A case series of nonintubated robotic-assisted bronchoscopy: a feasible alternative to intubated techniques
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Key findings
• Nonintubated robotic-assisted bronchoscopy (RAB) was successfully performed in seven patients, with 100% navigation accuracy and biopsy success.
• The procedure was completed in a mean time of 33.8 minutes, with a short recovery time of 26.7 minutes.
• Combining diagnostic bronchoscopy with subsequent therapeutic interventions, such as thoracoscopic surgery, under a single nonintubated anesthetic regimen, could streamline the workflow. In our study, the mean interval between biopsy and surgery was 24.2 minutes.
• Our study demonstrated the safety and feasibility of nonintubated RAB, especially for patients with small or obstructed airways.
What is known and what is new?
• RAB is widely used for pulmonary lesion management but is limited by the requirement for endotracheal intubation.
• Nonintubated RAB is safe and feasible for patients with challenging airways, achieving excellent diagnostic results, quicker recovery and patients comfort.
• Nonintubated RAB also aligns with the principles of “green anesthesia”.
What is the implication, and what should change now?
• Nonintubated RAB was a safe, efficient, and flexible alternative to traditional methods, particularly for patients with smaller airways or significant airway obstruction, which may expand the clinical applicability of RAB.
Introduction
Lung cancer remains the leading cause of cancer-related mortality globally, and thus advancements in diagnostic technologies for accurate biopsy and precise localization of pulmonary nodules are critically needed (1). Robotic-assisted bronchoscopy (RAB) has emerged as a transformative tool for lung nodule diagnosis (2-4), owing to its notable advantages, such as flexibility, stability, and adjustable angulation during the procedure. However, RAB traditionally requires general anesthesia with endotracheal (ET) intubation, which may not be suitable for patients who are unable to tolerate these invasive measures. Additionally, the specific requirements for ET tube size and alignment limit the application of RAB, particularly in patients with smaller airways, such as adolescents or females. In cases of significant airway obstruction caused by lesions, ET intubation may also be infeasible. Meanwhile, modifications such as cutting the ET tube to fit swivel adapters may further increase the risk of adverse events.
Nonintubated thoracic surgery, which eliminates the need for muscle relaxants and ET intubation, has been proven to be a safe and effective approach for patients unable to tolerate intubated anesthesia, contributing to favorable perioperative outcomes and accelerated recovery (5-7). This study examined a novel approach that combines nonintubated anesthesia with RAB to address these limitations, with the aim of evaluating the safety, feasibility, and potential benefits of nonintubated RAB. We present this article in accordance with the AME Case Series reporting checklist (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-169/rc).
Case presentation
A total of seven patients, comprising 10 lesions, were retrospectively analyzed. The procedure was performed using the Monarch RAB system (Johnson & Johnson, New Brunswick, NJ, USA). Prior to the RAB procedure, a high-resolution computed tomography (CT) scan was performed to assess the location and diameter of lesions. According to the proceduralist’s discretion, forceps biopsy or cytology brush was employed to biopsy lesions during procedures. Successful navigation was defined as the ability to reach within 1 cm of the virtual target. Rapid on-site evaluation (ROSE) was performed in all cases. Diagnostic accuracy was assessed by comparing biopsy results with final pathology or clinical follow-up. Negative results were considered true negatives if lesions resolved, were confirmed benign on repeat biopsy, or remained radiographically stable for ≥6 months. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients (or their legal guardians) for the publication of this case series and any accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Nonintubated anesthesia management
Nonintubated anesthesia followed a previously described protocol (6), with local anesthesia being combined with mild intravenous sedation to maintain patient spontaneous ventilation without the need for muscle relaxants or ET tube. To ensure optimal visualization and navigation, traditional bronchoscopy was performed to clean the airway and spray lidocaine on the glottis and trachea before the RAB procedure. Airway management was achieved with a laryngeal mask airway (LMA), which provided effective ventilation while minimizing airway trauma. Oxygen was delivered through the LMA at a flow rate of 2–3 L/min with FiO2 to maintain SpO2 >90% during the procedure. In case of intraoperative emergencies, such as persistent hypoxemia or hypercapnia, conversion to intubated general anesthesia was required to ensure patient safety (Figure 1A,1B).
Results
The cohort consisted of seven patients with a mean age of 57.6 years, a mean body mass index (BMI) of 23.4 kg/m2, and forced expiratory volume in 1 second percentage (FEV1%) of 96.5%. The mean lesion size, including both airway and pulmonary lesions, was 1.4 cm. One patient had lesions in the upper trachea and right main bronchus, causing a significant obstruction and preventing ET intubation (Figure 1C,1D). Of the eight pulmonary lesions, six were located in the right lung and two in the left lung. The mean caliber of airway was 10.5 mm, rendering them unsuitable for a 7.5-mm ET tube (Table 1).
Table 1
| Variables | Values |
|---|---|
| Patients | |
| Age (years) | 57.6±11.3 |
| Sex | |
| Female | 6 (85.7) |
| Male | 1 (14.3) |
| BMI (kg/m2) | 23.4±0.8 |
| FEV1 (%) | 96.5±8.2 |
| Airway caliber (mm) | 10.5±1.0 |
| Lesions | |
| Lesion location | |
| Airway | 2 (20.0) |
| RUL | 2 (20.0) |
| RML | 2 (20.0) |
| RLL | 2 (20.0) |
| LUL | 1 (10.0) |
| LLL | 1 (10.0) |
| Parenchymal location | |
| Airway | 2 (20.0) |
| Peripheral | 5 (50.0) |
| Middle | 2 (20.0) |
| Central | 1 (10.0) |
| Bronchus sign | 5 (50.0) |
| Lesion size (cm) | 1.4±0.9 |
Data are presented as mean ± standard deviation or n (%). BMI, body mass index; FEV1, forced expiratory volume in 1 second; LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.
