It is prime time for interventional pulmonology (IP), a relatively young subspecialty formally described about 25 years ago. An expanding arsenal of novel bronchoscopy innovations and advanced imaging, along with minimally invasive approaches for managing pleural disease and standardized training, have enabled this maturation.
“IP has evolved significantly from rigid bronchoscopes and cryoprobes to endobronchial ultrasound [EBUS] and contemporary advanced modalities,” said Yaron Gesthalter, MD, Associate Professor of Medicine at the University of California, San Francisco. “With recent innovations, the two major domains in IP—diagnostic and therapeutic—can now often be combined in one procedure or visit.”
While rigid bronchoscopes have been available since the 1800s, the field was propelled forward by the introduction of the dedicated silicone airway stent in the 1990s. And today, IP is in high demand.
While IP was initially developed primarily as a therapeutic modality, particularly for managing central airway obstruction (CAO) via rigid bronchoscopy, its role has expanded significantly beyond CAO and into diagnostics—spurring increasing demand.
Advances in bronchoscopy
Two key technological advances in bronchoscopic airway navigation are electromagnetic navigation (EMN) and robotic bronchoscopy (RAB), a safer and more effective artificial intelligence-guided, human-operated approach that evolved from EMN.
Septimiu D. Murgu, MD, FCCP, Professor of Medicine at University of Chicago Medicine, said the TARGET study is an example of how RAB has improved access and diagnostic yield for peripheral lung lesions.1 In the TARGET trial, RAB-guided peripheral lung lesion sampling was shown to be safe, with a lower incidence of complications, including pneumothorax, bleeding requiring intervention, and respiratory failure compared with conventional bronchoscopic approaches.1
“We learned that we could get further into the lung and sample smaller lesions, and that RAB offers the stability to operate and perform biopsies in a safer way,” Dr. Murgu said. Additionally, based on evidence from recent studies such as VERITAS and RELIANT, interventional pulmonologists can now access peripheral airways with greater precision, Dr. Gesthalter said.
The VERITAS study compared navigational bronchoscopy with radial EBUS and optional integrated digital tomosynthesis to conventional CT-scan-guided transthoracic needle biopsy.2 The data demonstrated the noninferiority of navigational bronchoscopy, with diagnostic accuracy comparable to that of CT-scan-guided biopsy. The safety profile favored navigational bronchoscopy, with a significantly lower pneumothorax rate (3.3% vs 28.3%).
The RELIANT bronchoscopy study compared the diagnostic yield of EMN with RAB.3
“The RELIANT data showed that EMN and RAB are equivalent from a diagnostic perspective,” Dr. Gesthalter said. “VERITAS, RELIANT, and other studies of diagnostic approaches are potentiating early and timely diagnosis for patients who might otherwise not receive further assessments. With advances in RAB, we have the stability and articulation to not only know where we are in the periphery spatially but also target different areas accurately.”
Leveraging imaging advances
Integrating conventional approaches like radial EBUS or cryoscopy with newer tools, such as digital tomosynthesis, cone-beam CT (CBCT) imaging, and augmented fluoroscopy, has transformed IP, increasing both accuracy and reach and enabling exploration of ablative and other therapeutic strategies.
Dr. Murgu said newer technologies can also provide a 3D view of the lung, enabling precise pathway mapping and in-lesion confirmation of the scope’s position.
The FRONTIER study, for instance, combined EMN with integrated digital tomosynthesis, resulting in a strict diagnostic yield of 89.5% in 18 patients with 19 nodules.4
“We would like to see larger studies in many centers to confirm these results, but the initial reports and our own experience are very promising,” Dr. Murgu said.
With improved diagnostic yield, newer modalities can help sample lymph nodes during the same procedure, enabling concurrent staging. Moreover, advanced bronchoscopic modalities carry a low risk of seeding the tumor in the pleural space, a risk associated with percutaneous transthoracic needle biopsies.5–7
“For all these reasons, if patients present with a lung nodule or mass suspected of being lung cancer, we favor going directly for bronchoscopic intervention,” he said.
Beyond nodule management
An important development in IP for nonmalignant disease management is the development of clinical practice guidelines, including CHEST’s 2025 guideline on CAO management.8 The World Association for Bronchology and Interventional Pulmonology has published guidance on stenting for the management of benign and malignant airway obstruction.9–10 In addition, CHEST and the American Thoracic Society released consensus criteria and reporting guidance for diagnostic yields in bronchoscopy.11
“These guidelines represent the accumulated evidence throughout recent decades, culminating in data-driven recommendations for the community on the type and timing of bronchoscopic procedures, using clinical, context-appropriate, patient-centered, safe, and effective approaches,” Dr. Murgu said.
Dr. Gesthalter concurred. “It is an exciting time for IP management of benign disease, especially in patients who have sequelae related to smoking history or pollutant exposure, such as emphysema,” he said. “There is room for optimism.”
Dr. Gesthalter pointed to the emerging potential of individualized stent design and 3D-printed stents— with less granulation and mucus impaction and improved tolerability—for patients with benign airway disease.
IP applications in critical care
“Any patient who is in the ICU on a ventilator due to CAO should not have care withdrawal considered before an interventional pulmonologist is consulted,” said Sujith V. Cherian MD, FCCP, highlighting the fundamental role of interventional pulmonologists in the ICU.
CAO remains a significant concern in patients with thoracic malignancies, with 13% presenting with the condition at diagnosis and an additional 5% developing it within a year following diagnosis.12 Rigid bronchoscopy remains a critical and technically successful procedure for relieving CAO, said Dr. Cherian, Associate Professor and Director of Interventional Pulmonology and Pleural diseases at Lyndon B. Johnson Hospital at the University of Texas Health McGovern Medical School.
During the past decade, interventional pulmonologists have been increasingly tasked with diagnostics in the ICU as well. For instance, although not widely practiced, interventional pulmonologists now perform EBUS-facilitated diagnosis of pulmonary embolism in the ICU for patients in whom an emergent CT scan is not feasible because of mobility limitations or critical illness, Dr. Cherian said.
Another diagnostic application is thoracoscopy, for complex pleural effusions or early management of empyema.13 Interventional pulmonologists also perform endobronchial/intrabronchial valve placement to manage persistent pneumothorax with a persistent air leak and manage hemoptysis.13 Percutaneous ultrasound gastrostomy and combined tracheostomy and gastrostomy in a single procedure are also increasingly being performed by interventional pulmonologists in the ICU.13
During and since the outbreak of the COVID-19 pandemic, the utilization of single-use flexible bronchoscopes (SUFBs) has been increasing in and out of ICUs.14–15 SUFBs offer significant advantages, including a range of sizes, suction capabilities, and options for ablative tools to relieve airway obstruction, Dr. Cherian said. Most importantly, SUFBs do not have the processing burden and costs associated with conventional reusable flexible bronchoscopes.
Training future interventional pulmonologists
IP is a growing specialty, with more than 40 IP training programs offered in the United States. In 2020, there were more than 300 American Association for Bronchology and Interventional Pulmonology (AABIP) board-certified US specialists, of whom 43% had completed an additional fellowship in IP.16 Dr. Murgu, who serves as the Clinical Simulation Oversight Director of CHEST’s Live Learning Subcommittee, said that number has grown to 605 in 2026.
Many professional organizations, including CHEST, offer education courses focused on these technologies, he said. AABIP also offers educational programs focused on advanced bronchoscopic procedures.
“Most people are getting their training through the IP fellowship,” Dr. Murgu said. “Device manufacturers also offer training programs conducted by expert faculty and in-house educational divisions.
“But IP training is not just about RAB and EBUS. It includes advanced therapeutic interventions in the central airways and pleural spaces. Especially because of these high-impact, relatively low-frequency procedures, a dedicated interventional pulmonology training is necessary to assure enough exposure, opportunities for deliberate practice, quality feedback, and thus a competency-oriented education.”
This article was originally published in the Summer 2026 issue of CHEST Physician.
References
1. Murgu S, Chen AC, Gilbert CR, et al. A prospective, multicenter evaluation of safety and diagnostic outcomes with robotic-assisted bronchoscopy: results of the Transbronchial Biopsy Assisted by Robot Guidance in the Evaluation of Tumors of the Lung (TARGET) trial. Chest. 2025;168(2):539-555. doi:10.1016/j.chest.2025.04.022
2. Lentz RJ, Frederick-Dyer K, Planz VB, et al. Navigational bronchoscopy or transthoracic needle biopsy for lung nodules. N Engl J Med. 2025;392(21):2100-2112. doi:10.1056/NEJMoa2414059
3. Paez R, Lentz RJ, Duke JD, et al. Robotic versus electromagnetic bronchoscopy for peripheral pulmonary lesions: a randomized trial (RELIANT). Am J Respir Crit Care Med. 2025;211(9):1644-1651. doi:10.1164/rccm.202409-1846OC
4. Saghaie T, Williamson JP, Phillips M, et al. First-in-human use of a new robotic electromagnetic navigation bronchoscopic platform with integrated tool-in-lesion tomosynthesis (TiLT) technology for peripheral pulmonary lesions: the FRONTIER study. Respirology. 2024;29(11):969-975. doi:10.1111/resp.14778
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9. Chaddha U, Agrawal A, Murgu S, et al. World Association for Bronchology and Interventional Pulmonology (WABIP) guidelines on airway stenting for benign central airway obstruction. Respirology. 2025;30(7):587-604. doi:10.1111/resp.70068
10. Chaddha U, Agrawal A, Kurman J, et al. World Association for Bronchology and Interventional Pulmonology (WABIP) guidelines on airway stenting for malignant central airway obstruction. Respirology. 2024;29(7):563-573. doi:10.1111/resp.14764
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