The authors want to thank the interventional pulmonology team, endoscopy staff, anesthesia team, cytopathology team, and hybrid operating room radiology technicians at UT Southwestern Medical Center.

The protocol described in this article outlines standard clinical practice. The University of Texas Southwestern Medical Center Institutional Review Board approved the prospective data collection of patients undergoing standard-of-care bronchoscopy with ssRAB (STU-2021-0346), and individual consent is waived for inclusion in our database. Routine procedure consent is obtained from the patient prior to the procedure. Patients who have DPLD radiographically and are acceptable candidates for bronchoscopic biopsy are referred for this procedure5,27. Patients over 18 years of age are deemed able to undergo the procedure by the referring and performing physicians. Exclusion criteria include bleeding disorders (elevated INR &#62;1.3, thrombocytopenia &#60;100,000/&#181;L), hypoxia with pulse oximetry &#60;90% on 2 L/min supplemental oxygen, pulmonary hypertension (echocardiographically measured systemic pulmonary artery pressure &#62;50 mmHg), or severe cardiac disease. The details of the equipment used in this study are listed in the Table of Materials.
1. Pre-procedural planning
<ol>
	<li>Upload the patient&#8217;s thin slice CT chest to the planning software. The software will automatically create a 3-dimensional reconstruction of the airways and lungs.</li>
	<li>Select targets in the lungs for proposed sampling approximately 10 mm from the pleural border. NOTE: This may be an area of ground glass, infiltrate, nodularity, or fibrosis after discussion with the referring physician, radiologist, or clinical judgment. Prior reported literature for peripheral lung lesions shows an increased diagnostic yield if the targeted area is&#160; &#62;2 cm28.</li>
	<li>Plan a pathway to each target site. 
	NOTE: In the event that the pathway is not feasible during the procedure, consider planning a secondary pathway.</li>
	<li>Review the plan in all three CT views (axial, coronal, and sagittal) and virtual bronchoscopy (Figure 1).</li>
	<li>Export the plan to the controller console.&#160;</li>
</ol>
2. Patient preparation
<ol>
	<li>Induce and maintain the patient under general anesthesia with a minimum size 8.0 single-lumen endotracheal tube. Use neuromuscular blockade and total intravenous anesthesia with ventilator protocols to reduce the development of atelectasis29. 
	NOTE: Monitoring of paralysis is performed using a train-of-four test with a peripheral nerve stimulator29.</li>
	<li>Tuck the patient&#8217;s arms to allow for full rotation of the c-arm during CBCT spin.</li>
	<li>Position the patient and c-arm so that the targeted area for TBLC is isocentered on fluoroscopy.</li>
</ol>
3. Conventional bronchoscopy
<ol>
	<li>Insert the diagnostic or therapeutic bronchoscope via a bronchoscope adapter into the endotracheal tube.</li>
	<li>Perform an airway examination and minimize suction to reduce the development of atelectasis30.</li>
	<li>Remove the bronchoscope.</li>
</ol>
4. Robotic-assisted bronchoscopy
<ol>
	<li>Docking
	<ol>
		<li>Move the robotic bronchoscope to a position adjacent to the patient.</li>
		<li>Dock the robotic arm with the magnetic bronchoscope adapter. Insert the catheter and vision probe into the endotracheal tube.</li>
	</ol>
	</li>
	<li>Registration
	<ol>
		<li>Position the catheter so that direct vision matches the virtual bronchoscope image at the carina.</li>
		<li>Maneuver the robotic catheter via a scroll wheel and track ball on the controller console into both mainstem airways, then bilateral upper and lower airways to collect airway data.</li>
		<li>Compare virtual versus actual bronchoscope images after registration is complete. If significant mismatching or divergence is noted, perform re-registration; otherwise, accept the registration.</li>
	</ol>
	</li>
	<li>Navigation
	<ol>
		<li>Maneuver the catheter using the scroll wheel and track ball on the controller console through the airways to the target lesion following the planned pathway.</li>
		<li>Use the &#8220;Preview Path&#8221; feature to follow images of the airways if divergence (discrepancy between the virtual and actual airways) is noted.</li>
	</ol>
	</li>
	<li>Use fluoroscopy, r-EBUS, and CBCT to confirm location.
	<ol>
		<li>Remove the vision probe when the catheter is within 5&#8211;10 mm of the target lesion.</li>
		<li>Advance the r-EBUS probe with probe rotation under fluoroscopy. Advance to the pleural border (Figure 2A).</li>
