The SEQUENCE Trial: Should Endobronchial Ultrasound QUeue bEfore or eNsuing to robotiC-assisted Bronchoscopy for pEripheral Pulmonary Nodule Biopsy? A Patient Randomized Control Trial Assessing the Effect of the Ordering of Robotic-assisted Bronchoscopy and Linear EBUS During the Same Anesthesia Event on Diagnostic Yield From Peripheral Pulmonary Nodule Biopsy
Phase: NA
Conditions: Pulmonary Nodules
Sponsor: Northwestern University

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PROTOCOL TITLE: “The SEQUENCE Trial”: Should Endobronchial ultrasound QUeue bEfore or 
eNsuing to robotiC-assisted bronchoscopy for pEripheral pulmonary nodule biopsy? A patient 
randomized control trial assessing the effect of the ordering of robotic-assisted bronchoscopy 
and linear EBUS during the same anesthesia event on diagnostic yield from peripheral 
pulmonary nodule biopsy. 
PRINCIPAL INVESTIGATOR: 
Chris Kapp, MD 
Pulmonary and Critical Care Medicine 
312-695-3800 #2 
Christopher.kapp@nm.org 
VERSION DATE: 
7/18/2024 
  
STUDY SUMMARY: 
Investigational Agent(s) 
(Drugs or Devices) 
None 
IND / IDE / HDE #  
Indicate 
Special Population(s) 
☐
☐
☐
☐
☐
Children  
Children who are wards of the state  
Adults Unable to Consent   
Cognitively Impaired Adults  
Neonates of Uncertain Viability  
☐Pregnant Women  
☐Prisoners (or other detained/paroled individuals)  
☐Students/Employees  
Sample Size 352 participants across all study sites 
Funding Source 
Northwestern University 
Indicate the type of consent to 
be obtained 
☒
☐
☐
Written  
Verbal/Waiver of Documentation of Informed Consent 
Waiver of HIPAA Authorization  
☐Waiver/Alteration of Consent Process   
Site ☐
☐
Lead Site (For A Multiple Site Research Study) 
Data Coordinating Center (DCC) 
Research Related Radiation  
Exposure 
☐
☒
Yes  
No  
DSMB / DMC / IDMC ☐
☒
Yes  
No 

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FEDERAL FUNDING: N/A 
OBJECTIVES: 
Robotic-assisted bronchoscopy (RaB) allows for peripheral pulmonary nodule (PPN) biopsy and linear 
endobronchial ultrasound (EBUS) lymph node staging contemporaneously in the same anesthesia event. 
The optimal sequence of procedures has not been elucidated, as linear EBUS yielding a diagnosis could 
obviate the need for RaB, but could also hinder RaB by leading to the development of atelectasis 
complicating navigation to the peripheral lesion. We propose the following aims for a multi-center, 
prospective, randomized clinical trial where patients either undergo RaB prior to staging linear EBUS or 
vice-versa during the same anesthesia event: 
• 
Specific Aim 1: To conduct a non-inferiority randomized trial to assess the effect of having RaB 
before staging linear EBUS or vice versa on diagnostic yield of peripheral nodule (5-29mm) 
biopsy.  
• 
Specific Aim 2: To assess potential harms and benefits of the use of intraoperative cone beam CT 
to assess the incidence of atelectasis in patients randomly assigned to have RaB before linear 
EBUS staging or vice versa.  
• 
Specific Aim 3: To determine the number of peripheral nodule lung biopsies prevented by 
performing linear EBUS prior to RaB.  
The aims above would be accomplished by the Interventional Pulmonary Outcomes Group (IPOG) with 
member institutions including high-functioning Ion RaB centers (Northwestern University, Vanderbilt 
University, Johns Hopkins University, New York University, University of North Carolina, University of  
California – Davis, University of Michigan, University of California -- San Diego, University of California -- 
San Francisco, Memorial Sloan Kettering, Ohio State University, Beth Israel Deaconess Medical Center) 
with myriad experience in performance of high-quality clinical research. This will be opened up to all 
members of the IPOG community in addition to those listed, so other sites may be added to complete 
enrollment goal sooner. This study would set the standard for optimizing the sequence of bronchoscopic 
procedures in patients at risk for early-stage malignancy. It would be a pragmatic assessment of 
diagnostic yield, assessment of the rate of occult lymph node metastasis, incidence and impact of 
atelectasis, and safety when patients are undergoing both peripheral nodule biopsy and staging linear 
EBUS. In addition, the pragmatic nature of the trial would permit adoption almost instantaneously at 
other institutions. 
BACKGROUND: 
Robotic-assisted bronchoscopy (RaB) has afforded proceduralists the ability to accurately reach the 
periphery of the lung for biopsy of pulmonary nodules1. This has paved the way for patients to undergo 
both biopsy of a peripheral nodule and a staging linear endobronchial ultrasound (EBUS) in the same 
anesthesia event, promoting quicker throughput from discovery of a lesion to guideline-adherent 
treatment2. Further, introduction and mainstream utilization of cone-beam CT (CBCT) has provided the 
bronchoscopist the ability to refine needle position with tool-in-lesion confirmation3. While there are no 
randomized clinical trials promoting efficacy of RaB and CBCT in comparison with other bronchoscopic 
methods, in single center retrospective studies, diagnostic yield has consistently proven to be in the 
7085% range, superior to prior technologies4-6.  
One of the limitations of utilization of RaB and CBCT is the detrimental effect that atelectasis plays in the 
bronchoscopy procedure. This can lead to false positive radial EBUS (rEBUS) signals and non-diagnostic 
procedures7. This incidence of atelectasis has been evaluated prospectively, using a protocol featuring 

