Beyond the Dedicated Suite: A Practical Review of Shared Imaging Platforms for Precision Interventional Pulmonology

1. Introduction

The increasing detection of small, peripheral, and subsolid pulmonary lesions has created new diagnostic and therapeutic challenges for interventional pulmonology (IP). Lung cancer screening and contemporary pulmonary nodule management have increased the number of indeterminate lesions requiring accurate localization and tissue diagnosis [1,2], including subsolid and subcentimeter nodules that may be difficult to approach using conventional biopsy techniques [3]. Although advances in navigation bronchoscopy have improved access to peripheral targets, discrepancies between preprocedural CT anatomy and intraprocedural lesion position (or CT-to-body divergence) can contribute to geographic miss, increasing the importance of confirming the actual tool–lesion relationship during the procedure [4,5]. Cone-beam computed tomography (CBCT), augmented fluoroscopy, and hybrid image guidance provide intraprocedural target localization and tool-in-lesion confirmation [5,6], and growing clinical evidence supports their integration into bronchoscopic workflows across multiple navigation and localization strategies [7,8,9,10,11,12,13]. Mobile CBCT has further expanded the potential availability of advanced image guidance beyond fixed imaging suites [14]. Despite these advances, access to appropriately equipped procedural environments remains a major implementation challenge. Fixed C-arm CBCT and hybrid suites have traditionally been developed for established high-volume specialties such as cardiology, electrophysiology, neurovascular intervention, and interventional radiology, while dedicated pulmonary suites remain uncommon. Consequently, many IP programs must adapt existing shared, multi-specialty infrastructure to support increasingly complex pulmonary interventions.

Rather than advocating for a single standardized room design, this review provides a practical framework for implementing precision IP across available imaging environments while progressing toward optimal facilities. Drawing on published literature alongside clinical experience across multi-site academic and cancer center environments, we describe the implementation of IP procedures across ceiling-mounted and floor-mounted CBCT suites, biplane systems, robotic CBCT and hybrid operating rooms, mobile C-arm platforms, and conventional CT suites. The review focuses on parenchymal lesion interventions using both bronchoscopic and percutaneous approaches, with particular attention to procedure–room matching, workflow adaptation, equipment configuration, and multidisciplinary implementation. Pleural, airway, and other non-parenchymal procedures are discussed only where they directly influence procedural workflow or room design.

2. Materials and Methods

This narrative review synthesized published literature on cone-beam CT, augmented fluoroscopy, mobile CBCT, hybrid operating room workflows, percutaneous thoracic intervention, and advanced interventional pulmonology procedures. PubMed, Google Scholar, and reference lists of relevant articles were reviewed using combinations of the terms “cone-beam CT,” “CBCT,” “augmented fluoroscopy,” “interventional pulmonology,” “bronchoscopy,” “peripheral pulmonary lesion,” “hybrid operating room,” “percutaneous lung biopsy,” “microwave ablation,” “lung ablation,” and “mobile C-arm.” Priority was given to peer-reviewed clinical series, prospective studies, systematic reviews, technical reviews, and published experience from interventional pulmonology-led or multidisciplinary thoracic programs. This was not designed as a systematic review or meta-analysis; therefore, no formal risk-of-bias assessment or pooled quantitative analysis was performed.

3. Workflows Under CBCT

Advanced imaging broadens the scope of interventional pulmonology beyond bronchoscopic access alone. CBCT, augmented fluoroscopy, and hybrid imaging platforms support bronchoscopic biopsy, percutaneous transthoracic biopsy and ablation, image-guided localization, and combined single-stage procedures. Accordingly, procedural planning should prioritize the approach that provides the safest and most accurate access to the target rather than defaulting to a single route.

3.1. Bronchoscopic Applications

During bronchoscopy, CBCT can update lesion position after procedural changes, provide augmented fluoroscopic guidance, and confirm the tool–lesion relationship before tissue acquisition or treatment. These functions have been incorporated into workflows using radial endobronchial ultrasound (rEBUS), electromagnetic navigation, ultrathin bronchoscopy, and other navigation techniques [7,8,9,10,11,12,13,15,16,17]. Published experience has progressed from CBCT-derived augmented fluoroscopic localization and lung marking [18,19,20,21] to image-confirmed bronchoscopic biopsy [15,17]. Robotic and shape-sensing bronchoscopy further improve catheter stability and pathway control, while CBCT provides complementary confirmation of the instrument position relative to the intraprocedural target [22].

