Bronchoscopy Training in the 21st Century

Today’s technology is giving tomorrow’s clinicians an edge. By shortening the learning curve, cutting time and cost, the bronchoscopy simulator is leading the way.

Bronchoscopy offers several different procedures to treat and diagnose a variety of pulmonary disorders.

Bronchoalveolar lavage (BAL) — Commonly done in patients with diffuse infiltrates, cavitary lesions or suspected chemical injury. It is a valuable tool in the management of pneumonia in patients with depressed immune status in whom there is a broad range of possible infecting organisms. The tip of the fiberoptic bronchoscope is wedged into a bronchial segment. Five aliquots of 25 cc of sterile normal saline are placed into the specified bronchial segment and then withdrawn immediately. The fluid is then sent to the laboratory for cultures and cytology.

Endobronchial forceps biopsy — This procedure is used for lesions that can be directly visualized. Small nodules, diffuse infiltrates, and toxic injury can be biopsied. A biopsy forceps is used to obtain pieces of the bronchial mucosa, bronchial wall, lung parenchyma or lesions.

Transbronchial biopsies (TBBX) — The biopsy forcep is advanced through the fiberoptic bronchoscope to the area of infiltrate or density under fluoroscopy, and several small lung tissue samples are obtained.

Transbronchial Needle Aspiration (TBNA) — Since its introduction, transbronchial needle aspiration has played an adjunctive role in diagnostic flexible bronchoscopy. Despite its proven usefulness, TBNA is not widely used. Transbronchial needle aspiration is a valuable, minimally invasive procedure for diagnosing and staging of lung cancer in patients, but it is underutilized by pulmonologists. There are technical problems with the procedure, which included faulty site selection, incomplete needle penetration and catheter kinking that prevents adequate suctioning. Because of these problems TBNA is currently underutilized and under-emphasized in bronchoscopy training programs.

A transbronchial needle is placed through the working channel of the bronchoscope into a segment of lung tissue where there is an abnormality. This needle is used to aspirate material from masses and/or enlarged lymph nodes. Once removed from the bronchoscope, a sample of the aspirated material is then expelled onto a glass slide. The transbronchial needle is flushed and this rinse (specimen) is processed by a concentration technique for later staining and evaluation.

As a rule, patients with abnormal coagulation and/or low platelet counts can prove to complicate the bronchoscopic procedure. Platelets count of 50,000 or better can be used as a general rule. Under these circumstances, special consideration of the risks and benefits and the consideration of the techniques used to enhance safety must occur prior to bronchoscopy. Each patient case is different and judged individually, and a patient could have a bronchoscopy performed with a lower platelet count.

In the bronchoscopy suite, topical 4 percent Lidocaine solution (5ml/200mg) is used in a nebulizer for upper airway anesthesia. Viscous 2 percent Lidocaine is applied to minimize nasal discomfort. Once the patient has become adequately sedated and comfortable, the bronchoscopy can begin.

The transnasal approach of flexible fiberoptic bronchoscopy begins with the examination of the nasal fossa, nasal pharynx, and larynx. (The transnasal approach to bronchoscopy is better tolerated by the patient and allows for better leverage of the scope.) The anatomy and mobility of the vocal cords are evaluated visually as the patient verbalizes an “E” sound. Next the entire circumference of the trachea is viewed.

The fiberoptic bronchoscope is passed to the carina, which is then examined for sharpness, position, and texture. Segmental bronchial orifices are systematically identified, evaluated, and suctioned free of secretions. Close attention is paid to color, texture, position size, and patency of the orifices. Appropriate tissue samples or fluid samples are taken as indicated.

After the bronchoscopy is completed, the patient is recovered in the bronchoscopy suite for three minutes to one hour. Close monitoring of the patients VS and SaO2 are documented every five minutes. Oxygen is weaned and tapered off.

When the patient is stable he/she can then be either discharged home or back to the floor. The patient must remain NPO for a minimum of one hour in order to prevent aspiration, due to the nebulization of the Lidocaine. Also, the patient will not be able to drive or make any judgment decisions for 24 hours after receiving IV sedation.