All patients successfully underwent navigation and biopsy under nonintubated anesthesia (Figure 1D-1F), without the need for conversion to intubated general anesthesia. The mean duration of the total procedure was 33.8 min, with a navigational accuracy of 100%. According to ROSE analysis, six patients were confirmed with a positive diagnosis, including five identified with primary thoracic malignancies and one with metastatic tumor. One patient classified as negative diagnosis, and the lesions regressed on follow-up imaging. Multiple-point biopsies also performed around lesions measuring 0.5 cm in the patient with airway tumor, yielding final diagnoses of hamartoma and fibrosis, which thereby delineated the tumor margin.
Following diagnosis, five patients with positive diagnosis proceeded to nonintubated thoracoscopic surgery under a single anesthetic regimen, which avoided the need for transitioning from single-lumen to double-lumen intubation as required in traditional approaches. The mean interval between diagnosis and resection was 24.2 minutes, and the postoperative recovery time was 26.7 minutes. The concordance between the preliminary and final pathology results was 100%. No intraoperative complications occurred during the procedures (Table 2).
Table 2
| Variables | Values |
|---|---|
| Operation time (min) | 33.8±17.9 |
| Conversion | 0 |
| Interval between diagnosis and resection (min) | 24.2±2.4 |
| Pathology | |
| Primary tumor | 7 (71.4) |
| Metastatic cancer | 1 (14.3) |
| Negative diagnosis | 2 (14.3) |
| Postoperative recovery time (min) | 26.7±7.7 |
| Postoperative complications | 0 |
Data are presented as mean ± standard deviation or n (%).
Discussion
RAB with the Monarch system was first reported by Rojas and coworkers in 2018 (8), was approved by the US Food and Drug Administration in 2019, and has gained widespread adoption for the diagnosis and treatment of pulmonary lesions (2-4). However, its reliance on intubated general anesthesia limits it applicability in patients unable to tolerate these measures. Additionally, the requirement for ET tubes of at least 7.5 mm in diameter restricts its use in patients with smaller airways, such as adolescents or females, and modifications such as cutting the ET tube to fit swivel adapters further increases the surgical risk.
A previous study (9) reported that females more often receive a 7.0-mm ET tube, and larger or unsuitable ET tube sizes may increase the risk of laryngeal injury, thus requiring multidisciplinary interventions. Nonintubated RAB addresses these limitations by avoiding ET intubation, expanding the applicability for patients with smaller airways. The absence of an ET tube also reduces interference with bronchoscope maneuverability, enhancing accuracy during biopsies and minimizing the need for procedural adjustments. In our cohort, all patients successfully underwent nonintubated RAB with 100% navigation accuracy. No patients experienced postoperative complications, underscoring the feasibility and safety of this approach. Compared to previous studies (2,3), which reported mean procedure times of 51–64 minutes, our study achieved a significantly shorter mean operation time of 33.8 minutes, highlighting the efficiency of nonintubated techniques.
Furthermore, combining diagnostic bronchoscopy with subsequent therapeutic interventions, such as thoracoscopic surgery, under a single nonintubated anesthetic regimen streamlines workflow. This approach circumvents the need for single- to double-lumen intubation transitions required in traditional methods and shortens recovery times. In our study, the mean interval between biopsy and surgery was only 24.2 minutes, and the mean postoperative recovery time was 26.7 minutes, reflecting improved procedural efficiency and enhanced patients comfort.
Nonintubated anesthesia also aligns with the principles of “green anesthesia” by reducing the reliance on volatile anesthetics, such as sevoflurane, isoflurane, or desflurane, which significantly contribute to greenhouse gas emissions (10). By employing intravenous anesthetics and regional nerve blocks, this approach minimizes the environmental footprint of the procedure, offering a sustainable alternative without compromising clinical outcomes.
Several limitations of this study still warrant emphasis. First, as a single-center retrospective study with small sample, its generalizability of non-intubated RAB remains uncertain. Advanced imaging modalities, such as cone-beam computed tomography (CBCT), have been shown to improve tool-in-lesion confirmation and diagnostic accuracy enhance tool-in-lesion confirmation and biopsy success (11). However, in our study, intraoperative imaging was not employed, which may have impacted localization precision.
Conclusions
Collectively, our findings suggest that nonintubated RAB may offer a safe, efficient, and environmentally favorable alternative to traditional RAB. This approach potentially enhances procedural precision, shortens recovery times, and broadens the clinical applicability of RAB. Based on our preliminary experience, non-intubated RAB appears to be a feasible and promising strategy for selected patients. Larger, multicenter studies are warranted to validate these findings and determine the long-term benefits of this approach.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-169/rc
Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-169/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-169/coif). S.L. serves as an unpaid editorial board member of Translational Lung Cancer Research from February 2025 to January 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. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients (or their legal guardians) for the publication of this case series and any accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
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/.
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