Expert Conversations: All About Robotic Bronchoscopy

In this podcast, Pulmonology Consultant Board Member Jaspal Singh, MD, MHA, MHS, interviews 3 early adopters of robotic bronchoscopy. Gustavo Cumbo Nacheli, MD; D. Kyle Hogarth, MD; and Michael A. Pritchett, DO, MPH, share insight into their experience with the innovative technology. They also discuss when is the right time to purchase the technology, how to choose a platform, and what innovations in the space may be on the horizon.

Jaspal Singh, MD, MHA, MHS, is medical director of both pulmonary oncology and critical care education, as well as a professor, at Atrium Health in Charlotte, North Carolina.

Gustavo Cumbo Nacheli, MD, is the director of Bronchoscopy and Interventional Pulmonology in the Pulmonary, Critical Care Medicine Division at Spectrum Health Medical Group in Michigan. He is also the associate director of the Pulmonary and Critical Care Fellowship Program at Michigan State University. Contributor Disclosure Form

D. Kyle Hogarth, MD, is a professor of medicine at the University of Chicago Medicine. There, he is also director of Bronchoscopy, co-director of the Lung Cancer Screening Program, and medical director of the Pulmonary Rehabilitation Program. Contributor Disclosure Form

Michael A. Pritchett, DO, MPH, is a pulmonology specialist at Pinehurst Medical Clinic in Pinehurst, North Carolina. Contributor Disclosure Form

TRANSCRIPT:

Jaspal Singh:  Welcome to Pulmonology Consultant. I’m Jaspal Singh, medical director of pulmonary oncology at Atrium Health. Today I have a great panel talking about robotic bronchoscopy, which is an interesting and innovative technology in the space of pulmonary medicine. With me today are Dr Gus Cumbo, Dr Kyle Hogarth, and Dr Michael Pritchett.

We have a number of questions to go. First, I’m going to go with you, Dr Cumbo. Tell us a little about robotics and why you went into robotics. What is the gain? Why should pulmonologists pay attention to this technology?

Gustavo Cumbo Nacheli: Thank you for that, Jaspal, and thank you for the invite in order to engage in this topic that lives close to my heart. The answer is very simple. There was an area of my interest, as I am a thoracic oncologist. My interest is in lung cancer, lung nodules. I saw significant unmet need in some areas of the lung that existing technologies were not able to reach.

I was able to share the vision of some of my colleagues that, if we were to be able to find a way to get to difficult to reach lesions, then a whole wide array of opportunities would present in order to, in the future, perform therapeutic interventions. In the aims of we go from diagnosis to treatment in hopefully one setting, allow faster access and turnaround of patient care.

Robotic platforms give me that opportunity of reaching pretty much any lesion that I wanted to, provide me the stability of doing such, a lot of control, and—at the end of the day–do it safely and expeditiously for patients.

JS: That’s great. That’s really exciting, Dr Cumbo. Thank you for that information. Dr Pritchett, you use a little different platform than Dr Cumbo does. What have you learned so far about the applications? Do you share that same vision, or do you have a little different take on that? Be curious about your thoughts.

Michael Pritchett: Thanks, Jaspal. I agree with Gus. I think that you’re going [laughs] to see a lot of commonality between the answers of all 3 of us here. We can’t overlook the one obvious thing, which is we like doing cool new stuff. We know that this is version one of the robots. Version two is going to get even better. It does offer significant advantages.

We’re also dedicated to being able to biopsy anything in the lung. Dr Hogarth used this phrase before, that he wants to own the lung. I really feel like, with the robotic platforms, that we can do that. Yes, we work with different robotic platforms, but I think we’re both able to do some pretty amazing things and things that we couldn't necessarily do before.

We like being very early in the process and giving our feedback and helping these companies make these things better.

At this point, when you’re talking about getting into robotics, we can get into minutia about the different factors, but we really want to talk as a whole about what robotics brings to the table. The bottom line is that the diagnostic yield with bronchoscopy by itself was not good enough, and we need something better.

JS: Now, that sounds wonderful. That sounds really exciting. In regards to this, take me back a little bit. I’m a pulmonologist. I do general pulmonary medicine, but I also do some of those thoracic oncology work that you all do in regards to lung nodules.

In my bronchoscopy suite, I have an array of different scopes. From different smaller scopes, ultrathin bronchoscopes now, to therapeutic scopes, to EBUS scopes. Tell me about where does this fit into the armamentarium? What happens to some of that other stuff that goes along? Where does the general pulmonologist fit into this stuff?

