Pulmonary Medicine

Interventional Bronchoscopy: Navigational Bronchoscopy

General description of procedure, equipment, technique

Navigational Bronchoscopy

Initially defined in 1995 and subsequently described in European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, interventional pulmonology is "the art and science of medicine as related to the performance of diagnostic and invasive therapeutic procedures that require additional training and expertise beyond that required in a standard pulmonary medicine training program." Clinical entities encompassed within the discipline include complex airway management, benign and malignant central airway obstruction, pleural diseases, and pulmonary vascular procedures.

Diagnostic and therapeutic procedures pertaining to these areas include rigid bronchoscopy, transbronchial needle aspiration, autofluorescence bronchoscopy, endobronchial ultrasound, transthoracic needle aspiration and biopsy, laser bronchoscopy, endobronchial electrosurgery, argon-plasma coagulation, cryotherapy, airway stent insertion, balloon bronchoplasty and dilatation techniques, endobronchial radiation (brachytherapy), photodynamic therapy, percutaneous dilatational tracheotomy, transtracheal oxygen catheter insertion, medical thoracoscopy, and image-guided thoracic interventions. This presentation focuses on rigid bronchoscopy.

Navigational bronchoscopy provides a virtual three-dimensional map of the lung, enabling the physician to perform an anatomically precise biopsy, place markers for radiation therapy, and/or facilitate surgical removal of a small peripheral lung lesion. Navigational systems use either electromagnetic or computer assistance to identify air columns in the lung to reach the final precise destination.

Indications and patient selection

Navigational bronchoscopy is used to perform biopsy of peripheral lung lesions, place markers for radiation therapy, and/or facilitate surgical removal of a small peripheral lung lesion.

Contraindications

The clinician's inability to perform bronchoscopy safely and the patient's ability to tolerate it safely are contraindications to the procedure.

Details of how the procedure is performed

Several preparatory steps are required prior to performing the bronchoscopy. A CT scan has to be performed to the specification of the bronchoscope manufacturer. The CT images are then transferred to a laptop computer containing specific proprietary software and the procedure is planned, creating a "virtual plan" that is placed in the navigational computer.

The bronchoscopy is performed in a standard manner with fluoroscopic assistance. A variety of steerable catheters can be utilized, and biopsy forceps or brushes may be passed to obtain tissue or to place fiducial markers.

Interpretation of results

Not applicable.

Performance characteristics of the procedure (applies only to diagnostic procedures)

Not applicable.

Outcomes (applies only to therapeutic procedures)

Several studies have reported a diagnostic yield of 64-69 percent. if the lesion was larger than 2cm, In a multicenter, randomized, controlled trial that studied three arms--EBUS, navigation system, and EBUS combined with navigation system--the diagnostic yield was only 72 percent. The result with EBUS alone was 69 percent and navigation only was 59 percent, while the combined yield of EBUS with ENB was 88 percent. This result has not been reproduced elsewhere.

Alternative and/or additional procedures to consider

An alternative procedure to consider is transthoracic needle biopsy.

Complications and their management

Common complications include pneumothorax and bleeding.

What’s the evidence?

Eberhardt, R, Anantham, D, Ernst, A, Feller-Kopman, D, Herth, F. "Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial". Am J Respir Crit Care Med. vol. 176. 2007. pp. 36-41.

Report describing multiple approaches to the assessment of peripheral lung lesions.

Eberhardt, R, Anantham, D, Herth, F, Feller-Kopman, D, Ernst, A. "Electromagnetic navigation diagnostic bronchoscopy in peripheral lung lesions". Chest. vol. 131. 2007. pp. 1800-1805.

Description of the use of navigational bronchoscopy for evaluation of peripheral lung lesions.

Gildea, TR, Mazzone, PJ, Karnak, D, Meziane, M, Mehta, AC. "Electromagnetic navigation diagnostic bronchoscopy: a prospective study". Am J Respir Crit Care Med. vol. 174. 2006. pp. 982-989.

A description of the technique of navigational bronchoscopy.
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