Navigating Atelectasis: Utilizing Transpulmonary Pressure to Enhance Robotic Bronchoscopy: A Single-Center, Prospective Study.

Background: Robotic navigation bronchoscopy (RNB) is effective for accessing peripheral lung lesions with precision and safety. However, the incidence of atelectasis during RNB can impede lesion identification. Higher positive end-expiratory pressure (PEEP) levels may mitigate atelectasis, but bedside assessment is challenging. Transpulmonary pressure (Ptp) assessment, proven useful in optimizing PEEP in ARDS, remains unexplored in RNB.

Methods: This single-center, prospective study enrolled 21 consecutive patients undergoing RNB. All patients were paralyzed and ventilated equally, including PEEP 10 cmH2O and Vt 6 to 8 cc/kg of ideal body weight, and had an esophageal balloon placed using established techniques. Once an adequate esophageal pressure (Pes) waveform was identified, the Pes was recorded. We used Pes as a surrogate for intrathoracic pressure to calculate Ptp.

Results: A total of 21 patients were enrolled (male 11, 52%), BMI (27±4.1). The mean nodule size was 26.83±9.33 mm. The diagnostic yield was 87% for malignancy. The mean Vt was 7.15±1.16 cc/kg. Mean Pes and Ptp were 9.64±3.76 cmH2O and 0.36±1.2 cmH2O, respectively. Eight patients had negative Ptp, and compared with patients with positive Ptp, there were more eccentric or no signals (75% vs. 45%) by rEBUS.

Conclusion: This study provides detailed instructions and feasibility of assessing Ptp in patients undergoing RNB and highlights a potential relationship between negative Ptp and the ability to obtain a concentric rEBUS signal. Our findings suggest that negative Ptp may be associated with a higher likelihood of encountering eccentric or absent rEBUS signals. Further research could enhance our understanding of pulmonary physiology during RNB.