		<li>Retract the r-EBUS probe under fluoroscopy approximately 10 mm from the pleural border to the anticipated biopsy target site. Use the r-EBUS probe to visualize the target area and assess the surrounding parenchyma and any vasculature in the potential biopsy area. Remove the r-EBUS probe.</li>
		<li>Insert the 1.1 mm touch cryoprobe via the catheter and extend under fluoroscopy to the pre-determined target area for biopsy (Figure 2B).</li>
		<li>Perform cone beam CT spin per system-specific protocol. The ventilation may be continued or held per provider preference using an end-inspiratory breath hold with the ventilator&#8217;s adjustable pressure-limiting valve set to match the positive end-expiratory pressure (PEEP) or vital capacity maneuver. 
		NOTE: The CBCT spin may be performed with the extension of the r-EBUS probe without rotation or 1.1 mm cryoprobe in the anticipated biopsy site.</li>
		<li>Interpret and compare the intra-procedure imaging to the pre-procedure CT chest and plan to ensure the catheter is at the target. If augmented fluoroscopy is available on the CBCT, segment the target for visualization with 2-D fluoroscopy during biopsy (Figure 3).</li>
		<li>Adjust the catheter based on fluoroscopy, CBCT, and r-EBUS to ensure that sampling occurs in the appropriate location.</li>
		<li>Repeat CBCT after the catheter is adjusted if necessary.</li>
	</ol>
	</li>
	<li>Tissue sampling
	<ol>
		<li>Ensure the 1.1 mm touch cryoprobe is in the appropriate biopsy position.</li>
		<li>Press the pedal to activate the freeze cycle from 4 s to 6 s, then retract the probe in one motion while continuing to depress the pedal.</li>
		<li>Release the pedal while placing the probe tip with tissue biopsy in sodium chloride 0.9% or fixative to release the biopsy from the tip.</li>
		<li>Repeat steps 4.5.1&#8211;4.5.3 to perform TBLC. 
		NOTE: The authors typically perform 1&#8211;4 biopsies at each site. During the biopsy process, the catheter may be adjusted slightly prior to each biopsy to ensure adequate tissue procurement; this may require repeating CBCT spins or using r-EBUS to confirm position in step 4.4.</li>
		<li>After the final biopsy, inject 1&#8211;2 mL of normal saline and air in a 10 mL Leuer lock syringe into the catheter to clear any blood or secretions.</li>
		<li>Insert the vision probe to view the sampling site and retract the catheter slowly. If there is evidence of bleeding via direct vision or blushing on fluoroscopy, then instill topical 1:10,000 epinephrine 1 mL, additional cold saline, or 50&#8211;100mg of tranexamic acid via Leuer lock syringe. Then, leave the catheter in place for 3&#8211;5 min for additional tamponade.</li>
		<li>Repeat step 4.5.6. If there is no evidence of bleeding, retract the catheter to the trachea.</li>
		<li>If significant bleeding is noted, then remove the robotic bronchoscope and follow protocols for the management of iatrogenic bleeding after flexible bronchoscopy31.</li>
	</ol>
	</li>
	<li>Additional target sites: If additional target sites are planned for biopsy, then repeat steps 4.3&#8211;4.5.</li>
	<li>After the conclusion of robotic-assisted bronchoscopy, retract the catheter, undock the robotic system, and move out of position.</li>
</ol>
5. Conventional bronchoscopy&#160;
<ol>
	<li>Reinsert the diagnostic or therapeutic bronchoscope through the bronchoscope adapter into the airways for airway examination and suctioning.</li>
	<li>If bronchoalveolar lavage is indicated, advance the bronchoscope into a subsegmental airway where TBLC was not performed to create a wedge. Instill serial aliquots of normal saline and then return via hand suction.&#160;</li>
</ol>
6. Procedure conclusion
<ol>
	<li>Remove the bronchoscope.</li>
	<li>Perform fluoroscopy or focused ultrasound5 to assess for pneumothorax. If pneumothorax is identified, consider the placement of a chest tube versus conservative management with serial observation depending on size and patient&#8217;s clinical status.</li>
	<li>If necessary, transfer the TBLC specimens to the container with a fixative if initially placed in 0.9% sodium chloride.</li>
	<li>Reverse anesthesia, extubate, and awaken the patient.</li>
	<li>Transfer the patient to the post-anesthesia care unit.</li>
	<li>Perform and review post-procedure chest radiograph (Figure 4).</li>
</ol>
7. Follow-up post procedure
<ol>
	<li>Review results from the bronchoscopy at a multi-disciplinary discussion attended by pulmonologists who are experts in interstitial lung disease, thoracic radiologists, and thoracic pathologists to determine an ILD subtype.</li>
	<li>Discuss the results of the bronchoscopy and MDD conference with the patient, as well as plans for further management and follow-up.&#160;</li>
</ol>