Changes in Medical Practice

Changes in medical practice that limit instruction and patient availability, the expanding options for diagnosis and management, and advances in technology are contributing to the greater use of simulation technology in medical education.¹ Each day there are a number of new and different diagnostic and therapeutic techniques to be mastered for endoscopy training.

Education in the medical field is very time consuming and costly. To learn bronchoscopy adds a potential risk for patients. Bronchoscopy training is very long. Bronchoscopy is currently taught by hands-on training in the clinical setting.

Next Best Thing to Being There

Defined broadly, a simulator replicates a task environment with sufficient realism to serve a desired purpose.² This allows the doctors to use the simulator and repeat the procedural experiences at their own pace. This improves patient safety by allowing the doctor to become better trained without putting patients at risk. These exercises or procedures would otherwise require numerous real-life encounters and costly hours of supervision.³

A bronchoscopy simulator allows doctors and other healthcare professionals to practice medical procedures without the risk to the patient by accurately duplicating the look and the feel of real-life situations.

The simulator can be used to train anyone who assists with the bronchoscopy. Doctors, nurses, technicians, and respiratory therapists can use the simulators to learn airway anatomy and to understand the wide range of bronchoscopic procedures. The simulator can be used to teach staff how to better assist the physician in the many different types bronchoscopic procedures.

Historically, the only way for healthcare providers to gain realistic experience has been to perform procedures on patients, cadavers or animals. Simulators were created to eliminate these potentially hazardous situations by providing a safer and more humane alternative training method. Simulation improves the teaching process. A physician can practice skills without the distracting worry of causing discomfort to a patient. A clinical instructor can direct his/her trainees to repeat any part of a procedure as many times as necessary. This would be impossible to do while working with a patient.

There are several benefits to this type of simulation system. First, a trainee who practices regularly on the simulator becomes familiar with the mechanics of the actual medical procedure before having to perform it in a clinical situation. This reduces stress during instruction, making it easier to concentrate on the necessary skills. Clinician confidence improves, and patients benefit from this improvement. Second, supervising physicians can minimize patient risk during training. Instructors can correct and advise trainees in detail during a simulated procedure. Demonstrations of difficult techniques that would cause a patient discomfort can be performed freely on the simulator.

The use of simulators is standard in many professions where the safety of large numbers of people is at stake. The application of simulation technology to endoscopic medical procedures began in the early 1990s with the emphasis on gastrointestinal endoscopic procedures. However, the technology at that time was not advanced enough to produce simulators that were realistic and/or affordable. One of the biggest technical hurdles was that these simulators required huge computers costing hundreds of thousands of dollars. In 1995, members of the bronchoscopy community recommended the development and use of simulators for flexible bronchoscopy training. Finally, in 1999, that vision was realized with the introduction of the first commercially available flexible bronchoscopy simulator, the Endoscopic Simulator for Flexible Bronchoscopy manufactured by Immersion Medical Inc.

Physicians are beginning to realize the potential benefits of simulation and are beginning to urge the medical community to adopt simulation technology for training and certification. Simulators have the potential to minimize the current necessity to learn and practice procedural skills on patients, allowing trainees to develop basic competence before treating patients. The justification of patients being subjected to the ‘see one, do one, teach one’ training method is nearing the end. Simulators will replace the need to practice procedures on recently deceased patients. In addition, the use of animals for medical procedure training will become unnecessary, alleviating the high cost of operating animal-training labs.

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

To begin the bronchoscopy, the user inserts the bronchoscope into the robotic device. The bronchoscope feels and acts like an actual flexible fiberoptic bronchoscope. The device tracks the motions of the flexible bronchoscope and reproduces the forces felt during an actual bronchoscopic procedure. The proximal end of the interface device is shaped like a human face with a port to insert the flexible bronchoscope through one of the nasal passages. The flexible bronchoscope tracks the manipulations of the tip control lever, the suction button, and video buttons. In addition, instruments are tracked as they are manipulated in the working channel. This allows for biopsies and other diagnostic and therapeutic procedures to be performed on the simulator.

