities and feasibility was assessed for EBUS . Diagnostic material was obtained in 80 % of patients with EBUS and 76 % of patients with fluoroscopy . There was a nonsignificant trend for EBUS to be better than fluoroscopy for lesions <3 cm in diameter . Four lesions could not be visualised with EBUS . There were no significant complications associated with the use of EBUS . Endobronchial ultrasound-guided transbronchial biopsy is feasible . It appears to be at least equivalent to fluoroscopy without the accompanying radiation exposure . Further large-scale studies are indicated to assess the possible role of endobronchial ultrasound as a potential imaging method of choice for the biopsy of peripheral lung lesions RATIONALE Endobronchial ultrasound ( EBUS ) and electromagnetic navigation bronchoscopy ( ENB ) have increased the diagnostic yield of bronchoscopic diagnosis of peripheral lung lesions . However , the role of combining these modalities to overcome each individual technique 's limitations and , consequently , to further increase the diagnostic yield remains untested . OBJECTIVES A prospect i ve r and omized controlled trial involving three diagnostic arms : EBUS only , ENB only , and a combined procedure . METHODS All procedures were performed via flexible bronchoscopy and transbronchial forceps biopsies were obtained without fluoroscopic guidance . In the combined group , after electromagnetic navigation , the ultrasound probe was passed through an extended working channel to visualize the lesion . Biopsies were taken if ultrasound visualization showed that the extended working channel was within the target . Primary outcome was diagnostic yield . The reference " gold st and ard " was a surgical biopsy if bronchoscopic biopsy did not reveal a definite histological diagnosis compatible with the clinical presentation . Secondary outcomes were yields by size , lobar distribution , and lesion pathology . Complication rates were also documented . MEASUREMENTS AND MAIN RESULTS Of the 120 patients recruited , 118 had a definitive histological diagnosis and were included in the final analysis . The diagnostic yield of the combined procedure ( 88 % ) was greater than EBUS ( 69 % ) or ENB alone ( 59 % ; p = 0.02 ) . The combined procedure 's yield was independent of lesion size or lobar distribution . The pneumothorax rates ranged from 5 to 8 % , with no significant differences between the groups . CONCLUSIONS Combined EBUS and ENB improves the diagnostic yield of flexible bronchoscopy in peripheral lung lesions without compromising safety RATIONALE Advanced bronchoscopy techniques such as electromagnetic navigation ( EMN ) have been studied in clinical trials , but there are no r and omized studies comparing EMN with st and ard bronchoscopy . OBJECTIVES To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions . Secondary outcomes included diagnostic yield of different sampling techniques , complications , and practice pattern variations . METHODS We used the AQuIRE ( ACCP Quality Improvement Registry , Evaluation , and Education ) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy ( TBBx ) for evaluation of peripheral lesions . MEASUREMENTS AND MAIN RESULTS Fifteen centers with 22 physicians enrolled 581 patients . Of the 581 patients , 312 ( 53.7 % ) had a diagnostic bronchoscopy . Unadjusted for other factors , the diagnostic yield was 63.7 % when no radial endobronchial ultrasound ( r-EBUS ) and no EMN were used , 57.0 % with r-EBUS alone , 38.5 % with EMN alone , and 47.1 % with EMN combined with r-EBUS . In multivariate analysis , peripheral transbronchial needle aspiration ( TBNA ) , larger lesion size , nonupper lobe location , and tobacco use were associated with increased diagnostic yield , whereas EMN was associated with lower diagnostic yield . Peripheral TBNA was used in 16.4 % of cases . TBNA was diagnostic , whereas TBBx was nondiagnostic in 9.5 % of cases in which both were performed . Complications occurred in 13 ( 2.2 % ) patients , and pneumothorax occurred in 10 ( 1.7 % ) patients . There were significant differences between centers and physicians in terms of case selection , sampling methods , and anesthesia . Medical center diagnostic yields ranged from 33 to 73 % ( P = 0.16 ) . CONCLUSIONS Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused . The diagnostic yields of EMN and r-EBUS were lower than expected , even after adjustment AIM To determine diagnostic rate , complications and patient tolerability of endobronchial ultrasound-guide sheath ( EBUS-GS ) and computed tomography (CT)-guided percutaneous core biopsy for peripheral lung lesions . METHODS Lesions > 1 cm diameter on CT were r and omised to either EBUS-GS or CT-guided biopsy .  