Background Information:

What are the other Names for the Procedure?

• ENB (Electromagnetic Navigational Bronchoscopy)
• Navigation Bronchoscopy (NB)
• NB (Navigation Bronchoscopy)

What is Electromagnetic Navigational Bronchoscopy procedure?

• Electromagnetic Navigational Bronchoscopy (ENB) is a diagnostic procedure that allows biopsies of small pulmonary nodules
• The procedure is mainly used in the diagnosis of lung cancer, in situations where the lung nodules are small and situated peripherally
• It allows taking samples such as biopsies or brushings from peripheral lung nodules

What part of the Body does the Procedure involve?

• An Electromagnetic Navigational Bronchoscopy procedure involves passing a flexible bronchoscope either through the nose or the mouth
• The scope is passed into the oro-pharynx (throat), larynx (voice box), trachea (windpipe), and the large and medium sized bronchi (airways)
• The scope is navigated close to the lung nodule using pre-planned CT chest and using electromagnetic field board during the procedure

Why is the Electromagnetic Navigational Bronchoscopy procedure Performed?

The reasons for performing an Electromagnetic Navigational Bronchoscopy procedure are as follows:

• To perform brushings or biopsies from peripheral lung nodules
• To place fiducial markers (small metal spheres or coils) in lung cancer nodule to guide stereotactic radiation therapy

What are some Alternative Choices for the Procedure?

• Electromagnetic Navigational Bronchoscopy is considered a minimally-invasive procedure
• As an alternative, patients may be referred directly to the thoracic surgeon for open lung biopsy (surgical lung biopsy) or lobectomy (removal of lobe of lung) for suspicious lung nodule in high-risk patients (such as smokers)

What are the Recent Advances in the Procedure?

The Electromagnetic Navigational Bronchoscopy procedure is considered an advanced procedure related to bronchoscopy in the diagnostic evaluation of suspicious lung nodules.

What is the Cost of performing the Electromagnetic Navigational Bronchoscopy procedure?

The cost of Electromagnetic Navigational Bronchoscopy procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Electromagnetic Navigational Bronchoscopy  procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378214/ (accessed on 11/11/19)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310707/ (accessed on 11/11/19)

http://amj.amegroups.com/article/view/4758/html (accessed on 11/11/19)

Prior to Electromagnetic Navigational Bronchoscopy procedure:

How is the Electromagnetic Navigational Bronchoscopy procedure Performed?

The Electromagnetic Navigational Bronchoscopy is usually an outpatient procedure.

• The patient is required to be under fasting prior to procedure per the physician recommendation
• The procedure can be done with following anesthesia: Intravenous medications, such as fentanyl and midazolam combination (conscious sedation), monitored anesthesia care (MAC) using propofol, or general anesthesia (with oral airway)
• Oxygen is administered for all types of anesthesia. Sometimes, topical anesthesia is sprayed in the oro-pharynx (throat) as well
• The flexible bronchoscope is then passed into the trachea and the airways inspected
• The CT scan of chest is pre-loaded into computer software. The patient is made to lie on an electromagnetic field board
• Tracking sensors are placed on the chest of the patient. A special biopsy catheter is then passed into the bronchoscope channel and navigated to the peripheral lung nodule
• Once the procedure is completed, the biopsy catheter and the bronchoscope are withdrawn

Where is the Procedure Performed?

An Electromagnetic Navigational Bronchoscopy procedure is usually performed in a hospital or outpatient endoscopy/surgical procedure suite.

Who Performs the Procedure?

The Electromagnetic Navigational Bronchoscopy procedure is usually performed by a pulmonologist. 

How long will the Procedure take?

• The actual procedure may take about 60 minutes depending on the location of the lung nodule
• On considering the pre-procedure examination and post-procedure recovery time, the total time in the procedure suite is between 4-6 hours

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider prior to Electromagnetic Navigational Bronchoscopy. This enables your healthcare provider in assessing the risks for the procedure and helps avoid complications.

• Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
• Medication history and any allergies to medications, latex etc.
• If the patient is under any of the following medications, it has to be promptly informed to the healthcare provider: Aspirin, clopidogrel (Plavix), ticagrelor (Brilinta), warfarin (coumadin), rivaroxaban (Xarelto), apixaban (Eliquis), dabigatran (Pradaxa), enoxaparin (Lovenox) etc. and any other blood thinners that he/she is currently taking
• Any medical or family history of bleeding disorders or blood clots
• Any unusual effects of anesthesia from prior surgery
• History of sleep apnea and CPAP use at home

What Preparations are needed, prior to the Procedure?

The physician performing the ENB procedure will evaluate the patient prior to procedure and discuss the details with risks for complications and obtain his/her permission (termed informed consent). 

