Narrative review—how to access nodules: role of new technology including navi- and robo-bronchoscopy

Abstract

: Implementation of lung cancer screening is expected to increase the detection of lung nodules, many of which will require intervention for diagnosis or management. Transbronchial approaches have generally shown a favourable risk profile relative to transthoracic techniques. Bronchoscopic interventions are therefore particularly attractive in comorbid and frail patient populations. Fundamental to any biopsy or local therapy is accurate device delivery. However, transbronchial techniques must work within the constraints of bronchial anatomy, which may not inherently lend itself to easy access of suspicious nodules. A variety of technologies have been developed to improve the clinicians’ ability to reliably access nodules via a transbronchial approach. The MEDLINE database was searched from 2000 through June 2020 on the topic of navigation bronchoscopy and associated technologies. This article will review several technology classes, including intraoperative imaging that provides real-time anatomic information (computed tomography fluoroscopy, cone-beam computed tomography, augmented fluoroscopy), navigation systems that facilitate planning/selection of bronchial tree pathways [virtual bronchoscopic navigation (VBN), electromagnetic navigation bronchoscopy (ENB)], evolutions in bronchoscope design that improve function within the peripheral lung [ultrathin bronchoscopy (UTB), robotic bronchoscopy], and new platforms that permit access beyond the bronchial wall (bronchoscopic transparenchymal nodule access, transbronchial access tool). Familiarity with the strengths and limitations of these technologies are critical for their effective use.