Advancements in Pulmonary Lesion Biopsy Through Robotic Bronchoscopy

<ol>
	<li>Jain, P., Hadique, S., Mehta, A. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transbronchial+lung+biopsy.">Transbronchial lung biopsy.</a> Interventional Bronchoscopy: A Clinical Guide. , 15-44 (2013).</li><li>Maher, T. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interstitial+lung+disease:+A+review.">Interstitial lung disease: A review.</a> JAMA. 331 (19), 1655-1665 (2024).</li><li>Wahidi, M. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+forceps,+cryoprobe,+and+thoracoscopic+lung+biopsy+for+the+diagnosis+of+interstitial+lung+disease:+The+chill+study.">Comparison of forceps, cryoprobe, and thoracoscopic lung biopsy for the diagnosis of interstitial lung disease: The chill study.</a> Respiration. 101 (4), 394-400 (2022).</li><li>Hutchinson, J. P., Fogarty, A. W., Mckeever, T. M., Hubbard, R. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=In-hospital+mortality+after+surgical+lung+biopsy+for+interstitial+lung+disease+in+the+United+States.+2000+to+2011.">In-hospital mortality after surgical lung biopsy for interstitial lung disease in the United States. 2000 to 2011.</a> Am J Respir Crit Care Med. 193 (10), 1161-1167 (2016).</li><li>Davidsen, J. R., Laursen, C. B., Skaarup, S. H., Kronborg-White, S. B., Juul, A. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transbronchial+lung+cryobiopsy+for+diagnosing+interstitial+lung+diseases+and+peripheral+pulmonary+lesions-a+stepwise+approach.">Transbronchial lung cryobiopsy for diagnosing interstitial lung diseases and peripheral pulmonary lesions-a stepwise approach.</a> J Vis Exp. 197, e65753 (2023).</li><li>Korevaar, D. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=European+Respiratory+Society+guidelines+on+transbronchial+lung+cryobiopsy+in+the+diagnosis+of+interstitial+lung+diseases.">European Respiratory Society guidelines on transbronchial lung cryobiopsy in the diagnosis of interstitial lung diseases.</a> Eur Respir J. 60 (5), 2200425 (2022).</li><li>Raghu, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Idiopathic+pulmonary+fibrosis+(an+update)+and+progressive+pulmonary+fibrosis+in+adults:+An+official+ATS/ERS/JRS/ALAT+clinical+practice+guideline.">Idiopathic pulmonary fibrosis (an update) and progressive pulmonary fibrosis in adults: An official ATS/ERS/JRS/ALAT clinical practice guideline.</a> Am J Respir Crit Care Med. 205 (9), e18-e47 (2022).</li><li>Maldonado, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transbronchial+cryobiopsy+for+the+diagnosis+of+interstitial+lung+diseases:+Chest+guideline+and+expert+panel+report.">Transbronchial cryobiopsy for the diagnosis of interstitial lung diseases: Chest guideline and expert panel report.</a> Chest. 157 (4), 1030-1042 (2020).</li><li>Rodrigues, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+yield+and+safety+of+transbronchial+lung+cryobiopsy+and+surgical+lung+biopsy+in+interstitial+lung+diseases:+A+systematic+review+and+meta-analysis.">Diagnostic yield and safety of transbronchial lung cryobiopsy and surgical lung biopsy in interstitial lung diseases: A systematic review and meta-analysis.</a> Eur Respir Rev. 31 (166), 210280 (2022).</li><li>Tang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transbronchial+lung+cryobiopsy+for+peripheral+pulmonary+lesions.