Advanced bronchoscopy platforms are transforming how we diagnose parenchymal pulmonary lesions, and the integration of volumetric imaging modalities—such as digital tomosynthesis and cone-beam computed tomography (CBCT)—is becoming an increasingly central part in these procedures. Intraprocedural volumetric imaging allows bronchoscopists to account for CT-to-body divergence in real time and directly visualize the relationship between the diagnostic tool and target lesion—a meaningful leap forward for procedural accuracy.
However, with greater imaging capability comes greater radiation exposure. The guiding principle for all image-guided procedures is “as low as reasonably achievable.” While patients understandably receive most of the attention when it comes to radiation risk, the more pressing long-term concern may be for the proceduralists and staff who are in the room procedure after procedure, year after year.
What the current research does and does not tell us
Current available data suggest patient radiation exposure during CBCT-guided diagnostic bronchoscopy falls below established safety thresholds and appears to be comparable to, or even lower than, that seen with CT-guided transthoracic needle biopsy.1–2 A recent single-center retrospective study found that effective radiation dose during CBCT-guided shape-sensing robotic-assisted bronchoscopy, averaging 3.5 CBCT spins per procedure, was comparable to that of CT-guided transthoracic biopsy—both roughly equivalent to the radiation amount of an abdominal CT scan.1
For bronchoscopists and staff members, early data are similarly encouraging. In one cohort study evaluating mobile CBCT-guided robotic-assisted bronchoscopy with a median of two spins per case, whole-body radiation equivalent dose was reported at approximately 1.48 μSv per procedure. At that rate, a clinician would need to perform more than 13,000 procedures before approaching annual occupational exposure limits set by the US Nuclear Regulatory Commission and the International Commission on Radiological Protection.3
Regardless, lessons learned from interventional cardiology and radiology remind us that we cannot become complacent. Occupational radiation exposure in those fields has been associated with increased site-specific risks, including leukemia, brain tumors, breast cancer, and thyroid cancer, in part through radiation-induced DNA damage.4 Notably, clustered reports of left-sided brain tumors among interventional cardiologists and elevated breast cancer rates among female proceduralists, even at doses below recommended thresholds, underscore the importance of sustained vigilance.5
Interventional pulmonology is a relatively new field with expanding modalities, increased use of volumetric imaging, and wide variability in practice. The long-term occupational implications for this specialty therefore remain largely unknown.
Practical steps toward safer practice
Currently, two priorities stand out.
First: Close the education gap. Many institutions implement basic radiation safety programs. However, the terminology and core concepts remain unfamiliar to many proceduralists. Standardized training that goes beyond checkbox compliance can foster true fluency in radiation safety principles and could significantly improve adoption of protective practices. High-exposure areas warrant particular attention; eye lens protection and proper upper torso shielding for women are often neglected despite evidence showing that properly fitted personal protective equipment and shielding can substantially reduce radiation dose.6
Second: Standardize how we measure and report radiation. The World Association for Bronchology and Interventional Pulmonology recently issued a white paper emphasizing that consistent reporting terminology is foundational to meaningful scientific comparison across platforms and institutions.7 Dose area product, cumulative air KERMA, radiation times, and number of volumetric spins should be adopted as standard radiation emission dose metrics. These may serve as useful surrogates for cross-platform and cross-institutional comparisons. Establishing these reporting standards now, while the field is still developing, will ensure that future studies can be meaningfully compared and that safety benchmarks are grounded in robust, consistent evidence.
Advanced bronchoscopy continues to evolve rapidly, driven by innovations in real-time imaging and navigational technologies that are improving diagnostic precision and patient safety. As transbronchial biopsy becomes increasingly the preferred, less invasive alternative for evaluation of peripheral lung nodules, our responsibility is to use our tools wisely, protecting not only our patients but also ourselves and our teams in the process.
References
1. Patel P, Ost DE, Shaller B, et al. Cone beam computed tomography-guided bronchoscopy versus computed tomography-guided transthoracic needle biopsy for peripheral pulmonary lesion diagnosis. Chest. Published online March 25, 2026. doi:10.1016/j.chest.2026.02.038
2. Styrvoky K, Schwalk A, Pham D, Madsen K, Chiu HT, Abu-Hijleh M. Radiation dose of cone beam CT combined with shape sensing robotic assisted bronchoscopy for the evaluation of pulmonary lesions: an observational single center study. J Thorac Dis. 2023;15(9):4836-4848. doi:10.21037/jtd-23-587
3. Kalchiem-Dekel O, Bergemann R, Ma X, et al. Determinants of radiation exposure during mobile cone-beam CT-guided robotic-assisted bronchoscopy. Respirology. 2024;29(9):803-814. doi:10.1111/resp.14765
4. Maris EL, Klaassen J, Hazenberg CEVB, Petri BJ, Trimarchi S, Herwaarden JA van. Systematic review on radiation-induced DNA damage and cancer risk in endovascular operators. J Vasc Surg. 2025;82(6):2283-2297.e1. doi:10.1016/j.jvs.2025.07.058
5. Reeves RR, Ang L, Bahadorani J, et al. Invasive cardiologists are exposed to greater left sided cranial radiation: the BRAIN study (Brain Radiation Exposure and Attenuation During Invasive Cardiology Procedures). JACC Cardiovasc Interv. 2015;8(9):1197-1206. doi:10.1016/j.jcin.2015.03.027
6. Kim DW, Jeon H, Joo JH, et al. Tungsten-bismuth shielding sheets for radiation safety in fluoroscopy-guided bronchoscopy: a phantom study. J Thorac Dis. 2026;18(2). doi:10.21037/jtd-2025-1763
7. Wijma IN, Casal RF, Cheng GZ, et al. Radiation principles, protection, and reporting for interventional pulmonology: a world association of bronchology and interventional pulmonology white paper. Respiration. 2024;103(11):707-721. doi:10.1159/000540102