• If anesthesia team is involved in the procedure, then they too will discuss details of anesthesia with risks for complications and obtain permission from the patient (informed consent)
• Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
• It is strongly advised not to use any cocaine about 7 to 14 days before procedure; and if so, it is important to discuss the same with the physician and anesthesia team
• Smoking should generally be avoided prior to procedure
• Generally, the patient is required to be on fast (no solids or liquids) for at least 8 hours prior to the procedure
• Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications taken) with their attending physician well in advance

What is the Consent Process before the Procedure?

The physician will obtain permission for the Electromagnetic Navigational Bronchoscopy procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Electromagnetic Navigational Bronchoscopy procedure?

• Blood tests and pregnancy test (if applicable) may be required prior to the procedure
• The patient may have already undergone a CT scan of the chest
• An EKG may be needed for anesthetic evaluation

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is an Electromagnetic Navigational Bronchoscopy (ENB)?
• Why is this procedure necessary?  How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Electromagnetic Navigational Bronchoscopy procedure:

What kind of Anesthesia is given, during the Procedure?

• The procedure can be done with following anesthesia: Intravenous medications, such as fentanyl and midazolam combination (conscious sedation), monitored anesthesia care (MAC) using propofol, or general anesthesia (with oral airway)
• Oxygen is administered for all types of anesthesia. Sometimes, topical anesthesia is sprayed in the oro-pharynx (throat) as well

How much Blood will you lose, during the Procedure?

Electromagnetic Navigational Bronchoscopy (ENB) is a minimally-invasive procedure, and hence there is little or no blood loss involved.  The risk of bleeding increases in biopsies of lung cancers.

What are the possible Risks and Complications during the Electromagnetic Navigational Bronchoscopy procedure?

The possible risks or complications that arise during the Electromagnetic Navigational Bronchoscopy procedure are:

• Lung collapse (pneumothorax) from lung biopsies
• Bleeding in the airways with lung biopsies
• Oxygen desaturations, low blood pressure, and arrhythmias (irregular heart rhythm)
• Anesthesia complications, such as respiratory depression, the need for mechanical ventilation, anaphylactic reactions, etc.

What Post-Operative Care is needed at the Healthcare Facility after the Electromagnetic Navigational Bronchoscopy procedure?

• The patient is usually observed by healthcare professionals (nurses) in the recovery area or post-anesthesia care unit (PACU), depending on the type of anesthesia that was given during the procedure
• The patient’s vital signs are monitored; he/she is observed for complications such as coughing blood
• A chest X-ray may be performed to rule out lung collapse or pneumothorax
• Sometimes, nebulizer treatment may be needed after the procedure

After the Electromagnetic Navigational Bronchoscopy procedure:

What are the possible Risks and Complications after the Electromagnetic Navigational Bronchoscopy procedure?

The possible risks and complications that arise after an Electromagnetic Navigational Bronchoscopy procedure include:

• Sore throat and cough for up to 6 to 24 hours after the procedure
• Low-grade fevers for 6 to 24 hours after procedure if lavage is done
• Coughing blood or blood clots following biopsies, if any performed
• Bronchospasm, which is manifested by difficulty in breathing. 
• Lung collapse, when biopsies are done
• Delayed clearance of anesthesia medications leading to prolonged respiratory depression and need for mechanical ventilation
• Uncommonly, low oxygen saturations or cardiac arrhythmias post procedure may result in patient being admitted for observation overnight in the hospital

What is the Prognosis after the Surgery?

• The recovery from the Electromagnetic Navigational Bronchoscopy procedure is generally excellent
• The patient is usually discharged after 30 minutes to 2 hours after the procedure. Typically, there may be a follow up with the physician in 2 weeks to review the results

When do you need to call your Physician?

Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

• Coughing fresh blood
• Shortness of breath more than usual or unexplained difficulty in breathing
• Worsening cough
• Unexplained chest pain

What Post-Operative Care is needed at Home after the Electromagnetic Navigational Bronchoscopy?

At home, the following post-operative care is recommended, after an ENB procedure:

• Take simple analgesics, such as acetaminophen (Tylenol) or ibuprofen (Advil), if needed
• Avoid any strenuous activity for a period recommended by the physician
• Do not drive (post-procedure) for a period of 24 hours
• Avoid smoking or drinking alcohol post-procedure
• Continue prescribed medications except for aspirin or blood thinners. It is important to check with the physician on when to resume aspirin or blood thinners
• Do not sign any legal documents post-procedure for a period of 24 hours

How long does it normally take to fully recover, from the Procedure?

Usually, it takes about 12 to 24 hours to completely recover from the effects of the anesthesia and Electromagnetic Navigational Bronchoscopy procedure.

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

The samples/tissue are usually sent to the microbiology and pathology departments in the hospital and subsequently disposed, as per the standard hospital protocol.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The samples/tissue is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Electromagnetic Navigational Bronchoscopy procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or hospital
• The pulmonologist or thoracic surgeon
• An anesthesiologist (if anesthesia was administered)
• A pathologist (if the tissue was sent for analysis)

The patient is advised to inquire and confirm the type of billing, before the Electromagnetic Navigational Bronchoscopy procedure is performed.