+A+narrative+review.">Transbronchial lung cryobiopsy for peripheral pulmonary lesions. A narrative review.</a> Pulmonology. S2531-0437 (23), 00163-00170 (2023).</li><li>Fielding, D. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+human+use+of+a+new+robotic-assisted+fiber+optic+sensing+navigation+system+for+small+peripheral+pulmonary+nodules.">First human use of a new robotic-assisted fiber optic sensing navigation system for small peripheral pulmonary nodules.</a> Respiration. 98 (2), 142-150 (2019).</li><li>Benn, B. S., Romero, A. O., Lum, M., Krishna, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+navigation+bronchoscopy+as+a+paradigm+shift+in+peripheral+lung+access.">Robotic-assisted navigation bronchoscopy as a paradigm shift in peripheral lung access.</a> Lung. 199 (2), 177-186 (2021).</li><li>Kalchiem-Dekel, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Shape-sensing+robotic-assisted+bronchoscopy+in+the+diagnosis+of+pulmonary+parenchymal+lesions.">Shape-sensing robotic-assisted bronchoscopy in the diagnosis of pulmonary parenchymal lesions.</a> Chest. 161 (2), 572-582 (2022).</li><li>Ali, M. S., Ghori, U. K., Wayne, M. T., Shostak, E., De Cardenas, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+performance+and+safety+profile+of+robotic-assisted+bronchoscopy:+A+systematic+review+and+meta-analysis.">Diagnostic performance and safety profile of robotic-assisted bronchoscopy: A systematic review and meta-analysis.</a> Ann Am Thorac Soc. 20 (12), 1801-1812 (2023).</li><li>Oberg, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+robotic-assisted+cryobiopsy+for+peripheral+pulmonary+lesions.">Novel robotic-assisted cryobiopsy for peripheral pulmonary lesions.</a> Lung. 200 (6), 737-745 (2022).</li><li>Verhoeven, R. L., F&#252;tterer, J. J., Hoefsloot, W., Van Der Heijden, E. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cone-beam+CT+image+guidance+with+and+without+electromagnetic+navigation+bronchoscopy+for+biopsy+of+peripheral+pulmonary+lesions.">Cone-beam CT image guidance with and without electromagnetic navigation bronchoscopy for biopsy of peripheral pulmonary lesions.</a> J Bronchology Interv Pulmonol. 28 (1), 60 (2021).</li><li>Verhoeven, R. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cone-beam+ct+and+augmented+fluoroscopy&#8211;guided+navigation+bronchoscopy:+Radiation+exposure+and+diagnostic+accuracy+learning+curves.">Cone-beam ct and augmented fluoroscopy&#8211;guided navigation bronchoscopy: Radiation exposure and diagnostic accuracy learning curves.</a> J Bronchology Interv Pulmonol. 28 (4), 262 (2021).</li><li>Kheir, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cone-beam+computed+tomography-guided+electromagnetic+navigation+for+peripheral+lung+nodules.">Cone-beam computed tomography-guided electromagnetic navigation for peripheral lung nodules.</a> Respiration. 100 (1), 44-51 (2021).</li><li>Setser, R., Chintalapani, G., Bhadra, K., Casal, R. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cone+beam+CT+imaging+for+bronchoscopy:+A+technical+review.">Cone beam CT imaging for bronchoscopy: A technical review.</a> J Thorac Dis. 12 (12), 7416 (2020).</li><li>Wagh, A., Ho, E., Murgu, S., Hogarth, D. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Improving+diagnostic+yield+of+navigational+bronchoscopy+for+peripheral+pulmonary+lesions:+A+review+of+advancing+technology.">Improving diagnostic yield of navigational bronchoscopy for peripheral pulmonary lesions: A review of advancing technology.