3.2. Percutaneous Applications

CBCT also supports percutaneous transthoracic biopsy and thermal ablation. Large series have demonstrated the feasibility and diagnostic performance of CBCT-guided transthoracic needle biopsy [23], while a recent 77-patient feasibility study reported CBCT laser-guided biopsy performed by an interventional pulmonologist in a hybrid operating room, with an overall diagnostic accuracy of 94.8% [24]. CBCT-guided microwave ablation, laser-guided lung ablation, combined ablation with thoracoscopic resection, and intrapulmonary trajectory adjustment further illustrate its therapeutic applications [25,26,27,28]. Transbronchial cryoablation is also undergoing early clinical evaluation [29]. These expanding applications reinforce the need to consider both bronchoscopic and percutaneous access when selecting and configuring procedural rooms.

3.3. Single-Stage and Combined Workflows

Hybrid imaging environments can integrate localization, diagnosis, and treatment within a single procedural episode. Reported workflows include augmented fluoroscopic bronchoscopic localization followed by thoracoscopic resection [30], image-guided pulmonary marking [31,32], and percutaneous ablation combined with thoracoscopic resection for multiple lesions [27]. Such approaches demonstrate the potential value of advanced imaging suites as shared procedural platforms capable of supporting complementary bronchoscopic, percutaneous, and surgical strategies according to lesion characteristics and multidisciplinary planning.

Taken together, the available evidence indicates that advanced interventional pulmonology and thoracic image-guided procedures can be performed across diverse imaging environments, including ceiling- and floor-mounted single-plane CBCT systems, biplane angiography platforms, robotic or hybrid operating-room CBCT systems, mobile three-dimensional C-arms, and conventional multidetector computed tomography (MDCT) suites. Table 1 provides a practical comparison of these platforms, highlighting their typical procedural environments, principal advantages for IP use, and workflow limitations, based on our experience. Because technical capability does not necessarily translate directly into procedural suitability, Table 2 further synthesizes the relative applicability of each platform across percutaneous, transbronchial, thoracoscopic, hybrid, and endovascular workflows.

4. Why a Dedicated Pulmonology CBCT Suite Is Uncommon

A dedicated pulmonary CBCT suite is an attractive reference model because it places airway access, anesthesia, bronchoscopy equipment, radiation protection, reconstruction workstations, and pulmonary staff within a single procedural environment. In practice, however, many institutions cannot begin with this model. The reasons are historical, spatial, financial, and organizational rather than purely technological [5,6].

First, the bronchoscopic use of CBCT is relatively recent. CBCT-guided bronchoscopy/endobronchial real-time navigation was first reported in 2014 by Hohenforst-Schmidt and colleagues, who described the use of CBCT for endobronchial real-time navigation [37]. This early report was later cited in technical reviews as the first published description of airway segmentation overlaid on fluoroscopic images during CBCT-guided bronchoscopy [5]. In contrast, C-arm CBCT-guided percutaneous transthoracic biopsy was already represented in larger thoracic intervention series from the early 2010s [23,33]. The later expansion of bronchoscopic CBCT literature—including CBCT-derived augmented fluoroscopy, tool-in-lesion confirmation, mobile CBCT-assisted bronchoscopy, robotic bronchoscopy with CBCT, and meta-analytic data—helps explain why most hospitals did not historically design fixed CBCT rooms around interventional pulmonology [5,6,7,8,9,10,11,12,13,14,15,16,17,22,30]. Conventional bronchoscopy suites were typically organized around airway access, endoscopy towers, anesthesia support, and fluoroscopy, rather than fixed angiographic CBCT, overlay workstations, and hybrid-room workflows [5,6].

Second, most fixed CBCT angiography systems were developed around cardiovascular, neurovascular, interventional radiology, or surgical workflows rather than the bronchoscope. As a result, room geometry, monitor placement, table controls, anesthesia access, C-arm parking, radiation shielding, and staff routines may not naturally match the needs of bronchoscopic or combined bronchoscopic-percutaneous IP procedures [5,6]. Third, hospital space is difficult to reclaim. Older hospitals may have limited expansion capacity, whereas newer hospitals may have already allocated advanced procedural rooms to established service lines. Finally, the capital cost of fixed CBCT or hybrid OR infrastructure, together with institutional hierarchy and room ownership, can make it unrealistic for an emerging IP program to request an immediately dedicated pulmonary CBCT suite.

This reality creates two practical pathways. The first is to upgrade an existing room so that it can support pulmonary procedures, including CBCT reconstruction, augmented fluoroscopy, laser guidance, compatible tables, bronchoscopy equipment, anesthesia access, storage, shielding, and staff training. The second is to share scheduled access to a room owned by another specialty. Both pathways require compromise. An IP team may need to work during protected procedural blocks, early time slots, or around cardiovascular, neurovascular, radiology, or surgical priorities. The advantage is that advanced IP can begin before a hospital commits to a purpose-built pulmonary CBCT suite [15,16,17,18,19,20,21,24,25,26,27,28,30,31,32,34,35], which is the purpose of this review article.

The first question for a shared room is therefore deceptively simple: can the C-arm perform the imaging required for the intended procedure? A fluoroscopy room without CBCT, a CBCT-capable room without practical reconstruction or overlay capability, or a system with inadequate image quality or field of view may appear advanced but fail at the decisive procedural step. Conversely, an older or non-dedicated room may still support safe and effective IP if its imaging capability, reconstruction workflow, table motion, anesthesia access, radiation behavior, and staff roles are understood [5,6,14,15,16,17,22,23,24,25,26,27,28,30,31,32,33,34,35,38]. The goal is not to force every room into a pulmonary template, but to match the room’s constraints to the lesion, the intended intervention, and the team’s procedural workflow.

5. The Standard Reference: Ceiling-Mounted CBCT Room for IP

For bronchoscopic IP, ceiling-mounted fixed C-arm CBCT systems may provide a practical starting configuration. The principal reason is physical access. A ceiling-mounted lateral approach can leave the patient’s head side relatively open for the bronchoscopist, anesthesiologist, bronchoscopy tower, ventilator circuit, and airway rescue (Figure 1A). This geometry may be relevant when procedures are performed under general anesthesia, when airway control and rapid team communication matter. It also reduces some of the crowding that occurs when a floor-mounted base competes for the same physical space as the bronchoscopist.

Ceiling-mounted systems can also support augmented fluoroscopic bronchoscopy when paired with a compatible workstation and software capable of CBCT reconstruction, target segmentation, image registration, and projection of three-dimensional information onto live fluoroscopy. This enables intraprocedural updating of lesion location and visualization of the tool–lesion relationship during bronchoscopy. Studies combining CBCT-derived augmented fluoroscopy with rEBUS, ultrathin bronchoscopy, electromagnetic navigation, and robotic platforms support the value of this approach for peripheral pulmonary lesion targeting [7,8,9,10,11,12,13]. Thus, for an IP program performing a high volume of peripheral pulmonary nodule procedures under anesthesia, a ceiling-mounted CBCT suite with appropriate workstation and overlay capabilities represents a practical reference configuration.

Still, ceiling-mounted systems also have workflow limitations and treating them as the only acceptable model can slow program development. Percutaneous procedures may be more constrained in some configurations, particularly when the needle path requires a skin entry site near the limits of the C-arm’s region of interest or when the gantry and table geometry make laser-guided alignment awkward. For both ceiling- and floor-mounted fixed systems, the scanned volume may not always capture both the lesion and skin entry point, especially in large patients, basal lesions, or oblique access paths. These limitations do not negate the value of ceiling systems; they simply mean that room choice should follow the procedure rather than a hierarchy of prestige.

However, most IP teams encounter a broader range of imaging environments than the ideal ceiling-mounted configuration. The practical differences among these rooms are not only related to CBCT capability, but also to airway access, C-arm parking, table movement, anesthesia positioning, workstation availability, and operator ergonomics (Figure 1 and Figure 2; Figure S1).

6. Adapting Non-Dedicated Rooms for IP

6.1. Floor-Mounted C-Arm CBCT Systems

Floor-mounted C-arm systems are often among the earliest fixed angiography platforms available to IP teams because they are common in older interventional radiology, vascular, and cardiovascular rooms. Compared with ceiling-mounted systems, where head-side access is generally more favorable for bronchoscopy and anesthesia (Figure 1A), the floor base and arc trajectory of floor-mounted systems may occupy the head-side working space and make bronchoscopy less ergonomic (Figure 1B). In some configurations, the bronchoscopist may stand near the foot of the C-arm or at an oblique angle, with implications for radiation exposure and hand position. Table movement, cable routing, and bronchoscopy tower placement should therefore be rehearsed before the first clinical case. These considerations are consistent with published reports describing workflow adaptation and room ergonomics as critical determinants of successful CBCT-guided bronchoscopy implementation [5,6,8].

