Prone positioning in cone beam CT-guided robotic bronchoscopy case series: a strategy to minimize atelectasis and improve access to posteromedial lower lobe nodules

Introduction

Robotic-assisted bronchoscopy (RAB) has emerged as an advanced platform that enhances maneuverability, reach, and stability in accessing peripheral lung nodules. When integrated with cone beam computed tomography (CBCT), augmented fluoroscopy (AF), and radial endobronchial ultrasound (EBUS), RAB enables real-time tool-in-lesion confirmation and has improved diagnostic yield, particularly for small or anatomically complex nodules (1,2).

Despite these advantages, anesthesia-related atelectasis frequently develops in dependent lung segments—most notably the posterior lower lobes—obscuring or displacing targets and reducing biopsy accuracy (3). This challenge is especially relevant for nodules located in the posteromedial lower lobes, paraaortic regions, and costophrenic angles, which are also technically difficult and associated with increased adverse events for percutaneous transthoracic needle biopsy (PTNB) (4).

Prone positioning, widely used in acute respiratory distress syndrome (ARDS) management to improve dorsal aeration, has recently been adapted to bronchoscopy. Early reports suggested that prone position reduces posterior atelectasis, enhances visualization of dependent nodules, and facilitates successful biopsy when lesions are inaccessible in the supine position (3,5) (Figure 1).

Figure 1 CBCT images (axial, sagittal, coronal) showing a lung nodule in the medial-posterior right lower lobe (arrows)—a location commonly affected by anesthesia-induced atelectasis. These regions are particularly challenging for biopsy due to early collapse after induction. CBCT, cone beam computed tomography.

The objective of this study was to evaluate the feasibility of performing RAB with CBCT guidance in the prone position to improve access and diagnostic yield for lung nodules in the posteromedial lower lobes (Figure 2). We present this article in accordance with the STROBE and AME Case Series reporting checklists (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1413/rc).

Figure 2 Fluoroscopic and cone beam CT images. (A) Fluoroscopic image showing RAB advancing into the posteromedial segment of the right lower lobe. (B) CBCT image with segmented airway and target nodule confirming tool-in-lesion alignment. CBCT, cone beam computed tomography; CT, computed tomography; RAB, robot assisted bronchoscopy.

Methods

This study was designed as a retrospective case series and was conducted at a single tertiary teaching hospital in Illinois, Advocate Lutheran General Hospital, with approval from the Wake Forest University School of Medicine Institutional Review Board (No. IRB00129918). All cases were identified using the institutional electronic medical record system (Epic). The study period extended from June 2024 through July 2025, during which patients undergoing RAB were systematically reviewed for eligibility. The rationale for this investigation was to evaluate the feasibility and outcomes of performing RAB in the prone position for posterior lower lobe pulmonary nodules (defined as any nodule in the lower lobes located posterior to the vertebral body on the axial CT plane), a population in which procedural access and visualization are often technically challenging.

Patients were considered eligible if they met the following inclusion criteria: (I) age 18 years or older; (II) underwent a procedure within the defined study period; and (III) had a posterior lower lobe pulmonary nodule confirmed on computed tomography (CT) imaging. Exclusion criteria consisted of patients with high-risk coronary artery disease (CAD), as the prone position presents significant barriers to effective advanced cardiac life support (ACLS) and chest compressions in the event of cardiopulmonary arrest. After applying these criteria, a total of twenty-eight patients were identified and included in the final analysis. Informed consent was obtained from all subjects involved in the study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

All patients were intubated under general anesthesia, placed in the prone position, and underwent transbronchial biopsy with RAB (Ion robotic bronchoscopy platform, Intuitive Surgical, Sunnyvale, CA, USA) in combination with real-time CBCT (SmartCT, Azurion image-guided therapy system, Philips, Amsterdam, Netherlands).

