Bronchoscopic biopsy of peripheral pulmonary lesions remains technically demanding because the operator must mentally translate 2D computed tomography (CT) images into the 3D bronchial route.

Mixed-reality (MR) head-mounted displays ease this load by keeping a positionable 3D reference in view during the procedure. Our group has used optical see-through MR (using HoloLens 2 by Microsoft and Holoeyes MD by Holoeyes Inc) for intraprocedural 3D holographic virtual bronchoscopy [1,2]. Separately, without this platform, we have shown the feasibility of Apple Vision Pro (AVP) for simulation-based bronchoscopy training [3].

We developed a prototype visionOS application that ingests the bronchoscope feed via the Network Device Interface (NDI; Vizrt Group) and renders it as a plane colocated with the patient-specific 3D airway model. We report a single-operator phantom feasibility study as a proof of concept.

All 10 target segments were reached, for a per-trial reach success of 10/10 (100%). The mean time-to-target was 37.5 (SD 5.0; range: 30‐44) seconds.

The integrated workspace remained operable throughout the session, which was completed without removing the headset. A single transient video freeze occurred during one trial (R5), from which the stream recovered immediately; its cause was subsequently identified as unbounded frame queuing in the NDI receiver and corrected. No loss of control, image corruption, or other instability occurred in the remaining trials. Latency was not measured during the trials; in bench measurements made 3 months later, on a subsequently modified build, latency of the NDI path relative to pass-through was 250 (median; IQR 232‐261) milliseconds, approximately 261 milliseconds from sensor to display (Multimedia Appendix 2).

Total SSQ severity was 0 before and 7.5 after the session. The increase was confined to the oculomotor domain (general fatigue and eyestrain, each rated slight). No nausea or disorientation was reported, and no adverse events occurred.

To the best of our knowledge, this is the first report to colocate a live bronchoscope video stream—ingested through a native NDI-based pipeline, without a third-party MR platform—and a patient-specific 3D airway model in a single immersive scene on AVP.

Our work shares a live-video approach with recent surgical applications of AVP [5,6] but applies it to peripheral bronchoscopy and colocates the endoscopic image with the patient-specific 3D airway model in one scene rather than beside separate 2D windows.

This study included no comparator, neither conventional bronchoscopy nor the 3D model without colocated video, and therefore cannot determine whether the integrated display confers any benefit over existing approaches; all findings are descriptive. The 10/10 reach success in a static phantom by a single experienced bronchoscopist is near-ceiling by design, cannot be attributed to the system, and is not evidence of efficacy. Target reach was assessed only to the segmental bronchus, the level the simulator labels. Workload was not assessed beyond the SSQ. The measured latency is not negligible; it was obtained 3 months after the trials on a modified build, at a single short range, and excluded the Ambu Broncho Simulator stage present during the trials, so it underestimates that configuration. A dedicated low-latency network and further reduction are prerequisites for clinical use. If the stream is interrupted, the video plane stalls while the locally rendered 3D model and the bronchoscope’s own monitor remain available, though this fallback was untested.

Future studies should include a controlled comparison against conventional bronchoscopy and against the 3D model without colocated video, a multioperator study with blinded timing, and an approved first-in-human case with a coregistered 3D model.