Introduction: Electromagnetic navigation bronchoscopy (ENB) and radial probe endobronchial ultrasound (RP-EBUS) are important emerging techniques to diagnose peripheral lung lesions. Yet, it is still unclear under which circumstances would the combination of ENB and RP-EBUS be optimal.

Methods: As a single center retrospective study, we enrolled the patients with peripheral pulmonary nodules who underwent bronchoscopic biopsy using ENB or RP-EBUS. All procedures were performed under moderate conscious sedation.

Results: ENB and/or RP-EBUS guided biopsy was conducted for 525 pulmonary nodules in 472 patients between December 2021 and December 2022. The median age of patients was 68 years (range 12?88). The mean diameter of lung nodules was 28.3 ± 12.8 mm and 64.8% (340 of 525) of nodules were solid. The diagnostic yield was not statistically different among three groups (70.3% for ENB, 63.0% for ENB+RP-EBUS, 62.7% for RP-EBUS, p-value = 0.313). Nevertheless, the diagnostic yield was superior in ENB+RP-EBUS group in the Tsuboi type II or III bronchus sign and part solid nodule with solid part less than 13mm (Odds ratio 2.42, 95% confidential interval 1.05?5.56, p=0.038). In terms of complication, the bleeding was significantly higher in group of ENB+RP-EBUS (6.2% in ENB+RP-EBUS, 3.7% in ENB, 0.6% in RP-EBUS, p-value <0.001).

Conclusions: In this study, we found that the combined technique of ENB+RP-EBUS shows higher diagnostic accuracy in Tsuboi type II or III and part solid nodule with smaller solid part, despite higher bleeding risk. Careful selection and combination of biopsy methods according to the characteristics of each nodule would be helpful to get more accurate diagnosis.