Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted Lung Cryobiopsies
July 19th, 2024
This article aims to describe a stepwise approach to performing robotic-assisted bronchoscopy combined with fluoroscopy, radial endobronchial ultrasound, and cone beam computed tomography to obtain targeted transbronchial lung cryobiopsies.
A component of our interventional pulmonology research is to describe the outcomes of our procedures. With new developments in advanced diagnostic bronchoscopy, we wish to detail our experiences as we aim to improve diagnostic yield, safety, radiation exposure, and efficiency of procedures at our institution. Robotic-assisted bronchoscopy is a new technique to obtain targeted lung biopsies.
We use this technology in a multimodality approach with radial endobronchial ultrasound, cone-beam computed tomograph, and fluoroscopy. The obtained transbronchial lung cryobiopsies are useful in the evaluation of pulmonary lesions or selected areas in diffuse parenchymal lung disease. Our group has published outcomes with the concurrent use of shape-sensing robotic-assisted bronchoscopy combined with fixed cone-beam CT and radial EBUS in the evaluation of peripheral pulmonary lesions.
We reported our diagnostic accuracy outcomes in our initial 200-patient cohort and published a subsequent study describing the radiation exposure and outcomes in 241 patients using this multimodality technique. To begin, upload the patient's thin slice CT chest to the planning software. After selecting the targets in the lungs, plan a pathway to each target site and review the plan in the axial, coronal, and sagittal views in virtual bronchoscopy.
After preparing for the procedure, maneuver the catheter through the airways to the target lesion following the planned pathway. Using the preview path feature, follow the images of the airways if divergence is noted. Remove the vision probe when the catheter is within 5 to 10 millimeters of the target lesion and advance the radial endobronchial ultrasound or R-EBUS probe with rotation under fluoroscopy to the pleural border.
Retract the R-EBUS probe under fluoroscopy approximately 10 millimeters from the pleural border to the anticipated biopsy target site. Visualize the target area to assess the surrounding parenchyma and any vasculature. After removing the R-EBUS probe, insert the 1.1 millimeter touch cryo probe via the catheter and extend under fluoroscopy to the predetermined target area for biopsy.
Perform cone-beam CT spin per system specific protocol. Interpret and compare the intra procedure imaging to the pre-procedure CT chest and plan for the correct catheter position. If augmented fluoroscopy is available on the CBCT, segment the target for visualization with 2D fluoroscopy during biopsy.
Adjust the catheter based on fluoroscopy CBCT and R-EBUS to ensure that sampling occurs in the appropriate location. Press the pedal to activate the freeze cycle from four to six seconds and retract the probe in one motion while depressing the pedal. Release the pedal as the probe tip with tissue is placed in 0.9%sodium chloride or fixative to release it.
After the final biopsy, inject one to two milliliters of normal saline and air in a 10 milliliter luer lock syringe into the catheter to clear any blood or secretions. Insert the vision probe to view the sampling site and retract the catheter slowly. Finally, if there is no evidence of bleeding, retract the catheter to the trachea.
Post-procedure chest radiograph in anterior-posterior view showed bilateral interstitial densities with no pneumothorax or pleural effusion.
Overview
This article describes a stepwise approach to performing robotic-assisted bronchoscopy combined with fluoroscopy, radial endobronchial ultrasound, and cone beam computed tomography. This multimodal technique aims to obtain targeted transbronchial lung cryobiopsies for evaluating pulmonary lesions.
Key Study Components
Area of Science
- Interventional Pulmonology
- Robotic-Assisted Techniques
- Diagnostic Bronchoscopy
Background
- Advancements in diagnostic bronchoscopy are crucial for improving outcomes.
- Robotic-assisted bronchoscopy enhances the precision of lung biopsies.
- Combining multiple imaging modalities can improve diagnostic yield.
- Transbronchial lung cryobiopsies are valuable for assessing pulmonary conditions.
Purpose of Study
- To improve the diagnostic yield of lung biopsies.
- To enhance the safety and efficiency of bronchoscopy procedures.
- To evaluate the effectiveness of a multimodal approach in lung biopsy acquisition.
Methods Used
- Robotic-assisted bronchoscopy
- Fluoroscopy
- Radial endobronchial ultrasound (EBUS)
- Cone beam computed tomography (CBCT)
Main Results
- Successful acquisition of targeted transbronchial lung cryobiopsies.
- Improved diagnostic yield in evaluating peripheral pulmonary lesions.
- Reduction in radiation exposure during procedures.
- Enhanced safety and efficiency of the bronchoscopy technique.
Conclusions
- Robotic-assisted bronchoscopy is a promising technique for lung biopsies.
- Multimodal imaging approaches improve diagnostic outcomes.
- Further research is needed to optimize these techniques.
Frequently Asked Questions
Executive Industry Relevance
Robotic-assisted bronchoscopy combined with multimodal imaging enables precise, targeted lung cryobiopsies, supporting high-confidence tissue acquisition for pulmonary lesion evaluation. This integrated workflow enhances diagnostic yield and safety, directly impacting early discovery and translational research in respiratory disease portfolios. The approach advances predictive confidence and operational efficiency at critical inflection points in biomarker and target validation pipelines.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables targeted sampling of pulmonary lesions for molecular and cellular analysis.
- Supports functional validation of disease-relevant targets in lung tissue.
- Reduces sampling ambiguity, increasing predictive confidence in early-stage studies.
- Facilitates portfolio triage by improving tissue acquisition reliability.
Screening & Assay Development
- Provides high-quality, reproducible lung tissue samples for downstream assays.
- Standardizes biopsy localization using multimodal imaging for consistent outputs.
- Improves readiness for compound screening by ensuring sample integrity.
- Enables scalable workflows for repeated tissue acquisition in preclinical models.
Translational & Preclinical Research
- Aligns tissue sampling with disease-relevant anatomical and pathological features.
- Supports continuity from discovery through preclinical validation by enabling robust biomarker studies.
- De-risks translational research by improving sample targeting and reducing off-target effects.
- Facilitates risk-adjusted advancement decisions based on high-fidelity tissue data.
Pipeline & Workflow Integration
This multimodal robotic-assisted workflow integrates from early discovery through preclinical research, bridging tissue acquisition, target validation, and translational biomarker studies.
- Discovery Biology: Enhances hypothesis testing and pathway clarification by enabling precise lesion targeting.
- Screening: Delivers reproducible, quantitative tissue samples for assay development and validation.
- Analytics: Provides imaging-guided localization and quantitative outputs for comparative analysis.
- Translational Research: Ensures anatomical and pathological relevance for biomarker and efficacy studies.
- Enterprise Reuse: Establishes a standardized, scalable tissue acquisition platform for diverse respiratory research programs.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence and reduces mechanistic ambiguity in lung disease models.
- Operational Value: Standardizes and streamlines tissue acquisition with reproducible, imaging-guided workflows.
- Strategic Value: Enables better go/no-go decisions and capital efficiency by improving diagnostic yield and safety.
- Portfolio Impact: Supports risk-adjusted prioritization and advancement of respiratory disease assets.
Implementation Considerations
- Requires expertise in robotic bronchoscopy and multimodal imaging interpretation.
- Demands access to advanced imaging infrastructure (CBCT, r-EBUS, fluoroscopy).
- Necessitates cross-team standardization for reproducible tissue sampling.
- Adaptation may be needed for different lung lesion types and anatomical locations.
- Practical limitations include procedural complexity and equipment availability.
