Recent advances in navigational platforms have led bronchoscopists to make major strides in diagnostic interventions for pulmonary parenchymal lesions. Over the last decade, multiple platforms including electromagnetic navigation and robotic bronchoscopy have allowed bronchoscopists to safely navigate farther into the lung parenchyma with increased stability and accuracy. Limitations persist, even with these newer technologies, in achieving a similar or higher diagnostic yield when compared to the transthoracic computed tomography (CT) guided needle approach. One of the major limitations to this effect is due to CT-to-body divergence. Real-time feedback that better defines the tool–lesion relationship is vital and can be obtained with additional imaging using radial endobronchial ultrasound, C-arm based tomosynthesis, cone-beam CT (fixed or mobile), and O-arm CT. Herein, we describe the role of this adjunct imaging with robotic bronchoscopy for diagnostic purposes, describe potential strategies to counteract the CT-to-body divergence phenomenon, and address the potential role of advanced imaging for lung tumor ablation.

Benign tracheal stenosis can cause dyspnea, wheezing, and cough mimicking other obstructive lung diseases which often leads to a delay in the diagnosis. Risk factors and etiologies for tracheal strictures include autoimmune diseases, infection, gastro-esophageal reflux disease (GERD), radiation injury and iatrogenic factors such as post-intubation and post-tracheostomy. Once suspected, tracheal strictures are diagnosed by performing a thorough evaluation involving clinical exam, laboratory workup, pulmonary function test, chest imaging and bronchoscopy. Bronchoscopy plays a pivotal role in the diagnosis of stenosis and along with the imaging and physiologic assessments leads to a proper description of the stenosis based on all parameters that matters for management. Surgical resection provides a definitive management in most patients with idiopathic or post intubation/tracheostomy stenosis, however, factors such as severe co-morbidities, length and location of the stricture can preclude patients from undergoing curative surgery. Several bronchoscopic interventions including mechanical or laser assisted dilation, electrosurgery (ES), airway stenting and pharmacological treatment with mitomycin C (MMC) and intralesional steroid have been reported in the literature for management of patients who are not surgical candidates. Herein, we review the role of bronchoscopy and illustrate the importance of a multi-disciplinary team (MDT) approach comprising of interventional pulmonologists, thoracic surgeons and otorhinolaryngologists in the diagnosis and management of patients with benign tracheal stenosis.

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