ADVANCES IN THE ENDOSCOPY SUITE:

Virtual Bronchoscopy

FLEXIBLE BRONCHOSCOPY is a safe and frequently performed procedure for the diagnosis and treatment of pulmonary disorders.^{1, 2} Since its introduction in 1968, the number of applications for flexible bronchoscopy have grown tremendously. Advanced diagnostic techniques such as transbronchial needle aspiration are now possible, as are therapeutic interventions, including laser ablation of tumors and placement of endobronchial stents. However, current bronchoscopy literature reflects an emphasis on the technologic aspects of the procedure rather than patient-centered outcomes.^3-8

In the 21st century, with this new age technology, we can manufacture simulators that can train physicians to do complex procedures prior to the actual hands-on experience with patients.

A simulator serves to replicate a task environment with sufficient realism to simulate a true-to-life environment.⁹ The physician uses the simulator to repeat the procedural experience at his or her own pace. In general, the simulator improves patient safety by allowing the physician to become better skilled without putting patients at risk. Without these exercises, physician training would otherwise require numerous real-life encounters and costly hours of supervision.

Medical training at some point must utilize live patients to hone the skills of healthcare professionals. At the same time, there remains an obligation to provide appropriate treatment that ensures patients’ safety and well being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based training has been utilized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training opportunities and minimize patient risk. Healthcare has lagged behind in the use of simulation applications for a number of reasons, including cost, rigorous lack of proof of benefit, and resistance to change.

The international patient safety movement and the U. S. federal policy agenda have recently created an atmosphere receptive to expanding the use of simulators in medical training, stressing the ethical imperative to “first, do no harm." It is believed that competency-based technology warrants that patients should no longer bear the burden of procedure-related learning.

The acquisition of new skills in bronchoscopy requires both supervised training and the opportunity for sufficient practice in the necessary endoscopic techniques. Bronchoscopy simulation offers a means of achieving these aims without placing patients at risk. In this way, the minimum necessary skill level can be successfully attained before trainees ever perform their first live procedure. Simulation-based skills assessment plays a major role in the determination of a provider’s competency.

Although medical trainees should be closely supervised, especially during the early part of their clinical training, it is inevitable that trainees will occasionally cause preventable patient injuries. Mistakes made during simulation exercises do not cause harm to actual patients and can be more easily exposed, discussed, and used for educational opportunities or teaching tools. Mishaps in the course of learning can be reviewed openly without the concerns of liability, blame, or even guilt — even the decisions and actions that may result in the death of the simulated patient can provide useful feedback.

Medical credentialing organizations, such as the American Board of Medical Specialties, are beginning to investigate the use of simulation for the evaluation of clinical skills. A wide variety of medical organizations are now encouraging and promoting the use and development of medical simulators.

Flexible bronchoscopy simulators will impact three major areas: training, pre-procedural planning and bronchoscopy credentialing. Pulmonary fellows, as well as other physicians who learn bronchoscopy, are now able to learn bronchoscopy on a simulator, prior to patient contact. Use of the simulator rapidly improves the fellow’s initial learning curve, so that the first time he or she performs a bronchoscopy on a patient, he or she will have the skills of a physician who has performed 20 to 30 bronchoscopies. This should significantly increase patient safety and comfort as well as the physician’s confidence level.

In addition, simulators will allow this initial training to occur in a time-efficient and costeffective manner. In a very short period of time, fellows can be exposed to a broad range of cases that reflect variations in patient anatomy, pathology, and physiology. This training can occur outside the endoscopy suite, thus decreasing the amount of teaching time required during bronchoscopy procedures performed on patients. This provides cost savings to the training institution as well a more efficient use of the attending physician’s time.

In addition, trainees can practice their case management skills on the simulator. Complications such as hemorrhage, pneumothorax and cardiorespiratory distress can be programmed to occur during a simulated case. The trainee must then respond in a timely and appropriate manner. Medical simulators are currently being used in anesthesia for crisis management training. This is analogous to pilots using flight simulators to practice their response to unexpected disasters, such as a power failure or the loss of an engine in mid-air.

