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Ann Thorac Surg 2004;78:287-291
© 2004 The Society of Thoracic Surgeons

Original article: general thoracic

Bronchoscopy simulator effectively prepares junior residents to competently perform basic clinical bronchoscopy

Matthew G. Blum, MDa*, Thomas W. Powers, BAb, Sudhir Sundaresan, MDc

a Division of Cardiothoracic Surgery, Chicago, Illinois, USA
b Northwestern Institute for Minimally Invasive Surgery and Technology, Chicago, Illinois, USA
c Department of Surgery, Northwestern Memorial Hospital, Chicago, Illinois, USA

Accepted for publication November 25, 2003.

* Address reprint requests to Dr Blum, 201 E Huron St, Chicago, IL 60611, USA
e-mail: mblum{at}nmh.org

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 Discussion
 References
 
BACKGROUND: Teaching procedural skills in a clinical setting is becoming increasingly difficult. Simulators can provide safe and inexpensive skills training. This randomized study was conducted to evaluate the effectiveness of a bronchoscopy simulator in teaching clinical bronchoscopy.

METHODS: Three groups of surgical residents were evaluated while performing an intraoperative flexible bronchoscopy. First year (PGY1) residents were randomly assigned to perform bronchoscopy either with (n = 5) or without (n = 5) preprocedural bronchoscopic simulator training (PreOp flexible bronchoscopic simulator, Immersion Medical, Gaithersburg, MD). Residents PGY2 to 3 (n = 3) with prior bronchoscopic experience (≥ 10 bronchoscopies) underwent evaluation without simulator training. Subjects were required to complete a systematic airway examination through a laryngeal mask airway with patients under general anesthesia. Evaluation criteria included procedure time, number of verbal and physical interventions by evaluator, and a rating of exam thoroughness, proficiency, and confidence.

RESULTS: The PGY1 subjects who trained on the simulator required significantly fewer verbal (6.2 ± 1.6 vs 3.2 ± 0.8) and physical (1.6 ± 0.2 vs 0.2 ± 0.4) cues and performed more systematic examinations (2.6 ± 0.5 vs 4.4 ± 0.9 on scale 1 to 5) than those who did not use the trainer. The skill level of PGY1 subjects who worked with the simulator was similar to that of PGY2 to 3 residents experienced in bronchoscopy. Procedural times were not different between groups as the evaluator maintained the pace of the examination using verbal and physical assistance.

CONCLUSIONS: One hour of training with the bronchoscopic simulator effectively taught residents basic bronchoscopy and familiarity with airway anatomy. Residents using the trainer performed first-time bronchoscopy nearly as competently as residents experienced with bronchoscopy.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 Discussion
 References
 
Steadily increasing time constraints for both residents and instructors has placed a premium on efficient and effective technical training. Simulators may be able to efficiently and uniformly provide basic skills training for some technologies and procedures. Instead of learning introductory skills when resident and patient anxiety is at its highest, residents trained with simulators can conduct procedures after familiarity with equipment, technique, and anatomy is established. Simulator training can also be cost-effective because operating or procedure room time is more expensive than time in a training lab. Maximizing training productivity during patient-trainee interactions becomes increasingly important as residency training becomes compacted into eighty hour work weeks and limited hospital time.

Greater sophistication and realism in computer simulation has resulted in simulators that can be meaningfully integrated into skills training [1]. Currently available technology can accurately simulate bronchoscopy on a conscious patient with basic airway pathology allowing trainees to gain meaningful experience that can be translated to the clinical setting. Guidelines for conducting competent bronchoscopy training have been published [2]. Many of these objectives are taught using the PreOp flexible bronchoscopic simulator (Immersion Medical, Gaithersburg, MD). Colt and colleagues [3] reported on their experience training five pulmonary-critical care residents using the Pre-Op endoscopy simulator. After a total of eight hours of training, the previously inexperienced group performed technically as well as board certified or eligible pulmonologists with more than 200 bronchoscopies each. Simulator training also improved proficiency of anesthesiology residents in conducting fiberoptic intubations [4].

Bronchoscopy skills needed by the junior surgical resident are different than those of pulmonologists and rarely involve fiberoptic intubation. Typical general surgical applications of the bronchoscope include assessing the main airways for traumatic disruption and toilet bronchoscopy for secretion management. Training for general surgeons should primarily emphasize bronchoscope control and normal lobar anatomy. Identifying subsegmental bronchial anatomy and unusual pathology are of secondary importance. This study was designed to determine how well a bronchoscopic training device could teach basic bronchoscopic skills.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 Discussion
 References
 
First year general surgery and preliminary residents (PGY1) and second and third year (PGY2 and PGY3) general surgery residents rotating through the thoracic surgery service were eligible to enter the study. A total of thirteen residents, divided into three groups, participated: Naïve PGY1 residents with no bronchoscopy training (n = 5); trained PGY1 residents after bronchoscopy simulator training (n = 5); experienced PGY2 to 3 residents with previous bronchoscopic experience (n = 3).

All PGY 1 residents went to the Northwestern Institute for Minimally Invasive Surgery and Technology (NIMIST) skills laboratory. They were instructed on the design of the study and randomized to the study group (trained) or PGY1 control group (naïve). The study group underwent instruction and training on the bronchoscopic simulator (PreOp flexible bronchoscopic simulator, Immersion Medical, Gaithersburg, MD) (Fig 1) while the naïve group received no simulator training. Randomization and simulator instructions were given by the technician in the NIMIST. The surgeon who evaluated the residents during the intraoperative bronchoscopy was blinded to the results of randomization.



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  		Fig 1. Patient simulator (foreground) with attached computer and video screen (background).

 
All PGY2 or PGY3 had previously been taught bronchoscopy and had used it clinically. They were asked to conduct an intraoperative bronchoscopy without working on the bronchoscopic trainer. Scores from this nonrandomized group served to help establish assessment benchmarks against which the trained group could be compared.

Simulator training
The bronchoscopy simulator includes a computer with a monitor, software, a realistic proxy bronchoscope (connected to the computer) (Fig 2) , and a patient simulator interface with a mounted faceplate. The faceplate is designed to simulate inserting the bronchoscope device into the nasal passage and airways. Realistic bronchoscope motions (tip flexion and extension, rotation of the bronchoscope, and depth of bronchoscope advancement) simulate the experience of an actual fiberoptic bronchoscopy. Sensors in the patient simulator detect the position of the bronchoscope tip and relay the information to the computer. The computer generates a real-time virtual image of the appropriate airway anatomy. Buttons on the bronchoscope device can be pressed to simulate suction and capture images of anatomy and pathology. A foot pedal can be depressed to simulate administration of lidocaine for maintenance of airway anesthesia and saline solution for washing.



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  		Fig 2. Proxy bronchoscope and face plate.

 
The trainer simulates bronchoscopy on a spontaneously breathing patient and thus requires appropriate topical anesthetization. Heart rate, electrocardiogram complexes, and oxygen saturations are continuously displayed. The simulator also gives clues to inadequate anesthetization (coughing, laryngeal spasm, desaturation).

Software programs for the simulator include an interactive anatomy model with video clips demonstrating and describing an actual fiberoptic bronchoscopy procedure. Nine adult practice cases were available for further training.

Residents assigned to receive training on the bronchoscopy simulator were instructed to focus on familiarizing themselves with the bronchoscope and navigating the airway in a systematic fashion while proceeding through the bronchoscopy practice cases. They were allowed to spend as much time as they desired with the simulator. They all were required to complete the anatomy module and at least one practice case.

Intraoperative bronchoscopic evaluation
All patients were undergoing preoperative bronchoscopy immediately before a thoracic procedure. There was no attempt to randomize or select the patient population further. All patients underwent general anesthesia and placement of a laryngeal mask airway for bronchoscopy. Because the patients were under general anesthesia, they did not require topical anesthetic. A single thoracic surgeon served as the examiner.

Residents undergoing intraoperative bronchoscopic evaluation were instructed to complete a thorough examination of all bronchi to the segmental level. They were asked to name relevant anatomy if they knew it but not to slow the exam if they were unsure of the name of the airway branch anatomy. Time was kept from the moment the subject inserted the bronchoscope into the laryngeal mask airway until completion of the examination. The number of times lobar bronchi were redundantly explored was recorded.

Efficiency was assessed by noting the number of verbal or physical prompts required, the thoroughness of the exam, and the total time to completion. Both the examiner and subject were asked to separately evaluate, on a scale of zero to five (five being the best), the level of confidence and the proficiency of the bronchoscopist. The examiner additionally rated the thoroughness of the bronchoscopy on a scale of zero to five. To control for previous endoscopic experience, subjects were asked to indicate the number of endoscopic and bronchoscopic procedures observed and performed before this study. Statistical analysis was done by the Mann-Whiney U test.

The project was approved by the Institutional Review Board of Northwestern University the Feinberg School of Medicine on October 5, 2001. Informed consent was received by all study subjects.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 Discussion
 References
 
Participants in the training group all completed the basic anatomy model and at least one patient simulation. The average number of patient simulations completed was 3.8. The amount of time spent with the simulator averaged 60 minutes.

The numbers of endoscopic and bronchoscopic procedures observed and performed were no different between the naïve and trained groups. (Table 1) The experienced group had all done ten or more bronchoscopies before evaluation.