Despite these limitations, floor-mounted systems can be clinically useful. They may provide excellent CBCT image quality, stable fluoroscopy, and laser guidance for percutaneous work [23,33]. In a center beginning a precision IP program, a floor-mounted room may be preferable to a conventional bronchoscopy suite if it offers reliable CBCT reconstruction, a usable workstation, and staff experienced with image-guided interventions. Accordingly, the suitability of a fixed CBCT suite is influenced by both the C-arm mounting configuration itself and its ability to provide reliable intraprocedural lesion localization, accurate tool–lesion assessment, and sufficient procedural access for safe instrument adjustment while maintaining airway or needle control. This principle underlies contemporary image-guided bronchoscopy workflows that emphasize confirmation imaging and real-time tool-lesion assessment rather than reliance on preprocedural navigation alone [4,7,9,13].

For bronchoscopic biopsy, floor-mounted systems require a disciplined setup: predefine the bronchoscopist position, park the C-arm before intubation when needed, confirm that the gantry can complete the spin without collision, and verify that the ventilator circuit, bronchoscope, and anesthesia tubing do not restrict C-arm rotation (Figure 1B). For percutaneous biopsy or ablation, floor-mounted systems may be particularly well suited to the workflow because their room configuration and imaging geometry are similar to those used for conventional image-guided percutaneous interventions. The table and gantry must still allow a laser or needle trajectory that includes both skin entry site and target lesion within the reconstructed field [23,33].

6.2. Robotic CBCT and Hybrid Operating-Room Systems

Robotic CBCT and hybrid operating-room platforms may offer multi-angle positioning and support multiple procedural workflows, while generally requiring substantial infrastructure, staffing, and scheduling resources. (Figure 1C). Compared with fixed ceiling or floor systems, robotic systems can often park away from the airway, approach the patient from multiple angles, and support laser-guided trajectories with automated patient- and table-referenced adjustment. These features may be relevant for complex percutaneous biopsy, microwave ablation, cryoablation, radiofrequency ablation, dye localization, and combined bronchoscopy-surgery workflows [24,25,26,27,28,30,31,32,35].

The hybrid operating room also solves a different problem: it permits single-stage care. A patient with multiple pulmonary lesions may undergo image-guided localization, ablation, and thoracoscopic resection without moving between rooms. Published experience from the NTUH/Biomedical Park group illustrates how hybrid operating-room CBCT can support single-stage augmented fluoroscopic bronchoscopy localization, thoracoscopic resection, microwave ablation, laser-guided ablation, and combined ablation-resection strategies [17,24,25,26,27,28,30,31,32,34,35]. Additional reports from thoracic surgery and interventional pulmonology literature have similarly demonstrated the feasibility of hybrid operating-room workflows for lesion localization, minimally invasive resection, and image-guided therapy [15,21]. Once image guidance, anesthesia, surgical backup, and pulmonary procedural expertise are co-located, the team can design lesion-centered pathways rather than room-centered pathways.

The limitations are predictable: cost, scheduling, staffing, anesthesia availability, room turnover, and competing surgical priorities. A hybrid operating room may provide technical capabilities suitable for complex combined workflows, although access may be limited by local scheduling, staffing, and competing surgical priorities. Programs should therefore avoid building a service that depends exclusively on the resource-intensive room unless procedural volume, institutional support, and scheduling authority are secure. These operational considerations have been highlighted in multiple reports evaluating implementation of advanced bronchoscopy and image-guided thoracic intervention programs [5,6].

6.3. Mobile C-Arm and Mobile CBCT Systems

Mobile CBCT and advanced three-dimensional C-arm systems are appealing because they lower the infrastructure barrier (Figure 1D). A mobile system can be brought to an operating room or procedural room that already supports anesthesia and bronchoscopy, avoiding the need for immediate construction. Early clinical experience suggests that mobile CBCT-assisted bronchoscopy can be performed safely and may improve peripheral lesion workflows, although image quality, field of view, reconstruction speed, software integration, and overlay capability vary by platform [14].

