Integration of robotic bronchoscopy and cone beam computed tomography: a narrative review

Background and Objective: The last decade has seen a rapid increase in technology available for the biopsy of pulmonary nodules. Historically, the diagnostic yield (DY) by conventional bronchoscopic navigation had varying results with DY close to 50%. This has led to the advent of newer technologies designed to increase yield. Initial technologies included bronchoscopy with fluoroscopy as a guide to radiographically visible lesions. Radial-endobronchial ultrasound (r-EBUS) was created, and a modest increase in diagnostic accuracy (DA) followed. Since that time, a number of novel technologies to aid in the diagnosis of pulmonary nodules have been introduced. Most recently, cone beam computed tomography (CBCT) with or without augmented fluoroscopy (AF), as well as robot assisted navigational bronchoscopy (RANB) have emerged. The objective of this review is to consider the DY of these most promising tools, how to optimize DY, and best practice into the future. Methods: A literature review was conducted using online database resources, searching from 2010 to 2023 for published peer review studies that evaluated the DY of various bronchoscopic technologies. Key Content and Findings: This review found that the use of CBCT and RANB have increased DA of bronchoscopy for the diagnosis of pulmonary nodules to as high as 90% and 86% respectively. However, the range of DY by modality varies considerably, and very few controlled, prospective studies exist. Even less common are studies comparing these interventions. Conclusions: While these new technologies potentially improve DY, further research is needed to directly compare these modalities in a controlled manner to guide best practice. Despite the limitations of available data, we propose a suggested workflow when using CBCT and RANB aimed at optimizing DY.