Experienced bronchoscopists will also benefit from simulators. Simulators can be used at hands-on courses that teach new or more advanced bronchoscopic procedures such as transbronchial needle aspiration, transbronchial biopsies, bronchoalveolar lavage, electrocautery, tracheobronchial stent placement, and the use of lasers in bronchoscopy. Bronchoscopy simulation can also be used to train healthcare providers who assist in bronchoscopy. Bronchoscopy nurses, technicians, and respiratory therapists can use the simulators to learn airway anatomy and to understand the wide range of bronchoscopic procedures.

Finally, bronchoscopy simulators will revolutionize the evaluation of bronchoscopy skills. Previously, there was no objective means of measuring both the cognitive and psychomotor skills need for bronchoscopy. Written or oral examinations can test some cognitive skills, but provide no measure of psychomotor skills, which are essential for bronchoscopy. The establishment of a minimum number of bronchoscopies that must be performed to achieve competence has been discussed, but agreement on the exact number remains undetermined. In addition, the performance of a minimum number of procedures does not accurately measure actual skills.

Simulators can record all decisions and actions made by the user and store these in a database. This allows for training programs to assess the skills of trainees and track their progress over time. In addition, credentialing and certifying organizations will be able to use simulators to develop a benchmark that physicians must attain before being deemed competent at bronchoscopy. The benchmark can be established by developing an extensive database of performance by competent bronchoscopists on a set of standardized cases on the simulator.

In one study, it was noted that expert bronchoscopists performed better on the simulator than intermediates who in turn performed better than novices in terms of procedure time, percentages of segments visualized, time in red-out and wall collisions.¹⁰ This study concluded that the bronchoscopy simulator was able to accurately assess bronchoscopy experience level. Training new fellows on the bronchoscopy simulator leads to more rapid acquisition of bronchoscopy expertise compared with conventional training methods.

Learning procedures using advanced medical stimulators is a step forward, but medical errors can result from ineffective processes and poor communication. After training in simulation centers occurs, teams can stop to reflect on what they have learned or what has transpired during the exercise as an essential part of the learning process.

An essential part of the solution to the problem of medical errors is better training, specifically, teaching healthcare professionals to learn from their mistakes. Simulation-based medical skills training provides practical learning opportunities in a safe environment in which mistakes can be acknowledged and corrected. It reinforces a new ethic regarding medical errors that calls for transparency of adverse events leading to clinical improvements.

The end result is a culture that is committed to professional accountability, critical assessment and lifelong learning. Better training in clinical skills means better care for the patients.

1. British Thoracic Society Guideline on Diagnostic Flexible Bronchoscopy. Thorax 2001:56:i1-i21.
2. Prakash UBS, Offord KP, Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest 1991;100:1668-1675.
3. I keda S, Yanai N, Ishikawa S. Flexible bronchofiberoscope. Keio J Med 1968;17:1–18.
4. Wang KP. Transbronchial needle biopsy for histology specimens. Chest 1989;96:226–227.
5. Chan AL, Siefkin AS, Albertson TE, Allen RP. YAG laser bronchoscopy: rigid or fiberoptic mode? Chest 1990;98:271–275.
6. Dasgupta A, Dolmatch BL, Abi-Saleh WJ, Mathur PN, Mehta AC. Self-expandable metallic airway stent insertion employing flexible bronchoscopy: preliminary results. Chest 1998;114:106–109.[
7. Harrow EM, Wajdy A, Blum J, Harkin T, Gasparini S, Addrizzo-Harris DJ, Arroliga AC, Wight G, Mehta AC. The utility of transbronchial needle aspiration in the staging of bronchogenic carcinoma. Am J Respir Crit Care Med 2000;161:601–607.
8. Maitre B, Jabber S, Maggiore SM, Bergot E, Richard JC, Bakthiari H, Housset B, Boussignac G, Brochard L. Continuous positive airway pressure during fiberoptic bronchoscopy in hypoxemic patients: a randomized double-blind study using a new device. Am J Respir Crit Care Med 2000;162:1063–1067.
9. Bushnell E, Gaba, D. M. Anesthesia Simulation and Patient Safety. Problems in Anesthesia 2001; In Press.
10. Ost, D, De Rosiers, A, Britt, EJ, et al Assessment of a Bronchoscopy Simulator, Am. J. Respir. Crit. Care., Volume 164, Number 12 December 2001, 2248-2255.

Share this article: Email, Slashdot, Digg, Del.icio.us, Yahoo!MyWeb, Windows Live Favorites, Furl
Add this article feed to: RSS, My Yahoo, Newsgator, Bloglines