Excluded were patients with severe chronic obstructive airway disease , lesions touching visceral pleura or hilum , and patients with symptoms needing bronchoscopic evaluation . Patients completed preprocedure and postprocedure question naires on tolerability . RESULTS Of 64 participants ( mean lesion size 29 ± 16 mm ) , 57 completed the study . Diagnostic sensitivity was 67 % for EBUS-GS and 78 % for CT-guided biopsy ( P = not significant ) . In those with negative results , in the EBUS group , nine had a CT-guided biopsy as a cross-over , seven of which were positive . In the CT group , four had cross-over EBUS-GS of which three were diagnostic . Sensitivity for malignancy was 17/23 for EBUS-GS ( 74 % ) and 23/26 ( 88 % , P = not significant ) . For lesions < 2 cm , CT-guided biopsy had a significantly better diagnostic yield ( 80 % vs 50 % , P = 0.05 ) . In EBUS-GS cases , for lesions with an air bronchogram , sensitivity was 89 % . Pneumothorax and intercostal catheter insertion occurred in three and two cases , respectively , for EBUS , and 10 and 3 cases for CT-guided biopsy ( P = 0.02 for pneumothorax ) . Nine unexpected admissions occurred after CT-guided biopsy compared with three after EBUS-GS . Overall , tolerability was high for both groups ; however three patients had moderate-to-severe pain  after CT-guided biopsy . CONCLUSIONS In lesions < 2 cm , CT-guided biopsy had higher yields ; however , EBUS-GS had better tolerability and fewer complications Background : Peripheral lung lesions are increasing in numbers . Endoscopic diagnosis is essential for the prevention of unnecessary operations . Conventional diagnostic procedures have limitations in availability and results . Objectives : Endobronchial ultrasonography ( EBUS ) was investigated as a means to guide transbronchial lung biopsy , to reduce the discomfort during the procedure and to improve diagnostic accuracy . Methods : In 50 cases , we performed transbronchial lung biopsy combined with EBUS and fluoroscopic guidance . The results were compared to 42 controls assessed by fluoroscopy only . Results : In 38 cases ( 76 % ) , EBUS could describe the peripheral lesion ( 33 from inside , including 9 cases with difficulties in fluoroscopic observation , and 5 from an adjacent bronchus , indicating the correct location of the lesion ) . If successfully placed inside , a change in the patient ’s position was not required , which helped to reduce patient discomfort .  Lung cancer was diagnosed in 24 patients and benign disease in 25 patients ; in 1 case diagnosis remained unknown . When the EBUS probe could be introduced inside the lesion , the sensitivity for cancer diagnosis and specificity for cancer exclusion were 100 % , respectively ( 15/15 , 18/18 ) . Compared to the controls in whom the biopsy site was determined by fluoroscopy only , the sensitivity tended to be superior by EBUS , although it did not reach statistical significance ( p = 0.06 ) . However , specificity and accuracy were statistically significant ( both p = 0.02 ) . Conclusions : When the lesion can be correctly described by EBUS from inside the lesion , EBUS is useful to guide transbronchial lung biopsy , can contribute to a reduction in patient discomfort and improves the accuracy of diagnosis . Additional navigation tools to increase correct positioning of the EBUS probe are desirable 
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Conclusion : Obtaining TBB sample s for histopathological diagnosis is enhanced by the addition of EBUS to conventional fluoroscopic guidance ; this is , especially important for patients with small peripheral lung lesions who benefit greatly from early diagnosis