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810 cmH2O of PEEP and limiting hyperoxia8, and results suggest this ventilator strategy does an 
adequate job preventing intraprocedural lung collapse. However, this study only evaluated incidence of 
atelectasis and did not elaborate on its impact on diagnostic yield. 
Page 2 of 10 
Further unknown is the optimal sequence of performance of RaB and a staging linear EBUS in patients 
with a radiographically normal mediastinum. Starting with either the RaB or Linear EBUS both have their 
pros and cons. The benefit to performance of a linear EBUS first is the potential to obviate the need for 
peripheral nodule biopsy by obtaining rapid, on-site pathologic feedback of occult nodal disease, 
reducing some of the risk of the procedure (i.e. bleeding and pneumothorax).6  Conversely, the pitfalls to 
performing linear EBUS first is the possible contribution of atelectasis resultant of the increased time 
from intubation to peripheral nodule biopsy, blood in the airway causing bronchospasm, and resorption 
atelectasis from hyperoxia9. There are no prospective data evaluating this in a randomized fashion, but 
one Monte Carlo simulation (with assumption of diagnostic yield from navigational bronchoscopy of 70% 
when performed first and 60% when performed second) suggested a higher diagnostic yield and less 
need for repeat procedure in the navigation first group, despite a 10% assumption of occult nodal 
disease10. 
As outlined in the specific aims above, the overarching goals of this study are to assess in a multicenter, 
randomized clinical trial performed by members of the Interventional Pulmonary Outcomes Group 
(IPOG), whether sequence of staging EBUS plays a role in diagnostic yield, incidence of atelectasis, and 
safety outcomes in patients undergoing RaB. 
STUDY ENDPOINTS: 
Primary Outcome will be the strict definition of diagnostic yield from the combined EBUS/RaB 
bronchoscopy procedure. 
Major Secondary Objectives:  
1) 
The incidence of atelectasis defined by the following pragmatic scale: 
a. No atelectasis, nodule visualized on CBCT 
b. Some atelectasis, but nodule still visualized on CBCT  
c. Atelectasis preventing nodule biopsy 
2) 
Next Generation Sequencing (NGS) sufficiency from EBUS and peripheral nodule biopsy 
3) 
PPN biopsies obviated by starting with EBUS first 
4) 
Safety outcomes (bleeding, pneumothorax) 
5) 
Procedural time 
6) 
Impact of patient factors (BMI, Pulmonary Function Tests, etc) on diagnostic yield STUDY 
INTERVENTION(S)  / INVESTIGATIONAL AGENT(S): N/A 
PROCEDURES INVOLVED: 
We propose a multicenter (Vanderbilt University, Johns Hopkins University, New York University,  
University of North Carolina, University of California – Davis, University of Michigan, University of  
California -- San Diego, University of California -- San Francisco, Memorial Sloan Kettering, Ohio State 
University, Beth Israel Deaconess Medical Center), pathologist-blinded (though not cytopathology onsite 
technician or physician), 1:1 randomized clinical trial evaluating the effect of performance of RaB then 

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staging linear EBUS versus staging linear EBUS first, followed by RaB. Patients evaluated by the 
interventional pulmonary service at their respective institutions will be enrolled if they are scheduled to 
undergo a peripheral pulmonary nodule biopsy, do not have significant (>1.0cm) mediastinal or hilar 
lymphadenopathy, and do not have FDG-PET/CT-avid lymphadenopathy. 
All patients located within outpatient pulmonary clinics or pre-operative holding areas planning to 
undergo a bronchoscopic biopsy of a peripheral pulmonary nodule accessible by RaB and staging linear 
EBUS bronchoscopy for initial diagnosis and possible staging will be eligible for participation. Patients will 
then be randomized in a 1:1 fashion to receive RaB 1st (R1) or linear EBUS 1st (E1). 
All patients will be consented and subsequently intubated in the usual fashion at the institution. Patients 
will be ventilated with the following parameters: 
• 
PEEP of 8-10 cmH2O. 
• 
SpO2 maintained between 92-99% with titration to prevent resorptive atelectasis.  
Then, the proceduralist will randomize the patient to either R1 or E1 (below). 
R1: The proceduralist will first perform an Ion robotic-assisted bronchoscopy in the usual fashion with 
calibration to the airway, navigation to the lesion, and biopsy using the bronchoscopists’ tool of choice 
(typically needle of varying gauge followed by either forceps or 1.1 mm cryoprobe). Rapid on-site 
evaluation (ROSE) from cytopathology can be utilized in these cases to confirm diagnoses, though is not 
mandatory. After completion, the patient will then undergo a staging linear EBUS to assess for occult 
nodal disease and providers will biopsy any enlarged (>5mm) lymph nodes. 
E1: The proceduralist will first perform a linear EBUS procedure to assess for occult nodal disease and 
lymph node biopsies will be taken at the discretion of the proceduralist. All lymph nodes >5mm will be 
biopsied based on current guidelines. The proceduralist will then move on to perform peripheral biopsy 
via use of RaB. 
All patients: During the RaB procedure, CBCT will be utilized to assist the bronchoscopist with tool-
inlesion confirmation when navigating to and biopsying the PPN. Atelectasis will be evaluated based on 
the following scale 1) no evidence of atelectasis, 2) atelectasis as determined by the bronchoscopist, but 
not obscuring the lesion and able to proceed with nodule biopsy, or 3) atelectasis preventing biopsy of 
the nodule. This score will then be recorded. 
Upon completion of the procedure, diagnostic yield will be defined by strict criteria, and only data from 
the initial procedure and not follow-up will be taken into account as per the recently published American 
Thoracic Society consensus statement11. A diagnostic procedure will be defined as a malignancy or a 
specific benign diagnosis (i.e. granuloma or organizing pneumonia). Atypical cells, nonspecific chronic 
inflammation, and other diagnoses without actionable information will be considered non-diagnostic. At 
30-days follow up, sufficiency for NGS, need for an additional diagnostic procedure, and assessment of 
culture data will be undertaken by a member of the study team.  
Patients with a non-diagnostic PPN biopsy will be followed for one-year assessing for requirement of an 
additional diagnostic procedure or radiographic stability. They will not require another study visit.  This 
will be performed via chart review by the research team. 
Data will be collected and stored in a de-identified manner in a redcap database hosted by Northwestern 
University. 