Dr Hogarth, I’d be curious about how your thoughts are to how to grab a hold of this technology and how to think about it.

Kyle Hogarth: Well, what you highlighted there, Jaspal. Some of that has been the natural evolution of bronchoscopy. When I had my first bronchoscopy suite ever, I had 3 instruments and one scope. That’s obviously expanded a little bit there as the field has expanded.

I think when you’re talking about the various devices and processes that we have...Obviously, the advent of EBUS has changed the mediastinum, so that’s a whole different discussion. We’re talking, obviously, about peripheral bronchoscopy today and the role that robotics would play in that.

I guess what I would always say is that the best tool for the periphery in the lung is the one that you feel the most comfortable with. It is worth trying many of the ones that are available out before you purchase.

It’s important because there are some people who swear by one certain technology vs another, but that might be their bias of how their brain is wired and why they like that one vs another. You might be different. You also might have different financial restraints, and constraints, etc. A couple things to remember.

I do a lot of bronchoscopy. I am not an interventional pulmonologist. I did not do an interventional pulmonary fellowship. I do not do rigid bronchoscopy. I do, however, bronch all the time and do very little all general pulmonary.

The beauty, I think, of these peripheral procedures is that they are, relatively speaking, not that difficult to learn if you apply yourself, if you spend the time and the effort.

I think advantages that the robotic platforms and robotics in general offer here is that the learning curve appears to be less steep, other than obviously set up, and that the extra abilities that you get from the robotic platforms in regards to stability and accuracy change your approach to the periphery. That’s the real advantage here.

There must be some amount of a push. I already know of 2 other devices that are robotically platform‑based in early development. This is going to get to be a crowded field as it moves forward.

Bronchoscopy, we have wonderfully evolved. We have more equipment and more tools to go down all of that equipment. If you looked at the first cardiology lab back in the mid ’80s to now, there is a natural evolution. Thankfully pulmonary and bronchoscopy in general were on that wave as well.

JS: Thank you for that, Dr Hogarth. That’s a great segue. The 3 of you, I look at as early adopters and innovators in the space. All 3 of you have been adopting this technology, helping to refine the technology of the first couple of systems out there.

You’ve learned a lot. I was curious as to...You mentioned technologies will continue to evolve. If you’re in my position, for example, I work for a large health system. We are actively looking to acquire a system. Would you recommend we wait because of other technologies that are coming down the pipeline. New entrants in the space, what is your general recommendation of what you’ve learned so far? We’ll start with Dr Cumbo.

GCN: Thank you. That’s a very interesting question. That has to be with the direction that each pulmonologist wants to take in their own thoracic oncology program. In my case, we had a large unmet need, and a lot of procedures that have been referred as a repeat procedure, often times there’s a transthoracic needle and then we do an EBUS. We should find the best platform that consolidates and allows access for expeditious workups and hopefully in the future treatment.

To me, to be an early implementer of this technology was a challenge. There were significant barriers financially and logistically. To some degree, the lack of evidence to sustain and make the argument for a system to make a large capital investment.

If we have the vision that we want to push the boundaries of the ways that we have been doing things to the ways that we should be doing things, then with some executive and administrative buy‑in, this dream of taking a step in the right direction can come to fruition.

There’s some hesitancy from doctors to jump on something that has to be retrained. We all train in traditional bronchoscopy. We all had a lot of experience in handling the regular fiber optic scope.

At the end of the day, we cannot keep on doing things the same way for 20 years. This breakthrough technology will undoubtedly empower us as pulmonologists to take that leap of faith and dive into the depths of the lung.

It’s in what you find whenever you get past that third or fourth generation bronchi. Whenever you start thinking about other technologies that you can use to complement the robotic one… the sky’s the limit.

It’s essentially buying a vision of doing things better and learning how to improve the ways, better the ways than the traditional gestalt is indicating in this day and age.

KH: So, Jaspal, to answer that also, anytime you buy a new technology, you’re going to buy the iPhone-whatever. You know the new is going to come out a year later and then the year to that. It is very similar to computers and iPhones. If you just keep waiting, you will never purchase anything.

The technology will keep advancing. But the other nice thing is that the robotic platforms—the 2 that are currently on the market—obviously, the hardware in the sense of the robotic technology. What powers both of them extensively clearly is software.

