治疗前应尽量通过图像引导的微创诊断方法对中高风险恶性肺结节进行诊断。已经开发出多项技术创新，可通过支气管内导航到达这些病灶并获得组织进行诊断。本综述主要讨论导航支气管镜检查中的三个基本步骤：导航、位置确认和采样，重点关注锥形束计算机断层扫描（CBCT）。在导航方面，超薄支气管镜结合虚拟支气管镜导航、电磁导航和机器人辅助支气管镜均取得了良好的导航指导效果，但无法确认位置或指导活检定位。将这些技术与辅助成像工具（如径向内支气管超声和透视）相结合，诊断效果得到了改善。对于病灶进入的确认，径向内支气管超声可以提供局部详细的超声图像，并可与透视相结合，测量结节接触区域长度和确定导管在采样中的位置。CBCT是唯一可以提供精确三维位置确认的技术。在组织获取方面，达到目标和获得诊断往往存在超过10%的差异。这种差异是多因素引起的，包括呼吸运动、样本较小、工具刚性引起的探头位移和肿瘤的非均质性。通过针对氟脱氧葡萄糖（FDG）亲合区域、即时快速现场评价的反馈、选择具有不同被动刚度的采样工具、增加活检数量以及（未来）导管修改（如机器人辅助）等方式可以提高诊断效果。CBCT辅助透视（CBCT-AF）基于导航支气管镜结合导航指导和3D图像确认仪器在病灶中的定位。CBCT-AF可以将病灶与导航路径叠加显示，且能够描绘经肺组织的路径。它可以帮助实时在3D中进行引导和验证采样。缺点是学习曲线陡峭、辐射的应用以及混合手术室的有限可用性/进入性。移动C型臂可以提供3D成像，但由于功率较低和对比噪声比较低而导致图像质量较差，成为限制因素。综上所述，经验丰富的多模态方法似乎是实现诊断准确率>85%的最佳选择。适当的病例选择或详细的3D成像对获得高准确度至关重要。对于当前和未来的经支气管治疗，高分辨率（CBCT）3D成像至关重要。《转化医学年鉴》2023，版权所有。

Pulmonary nodules with intermediate to high risk of malignancy should preferably be diagnosed with image guide minimally invasive diagnostics before treatment. Several technological innovations have been developed to endobronchially navigate to these lesions and obtain tissue for diagnosis. This review addresses these technological advancements in navigation bronchoscopy in three basic steps: navigation, position confirmation and acquisition, with a specific focus on cone-beam computed tomography (CBCT). For navigation purposes ultrathin bronchoscopy combined with virtual bronchoscopy navigation, electromagnetic navigation and robotic assisted bronchoscopy all achieve good results as a navigation guidance tool, but cannot confirm location or guide biopsy positioning. Diagnostic yield has seen improvement by combining these techniques with a secondary imaging tool like radial endobronchial ultrasound (rEBUS) and fluoroscopy. For confirmation of lesion access, rEBUS provides local detailed ultrasound-imaging and can be used to confirm lesion access in combination with fluoroscopy, measure nodule-contact area length and determine catheter position for sampling. CBCT is the only technology that can provide precise 3D positioning confirmation. When focusing on tissue acquisition, there is often more than 10% difference between reaching the target and getting a diagnosis. This discrepancy is multifactorial and caused by breathing movements, small samples sizes, instrument tip displacements by tool rigidity and tumour inhomogeneity. Yield can be improved by targeting fluorodeoxyglucose (FDG)-avid regions, immediate feedback of rapid onsite evaluation, choosing sampling tools with different passive stiffnesses, by increasing the number biopsies taken and (future) catheter modifications like (robotic assisted-) active steering. CBCT with augmented fluoroscopy (CBCT-AF) based navigation bronchoscopy combines navigation guidance with 3D-image confirmation of instrument-in-lesion positioning in one device. CBCT-AF allows for overlaying the lesion and navigation pathway and the possibility to outline trans-parenchymal pathways. It can help guide and verify sampling in 3D in near real-time. Disadvantages are the learning curve, the inherent use of radiation and limited availability/access to hybrid theatres. A mobile C-arm can provide 3D imaging, but lower image quality due to lower power and lower contrast-to-noise ratio is a limiting factor. In conclusion, a multi-modality approach in experienced hands seems the best option for achieving a diagnostic accuracy >85%. Either adequate case selection or detailed 3D imaging are essential to obtain high accuracy. For current and future transbronchial treatments, high-resolution (CBCT) 3D-imaging is essential.2023 Annals of Translational Medicine. All rights reserved.