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The research team will also collect demographic data from the EMR, procedural characteristics, and 
pathologic outcomes. Collected data will include lymph node characteristics, procedural characteristics 
including time at each lymph node station, pathologic diagnosis, and adverse events as follows: 
• 
Demographics: Age, sex, race/ethnicity 
• 
Dates: Age (though not specific DOB), date of procedure. 
• 
Nodule characteristics: Size, spiculation, location in the lung. 
• 
Lymph Node characteristics: Size of the lymph node and other characteristics may be 
documented in the REDCap form. 
• 
Procedural Characteristics: Ventilation parameters, time of procedure, number of CBCT spins, 
radiation from the CBCT (mGy and time). 
• 
Final Pathologic Diagnosis:  Strict reporting of diagnostic yield (malignant or specific benign 
diagnoses of granuloma or organizing pneumonia will be counted as diagnostic). 
• 
One Year Follow Up: Will occur for patients with a non-diagnostic initial procedure to discern if 
another procedure made the diagnosis, or if the nodule displayed benign characteristics on 
imaging follow up . 
• 
Adverse Events: Any AEs that occur during the procedure will be recorded and assessed by the PI 
or Sub-Is regarding their relationship to the study procedures. 
DATA AND SPECIMEN BANKING 
Data will be stored in a secure REDCap database hosted on the Northwestern website with password 
protection only accessible to study personnel.  All identifiers (Patient Name, DOB, MRN, contact 
information) will be stored in StudyTracker, aside from dates (date of consent, date of procedure).  Once 
the study is closed, identifiers stored in StudyTracker will no longer be accessed, ensuring that the data 
retained is a limited dataset (with no identifiers included aside from dates as noted above). Data sharing 
agreements will be put into place for outside institutions and only the limited dataset will be shared 
between the groups. 
SHARING RESULTS WITH PARTICIPANTS 
Results from the study will not be shared with participants.  

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STUDY TIMELINES 
Patients will be enrolled before or on the day of their standard of care RaB and linear EBUS procedure 
and this will be the only study visit. Patients’ data will then be evaluated at the 30-day mark to obtain 
strict definition of diagnostic yield. Patients with a non-diagnostic bronchoscopy will then fall into the 1 
year follow up category and the study team will reassess their data at one year, without another 
required visit from the subject. 
INCLUSION AND EXCLUSION CRITERIA 
Inclusion Criteria: Any adult patient undergoing RaB with CBCT for a peripheral pulmonary lesion 
(829mm) that will also have a staging linear EBUS performed in the same anesthesia event.  
Exclusion Criteria:  
1) Patient is known to be less than 18 years old, pregnant, or a prisoner. 
2) Proceduralist deems lesion is not safe for biopsy. 
3) Patient has evidence of PET-Avid mediastinal/hilar adenopathy that could obviate the need for 
peripheral pulmonary nodule biopsy. 
4) Patient has evidence of enlarged hilar or mediastinal lymph nodes (>1.0cm) on non-PET CT of 
the chest. 

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5) Peripheral pulmonary nodule is ≥30mm in diameter 
VULNERABLE POPULATIONS 
Will not be recruited for this study. 
PARTICIPANT POPULATION(S) AND POWER CALCULATION 
Non-inferiority 
This study will be powered to detect the equivalence of the two procedural sequences, R1 and E1, with 
respect to the primary outcome, diagnostic yield. Preliminary data suggest a diagnostic yield of 75% 
within the E1 intervention arm. Sample size calculations assumed power of 80% with a 5% type-1 error 
rate from a non-inferiority test (limit = 2.5%) for the difference between two proportions (one-sided 
ztest with pooled variance) (TABLE).  
TABLE. Sample size needed to detect equivalence between study arms from a one-sided z-test with 
pooled variance of two proportions assuming 80% power and alpha = 0.05 
 
