Learning and Teaching Bronchoscopy in the ICU
By Stephen W. Crawford, MD, Pulmonary Medicine, Naval Medical Center, San Diego, CA, is Associate Editor for Critical Care Alert.
Dr. Crawford is a consultant for Cubist Pharmaceuticals, and is on the speaker’s bureau for Ortho-Biotech.
Airway Management is an integral and frequent component of care of the critically ill. Problems occur on a regular basis and include endotracheal intubation for respiratory failure, evaluation for intrinsic or extrinsic airway obstruction, obstructive sleep apnea, excessive or retained secretions, endotracheal or tracheostomy tube placement, assessment of endotracheal tube position and evaluation and management of airway bleeding. The skills to manage these complications are integral to the effective critical care physician and are emphasized in training programs and textbooks.
Flexible bronchoscopy is a key adjunct to the evaluation and management of the airway. This modality permits visualization of the airway, can guide treatment interventions, can obtain diagnostic specimens, and can relieve obstructions due to secretions and foreign bodies. In the modern ICU, flexible bronchoscopy is readily available with portable fiberoptic or video scopes. It is used routinely to aspirate retained secretions from endotracheal tubes in many units. Within the common uses in the ICU the use of the flexible bronchoscope is generally safe.
However, training in flexible bronchoscopy appears to be variable. Within combined pulmonary and critical care medicine fellowship training programs, a substantial amount of time is spent in the bronchoscopy suite learning the technique from clinicians with years of experience. Surveys among pulmonary medicine trainees revealed that each performed an average of 77 bronchoscopic procedures per year under supervision of experienced bronchoscopists.1 The vast majority of these programs utilized one-on-one training. I am unaware of any standardized training received in isolated critical care training programs, or of the qualifications of the supervisors.
Virtual Reality Simulation in Bronchoscopy Training
Virtual reality (VR) simulation is routinely used in aviation and military training to assist with teaching and assessing proficiency. In VR simulation, a computer graphically interfaces with model instruments and provides tactile and visual feedback to operators in a realistic environment without risk to operator, subjects or equipment. Flexible bronchoscopy VR simulation has been in use for several years with a relatively portable model. The simulators allow for the teaching and assessment of several important skills, including basic airway navigation, inspection and bronchial segment identification, as well as endobronchial suctioning, forceps biopsy, and transtracheal or carinal needle aspiration. In contrast to traditional stationary plastic airway models often used in training, VR simulation provides a more realistic experience. VR simulation mimics airway movements of breathing and coughing, airway visual compromise from bleeding, and physiological responses to the procedure and medications with alterations in oxygenation, pulse and blood pressure.
Several centers have studied flexible bronchoscopy VR simulation in the training environment. Ost et al demonstrated that the proficiency at avoiding contact with the lumen walls and identification of bronchial segments with the VR simulator correlated with the number of bronchoscopy procedures performed and years of experience.2 Moreover, they and others showed that training with the VR simulator significantly improved the performance of novice bronchoscopists.
Importantly for training purposes, the use of a VR simulator for bronchoscopy improves novices’ skills quickly. The manual dexterity and accuracy of identifying specific bronchial segments of novice bronchoscopists equaled or exceeded that of those who performed more than 200 procedures with only 4 hours of instruction and 4 hours of individual experience on the simulator.3 In this study by Colt et al, the performance using the simulator correlated with that using other bronchoscopy models, thus confirming the generalizability of the skills. In an effort to determine how quickly these skills are acquired, Moorthy et al compared novice to experienced bronchoscopists over time. Most of the measurable skills were statistically similar between the groups after 3 to 6 training sessions with the novices.4 Recently, Blum et al reported a study that is most applicable to the ICU setting.5 One hour of VR simulation training significantly improved the performance of surgical residents in performing bronchoscopy in the operating room in patients already under general anesthesia.
These are encouraging results and have important implications for improving the training in bronchoscopy in the ICU. They suggest that basic skills can be acquired more quickly, under more controlled training circumstances and at less risk to patients than the traditional methods of learning primarily in the live-patient clinical setting. This is very important where the training setting is the ICU and the potential risk among critically ill patients is high. Because of clinical instability of the patient often there is no time to teach, review anatomy, and repeat bronchial inspection. This limits the training value of procedure. Alternatively, requiring a critical care medicine trainee to spend valuable training time in an outpatient bronchoscopy setting to learn these skills may detract from the overall educational mission. Use of a VR simulator may address these concerns and provide superior acquisition of skills in less time.
How Many Procedures are Required?
The number of appropriately supervised procedures required to become competent at bronchoscopy is a matter of controversy. In general, experts recommend between 50 and 100 procedures before operators should be considered competent.6-8 The American Thoracic Society suggests at least 50 supervised flexible bronchoscopic procedures for eligibility to the specialty board examination. However, recent work with VR simulation has cast doubt on the number of procedures necessary to develop basic bronchoscopy competency.
We recently studied specific critical bronchoscopy skills, aside from those of speed, avoiding contact with lumen walls and identification of anatomy.9 We compared the ability to enter specifically requested bronchial segments on command among bronchoscopists of varying levels of training. Moreover, we assessed knowledge of basic bronchoscopy history, anatomy, and techniques with a computer-based examination. Surprisingly, the ability to consistently and correctly identify and enter specific bronchial segment orifices was not demonstrated by anyone with less than 200 actual bronchoscopies performed. This is much higher than any expert or professional society currently recommends for certification. Equally important to the training of these procedures, there was no correlation between the fund of knowledge about bronchoscopy and the level of training, number of procedures performed, and technical skill at bronchoscopy. This strongly suggests that true "competency" in bronchoscopy should not be assumed based on years of training or on an arbitrary number of procedures performed. Formalized, quantifiable testing should be performed to assess technical and information-based competence.
Other Available Training Resources
Web-based training assistance is now available. "The Essential Bronchoscopist" web site (www.ucihs.uci.edu/com/pulmonary/bronchoscopy) provides computer-based learning and knowledge assessment modules. Completion of these modules is required at the Pulmonary & Critical Care Medicine training program at Naval Medical Center San Diego for bronchoscope training. Also, web-based training programs and bronchoscopy atlases are under development through the following web site and Bronchoscopy International (www.bronchoscopy.org).
The Role of the Bronchoscopy Assistant
The training implications of these studies of bronchoscopy education extend beyond the medical trainees. The results of the studies reviewed here suggest that there is a role for improving, reviewing, and demonstrating maintenance of bronchoscopy skills among critical care providers after completion of training. VR simulation provides quantifiable measures of these skills and would be an adjunct to procedure credentialing by medical staff departments. Additionally, bronchoscopy-training models can be used to train ancillary procedure staff. Technical support staff can become familiar with and proficient in their duties in a safe and reproducible environment.
The role of the assistant in bronchoscopy in the ICU is undefined. However most of us prefer to have an adequately trained technician to assist with equipment and ventilator adjustment during the procedure. At the very least, someone separate from the bronchoscopists must be assigned to monitoring the patient during the procedure.
Non-Physicians as Bronchoscopists
On a more controversial topic, I am confident that bronchoscopy-training models, such as a VR simulator can be used to train non-physician support staff to perform basic bronchoscopy in the ICU. Basic endotracheal tube assessment and airway suctioning are routine ICU procedures. Urgency in performing these procedures is common in the ICU and can task the limited number of busy critical care physicians. Competently trained non-physician staff that demonstrated knowledge and proficiency in airway anatomy, bronchoscopic dexterity and complication mitigation and management could perform many of these bronchoscopic procedures. Non-physician staff could master basic procedures such as assessment of endotracheal tune location, suctioning of secretions and locating bleeding. The initial situations most likely to benefit from training such bronchoscopist-extenders are military medical theaters and those ICU settings with limited physician support. VR simulation is an ideal modality to teach and demonstrate such proficiency to non-physician support staff and can lead to more complete and safer patient care.
Bronchoscopy is a commonly performed and essential adjunct to airway management in the ICU. Training in these procedures is not standardized nor is the degree or type of training required. True competency is difficult to determine without reproducible testing measures. Training models such a virtual reality simulators provide both an ideal training and proficiency assessment tool. Web-based educational tools will assist with procedural knowledge and training. Improved and standardized procedural training in bronchoscopy will undoubtedly advance patient care and safety in the ICU.
The opinions expressed are those of the author and do not necessarily reflect those of the US Navy or the Department of Defense.
- Haponik EF, et al. Bronchoscopy training: current fellows’ experiences and some concerns for the future. Chest. 2000;118:625-630.
- Ost D, et al. Assessment of a bronchoscopy simulator. Am J Respir Crit Care Med. 2001;164:2248-2255.
- Colt HG, et al. Virtual reality bronchoscopy simulation: a revolution in procedural training. Chest. 2001;120:1333-1339.
- Moorthy K, et al. Evaluation of virtual reality bronchoscopy as a learning and assessment tool. Respiration. 2003;70:195-199.
- Blum MG, et al. Bronchoscopy simulator effectively prepares junior residents to completely perform basic clinical bronchoscopy. Ann Thorac Surg. 2004;78:287-291.
- Standards for training in endoscopy. Statement of the Committee on Bronchoesophagology, American College of Chest Physicians. Chest. 1976;69:665-666.
- Guidelines for competency and training in fiberoptic bronchoscopy. Section on Bronchoscopy, American College of Chest Physicians. Chest. 1982;81:739.
- Prakash UB, et al. Bronchoscopy in North America: the ACCP survey. Chest. 1991;100:1668-1675.
- Crawford SW, Colt HG. Virtual reality and written assessments are of potential value to determine knowledge and skill in flexible bronchoscopy. Respiration. 2004;71:269-275.