• Sarcoidosis
• Bronchoscopy

We thank Dhooria et al1 for their complimentary comments on our review article about linear endobronchial ultrasound.2 We congratulate them on their carefully performed randomised controlled trial comparing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in conjunction with transbronchial lung biopsies (TBLB) and endobronchial biopsies (EBB) with conventional non-ultrasound-guided transbronchial needle aspiration (cTBNA) in conjunction with TBLB and EBB for the diagnosis of sarcoidosis.3 In this study, they showed that EBUS-TBNA, as an individual test, has the highest diagnostic yield for granulomas in sarcoidosis (74.5%), a figure similar to that shown by other groups4 ,5 and considerably better than that achieved by cTBNA (48%).

Bronchoscopists now have a considerable armamentarium to choose from for investigating suspected sarcoidosis including EBUS-TBNA, cTBNA, endoscopic ultrasound, EBB, TBLB and bronchoalveolar lavage. Therefore, the question that arises is which is the best combination? To some extent, this will be defined by availability and expertise. Dhooria et al and others suggest that EBUS-TBNA in combination with TBLB optimises yield (90.9%), but it must be remembered that headline figures achieved by expert practitioners may not be achievable by all. Furthermore, the additional yield provided by TBLB must be tempered by the risk of complication, specifically pneumothorax, which although admirably low in the study by Dhooria et al has been reported by others as occurring in 1–6% of cases.6 In situations where EBUS-TBNA is not available, cTBNA in combination with EBB and TBLB probably provides the highest accuracy but again is very dependent upon disease prevalence and expertise.7

Although it seems likely that EBUS-TBNA±TBLB will become the standard of care for investigating pulmonary sarcoidosis, further carefully designed comparative studies are warranted and these would benefit further from having a cost-effectiveness component.