Diagnostic yield in E1 arm = 75% 
Observed  
diagnostic yield in 
R1 arm 
82% 
83% 
84% 
85% 
Total sample size 
462 
372 
304 
252 
Total sample size 
accounting for 5% 
drop out 
487 
392 
320 
266 
Enrollment per 
study arm 
244 
196 
160 
133 
 
Diagnostic yield in E1 arm = 80% 
Observed  
diagnostic yield in 
R1 arm 
87% 
88% 
89% 
90% 
Total sample size 
378 
302 
244 
202 
Total sample size 
accounting for 5% 
drop out 
398 
318 
257 
192 
Enrollment per 
study arm 
199 
159 
129 
96 
Using the sample size calculations of an approximation of 75-80% diagnostic yield in E1 and an observed 
difference in diagnostic yield of 8-9% (84% or 88%, respectively) for the R1 arm with a 5% dropout rate 
(due to patients being consented and subsequently not undergoing a biopsy), the sample size required in 
each group would be 176 participants for a total of 352 participants across all study sites. 
Statistical analysis 

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The primary outcome, diagnostic yield, is binary. Statistical equivalence tests based on a normal 
approximation to a binomial distribution will be used to determine whether the prevalence of the 
outcome in the two intervention groups are the same. Exploratory subgroup analyses will be conducted 
in the following groups: site of nodule (upper lobe or not) and nodule size (8-1.5mm or 1.6-2.9mm). 
Secondary outcomes will be analyzed via generalized linear models, with link functions chosen based on 
the outcome type (logit for binary outcomes, identity for continuous outcomes).  
RECRUITMENT METHODS 
Patients who are scheduled for a standard of care RaB with linear EBUS at Northwestern or one of the 
other participating institutions will be screened by the study team. All patients undergoing a RaB with 
linear EBUS for a peripheral nodule biopsy who meet the inclusion criteria may be approached for 
participation.  Patients may be approached before or on the day of the planned standard of care 
procedure by one of the study team members to provide informed consent. Patients may be approached 
in person during their standard of care clinic or bronchoscopy visit, or one of the study team members 
may contact the patient by phone and/or email.  If the patient is contacted by phone or email, and are 
interested in hearing more about the study, the study team will send the consent form by email to the 
patient and arrange a time to discuss the study over the phone or video call. If the patient agrees to 
participate, the study team will send the consent form for signature via DocuSign and will send a final 
signed copy by email back to the study participant.  The study team will document that the consent 
process took place remotely in StudyTracker. 
Any patients not wishing to participate in the study will still have the standard of care procedure 
completed at the assigned time. 
COMPENSATION FOR PARTICIPATION IN RESEARCH ACTIVITIES None 
WITHDRAWAL OF PARTICIPANTS 
Subjects who provide informed consent but are determined to be ineligible will be considered screen 
failures. The reason for screen failure will be documented and the procedure will continue as per 
standard of care. 
RISKS TO PARTICIPANTS 
There is no expected physical risk related to whether RaB or linear EBUS is performed first. There is 
equipoise as to the preferred method and each are practiced throughout the world based on provider 
preferences. There are no studies to date to suggest superior efficacy or higher risk with either method.   
There is the risk of loss of confidentiality of health information. To minimize this risk, all coded clinical 
data collected and used as part of this project will be stored in a secure REDCap database or on a 
password-protected spreadsheet stored securely by the PI/Co-Is. Only elements of dates will be included 
in the REDCap database (date of consent, date of procedure, etc.). The key linking the code to identifying 
information (name, DOB, MRN, contact information) will be stored securely in StudyTracker.   
POTENTIAL BENEFITS TO PARTICIPANTS 
There is no direct benefit to participants. This research may help us determine the optimal way to 
perform this procedure, potentially saving environmental costs or time under anesthesia in the future. 