Tissue samples were obtained using multimodality tools including fine needle aspiration (Intuitive Surgical) biopsy forceps (Intuitive Surgical) as well as 1.1-mm cryoprobe (Erbe, Tuebingen, Germany). A complete mediastinal lymph node staging was performed in all patients using EBUS, with systematic evaluation and sampling of standard nodal stations. Lymph nodes were sampled sequentially according to established staging protocols, and transbronchial needle aspiration (TBNA) was performed for any node measuring ≥5 mm in short-axis diameter or deemed clinically significant by the operator. Procedure time was recorded for each case and was defined as the interval from insertion of the bronchoscope at the initiation of bronchoscopy until completion of RAB with lesion sampling and full mediastinal lymph node staging by EBUS.

To standardize the performance of RAB in the prone position, we developed and implemented a detailed procedural protocol aimed at ensuring CBCT-centered imaging of lung nodules, improving lesion accessibility, optimizing visualization, and maintaining patient safety. The protocol was developed through multidisciplinary collaboration among interventional pulmonology, anesthesiology, and radiology teams, and refined through iterative application in clinical practice. Each step was deliberately structured to address the unique challenges of performing RAB in the prone position, including airway management, patient stabilization, robotic docking, and integration of advanced imaging. By presenting this process in detail, our goal was to establish a reproducible and safe approach that can be implemented at other centers performing RAB for posterior lower lobe pulmonary nodules.

Airway management and endotracheal tube (ETT) placement

Airway is secured through endotracheal intubation under general anesthesia. An appropriately sized ETT, ideally with an internal diameter of 8.0 mm or greater, is recommended to ensure adequate passage of the robotic bronchoscope while minimizing scope friction within the ETT and reducing the risk of airway compromise. The tube is positioned with the cuff just below the vocal cords, avoiding excessively deep placement that could result in mainstem intubation. Prior to turning the patient prone, a flexible bronchoscope is advanced through the ETT while the patient remains in the supine position to verify placement, confirming that the distal tip lies above the carina in the mid-trachea. This verification step is critical because, once the patient is positioned prone, even minor changes in head or neck alignment can cause the tube to advance into a mainstem bronchus and compromise ventilation. Establishing correct positioning at the outset minimizes the need for subsequent tube adjustments, which can be technically challenging once the patient is prone and, in some cases, may necessitate returning the patient to the supine position to reposition the ETT.

ETT securing and circuit adaptation

Once correct tube placement has been confirmed, the ETT is secured at the corner of the mouth corresponding to the side of robotic docking when the patient is in the prone position. For example, if the robotic arm docks from the patient’s left side while the patient is prone, the ETT should be fixed toward the left corner of the mouth. This orientation reduces angulation at the oropharynx, facilitates docking of the robotic bronchoscope, and minimizes torque on the airway. To accommodate positional changes and allow for unrestricted CBCT gantry rotation, accordion-style circuit extensions are attached to the ventilator’s tubing. These flexible extensions reduce circuit tension, prevent inadvertent tube dislodgement, and allow the anesthesia team to adjust the patient’s position or the ventilator circuit without disrupting the robotic platform (Figure 3).

Figure 3 The ETT is taped to the side corresponding side as the robotic docking—here, to the left—to allow left-sided access while proned, with accordion circuits providing flexibility during repositioning and CBCT gantry movement. CBCT, cone beam computed tomography; ETT, endotracheal tube.

Operating room setup and patient support

A prone pillow with a lateral outlet is used to support the patient’s head and simultaneously permit the ETT to exit laterally without kinking or compression. Additional gel pads or foam cushions are placed beneath pressure-prone areas, including the chest, pelvis, and knees, to distribute weight evenly and decrease the risk of pressure injury or peripheral nerve compression. Stabilizing rolls are positioned at the shoulders and pelvis to limit lateral drift of the patient during table adjustments and imaging maneuvers, maintaining proper midline alignment throughout the procedure (Figure 4).

Figure 4 Prone positioning setup includes a fluoroscopy-compatible table, prone headrest to prevent ETT kinking, and foam pads for pressure relief and stability. ETT, endotracheal tube.

