Unlocking the potential of robotic-assisted bronchoscopy: overcoming challenging anatomy and locations

Abstract

Robotic-assisted bronchoscopy (RAB) was recently added to the armamentarium of tools used in sampling peripheral lung nodules. Protocols and guidelines have since been published advocating use of large oral artificial airways, use of confirmatory technologies such as radial endobronchial ultrasound (R-EBUS), and preferably limiting sampling to pulmonary parenchymal lesions. We present three clinical cases where RAB was used unconventionally to sample pulmonary nodules in unusual locations and in patients with challenging airway anatomy. In case 1, we introduced the ion catheter through a nasal airway in a patient with trismus. In case 2, we established a diagnosis by sampling a station 5 lymph node, and in case 3, we sampled a lesion located behind an airway stump from previous thoracic surgery. All three patients would have presented significant challenges for alternative biopsy modalities such as CT-guided needle biopsy or video-assisted thoracic surgery.

Keywords: biopsy; bronchoscopy; robotic bronchoscopy.

Figure 1.

(a) Trismus limiting oral intubation and (b) 6.5 ETT through nare and connected to Ion adapter. ETT, endotracheal tube.

Figure 2.

(a) and (b) PET/CT scan showing pet +LUL nodule and station 5 adenopathy. LUL, left upper lobe. (c) and (d) Fluoroscopic image of Ion needle in station 5 and lung window view of lymph node station 5. PET/CT, Positron Emission Tomography/Computed Tomography.

Figure 3.

(a) PET + nodule behind LUL bronchus stump. (b) Ion catheter visualized with another bronchoscope view. (c) and (d) Virtual view of PET + nodule behind airway stump. LUL, left upper lobe.