Software can continuously be updated. In fact, there already have been updates. The other nice thing is that you’re not buying V1, if you will, and then 2 years later, it’s going to be completely different. There will be iterations throughout the time until there are large hardware advances. And so you’re not buying outdated technology even when you decide to make that purchase because the technology updates, the software updates, will continue on until those 2 companies and anything else coming down the pipeline that there represent large jumps forward.

JS: Thank you both for that. I’m going to ask Dr Pritchett to either comment on that or also, Dr Hogarth, I think you had a segue the other question I had. What does the future in this space look like? Dr Pritchett, just curious about your thoughts.

MP: I think it’s a great question. It’s a question that a ton of hospital systems and pulmonologists are asking right now. Things are tight financially with COVID crisis and things like that. The bottom line is that now is really the time to get in.

These companies have proven track records. You want to work with a company that has a proven track record that’s going to continue to innovate and continue to advance. Don’t let anybody fool you. Both these companies are already working on their second and third versions back in their labs and making improvements based on this.

If there was hesitancy, when to pull the trigger, it would have been at the very beginning. I shared that hesitancy, like, “I haven’t seen any data. I don't have any friends that have this. I can’t go watch anybody do these procedures.” I would be real hesitant.

Now there’s thousands of cases done with Auris, hundreds of cases done with Ion. You’ve been to my site, you’ve seen robotic bronchoscopy yourself. The worry goes away in that thing. It’s kind of like the adage of, if you wait until you’re ready to have kids, you’ll never have kids. You just need to jump out there and do it and get moving. 

As far as what's coming next, I think you’re going to see the technologies get better. The one thing that’s clearly missing with robotics is, you don’t have real‑time fluoroscopic or radiographic conformation of where you’re at outside of radial probe.

Even though we use fancy terms like shape‑sensing and optical recognition of airways and things like that, like most of the companies do, we still are lacking something in terms of CT‑to‑body divergence. All these technologies are based on the pre‑op CT that you did, and we know that there’s divergence.

What we’d like to see is integration whether it’s with cone‑beams or with tomosynthesis‑based corrections like fluoroscopic navigation is doing. When you harness the radiographic ability to find out exactly where you’re at, then combine that with your robotic precision and movements, then that’s the game‑changer.

That’s what’s coming next along with lots of different software upgrades, as Kyle mentioned.

CGN: I agree with our colleagues here. I envision a future in which we will allow patient access in some of these platforms. Maybe also working on some innovation. The future is bright, the application of these are endless. I echo Michael. There’s never a right time.

It’s a really powerful tool that should not be feared. It should be adopted, and it should be learned. It will be a tool of empowerment us pulmonologists.

KH: Jaspal, also before I forget, there are some really powerful nonrobotic tools that have come out just recently and are more in development that I think will make us better endoscopists. The potential integration of those technologies into robotic platform offers a lot of potential appeal. There was a lot of “ifs” in all of that, but I think that’s where the excitement also grows.

As this space has continued to grow and as the number of CT scans and the need for lung nodule diagnostics has continued to grow, then that is obviously a potential market. That is then where a lot of researchers are indeed, money has been going.

The other nice benefit to being in this space for all of us is the knowledge that this space will continue to grow and develop because it's a viable space for people to invest in.

JS: You guys have all provided a really nice overview of the robotic technologies. What your perception is, how you use them, how you came to adopt and invest in these processes. You’ve all 3 had to master these processes to the point at which they are to date.

We’ve discussed some of the future applications potentially coming out and additional innovations of space. I’m going to change it a little bit now. A couple of you use one platform, one of you uses Auris, one of you uses the Intuitive.

Not to put one against the other, but what do you see are advantages unique to your specific platform, if you don’t mind, for our listeners? Start with Dr Pritchett.

MP: With the Intuitive robot, I think that we’re going to talk about differences and you’re going to hear some marketing stuff and you’re going to hear some real stuff. What we don’t know yet is, how much of a difference that actually makes. That’s going to be studies that come along. I will still tell you the differences I recognize that you have to take some of these with a grain of salt.

The Intuitive has a smaller catheter that, in theory, can reach out further with less resistance and has a removable camera. You have vision when you need it, then when you’re ready to biopsy you pull the camera out. Kind of like you do with radio probes. It’s a thinner, 3.5 mm outer diameter.

The other advantage is that it’s not tied to electromagnetic navigation. Again, this is version one of these things. My guess is these things are going to go away, but it has a novel navigation system called Shape Sensing Technology that uses an optical fiber to know where it’s at.