Upper extremity and intravenous (IV) line management

The patient’s arms were positioned securely along both sides of the body with the thumbs oriented anteriorly. This configuration was selected to minimize the risk of brachial plexus traction or compression by avoiding excessive abduction, hyperextension, or asymmetry between the upper extremities. After positioning, all IV access points were tested for patency with a saline flush and then reinforced with secure adhesive tape or commercial anchoring devices to prevent accidental dislodgement during repositioning or cone-beam gantry rotation. IV access was extended and positioned in a manner that allowed unobstructed reach for the anesthesia team while remaining outside the operative field of the robotic system and CBCT gantry. IV tubing and monitoring cables were carefully routed away from high-motion areas and potential pressure points to reduce the risk of occlusion, kinking, traction during cone-beam spin, or compression. Prior to initiating the procedure, a comprehensive safety check was performed to confirm the stability of IV access and monitoring leads, as well as to ensure that no direct pressure was exerted on vulnerable structures such as the eyes, face, genitalia, or bony prominences (Figure 5).

Figure 5 The patient is secured in a prone position using stabilizing straps to maintain alignment.

Spinal and cervical alignment

Special attention was directed to spinal and cervical alignment to maintain the head and neck in a neutral position, avoiding hyperextension, flexion, or rotation. Proper alignment is critical not only for patient comfort but also for ensuring ETT patency. After the patient was placed in the prone position, the anesthesia team reassessed ETT function using capnography and manual ventilation to confirm unobstructed airflow. Any necessary adjustments were performed at this stage to maintain stability and to centralize the target lesion before docking the robotic bronchoscope (Figure 6).

Figure 6 The robotic system ready to be docked after confirming the lesion is centered within the CBCT field of view. CBCT, cone beam computed tomography.

Lesion targeting and table adjustment

After placing the patient in the prone position, care is taken to ensure that the patient remains properly padded and supported throughout subsequent adjustments. Once the patient is stabilized, the table is adjusted to align the target lesion within the central field of the CBCT in the anteroposterior (AP) fluoroscopy view, followed by adjustment of the table height to centralize the lesion in the lateral fluoroscopy view. This step is critically important to guarantee that the lesion is accurately centered, as posterior lung nodules in the prone position often rise to the highest point of the chest cavity. Special attention is required to confirm that the nodule remains within the fluoroscopy field, which at times necessitates lowering the table more than is typical in supine cases, an issue that must be addressed prior to docking the robotic system. Priority is therefore given to this step ahead of robotic docking to ensure precise lesion centralization and optimal visualization during CBCT spin (Figure 6).

Robotic bronchoscopy docking, insertion, and navigation

The robotic bronchoscope is docked to the ETT from the predetermined side, and the trajectory of the robotic arm is verified to ensure that it does not interfere with CBCT gantry rotation or restrict anesthesia access. Scope insertion begins once docking is complete. The robotic bronchoscope is generously lubricated to facilitate passage through the ETT, as sharper angulation is often encountered when the tube exits laterally from the mouth in the prone position. Slow, deliberate insertion reduces resistance and minimizes the risk of mucosal trauma. After insertion, the operator must recognize that anatomical orientation is reversed because of the prone position: the anterior tracheal wall appears posterior, and the right and left main bronchi are also inverted. To correct for this, a 180-degree rotation of the bronchoscopy view is required before advancing the scope into the target airway. Once reoriented, navigation proceeds as in any other RAB case, with CBCT confirmation obtained prior to biopsy (Figure 7).

Figure 7 The bronchoscope is inserted, accounting for the sharper ETT angulation that occurs with lateral exit in the prone position. ETT, endotracheal tube.

