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Image-Guided Bronchoscopy for Peripheral Pulmonary Lesions (PPLs)

Introduction

Peripheral pulmonary lesions (PPLs)—also called peripheral lung lesions (PLLs)—are small nodules or abnormalities located in the outer regions of the lungs. These lesions are increasingly detected due to the widespread use of high-resolution CT scans and low-dose CT screening for lung cancer. While early detection improves outcomes, PPLs are often challenging to biopsy using standard flexible bronchoscopy because they lie far from the central airways.

To address this challenge, image-guided bronchoscopy (IGB) techniques have been developed. These advanced technologies allow pulmonologists to navigate precisely through the airways and obtain tissue samples safely and accurately—often avoiding more invasive surgical procedures.

At KIMSHEALTH, image-guided bronchoscopy is an integral part of the early diagnosis and staging of lung cancer, as well as the evaluation of benign lung diseases, using evidence-based, patient-centred approaches.

Epidemiology of Peripheral Pulmonary Lesions

CT screening studies in high-risk smokers report lung nodules in up to 50% of individuals
Incidental lung nodules are found in around 30% of CT scans in the general population
Millions of chest CT scans are performed annually, and detection rates are rising with:
- Low-dose CT screening programmes
- Newer CT scanners capable of detecting very small lesions

As detection increases, there is a growing need for safe, minimally invasive biopsy techniques capable of diagnosing these lesions accurately—driving the rapid adoption of IGB technologies.

What Is a Peripheral Pulmonary Lesion?

A peripheral pulmonary lesion is typically:

A lung nodule less than 3 cm in size
Located in the outer (peripheral) lung fields
Solid or subsolid
Benign or malignant

Because of their location, PPLs are poorly accessed by conventional bronchoscopy, making advanced navigation techniques essential.

Indications for Image-Guided Bronchoscopy

Primary Indication: Biopsy of PPLs

Image-guided bronchoscopy is most commonly used to:

Obtain tissue from suspected lung cancers
Diagnose indeterminate lung nodules
Reduce the need for surgical lung biopsy

Additional Clinical Uses

Although less common, IGB can also be used to:

Mark lung lesions before treatment
Fiducial marker placement for stereotactic radiotherapy
Tattooing lesions before surgical removal
Investigational therapies
Local delivery of cryotherapy, radiofrequency ablation, microwave ablation, or brachytherapy (in specialised centres)

Contraindications to Image-Guided Bronchoscopy

General Contraindications

These are similar to standard bronchoscopy and include:

Severe hypoxia
Unstable heart conditions
Uncorrectable bleeding disorders

Technique-Specific Considerations

Electromagnetic navigation bronchoscopy (ENB) and some robotic systems may require special consideration in patients with pacemakers or defibrillators
Available data suggest ENB can be performed safely with cardiology consultation and post-procedure device checks
Contrast allergies are not a contraindication, as most IGB techniques do not use contrast agents

Types of Image-Guided Bronchoscopy Techniques

Several IGB technologies are available. Diagnostic yield typically ranges from 50% to 88%, depending on lesion size, location, and technique used.

Virtual Bronchoscopy (VB)

What Is Virtual Bronchoscopy?

Virtual bronchoscopy is a non-invasive imaging technique that reconstructs the airways using CT data to create a 3D airway map.

It does not involve inserting a scope
It does not collect tissue samples

Role in Diagnosis

VB is primarily used for:

Pre-procedure planning
Creating a navigational pathway for other biopsy techniques (virtual bronchoscopic navigation, VBN)

Virtual Bronchoscopic Navigation (VBN)

How VBN Works

Planning Phase

Thin-slice CT images are uploaded to specialised software
A virtual pathway from the airway to the lesion is created

Guidance Phase

Virtual airway images are synchronised with real-time bronchoscopy
The bronchoscope is guided branch-by-branch to the target

Biopsy Phase

Sampling is performed using:

Forceps or brush biopsy
Radial probe endobronchial ultrasound (RP-EBUS)
Optional fluoroscopy

Effectiveness

Diagnostic yield: 67–80%
Lower yield for lesions ≤2 cm
Accuracy improves when combined with RP-EBUS or fluoroscopy

Electromagnetic Navigation Bronchoscopy (ENB)

How ENB Works

ENB functions like a GPS system for the lungs.

Planning Phase

CT data generate a 3D airway map
A navigation pathway to the lesion is selected

Guidance and Biopsy Phase

An electromagnetic field tracks a sensor-equipped catheter
Instruments are guided in real time to the lesion

Biopsy techniques include:

Forceps biopsy
Brush sampling
Transbronchial biopsy
Catheter aspiration

ENB is frequently combined with RP-EBUS to confirm lesion location.

Effectiveness

Diagnostic yield: 44–75% (average ~65%)
Meta-analyses report yields around 74%

Factors That Improve Yield

Lesion size >2 cm
Upper or middle lobe location
Visible bronchus leading to lesion
Combined RP-EBUS use
Rapid on-site cytology evaluation (ROSE)

Risks

Pneumothorax: 3–5% (few require chest tube)
Bleeding: ~1–2%
Respiratory complications: <1%

Robot-Assisted Bronchoscopy (RAB)

What Is Robot-Assisted Bronchoscopy?

Robot-assisted bronchoscopy represents the newest advancement in IGB, using robotic control systems to reach difficult-to-access lung lesions with greater stability and precision.