Procedure
The IonTM Endoluminal System by Intuitive was used. A CT with 1.5 mm thick slices was uploaded into the PlanPointTM software. After airway segmentation by the software, target lesions were identified in both the right upper and lower lobes, pathways were planned and reviewed through a virtual simulation. The patient was intubated with a 6.0 endotracheal tube (ETT). A 4.2 mm bronchoscope (Olympus BF-P190TM) was first used to complete a standard airway examination and aspirate secretions. The Ion system was then docked to the ETT via a magnetic adapter and the 3.5mm catheter with the vision probe inside it was inserted into the ETT. A standard registration including verification of the main carina and airways in each of the four quadrants was performed. The catheter was then navigated close to the right lower lobe target lesion under direct visualization and in accordance with the virtual navigation path created using the pre-procedure CT scan. Due to the small size of sub-segmental airways, we could not get closer than 22 mm from the RUL target nodule, and 32 mm from the RLL target nodule. However, we chose the RLL target for biopsy as we were able to introduce the catheter into an airway leading directly to the nodule (Figure 2). There was no appreciable CT-to-body divergence. The vision probe was then removed, and a rEBUS probe was inserted, which revealed a concentric signal. The rEBUS probe was then removed and multiple forceps biopsies were performed using the Olympus EndoJaw Disposable Biopsy Forceps with fluoroscopic guidance using a overlay of an image of the rEBUS probe extended to the distal end of the nodule. After several pieces of tissue were obtained, a BAL was performed. There were no immediate complications and a post-operative chest X-ray was unremarkable without evidence of pneumothorax.
The infectious work up was again negative. The pathology slides showed benign, distorted/hemorrhagic lung parenchyma with minimal inflammatory infiltrate, occasional hemosiderin-laden macrophages and several foci of dystrophic calcification (Figure 1). Due to right-sided unilaterality, vascular dysfunction was considered but CT angiography, trans-esophageal echocardiogram, and cardiac catheterization showed normal flow within the right-sided vessels and anastomosis.