</a> J Thorac Dis. 12 (12), 7683 (2020).</li><li>Styrvoky, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Shape-sensing+robotic-assisted+bronchoscopy+with+concurrent+use+of+radial+endobronchial+ultrasound+and+cone+beam+computed+tomography+in+the+evaluation+of+pulmonary+lesions.">Shape-sensing robotic-assisted bronchoscopy with concurrent use of radial endobronchial ultrasound and cone beam computed tomography in the evaluation of pulmonary lesions.</a> Lung. 200 (6), 755-761 (2022).</li><li>Styrvoky, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radiation+dose+of+cone+beam+ct+combined+with+shape+sensing+robotic+assisted+bronchoscopy+for+the+evaluation+of+pulmonary+lesions:+An+observational+single+center+study.">Radiation dose of cone beam ct combined with shape sensing robotic assisted bronchoscopy for the evaluation of pulmonary lesions: An observational single center study.</a> J Thorac Dis. 15 (9), 4836 (2023).</li><li>Inomata, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Utility+of+radial+endobronchial+ultrasonography+combined+with+transbronchial+lung+cryobiopsy+in+patients+with+diffuse+parenchymal+lung+diseases:+A+multicentre+prospective+study.">Utility of radial endobronchial ultrasonography combined with transbronchial lung cryobiopsy in patients with diffuse parenchymal lung diseases: A multicentre prospective study.</a> BMJ Open Respir Res. 8 (1), e000826 (2021).</li><li>Zhou, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+diagnostic+efficacy+of+cone+beam+computed+tomography-guided+transbronchial+cryobiopsy+for+interstitial+lung+disease:+A+cohort+study.">Safety and diagnostic efficacy of cone beam computed tomography-guided transbronchial cryobiopsy for interstitial lung disease: A cohort study.</a> Eur Respir J. 56 (2), 2000724 (2020).</li><li>Benn, B. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cone+beam+CT+guidance+improves+transbronchial+lung+cryobiopsy+safety.">Cone beam CT guidance improves transbronchial lung cryobiopsy safety.</a> Lung. 199, 485-492 (2021).</li><li>Ali, S. O., Castellani, C., Benn, B. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transbronchial+lung+cryobiopsy+performed+with+cone+beam+computed+tomography+guidance+versus+fluoroscopy:+A+retrospective+cohort+review.">Transbronchial lung cryobiopsy performed with cone beam computed tomography guidance versus fluoroscopy: A retrospective cohort review.</a> Lung. 202 (1), 1-9 (2023).</li><li>Hackner, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transbronchial+lung+cryobiopsy:+Prospective+safety+evaluation+and+90-day+mortality+after+a+standardized+examination+protocol.">Transbronchial lung cryobiopsy: Prospective safety evaluation and 90-day mortality after a standardized examination protocol.</a> Thera Adv Respir Dis. 16, 17534666221077562 (2022).</li><li>Kops, S. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+yield+and+safety+of+navigation+bronchoscopy:+A+systematic+review+and+meta-analysis.">Diagnostic yield and safety of navigation bronchoscopy: A systematic review and meta-analysis.</a> Lung Cancer. 180, 107196 (2023).</li><li>Pritchett, M. A., Lau, K., Skibo, S., Phillips, K. A., Bhadra, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anesthesia+considerations+to+reduce+motion+and+atelectasis+during+advanced+guided+bronchoscopy.">Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy.</a> BMC Pulm Med. 21 (1), 1-10 (2021).</li><li>Paradis, T. J., Dixon, J., Tieu, B. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+bronchoscopy+in+the+diagnosis+of+airway+disease.">The role of bronchoscopy in the diagnosis of airway disease.</a> J Thorac Dis. 8 (12), 3826 (2016).</li><li>Bernasconi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Iatrogenic+bleeding+during+flexible+bronchoscopy:+Risk+factors,+prophylactic+measures+and+management.">Iatrogenic bleeding during flexible bronchoscopy: Risk factors, prophylactic measures and management.</a> ERJ Open Res. 3 (2), 00084 (2017).</li><li>Bian, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+diagnostic+efficiency+and+safety+of+transbronchial+lung+cryobiopsy+using+1.1-mm+cryoprobe+in+diagnosing+interstitial+lung+disease.">The diagnostic efficiency and safety of transbronchial lung cryobiopsy using 1.1-mm cryoprobe in diagnosing interstitial lung disease.</a> Research Square. , (2024).</li><li>Kronborg-White, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+pilot+study+on+the+use+of+the+super+dimension+navigation+system+for+optimal+cryobiopsy+location+in+interstitial+lung+disease+diagnostics.">A pilot study on the use of the super dimension navigation system for optimal cryobiopsy location in interstitial lung disease diagnostics.</a> Pulmonology. 29 (2), 119-123 (2023).</li><li>Abdelghani, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Imaging+modalities+during+navigational+bronchoscopy.">Imaging modalities during navigational bronchoscopy.</a> Expert Rev Respir Med. 18 (3-4), 175-188 (2024).</li><li>Chen, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+diagnostic+value+of+transbronchial+lung+cryobiopsy+combined+with+rapid+on-site+evaluation+in+diffuse+lung+diseases:+A+prospective+and+self-controlled+study.">The diagnostic value of transbronchial lung cryobiopsy combined with rapid on-site evaluation in diffuse lung diseases: A prospective and self-controlled study.</a> BMC Pulm Med. 22 (1), 124 (2022).</li><li>Goorsenberg, A., Kalverda, K. A., Annema, J., Bonta, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Advances+in+optical+coherence+tomography+and+confocal+laser+endomicroscopy+in+pulmonary+diseases.">Advances in optical coherence tomography and confocal laser endomicroscopy in pulmonary diseases.</a> Respiration. 99 (3), 190-205 (2020).</li><li>Kheir, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+bronchoscopic+lung+cryobiopsy+and+a+genomic+classifier+in+the+multidisciplinary+diagnosis+of+diffuse+interstitial+lung+diseases.">Using bronchoscopic lung cryobiopsy and a genomic classifier in the multidisciplinary diagnosis of diffuse interstitial lung diseases.</a> Chest. 158 (5), 2015-2025 (2020).</li><li>Chaudhary, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interstitial+lung+disease+progression+after+genomic+usual+interstitial+pneumonia+testing.">Interstitial lung disease progression after genomic usual interstitial pneumonia testing.</a> Eur Respir J. 61 (4), (2023).</li><li>Tian, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+confocal+laser+endomicroscopy+in+pulmonary+medicine.">The role of confocal laser endomicroscopy in pulmonary medicine.</a> Eur Respir Rev. 32 (167), 2201245 (2023).</li></ol>