Team coordination and intraoperative safety

Successful execution of the prone RAB protocol requires effective communication and coordination among the anesthesia team, nursing staff, radiology technologists, and the interventional pulmonology team. Whenever possible, performing the procedure with the same dedicated team from all specialties is highly advantageous. Team familiarity with one another’s roles and with the stepwise details of the protocol significantly shortens positioning time and ensures a smooth, coordinated workflow. This consistency also reduces variability, minimizes the likelihood of errors or omissions during the proning process, and allows for early recognition and correction of potential issues before they affect patient safety. A well-practiced team anticipates each step, from airway verification and patient padding to table adjustments and robotic docking, making the transition to prone both faster and safer. The cumulative effect is improved patient safety, reduced anesthesia and fluoroscopy time, and enhanced overall procedural efficiency. After completion of RAB sampling and tissue collection, patients are repositioned to the supine position to limit overall time spent prone. This transition reduces the risks associated with prolonged proning and facilitates completion of a full mediastinal lymph node staging with EBUS-TBNA.

This structured protocol was applied consistently across all cases in the study, allowing evaluation of the safety, feasibility, and diagnostic performance of prone-position RAB with CBCT guidance in a reproducible way that can be adopted in routine clinical practice.

Results

Our study included 28 patients. The median age was 74.5 years (range, 42–87 years), with an average age of 71.9 years. There was a nearly equal sex distribution, with 15 males and 13 females. The American Society of Anesthesiologists (ASA) classification reflected the overall comorbid status of the population: 3 patients (10.7%) were ASA II, 13 patients (46.4%) were ASA III, and 12 patients (42.9%) were ASA IV.

The mean BMI was 26.8 kg/m² (range, 17.0–37.3 kg/m²). In total, 22 patients (78.6%) had BMI <30 kg/m² and 6 patients (21.4%) had BMI >30 kg/m². Of those with BMI >30 kg/m², two patients presented with posterior right upper lobe (RUL) nodules. Given the posterior location and elevated BMI, these patients were placed in the prone position to minimize anesthesia-related atelectasis and to optimize access to the lesions. Importantly, all nodules in this series were posterior and medial in location, underscoring the rationale for prone positioning.

The mean nodule size was 11 mm, with the smallest measuring 5 mm and the largest 31 mm. Nodules were evenly distributed between the right lower lobe (RLL, n=13, 46.4%) and left lower lobe (LLL, n=13, 46.4%), with 2 nodules (7.1%) in the RUL.

The mean procedure time was 69.6 minutes (range, 41–108 minutes), measured from scope insertion to scope removal. This duration encompassed all procedural components, including CBCT spins, lung nodule segmentation, AF, transbronchial biopsy, and complete mediastinal and hilar lymph node staging with EBUS-TBNA, which was performed in all patients.

Pathology demonstrated diagnostic malignant samples in 20 patients (71.4%) and diagnostic benign samples in 5 patients (17.9%), while 3 patients (10.7%) yielded non-diagnostic specimens. This corresponded to an overall diagnostic yield of 89.3%. Non-diagnostic cases were not malignant, and all are currently undergoing surveillance with follow-up CT chest imaging at 3 months to confirm the benign nature of the lesions; at the time of this report, none of these follow-up scans were yet due. Among the malignant cases (n=20), adenocarcinoma was the most common, diagnosed in 12 patients (60%) with acinar, papillary, micropapillary, and mucinous growth patterns represented. Squamous cell carcinoma was identified in 6 patients (30%), including both keratinizing and non-keratinizing subtypes. Metastatic malignancies accounted for 2 cases (10%), consisting of colorectal adenocarcinoma, pancreatic mucinous adenocarcinoma, a gynecological primary, and one high-grade pleomorphic sarcoma with epithelioid features. Benign diagnostic samples (n=5) included necrotizing and non-necrotizing granulomas as well as a benign cyst (Table 1).

Discussion

The physiologic rationale of prone positioning is clear: when patients are supine under general anesthesia, relaxation of the diaphragm, loss of functional residual capacity, and compressive forces from the heart and mediastinum increase pleural pressures in dependent regions. This leads to collapse of posterior alveoli and preferential ventilation of anterior lung segments, thereby worsening ventilation/perfusion (V/Q) mismatch (6-8). Prone positioning reverses this distribution by shifting compressive forces away from posterior lung units, promoting dorsal aeration and improving perfusion matching to previously under-ventilated lung regions (9,10).