Mobile systems are particularly relevant for resource-variable hospitals. They may provide a feasible entry option for a center that cannot obtain a dedicated fixed suite, cannot control the angiography schedule, or needs to prove procedural demand before capital investment. The tradeoff is that mobile systems may not provide the same integrated workstation, laser-guided trajectory planning, or live augmented fluoroscopy as a mature fixed CBCT suite [6,14]. Their role should therefore be defined honestly: they are not always a substitute for a hybrid room with integrated CBCT and image-guidance capabilities, but they can be a bridge from conventional bronchoscopy toward precision IP. As with fixed CBCT systems, the key determinant of value is whether the platform can provide reliable intraprocedural confirmation of lesion and tool position [4,7,13].

6.4. Biplane Angiography Rooms

Biplane rooms are typically designed for neurovascular or cardiovascular intervention. For interventional pulmonology, the presence of two independently positioned imaging arms within the procedural field is both a principal advantage and a potential limitation. The second plane may restrict access to the patient, monitors, anesthesia machine, bronchoscopy workstation, or the operator’s preferred position. In many older biplane configurations, only one plane can perform CBCT while the other is essentially fluoroscopic. In such rooms, the pulmonary team must understand which plane provides CBCT, which plane can generate overlay, and how to park the unused arm without compromising sterility or safety.

Two practical configurations are illustrated in Figure 3. In Plan A (Figure 3A,B), the floor-mounted arm serves as the primary CBCT system. Figure 3A demonstrates its use during a bronchoscopic procedure, whereas Figure 3B demonstrates a percutaneous intervention using the same floor-mounted imaging geometry. This approach permits CBCT acquisition but may constrain head-side working space because the floor-mounted arm and its supporting structure remain close to the airway and operator position. Although Plan A can support both bronchoscopic and percutaneous procedures, its ergonomics may be less favorable when extensive head-side access is required.

A distinct Plan B configuration is shown in the lower panels of Figure 3. In Figure 3C, the floor-mounted arm is parked laterally, thereby removing it from the immediate head-side workspace and creating a geometry that more closely resembles that of a ceiling-mounted single-plane system. This provides substantially greater access around the patient’s head for the bronchoscopist, anesthesiologist, bronchoscopy tower, and airway equipment. Figure 3D demonstrates the operational configuration of Plan B, in which the ceiling-mounted arm is positioned around the patient and provides the additional rotational freedom required to complete CBCT acquisition while maintaining the wider head-side working space. Importantly, unlike conventional biplane systems in which the secondary ceiling-mounted arm may be limited to fluoroscopy, newer-generation systems may permit CBCT acquisition from the ceiling-mounted arm itself, allowing it to function independently while the floor-mounted arm remains parked.

The biplane suite may therefore be considered a shared-room opportunity rather than a compromise to be avoided. It may support IP workflows when its imaging capabilities, arm movement, room geometry, and workstation functions are understood by the procedural team. In appropriately equipped newer-generation systems, the ability to transition between a floor-mounted Plan A and a ceiling-arm Plan B configuration may permit the same room to support bronchoscopic, percutaneous, and potentially combined workflows while preserving procedural access. As with other advanced imaging environments, experience from bronchoscopy programs suggests that procedural success depends as much on workflow integration, imaging confirmation, and team familiarity as on the imaging platform itself [4,7,9].

6.5. Conventional MDCT-Guided Intervention as a Comparator and Partner

MDCT-guided thoracic intervention remains important, especially for percutaneous biopsy and ablation. Large C-arm CBCT-guided percutaneous transthoracic needle biopsy series show that needle-based lung procedures can achieve high accuracy when lesion visualization and trajectory control are strong [23,33]. The purpose of this review is not to imply that CBCT is the only acceptable pathway. For some lesions, especially those requiring a direct percutaneous route and not a bronchoscopic workflow, MDCT may remain efficient, familiar, and diagnostically robust.

The limitation of conventional CT is integration. It is less suited to live bronchoscopic navigation, fluoroscopic overlay, and one-room bronchoscopy-percutaneous-surgical workflows. CT rooms may also be difficult to coordinate with anesthesia, bronchoscopy equipment, sterile ablation setup, or thoracic surgery. A mature IP program should therefore view MDCT and CBCT as complementary rather than mutually exclusive. The question is which room best serves the lesion and planned intervention. Contemporary guidelines and expert reviews increasingly emphasize a multimodality approach in which bronchoscopy, CBCT, fluoroscopy, robotic navigation, and CT-guided intervention are selected according to lesion characteristics, procedural goals, and local expertise rather than adherence to a single technology platform [5,6].