DP has no conflicts of interest to declare. KS reports a relationship with Intuitive Surgical Inc. that includes travel reimbursement.

This manuscript provides a stepwise approach for performing RAB with fluoroscopy, r-EBUS, and cone beam CT to obtain targeted TBLC.&#160;
There are several critical steps in this protocol. First, patient selection is imperative to ensure patients are both appropriate candidates (the biopsy procedure may have a direct impact on diagnosis and further care) and medically able to undergo the procedure5,6. Pre-procedure preparation includes...

Flexible bronchoscopy with transbronchial lung biopsy (TBBX) is a diagnostic modality used for the evaluation of abnormal chest imaging, including masses, nodules, non-resolving infiltrates, or parenchymal lung diseases1. Diffuse parenchymal lung diseases (DPLD) can often be characterized by fibrosis and/or inflammation. While some patients can be diagnosed noninvasively with a thorough history, physical examination, relevant serologies, high-resolution computed tomography (HRCT) findings, and multi-disciplinary discussion (MDD), many patients need an invasive procedure to establish a diagnosis2. Conventional transbronchial lung biopsies with forceps are limited due to small biopsy size and crush artifacts; as a result, surgical lung&#160;biopsy has been considered the gold standard, although it has significant morbidity and mortality3,4.
Transbronchial lung cryobiopsy (TBLC) is a technique that can be used to diagnose interstitial lung disease (ILD) or diffuse parenchymal lung disease (DPLD) and might serve as an alternative to surgical lung biopsy (SLB)5. According to the European Respiratory Society guidelines, TBLC is recommended as a substitute for SLB in eligible patients6. Similarly, the American Thoracic Society guidelines offer a conditional recommendation for TBLC as an alternative to SLB in medical centers with the necessary expertise in performing and interpreting TBLC results7. TBLC has historically provided good accuracy in diagnosis compared to SLB but is limited by complications, including bleeding and pneumothorax8. A recent meta-analysis showed an overall diagnostic yield of 77% that improved to 80.7% with MDD, and reported a pneumothorax rate of 9.2% and bleeding rate of 9.9%9. TBLC is also used in the evaluation of PPLs10.&#160;
The development of robotic-assisted bronchoscopy (RAB) allows for targeted sampling in the lung by navigating through the airways under direct vision with easy catheter maneuverability, precise catheter tip articulation, stability, and the ability to maintain a bronchoscopic wedge in distal airways with the catheter using a robotic arm. The Ion endoluminal system utilizes shape-sensing technology for navigation to access specific targeted areas in the lung. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profile, primarily for PPLs suspicious of malignancy11,12,13,14. A 1.1 mm cryoprobe for TBLC combined with ssRAB has been shown to be safe and effective for the diagnosis of pulmonary nodules compared to transbronchial biopsy with forceps15. This technique can be used to obtain targeted lung biopsies larger than conventional transbronchial biopsies using forceps that are relatively free of crush artifacts.&#160;
Radial endobronchial ultrasound (r-EBUS) and cone beam computed tomography are used in conjunction with conventional bronchoscopy, electromagnetic, or robotic navigational systems for real-time confirmation prior to sampling PPLs16,17,18,19,20,21,22. R-EBUS has also been utilized during TBLC for DPLD to increase the pathologic confidence of lung specimens, decrease bleeding, and have a shorter procedure time23. The addition of CBCT has improved the safety profile of TBLC for DPLD by confirming the probe tip is in a safe zone for biopsy, allowing objective measurement of the distance from the pleura with the ability to visualize and avoid vasculature24,25,26.&#160;
This protocol will describe a procedure to obtain targeted TBLC in the setting of parenchymal lung disease for patients who are able to tolerate and benefit from the procedure using the Ion endoluminal system in conjunction with fluoroscopy, r-EBUS, and CBCT in a clinical setting under general anesthesia. This multimodal approach allows for precise sampling of targeted areas of interest.&#160;