These physiologic dynamics are particularly relevant where lesions in the posterior and lower lung fields are among the most challenging to biopsy. PTNB achieves high diagnostic sensitivity, but the risk of pneumothorax (reported in 10–50% of cases), hemorrhage, and hemoptysis is amplified in posteromedial lower lobes and near proximity to critical vascular and abdominal structures (2). Furthermore, the steep trajectory required for needle access in these regions increases the likelihood of transgressing vital structures. In some patients, excessive respiratory motion or cardiac pulsations exaggerate this risk. From a bronchoscopic standpoint, the anatomy of dependent lung regions also imposes barriers: the airways are narrower, take more acute angulations, and often terminate before directly reaching the lesion. Even with the enhanced maneuverability of RAB, catheter stability can be difficult to maintain in these regions. Together, these factors explain why posterior and basal nodules continue to be associated with lower diagnostic yield and higher procedural risk compared to upper-lobe lesions (11).

The I-LOCATE trial demonstrated the extent of anesthesia-induced atelectasis: 89% of patients undergoing navigational bronchoscopy developed atelectasis in at least one bronchial segment, with over half of cases occurring in posterior lower lobe segments (4). Evidence from Sagar et al. confirmed that atelectasis develops within 40–60 minutes of anesthesia, most frequently in posterior lower lobes, while upper lobes remain largely spared (4). Atelectasis not only obscures target nodules but also produces imaging artifacts that mimic solid lesions. On radial EBUS, atelectatic lung tissue can appear echogenic, leading to false positives and inadvertent sampling of normal parenchyma. Another compounding factor is CT-to-body divergence, the discrepancy between preoperative imaging and intraprocedural anatomy under anesthesia. Divergence arises from diaphragm displacement, lung volume loss, and atelectasis, which shift nodules relative to their mapped positions. These shifts are not subtle; prior studies have shown divergences of up to 20 mm in the lower lobes, enough to completely move a small nodule out of reach of the biopsy tool. This distortion is exaggerated in the supine position, where gravitational forces and mediastinal mass effect worsen collapse of posterior lung tissue. For RAB, where successful tissue acquisition depends on maintaining a stable catheter tip in a small, shifting target, CT-to-body divergence represents a formidable barrier that undermines even the most advanced navigation platforms (5).

Several anesthesia strategies have been explored to counteract atelectasis and divergence. These include limiting FiO₂ to 0.6–0.8 to reduce absorption atelectasis, applying positive end expiratory pressure (PEEP) of 10–12 cmH₂O, and using larger ETTs with non-depolarizing neuromuscular blockade to optimize ventilation (12). Imaging during end-inspiratory breath holds has also been used to improve lesion visualization and reduce motion artifacts. While these measures are helpful, they demand vigilant anesthetic management and may increase the risk of barotrauma, volutrauma, or hemodynamic instability, particularly in obese patients with already reduced functional residual capacity. Elevated PEEP can also impede venous return and lower cardiac output, creating new risks during prolonged procedures. In contrast, our study showed that prone positioning allows excellent aeration of dependent lung regions with minimal reliance on such maneuvers. All procedures were completed with PEEP ≤5 cmH₂O and tidal volumes of 6–8 mL/kg ideal body weight, underscoring that proning alone may substitute for complex ventilatory strategies, simplifying workflow and improving safety.

In our series, this physiologic advantage translated into consistent visualization and tool-in-lesion confirmation in locations typically associated with nondiagnostic rates.

Technological integration amplifies these gains. CBCT provides real-time, high-resolution three-dimensional imaging, enabling operators to directly confirm whether tools are within the lesion. AF overlays CBCT reconstructions on live fluoroscopy, allowing continuous visualization throughout multiple biopsies (13). This dual approach addresses one of the greatest challenges in bronchoscopy: maintaining confidence in tool positioning as lung anatomy shifts during the procedure. Beyaz et al. demonstrated that CBCT-AF integration reduces the need for repeat spin acquisitions, shortens procedure times, and enhances accuracy (14). In the prone setting, these advantages are even more critical. By counteracting progressive atelectasis and divergence, CBCT-AF provides a dynamic roadmap that remains reliable throughout the case. For operators, this translates into greater efficiency, fewer interruptions, and reduced sampling error. For patients, it increases the likelihood of obtaining diagnostic tissue without exposing them to prolonged anesthesia or repeat procedures.