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DATA MANAGEMENT AND CONFIDENTIALITY 
To protect confidentiality, all data will be coded with a study code. Data will be password-protected and 
stored securely by the PI/Co-Is on their computers, on FSMResFILES or NM SharePoint, and on a REDCap 
database. Coded data will be stored on REDCap until at least 3 years after study closure. Coded data may 
be shared with other investigators conducting IRB-approved projects that reference the use of these 
data, upon permission from the PI. Codes will be linked to identifying information (name, DOB, MRN, 
contact information) via StudyTracker. 
PROVISIONS TO PROTECT THE PRIVACY INTERESTS OF PARTICIPANTS 
Consenting done in person will be conducted in a private location at the clinic or bronchoscopy suite.  All 
participants will be informed that participation in this study is optional and will not affect their medical 
care.  All personal health information will be coded at the time of collection. Only the authorized 
research personnel for this study will have access to the key linking the code to the participant’s name 
and other identifying information. Identifying information may be used to obtain health information 
from the electronic medical record (Epic) for this research study. The key to the code will be kept in 
confidential files with standard security precautions and will never leave Northwestern University. 
ECONOMIC BURDEN TO PARTICIPANTS 
There are no costs to the participant for being in this study. The bronchoscopy procedure is performed 
for standard of care and will be billed to the patient and/or to the patient’s insurance company in the 
usual way.  Insurance dictates procedural cost and reimbursement and is not based on the equipment 
used or order in which it is performed. 
CONSENT PROCESS 
Written informed consent will be obtained from each participant by the PI, Co-Is, or their study 
coordinators, either at the time of an in-person visit or remotely. If consent if obtained remotely, the 
research coordinator will contact the patient by phone or email to arrange a time to review the informed 
consent form (ICF). The research coordinator will send the ICF by email ahead of time to the patient and 
will arrange to speak with the participant via phone or video call for the consent review. If the patient is 
interested in participating, the coordinator will send the ICF for signature via DocuSign and will send a 
final copy by email back to the participant. The coordinator will also document that the ICF process took 
place virtually in StudyTracker. The physicians and study coordinators will verbally explain the study in 
detail and ensure that any questions are answered before prospective participants sign the consent 
form. They will reinforce that participation in the study is voluntary and they can withdraw their consent 
at any time. 
Consent may be obtained on the day of the procedure.  Consent will not follow any stressful situation (ie, 
patient being informed he/she may have cancer) and will not be conducted if the patient has received 
any mind-altering medications or anesthesia. Patients will be assessed for their capacity to consent by 
the ability to show comprehension of the research, ask appropriate questions, and appear properly 
oriented. A signed copy of the consent form will be offered to participants. 
NON-ENGLISH SPEAKING PARTICIPANTS 
We will utilize the short form consent with the assistance of a translator for non-English speaking 
participants. Once the same short form has been used for two participants or the English main ICF has 
undergone revision, we will translate the main ICF.  

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WAIVER OR ALTERATION OF CONSENT PROCESS: N/A 
PROTECTED HEALTH INFORMATION (PHI AND HIPAA) 
A HIPAA Authorization will be obtained as part of the consent form for the use of Protected Health 
Information (PHI). Health information that we may collect and use for this research includes: 
• 
Names 
• 
Dates: All elements of dates directly related to an individual, including birth date, date of 
procedure, etc. 
• 
Contact information (Address, telephone number, email address) 
• 
Medical record number 
• 
Demographic information (Age, sex, race/ethnicity) 
• 
Information related to the EBUS bronchoscopy (such as procedural characteristics including time 
at each lymph node station) 
• 
Bronchoscopy results (such as lymph node characteristics, pathologic diagnosis) 
• 
One-year follow up of clinical data for persons undergoing non-diagnostic initial procedure 
(radiology results, other biopsy results) 
WAIVER OF HIPAA AUTHORIZATION: N/A 
QUALIFICATIONS TO CONDUCT RESEARCH AND RESOURCES AVAILABLE 
All physicians performing the EBUS procedures for this research are study investigators.  The PI and Co-Is 
have extensive experience in clinical research and the Division of Pulmonary and Critical Care Medicine 
has experienced research managers and coordinators who will assist with this study, including 
consenting patients, creating a REDCap database for data collection, and obtaining and entering clinical 
data.  
The PI/Co-Is perform 5-7 RaB procedures per week, so have sufficient volume of patients to conduct this 
study.  
MULTI-SITE RESEARCH: This research will be performed at Northwestern University as the host site, with 
Vanderbilt University, Johns Hopkins University, New York University, University of North Carolina, 
University of California – Davis, University of Michigan, University of California -- San Diego, University of  
California -- San Francisco, Memorial Sloan Kettering, Ohio State University, Beth Israel Deaconess 
Medical Center potentially contributing data from their patients. This will be opened up to all members 
of the IPOG community, so other sites may be added to complete enrollment goal sooner.  Although this  
is a multi-site study, Northwestern University IRB will serve as the IRB of record only for the 
Northwestern study site.  All other sites will obtain local IRB approval for this study. 
REFERENCES:  
1. 
Yarmus L, Akulian J, Wahidi M, et al. A Prospective Randomized Comparative Study of Three 
Guided Bronchoscopic Approaches for Investigating Pulmonary Nodules: The PRECISION-1 Study. 
Chest.  
2020;157(3):694-701. 
2. 
Kuhlengel TK, Bascom R, Higgins WE. Efficient procedure planning for comprehensive lymph 
node staging bronchoscopy. J Med Imaging (Bellingham). 2022;9(5):055001. 