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.9% normal saline, 1000 mL</td>
			<td>Any make</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>10 mL Leuer lock syringes</td>
			<td>Any make</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>20 mL slip tip syringes</td>
			<td>Any make</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Bronchoscope</td>
			<td>Intuitive</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Bronchoscope processor and video screens</td>
			<td>Intuitive</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Carbon dioxide gas tank</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cone beam computed tomography system with c-arm and controller console</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Disposable valve for biopsy channel</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Disposable valve for suction</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>ERBECRYO 2 1-pedal footswitch AP &#38; IP X8 Equipment US</td>
			<td>Erbe</td>
			<td>20402-201</td>
			<td></td>
		</tr>
		<tr>
			<td>ERBECRYO 2 Cart</td>
			<td>Erbe</td>
			<td>20402-300</td>
			<td></td>
		</tr>
		<tr>
			<td>ERBECRYO 2 Cryosurgical unit</td>
			<td>Erbe</td>
			<td>10402-000</td>
			<td></td>
		</tr>
		<tr>
			<td>ERBECRYO 2 System</td>
			<td>Erbe</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Flexible Cryoprobe, OD 1.1 mm, L1.15 m with oversheath, OD 2.6 mm, L817 mm</td>
			<td>Erbe</td>
			<td>20402-401</td>
			<td></td>
		</tr>
		<tr>
			<td>Flexible gas hose; L 1m for Erbokryo CA/AE/ERBECRYO 2</td>
			<td>Erbe</td>
			<td>20410-004</td>
			<td></td>
		</tr>
		<tr>
			<td>Gas bottle adapter H; CO2; Pin index</td>
			<td>Erbe</td>
			<td>20410-011</td>
			<td></td>
		</tr>
		<tr>
			<td>Ion endoluminal system with robotic arm, controller console</td>
			<td>Intuitive</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ion fully articulating catheter</td>
			<td>Intuitive</td>
			<td>490105</td>
			<td></td>
		</tr>
		<tr>
			<td>Ion instruments and accessories</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ion peripheral vision probe</td>
			<td>Intuitive</td>
			<td>490106</td>
			<td></td>
		</tr>
		<tr>
			<td>Laptop with PlanPoint planning software</td>
			<td>Intuitive</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Probe driving unit</td>
			<td>Olympus</td>
			<td>MAJ-1720</td>
			<td></td>
		</tr>
		<tr>
			<td>Radial EBUS Probe</td>
			<td>Olympus</td>
			<td>UM-S20-17S or UM-S20-20R-3</td>
			<td></td>
		</tr>
		<tr>
			<td>Radial endobronchial ultrasound system</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Specimen containers with fixative per institution standards</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile disposable cups</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Suction tubing</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Topical 1:10,000 epinephrine, 10 mL</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Topical tranexamic acid 1000mg, 10 mL</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Universal ultrasound processor&#160;</td>
			<td>Olympus</td>
			<td>EU-ME2</td>
			<td></td>
		</tr>
		<tr>
			<td>Wire basket; 339 x 205 x 155 / 100 mm</td>
			<td>Erbe</td>
			<td>20180-010</td>
			<td></td>
		</tr>
	</tbody>
</table>

robotic-assisted bronchoscopy combined with multimodal imaging for targeted lung cryobiopsies

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways under direct vision after establishing a pathway to a target lesion based on mapping performed on a 3-dimensional (3D) lung and airway reconstruction obtained from a pre-procedure thin-slice computed tomography chest. RAB has maneuverability to distal airways throughout the lung, precise catheter tip articulation, and stability with the robotic arm. Adjunct imaging tools such as fluoroscopy, radial endobronchial ultrasound (r-EBUS), and cone beam computed tomography (CBCT) can be used with RAB. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profiles in both malignant and non-malignant processes for the biopsy of peripheral pulmonary lesions (PPLs). A 1.1 mm cryoprobe combined with ssRAB has been shown to be safe and effective for the diagnosis of PPLs compared to a traditional bronchoscopy with forceps biopsy. This technique can also be used for targeted lung sampling in benign processes. The aim of this article is to describe a stepwise approach to performing RAB combined with fluoroscopy, r-EBUS, and CBCT to obtain targeted transbronchial lung cryobiopsies (TBLC).

Author Spotlight: Expanding Interventional Pulmonology Research with Robotic-Assisted Bronchoscopy

Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted 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 tomography, 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.

The described technique allows for targeted transbronchial lung cryobiopsies via RAB with fluoroscopy, r-EBUS, and CBCT guidance. Compared to conventional bronchoscopy with random TBLC, this technique allows for targeting specific areas of DPLD or PPLs of interest while assessing surrounding structures prior to biopsy. This technique can be used with r-EBUS and fluoroscopy only or with a combination of CBCT. While this technique had been devised for PPLs, it can be utilized in benign and diffuse parenchymal lung...

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.&#160;

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways ...

robotic-assisted-bronchoscopy-combined-with-multimodal-imaging-for

Research

JoVE Journal

Medicine

Combining Radial Endobronchial Ultrasound and CBCT with Robotic Bronchoscopy for Lung Biopsies

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 five 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 an posterior view showed bilateral interstitial densities with no pneumothorax or pleural effusion.

263 Views.  University of Texas Southwestern Medical Center.  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. 

Advancements in Pulmonary Lesion Biopsy Through Robotic Bronchoscopy

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