Safety and physiological effects of a 20-minute inspiratory breath hold during robotic-assisted bronchoscopy with integrated cone-beam CT: A multicenter observational study

Background: Robotic-assisted bronchoscopy (RAB) with integrated cone-beam CT (CBCT) enables diagnosis of small peripheral pulmonary lesions (PPL) without a bronchus sign. To minimise motion artefacts and atelectasis, a 20-minute inspiratory breath hold can be applied in intubated patients under non-depolarising muscle relaxation. This study analysed safety and arterial blood gases (ABG) in patients with cardiopulmonary comorbidities to evaluate feasibility and physiological limitations ([ Fig. 1 ]). Methods: Patients undergoing RAB+CBCT, including a subset of patients where arterial lines were indicated, were included from two tertiary hospitals. Inspiratory breath holds were maintained for up to 20 minutes (P insp 10 mBar, Fi O2 1.0 at 10 L/min), with ABG recorded at 0, 5, 10, 15, and 20 minutes. Results: A total of 504 breath holds were performed in 316 patients (mean age 68±11 years; 29% with chronic obstructive pulmonary disease; 1.9% with pulmonary hypertension; median lung diffusion capacity 71% predicted [IQR 53–88]). One adverse event (0.2%) occurred: transient severe hypotension (MAP 25 mmHg) and hypoxemia occurred 3 minutes after the breath hold, necessitating 1 minute of CPR, followed by full recovery. In 42 patients with ABG data, paCO₂ peaked at 9.6 kPa (95% CI 8.9–10.4) and pH declined to 7.17 (95% CI 7.15–7.21) at 20 minutes. All parameters normalised rapidly after re-ventilation, confirmed by end-tidal CO₂ monitoring. Conclusions: A 20-minute breath hold during RAB enables motion-free CBCT imaging and biopsy of small PPL while maintaining a closed ventilation system and flexible patient positioning. It is well tolerated, even in patients with cardiopulmonary comorbidities, with transient physiological changes that resolve rapidly, supporting safe and broader clinical use. Fig. 1 Publication History Article published online: 04 March 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany