Evaluation of a novel method of teaching endobronchial ultrasound: physician- versus respiratory therapist-proctored simulation training.

BACKGROUND: Computer endobronchial ultrasound (EBUS) simulators have been demonstrated to improve trainee procedural skills before attempting to perform EBUS procedures on patients. OBJECTIVE: To compare EBUS performance following training with computer simulation proctored by EBUS-trained respiratory therapists versus the same simulation training proctored by an interventional respirologist. METHODS: The present analysis was a prospective study of respiratory medicine trainees learning EBUS. Two cohorts of trainees were evaluated using a previously validated method using simulated cases with performance metrics measured by the simulator. Group 1 underwent EBUS training by performing 15 procedures on an EBUS simulator (n=4) proctored by an interventional respirologist. Group 2 received identical training proctored by a respiratory therapist with special training in EBUS (n=10). RESULTS: No significant differences between group 1 and group 2 were apparent for the primary outcome measures of total procedure time (15.15±1.34 min versus 14.78±2.88 min; P=0.816), the percentage of lymph nodes successfully identified (88.8±5.4 versus 80.91±8.9; P=0.092) or the percentage of successful biopsies (100.0±0.0 versus 98.75±3.95; P=0.549). The learning curves were similar between groups, and did not show an obvious plateau after 19 simulated procedures in either group. DISCUSSION: Acquisition of basic EBUS technical skills can be achieved using computer EBUS simulation proctored by specially trained respiratory therapists or by an interventional respirologist. There appeared to be no significant advantage to having an interventional respirologist proctor the computer EBUS simulation.

Trainee impact on advanced diagnostic bronchoscopy: an analysis of 607 consecutive procedures in an interventional pulmonary practice.

BACKGROUND AND OBJECTIVE: Complications during advanced diagnostic bronchoscopy are rare and include: pneumothorax, bleeding, mediastinitis and lymphadenitis. Increased complications have been demonstrated in patients undergoing routine bronchoscopy procedures performed by trainees. This study aimed to determine the impact of trainees during advanced diagnostic bronchoscopy on procedure time, sedation use and complications. METHODS: A retrospective review of a quality improvement database including consecutive pulmonary procedures performed by an interventional pulmonologist (D.R.S.) at the University of Calgary, from 1 July 2007 to 1 April 2011. RESULTS: Six hundred seven (55.2%) of the 1100 procedures involved an advanced diagnostic procedure defined as: endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), electromagnetic navigation bronchoscopy (ENB) and/or peripheral EBUS. A trainee participated in 512 (84.3%) procedures. A complication occurred in 25 patients (4.1%), with a trend towards increased complication rates in the trainee group (4.7% vs 1.1%, difference 3.6%, P = 0.076). Significant differences were seen when a trainee participated versus when no trainee participated for procedure length (58.32 min vs 37.69 min, difference 20.63 min (95% confidence interval: 19.07-22.19), P = 0.001) and for the dose of propofol (178.3 mg vs 137.1 mg, difference 41.2 mg (95% confidence interval: 19.81-63.38), P = 0.002). CONCLUSIONS: In an academic interventional pulmonology practice utilizing the apprenticeship model, trainee participation in advanced diagnostic bronchoscopy increased procedure time, increased the amount of sedation used and resulted in a trend to increased complications. Attempts to modify trainee procedural training to reduce the burden of procedural learning for patients are warranted.

Wet laboratory versus computer simulation for learning endobronchial ultrasound: a randomized trial.

BACKGROUND: Linear endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) is a revolutionary bronchoscopic procedure that is challenging to learn. OBJECTIVES: To compare two methods used to teach EBUS-TBNA: wet laboratory (lab) versus computer EBUS-TBNA simulation. METHODS: A prospective, randomized study of respirologists, thoracic surgeons and trainees learning EBUS-TBNA at a two-day continuing medical education course. All subjects received education via a series of lectures and live cases, followed by randomization to learn EBUS-TBNA predominantly either by wet lab simulation (n=6) or computer simulation (n=6). All subjects then completed testing of their EBUS-TBNA skills via a previously validated method using simulated cases on EBUS-TBNA simulators and questionnaires evaluating learner preferences. RESULTS: There were no significant differences between the computer EBUS-TBNA simulator group and the wet lab group in procedure time (25.3±6.1 min versus 25.2±2.5 min; P=0.984) and percentage of successful biopsies (81.3±14.9% versus 74.0±17.3%; P=0.453). The computer simulator group performed significantly better than the wet lab group in the percentage of lymph nodes correctly identified (70.4±16.7% versus 42.9±19.9%; P=0.002). Wet lab simulation was associated with increased learner confidence with operating the real EBUS-TBNA bronchoscope. All subjects responded that wet lab and computer EBUS-TBNA simulation offered important complementary learning opportunities. CONCLUSION: Computer EBUS-TBNA simulation and wet lab simulation are effective methods of learning basic EBUS-TBNA skills and appeared to be complementary.

Simulation in flexible bronchoscopy and endobronchial ultrasound: a review.

Flexible bronchoscopy is a widely used medical procedure performed by a variety of specialists. Learning flexible bronchoscopy in a clinical setting is associated with increased learner anxiety, introduces significant variability into the learning experience, and increases complications placing the burden of learning on the patients. Bronchoscopy simulation involves the use of inanimate models, wet lab models, or computerized virtual reality simulators to teach and evaluate bronchoscopy skills, with the advantage of standardization of the teaching and assessment techniques without risk to the patient. The aim of this study is to provide a review of the major evidence supporting the use of bronchoscopy simulation to date and to identify limitations in the literature to stimulate further research incorporating these exciting teaching modalities.

Use of tunneled pleural catheters for outpatient treatment of malignant pleural effusions.

PURPOSE OF REVIEW: Malignant pleural effusion is a common complication in advanced malignancy that causes debilitating symptoms which result in impaired quality of life. The primary therapeutic goal in malignant pleural effusion management is effective palliation of the associated respiratory symptoms. Pleurodesis by chest tube or thoracoscopy is widely accepted as the gold standard treatment, although these treatments are not without problems. Tunneled pleural catheters represent a new safe and effective outpatient treatment option for these patients, with no reported mortality and minimal morbidity. RECENT FINDINGS: Chest tube insertion with talc slurry and thoracoscopy with talc insufflation are effective methods for achieving spontaneous pleurodesis, although associated with significant morbidity and mortality. A growing body of evidence is confirming that long-term palliation of malignant pleural effusion can be achieved by using tunneled pleural catheters in a large proportion of relatively unselected patients on an outpatient basis. SUMMARY: The optimal method for palliative management of malignant pleural effusion remains controversial. The high success rates, low complication rates and efficacy in patients with a wide range of performance status support the use of tunneled pleural catheters as a first-line treatment for symptomatic malignant pleural effusion.