A monitor displays computer-generated images of the airway as the user navigates through the virtual anatomy. Texture maps based on videotapes of actual bronchoscopic images are added to the airway models to give the mucosa a realistic look. Using different CAT scan data sets allows for the development of a variety of simulated cases that reflect a range of patient anatomy and pathology.

In addition to being anatomically correct, the virtual patient also behaves in a realistic manner. The patient breathes, coughs, bleeds, and exhibits changes in vital signs. Complications are programmed in such as lidocaine toxicity causing the patient to seize or develop a cardiac arrhythmia.

The simulation computer software records all the actions of the user and stores this information in a database. Information that is collected and displayed includes time of procedure, number of times that the bronchoscope tip collides with airway walls, the percentage of bronchial segments entered, and the amount of lidocaine used.

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 takes the fellow up the initial learning curve, so that the first time he or she performs a bronchoscopy on a patient, they will have the skills of a physician who has performed 20 to 30 bronchoscopies. This will increase patient safety and comfort.

Simulators will allow this initial training to occur in a time-efficient and cost-effective 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 and allows for 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’ CME courses that teach new or more advanced bronchoscopic procedures such as TBNA, 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 could revolutionize the evaluation of bronchoscopy skills. Previously, there was no objective means of measuring both the cognitive and psychomotor skills of bronchoscopy. Written or oral examinations can test some cognitive skills, but provide no measure of psychomotor skills. The establishment of a minimum number of bronchoscopes that must be performed to achieve competence has been discussed, but agreement on the exact number has proved impossible. 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 a completed study it was noted that expert bronchoscopists performed best on the simulator followed by intermediates and then novices in terms of procedure time, percentages of segments visualized, time in redout and wall collisions.⁴ 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.⁵

1. Issenberg SB, McGehie WC, Hart IR, et al. (1999) Simulation technology for health care professional skills training and assessment. JAMA 282,861-867.

2. Bushnell E, Gaba, D M. Anesthesia Simulation and Patient Safety. Problems in Anesthesia 2001; In Press.

3. Issenberg SB, McGehie WC Hart IR, et al (1999) Simulation technology for health care professional skills training and assessment. JAMA 282,861-867.

4. 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.

5. Ibid.

A Brief History of Bronchoscopy

Gustav Killian is known as the father of bronchoscopy. In 1897, a Black Forest farmer had aspirated a piece of bone while eating his soup. Listening to his breathing, Killian heard a wheezing noise in the farmer’s right lung. Killian used a head mirror as light source and forceps to remove the bone splinter, which was 11 mm long and 3 mm thick. He became famous for his expertise in removing foreign bodies including; beans, buttons, coins and a tin whistle.

In May 1898, about one year after his initial experiments, Killian described some basic facts of modern bronchoscopy: “The bronchial tubes are elastic, mildly flexible and can be dilated. It is hence possible under local anesthesia to carefully insert the instruments from the bifurcation into the different sites and to view the small branches.”

In Philadelphia, Chevalier Jackson made the next important advancement in 1904. He produced a bronchoscope with a small light bulb at its distal end, and incorporated a suction device. The main emphasis of this method was the retrieval of foreign bodies.

The image quality was further improved by incorporating a telescopic lens in the system, which worked on the principal of a series of small lenses installed at various angles. The introduction of this instrument in bronchoscopy opened new areas of examination and expanded the applications beyond foreign body removal to the localization of hemoptysis and endobronchial disease, mainly tuberculosis and other infections.

Today, a number of fiberoptic bronchoscopes are readily available, varying in external diameter, type of channel, and the degree of flexion and extension of the tip. The choice of instrument is determined by the specific purpose for which the fiberoptic bronchoscope is to be used and physician preference.¹

It is important to understand and identify the reasons why someone might have a bronchoscopy. To visually examine the airways for possible tumor, obstruction, secretions or a foreign body; diagnosis of disease processes such as interstitial pulmonary disease, infection and carcinoma by obtaining bronchial washing, brushing and/or biopsy; therapeutic removal of foreign bodies, mucous plugs, and excessive secretions; localization of the site and cause of hemoptysis and for the treatment of malignant airway obstruction.

1. Lesser, S. Bronchoscopy: The Procedure & the Patient. Baltimore, MD: University of Maryland, 1997:11.

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