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3. 
Styrvoky K, Schwalk A, Pham D, et al. Shape-Sensing Robotic-Assisted Bronchoscopy with 
Concurrent use of Radial Endobronchial Ultrasound and Cone Beam Computed Tomography in 
the Evaluation of Pulmonary Lesions. Lung. 2022;200(6):755-761. 
4. 
Kalchiem-Dekel O, Connolly JG, Lin IH, et al. Shape-Sensing Robotic-Assisted Bronchoscopy in the 
Diagnosis of Pulmonary Parenchymal Lesions. Chest. 2022;161(2):572-582. 
5. 
Fernandez-Bussy S, Garza-Salas A, Barrios-Ruiz A, et al. Shape-Sensing Robotic-Assisted 
Bronchoscopy in the Multiple Pulmonary Nodules Diagnosis During a Single Anesthetic Event.  
Respiration. 2024. 
6. 
Thiboutot J, Pastis NJ, Akulian J, et al. A Multicenter, Single-Arm, Prospective Trial Assessing the 
Diagnostic Yield of Electromagnetic Bronchoscopic and Transthoracic Navigation for Peripheral 
Pulmonary Nodules. Am J Respir Crit Care Med. 2023;208(8):837-845. 
7. 
Sagar AS, Sabath BF, Eapen GA, et al. Incidence and Location of Atelectasis Developed During 
Bronchoscopy Under General Anesthesia: The I-LOCATE Trial. Chest. 2020;158(6):2658-2666. 
8. 
Salahuddin M, Sarkiss M, Sagar AS, et al. Ventilatory Strategy to Prevent Atelectasis During 
Bronchoscopy Under General Anesthesia: A Multicenter Randomized Controlled Trial 
(Ventilatory Strategy to Prevent Atelectasis -VESPA- Trial). Chest. 2022;162(6):1393-1401. 
9. 
Khan A, Bashour SI, Casal RF. Preventing atelectasis during bronchoscopy under general 
anesthesia. J Thorac Dis. 2023;15(6):3443-3452. 
10. 
Kammer MN, Heideman BE, Maldonado F. Should We Start With Navigation or Endobronchial 
Ultrasound Bronchoscopy?: Insights From Monte Carlo Simulations. Chest. 2022;162(1):265-268. 
11. 
Gonzalez AV, Silvestri GA, Korevaar DA, et al. Assessment of Advanced Diagnostic Bronchoscopy  
Outcomes for Peripheral Lung Lesions: A Delphi Consensus Definition of Diagnostic Yield and  
Recommendations for Patient-centered Study Designs. An Official American Thoracic Society/American 
College of Chest Physicians Research Statement. Am J Respir Crit Care Med. 2024;209(6):634-646.