The practical utility of an imaging platform for interventional pulmonology is determined not simply by the availability of CBCT, but by the interaction between imaging capability and procedural workflow, including room geometry, airway and anesthesia access, gantry mobility, patient positioning, workstation functionality, and compatibility with bronchoscopic, percutaneous, or combined interventions. As summarized in Table 3, successful applications have been reported across a broad range of configurations, including fixed ceiling- and floor-mounted systems, robotic C-arms, mobile three-dimensional C-arms, biplane angiography systems, and hybrid CT/CBCT environments. These platforms have supported transbronchial biopsy, localization, and ablation, as well as transthoracic biopsy, localization, and ablation, indicating that advanced thoracic image guidance is not confined to a single hardware architecture. Rather, the suitability of a platform should be assessed according to whether it can provide reproducible intraprocedural imaging, adequate procedural access, and reliable integration with the intended intervention.

7. Practical Challenges in Shared Suites

Shared procedural suites should not be regarded as universally adaptable environments, as their physical layout and workflow are typically optimized for the specialty for which they were originally designed. Each room carries the assumptions of the specialty that originally built and operated it. A neurovascular suite is designed around a different operator position, table height, monitor orientation, shielding pattern, emergency workflow, and instrument path than a bronchoscopy suite. A cardiovascular room is usually organized around groin or radial vascular access rather than airway access. A hybrid operating room prioritizes surgical sterility, operating-room turnover, and multidisciplinary scheduling. These design characteristics reflect the requirements of the suite’s primary specialty and should be systematically evaluated before implementing pulmonary procedures. Successful adaptation requires the IP team to understand the room’s imaging capability, airway access, C-arm motion, table behavior, workstation workflow, radiation profile, anesthesia setup, and scheduling hierarchy [5,6,34,38].

A shared-suite IP program should therefore perform a structured room assessment before clinical implementation. At minimum, the team should confirm whether the room can acquire CBCT of the target with adequate field of view and image quality; generate augmented fluoroscopy, overlay, or laser guidance when needed; complete a C-arm spin after final patient positioning, intubation, draping, and equipment setup; preserve head-side access for bronchoscopy and airway rescue; accommodate percutaneous trajectories when planned; and provide appropriate radiation shielding and dosimetry. A proposed pre-case checklist for adapting shared imaging rooms to IP is provided in Table S1.

An important planning consideration is the availability of a predefined backup plan. A shared-room IP program should not depend on improvisation during a crowded procedure. If CBCT reconstruction, overlay, laser guidance, or workstation transfer fails, the team should know in advance whether the case will proceed as conventional bronchoscopy, convert to CT-guided biopsy, proceed to surgical localization, or be rescheduled. This decision should be made before anesthesia, not after the patient is already positioned in a room designed for another workflow.

8. Anesthesia and Procedural Control

Anesthesia planning in precision IP should account not only for procedural requirements but also for room geometry. In bronchoscopy, particularly robotic-assisted bronchoscopy (RAB), the anesthesia machine, robotic platform, bronchoscopy equipment, monitors, and imaging system may all compete for limited space around the patient. Equipment placement must preserve airway access while allowing unobstructed C-arm rotation and safe movement of the bronchoscopist and procedural team.

The use of an elongated breathing circuit or extension tubing can provide additional flexibility by allowing the anesthesia machine to be positioned farther from the procedural field while maintaining ventilation and airway control. This may be particularly useful in CBCT-guided bronchoscopy or RAB, where equipment crowding near the head of the patient can restrict imaging trajectories. Room setup should therefore be planned jointly by the anesthesia, bronchoscopy, and imaging teams before the procedure, with particular attention to C-arm clearance, robotic positioning, tubing length, and access to the airway [5,6]. Dry runs during early implementation can help identify spatial conflicts before clinical cases.

9. Radiation Safety and Occupational Exposure

Radiation safety deserves its own section because IP operators often stand differently from the specialists for whom the room was designed. A cardiovascular operator may work near the groin or radial access site behind established shielding, whereas a bronchoscopist may stand near the head, shoulder, or foot depending on the C-arm configuration. Percutaneous IP adds another exposure pattern because the operator may stand close to the beam during needle alignment, confirmation scans, or ablation checks [23,24,26,33].