Obesity further underscores the value of this approach. In I-LOCATE, each unit increase in BMI increased the likelihood of additional atelectatic segments, predominantly in dependent regions (4). Our series included 26.3% obese patients, yet diagnostic yield remained high and ventilator pressures low, highlighting the unique physiologic support provided by proning. By eliminating the need for high PEEP and tidal volumes, proning reduces risks of barotrauma and hemodynamic compromise, two complications to which obese patients are particularly vulnerable.

While the physiologic and procedural benefits are clear, safety considerations remain essential. Patients with significant cardiac comorbidities may face increased risk of anesthesia-related cardiac events, and prone positioning complicates resuscitation. Historically, cardiac arrest in the prone position required repositioning to supine before cardiopulmonary resuscitation (CPR) could be initiated, delaying intervention. Liu et al. demonstrated that chest compressions can be delivered effectively in the prone position by straddling the bed and placing hands apart above the scapulae at the mid-thoracic level. This method achieved the best compression depth and lowest rescuer fatigue compared to other prone techniques (15). Although absolute compression quality remains inferior to supine CPR, the capacity to initiate immediate compressions without repositioning can be lifesaving, especially in high-risk patients. For institutions adopting prone bronchoscopy, it is critical to establish clear resuscitation protocols in collaboration with anesthesia and nursing teams, ensuring equipment readiness and staff familiarity with prone CPR. This multidisciplinary planning mitigates risk and supports the safe expansion of prone bronchoscopy.

Our retrospective case series demonstrated that RAB with CBCT and AF in the prone position achieved a diagnostic yield of 89.3% for nodules with a mean size of 11 mm, all of which were located in posterior and medial regions. This compares favorably to published yields of PTNB and RAB performed in the supine position, particularly for nodules <15 mm or in dependent locations, where nondiagnostic rates are highest. Among our cohort, malignant diagnoses were most frequently adenocarcinoma (60%) and squamous cell carcinoma (30%), with a smaller proportion of metastatic malignancies (10%). Benign diagnostic samples included granulomas and one cyst, while non-diagnostic cases represented only 10.7% of the cohort and are currently under close follow-up with interval CT surveillance. Importantly, procedure times incorporated not only RAB navigation and biopsy but also CBCT spins, fluoroscopic segmentation, and systematic mediastinal and hilar staging with EBUS-TBNA, underscoring the comprehensive nature of this approach. These results highlight that prone positioning with CBCT-AF can provide high diagnostic accuracy in anatomically challenging lesions while maintaining procedural efficiency and safety.

These findings suggest that integrating prone positioning with RAB and CBCT may be a useful option for anatomically challenging posterior lung nodules. By reducing anesthesia-related atelectasis, minimizing CT-to-body divergence, and enabling consistent tool-in-lesion confirmation, this approach appears to offer both physiologic and procedural advantages. However, the results should be interpreted in the context of certain limitations, including the retrospective, single-center design, which may affect generalizability. To support reproducibility, a detailed description of the protocol has been provided for use in other centers. Another limitation is the absence of direct comparison with similar nodules sampled in the supine position. Such a comparison is difficult, as patient selection criteria often favor prone positioning; performing these procedures in supine patients could increase the risk of atelectasis and lower the diagnostic yield. Future multicenter trials will be important to confirm generalizability, refine patient selection, and explore cost-effectiveness, particularly in cases where repeat biopsy may be required because of atelectasis formation. Incorporating training programs for prone positioning techniques may also help improve diagnostic yield in challenging cases. Simulation of prone CPR, informed by prior experience, together with workflow adaptations, could further support safe and efficient adoption across institutions.