The footprint of this system is very nice. It integrates very well with cone‑beams and doesn’t have to be at one place. It can be moved all around. It has it’s own proprietary needles. They’re flexible, they come with it and they lock on. It’s like an Avis needle, which is really cool.

The software allows you to know how far you are from the fluoro, so then you can set your needle depth to how far you want it. There’s some cool software things that are in this, but that’s some of the advantages, if you will, of the Iona platform.

KH: I like what Mike said in the sense that... what he says in the very beginning. There’s pros and cons to all technology, not even just robotics. In some cases, it’s going to be what your hospital is going purchase you, and in some cases it’s going to be what feels better to you.

Say, if it’s Mike, I'm really waiting for data, we all have our own biases. I guess one of the key differences to the Auris platform, from what Mike said, it’s a sheath and scope design. You actually have 2 devices that you can essentially drive using the one as essentially an ability to retract on airways to pull lesions into a better line of view.

Then, you also have always‑on vision so that the entire time you're seeing what you’re scoping. Whether that matters medically versus people who are using it will tell you that it’s great to be able to see because it feels like a bronchoscopy at all times.

But Mike’s right. I don’t know if that matters one way or the other. Gus and I both have the Monarchs, so we’re biased from that. I’m a consultant for Auris; I’m doubly biased I suppose. I think Mike’s a consultant for Ion and Gus is a consultant for Auris as well, so we’re all biased inherently.

Some other things, you can use the Monarch with cone‑beam as well. Gus actually is the leading Monarch‑cone‑beam user in the country. I’ve said before to people who have called to ask me my opinions on one vs the other, and they’re not sure what they’re going to get and sometimes there’s multiple issues at play.

My answer is, my definitive bias is, if you’re going to get a new system, I think the robot is the route to go. Which one is...there will be plenty of people that will market to you one way or the other and show you data and whatnot. After you play with both you can make up your own mind as to which one is better.

One other potential thing that’s of interest when we talk about health systems and money, is that the Monarch system will be submitted for approval for urology applications in the very beginning of 2021.

There is the potential that that device is going to get utilized not just by a pulmonologist once or twice a week on nodule day, but also used once or twice a week by urology, so more potential use out of the capital purchase.

Now, it’s got to get FDA approval for that. There’s a double “if” in there. There is that other potential lure of one platform over another. That has nothing to do with us in bronchoscopy but has everything to do with your discussions with the C‑suite. [laughs]

GCN: Absolutely. Again, I think that there’s value on both platforms. I think that the tool is only as good as the operator that is wielding such power.

To me, when I had to make the decision to implement robotic bronchoscopy, there was literally no evidence behind it other than some categorical studies. What I decided is that I had to...Like I do with my shoes, I don’t buy it through catalogue. I go, and I try it on, and I walk in it a little bit. I try the platforms. I figured out which one was the one that fit better my needs. I am extremely pleased with the result that I have with my platform.

I don’t doubt that potentially … cross‑platform and in the new iterations of Ion, there may be benefits, I don’t doubt that at all. I guess that for me, it fit well. I knew that I was able to get as far as I wanted to. I knew that I could use my tools under direct visualization to maybe, intubate an eighth‑generation bronchus. I push a little bit maybe the rate of probe.

I stent open and I get my 2‑mm scope through to point one, and to me, to be able to see all the way maybe even by sector a little bit the wall or maybe get the scope perpendicular to a bronchus to cross country 2 cm and know that the needle went exactly where I needed it to go. To me, that’s an advantage, strategically and practically, that I’m not willing to forego.

All in all, I think that the platform that gets the job done in pulmonologists’ hands is the right one. I think that there are cons and pros with both, but to me, not losing sight and to be able to know exactly where my instrument is going… that for me that’s by far the thing that I like the most about the platform that I adopted.

KH: You know Jaspal, other C‑suite considerations as well. Mike maybe alluded to this too, that when we talked about the potential for the Monarch across uses. But let us not forget Intuitive obviously has a large presence in the surgical robotics location. And so depending on the hospital's affiliation with Intuitive, there may be financial incentives to be working with the Ion as well, based off just that collaborative nature.

JS: Well, thanks, guys, so much for your thoughts on robotic bronchoscopy. I think you’ve given our listeners a lot to think about. I think all 3 of you bring such great innovation, and ideas, and experience to this very cool space in which our pulmonary teams can think about how to improve patient care.

On behalf of Pulmonology Consultant and Consultant360, I’d like to thank you all for your time and your efforts. Look forward to hearing more about how you’re learning to do robotic bronchoscopy in the future. Thank you so much.