The ALARA principle remains the foundation, but practical implementation must be room-specific. International guidance on CBCT radiation protection emphasizes dose optimization, staff training, dose monitoring, and special care when fluoroscopy and tomographic acquisition are combined [38]. Technical reviews of CBCT bronchoscopy also highlight the need to balance intraprocedural confirmation with radiation exposure [5,6]. Bronchoscopic CBCT learning-curve data show that both diagnostic accuracy and radiation performance can improve with experience, while the NTUH group’s radiation analysis of augmented fluoroscopic bronchoscopy reinforces that IP teams should measure and manage exposure rather than assume that dose patterns from cardiology or radiology translate directly to pulmonary workflows [9,34].

Practical dose reduction begins before the case. The team should select the lowest-dose CBCT protocol that still answers the procedural question, limit the scan range to the target region, avoid unnecessary repeat spins, and confirm that the lesion, tool, and intended pathway are within the field of view before acquisition. During fluoroscopy, operators should use pulsed fluoroscopy, collimation, last-image hold, low magnification when feasible, short fluoroscopy runs, and clear verbal commands before imaging. During CBCT acquisition, staff who are not required at the table should step back or move behind shielding, while the operator should maximize distance from the source whenever procedural control allows.

A shared suite should routinely track dose-area product, reference air kerma when available, fluoroscopy time, number of CBCT acquisitions, operator position, shielding use, and staff dosimetry. Protective measures should include lead aprons, thyroid shields, lead eyewear, ceiling-suspended or mobile barriers, table-side shielding when available, and consistent personal dosimeter use.

10. A Practical Decision Framework for Centers Without a Dedicated IP Suite

For centers without a dedicated pulmonary CBCT suite, precision IP can be developed through a stepwise, lesion-centered approach. The first step is to define the initial clinical service: peripheral bronchoscopic biopsy, bronchoscopic localization, percutaneous biopsy, ablation, or combined localization-resection. The second step is to inventory existing procedural environments, including the bronchoscopy suite, CT room, angiography room, biplane suite, hybrid operating room, mobile CBCT platform, and surgical operating room. The third step is to match each intended procedure to the room that can answer the key imaging and workflow question with the least compromise.

This approach reframes limited infrastructure as staged program development rather than a fixed barrier. A mobile CBCT platform may support early CBCT-assisted bronchoscopy; a shared angiography room may support percutaneous biopsy or ablation; a biplane suite may support selected bronchoscopic procedures once one plane can be parked; and a hybrid operating room may be reserved for complex combined cases. Early cases should be selected according to room capability, not only clinical ambition. From the beginning, programs should collect outcome, complication, radiation-dose, anesthesia, room-time, and scheduling data. These data can then justify protected room access, targeted equipment upgrades, or eventual construction of a dedicated pulmonary suite. Table S1 exhibits a pre-case checklist before adapting a shared imaging room to interventional pulmonology.

11. Future Directions

Future developments in precision IP will likely emphasize integration rather than any single platform. Robotic bronchoscopy with intraprocedural imaging, mobile CBCT, hybrid operating rooms, adaptive navigation, and expanding percutaneous techniques may increasingly support combined diagnosis, staging, localization, and treatment. Program development should evolve in parallel, with training encompassing imaging literacy, room selection, percutaneous anatomy, anesthesia coordination, radiation safety, and complication management.

However, evidence directly comparing imaging platforms and room configurations remains limited, with much of the available literature derived from technical reports, feasibility studies, and single-center experiences. Platform performance is also influenced by software capabilities, workflow design, room configuration, and operator experience; therefore, the assessments in this review should be interpreted as a practical synthesis rather than evidence of comparative superiority. Future multicenter studies should compare diagnostic and therapeutic outcomes, radiation exposure, workflow efficiency, and implementation across imaging environments to establish evidence-informed procedure–room matching. Ultimately, the optimal IP infrastructure may not be a single dedicated suite, but a coordinated network of rooms selected according to the needs of each procedure.

12. Conclusions

Advanced IP need not begin in a purpose-built pulmonary CBCT suite. Fixed single-plane, biplane, robotic or hybrid, mobile CBCT, and conventional CT environments can support selected pulmonary interventions when imaging capability, procedural access, anesthesia requirements, radiation safety, and local workflow are matched to the intended procedure. Structured room assessment and staged implementation can allow programs to expand toward increasingly complex bronchoscopic, percutaneous, and combined workflows.