Conclusions

Prone positioning during RAB, when combined with CBCT and AF, provides an effective strategy for sampling anatomically challenging posterior lung nodules. This approach enhances visualization and mitigates anesthesia-related atelectasis and CT-to-body divergence, supporting high diagnostic yield while maintaining procedural safety and efficiency. Further prospective, multicenter studies are needed to confirm these findings and guide broader implementation.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE and AME Case Series reporting checklists. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1413/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1413/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1413/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1413/coif). F.K. serves as an Associate Editor-in-Chief of Journal of Thoracic Disease from May 2024 to April 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the Wake Forest University School of Medicine Institutional Review Board (No. IRB00129918). Informed consent was obtained from all subjects involved in the study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Folch EE, Pritchett MA, Nead MA, et al. Electromagnetic Navigation Bronchoscopy for Peripheral Pulmonary Lesions: One-Year Results of the Prospective, Multicenter NAVIGATE Study. J Thorac Oncol 2019;14:445-58. [Crossref] [PubMed]
2. Gasparini S, Bonifazi M, Wang KP. Transbronchial needle aspirations vs. percutaneous needle aspirations. J Thorac Dis 2015;7:S300-3. [Crossref] [PubMed]
3. Bhadra K, Condra W, Setser RM. Out of the Box Thinking: Prone Bronchoscopy to Reduce Atelectasis. J Bronchology Interv Pulmonol 2022;29:e57-60. [Crossref] [PubMed]
4. Sagar AS, Sabath BF, Eapen GA, et al. Incidence and Location of Atelectasis Developed During Bronchoscopy Under General Anesthesia: The I-LOCATE Trial. Chest 2020;158:2658-66. [Crossref] [PubMed]
5. Pritchett MA, Bhadra K, Calcutt M, et al. Erratum to virtual or reality: divergence between preprocedural computed tomography scans and lung anatomy during guided bronchoscopy. J Thorac Dis 2020;12:4593-5. [Crossref] [PubMed]
6. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-68. [Crossref] [PubMed]
7. Qadri SK, Ng P, Toh TSW, et al. Critically Ill Patients with COVID-19: A Narrative Review on Prone Position. Pulm Ther 2020;6:233-46. [Crossref] [PubMed]
8. Khan A, Bashour SI, Casal RF. Preventing atelectasis during bronchoscopy under general anesthesia. J Thorac Dis 2023;15:3443-52. [Crossref] [PubMed]
9. Gattinoni L, Caironi P, Pelosi P, et al. What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 2001;164:1701-11. [Crossref] [PubMed]
10. Gattinoni L, Brusatori S, D'Albo R, et al. Prone position: how understanding and clinical application of a technique progress with time. Anesthesiol Perioper Sci 2023;1:3. [Crossref] [PubMed]
11. van der Heijden EHFM, Verhoeven RLJ. Robotic Assisted Bronchoscopy: The Ultimate Solution for Peripheral Pulmonary Nodules? Respiration 2022;101:437-40. [Crossref] [PubMed]
12. Pritchett MA, Lau K, Skibo S, et al. Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy. BMC Pulm Med 2021;21:240. [Crossref] [PubMed]
13. Styrvoky K, Schwalk A, Pham D, et al. Shape-Sensing Robotic-Assisted Bronchoscopy with Concurrent use of Radial Endobronchial Ultrasound and Cone Beam Computed Tomography in the Evaluation of Pulmonary Lesions. Lung 2022;200:755-61. [Crossref] [PubMed]
14. Beyaz F, Verhoeven RLJ, Hoogerwerf N, et al. Cone Beam Computed Tomography-Guided Navigation Bronchoscopy with Augmented Fluoroscopy for the Diagnosis of Peripheral Pulmonary Nodules: A Step-by-Step Guide. Respiration 2025;104:216-28. [Crossref] [PubMed]
15. Liu Q, Li B, Zhou S, et al. The effect of hand and body position on chest compression quality and rescuer fatigue in prone cardiopulmonary resuscitation. Resusc Plus 2024;20:100787. [Crossref] [PubMed]