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  		Table 1. Prebronchoscopy Flexible Endoscopic Experience

 
Times to completion of bronchoscopy were not different between groups (Table 2). The pace of the exam was maintained by the evaluating surgeon giving verbal and physical assistance. No patients in the naïve or trained groups had anatomic abnormalities which impaired bronchoscopy from obstruction, bleeding, or secretions. One patient in the experienced group had thick secretions throughout all airways that significantly impaired the exam. This clearly impacted on the average time for this group as the exam took longer (670 seconds) than any other. Nevertheless, a thorough, complete exam was performed as efficiently as possible. Exams by subjects in the trained group were far more thorough and efficient and required far fewer verbal and physical directions than those in the naïve group. The naïve group redundantly examined lobar bronchi far more frequently than the trained group. Interestingly, the trained group performed exams that were as thorough as those who were experienced. Subjects in the trained group were perceived by the evaluating surgeon to be slightly less confident than the experienced group. Identification of anatomy was better by the experienced group, but no participant in any group was able to correctly identify all segmental anatomy.


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  		Table 2. Intraoperative Bronchoscopy Evaluation

 
On the post bronchoscopy self-evaluation questionnaire, the "trained" residents were asked if they thought the trainer was helpful and adequately trained them for bronchoscopy. They universally very strongly agreed (average 4.5 on a scale of 0 to 5). They all recommended that it be used as a standard teaching tool on the thoracic rotation.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 Discussion
 References
 
Bronchoscopy is a basic skill that all surgical residents should master early in training. Intraoperative bronchoscopy before thoracic procedures provides an ideal opportunity for residents to learn bronchoscopic techniques. We found that even one hour of work with the simulator dramatically improved the ability of junior residents to perform bronchoscopy. This allowed them to concentrate on relevant pathology and anatomy during their intraoperative bronchoscopy.

This study was only intended to test the simulator's ability to familiarize untrained residents with basic bronchoscopy. The training modules used in this study did not emphasize teaching the segmental anatomy, nor were the trainees asked to concentrate on learning it. However, the training modules that emphasize segmental anatomy may be useful for training thoracic surgery residents. We use the simulator to rapidly familiarize residents with basic bronchoscopy. Additional bronchoscopy skills and anatomy are subsequently taught in the clinical setting. The trainer does not adequately simulate secretion management. It would also not likely be beneficial in training management of problems that require rigid bronchoscopy.

Our simulator is maintained as part of a minimally invasive surgery training center; it is simple to operate and does not require a technician for maintenance. The bronchoscopy simulator is part of an endoscopic training system that can also simulate flexible sigmoidoscopy. The $35,000 cost of the device could thus be shared by surgery, pulmonary, and GI divisions.

Residents rotating through the thoracic intensive care unit (ICU) surgery service one year after their training continued to exhibit excellent handling of the flexible bronchoscope for common ICU applications. We have now implemented the trainer as part of the thoracic surgery rotation for PGY1 residents. Junior residents who train for as little as 60 minutes on the bronchoscopy simulator perform relaxed, efficient, and thorough basic clinical bronchoscopy.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
Discussion
 References
 
The simulator was purchased by funds donated to the NIMIST laboratory from the United States Surgical Corp.


   Discussion
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 Discussion
References
 
DR MARK B. ORRINGER (Ann Arbor, MI): Dr Blum and his associates are to be congratulated for bringing before this Society the exciting, thought-provoking issue of medical simulation and its potential for our specialty. Most of us in this room have grown up proud of surgical residencies, which assumed somehow in 6 to 8 years we would be exposed to a sufficient breadth and depth of illnesses that we would all acquire the necessary skills to treat them, that older surgical faculty would provide the needed technical guidance, and that while training on rich and poor alike, the poor and uninsured would bear the disproportionate share of our inexperience. The Halsted tradition under which I trained at Hopkins provided me as chief resident my own patient floor and my own operating room for that year. Each resident had learned from the resident before in the program. The presence of an attending in the resident's operating room was a stigma that reflected the need for more senior supervision, and it just never happened. This tradition of "learning on the patient" has been strongly challenged since 2000 when the Institute of Medicine's report "To Err is Human: Building a Safer Health System" was released highlighting the problem of patient medical errors in our profession and recommended that we utilize proven methods of training, such as simulation, in our educational process.

At a recent 2-day symposium last year of surgeons, educators, engineers and experts in educational testing sponsored by the American College of Surgeons, the group concluded that improvement of patient safety is a vital need of today's surgeons, and simulation technology may play a role in advancing this goal. And the College is dedicating itself to improving the safety of surgical patients, in part through its use of medical simulation, which it is anticipated will facilitate: (1) screening surgeons, both young and old, for demonstrable aptitude in new technologies; (2) initial surgical training in various areas, correcting for case mix inequalities, which are inevitable in our training programs; (3) continuing education of surgeons through a consistently reproducible process; (4) periodic assessment of acquired surgical skills; and finally (5) maintenance of proficiency by allowing rehearsal of complex patient-specific procedures.

You have heard many times at this meeting that the old days are gone. And it is probably better that future thoracic surgeons first learn on a simulator how to do subclavian vein cannulations, chest tube insertions, and even vascular anastomoses, which can now be done virtually, rather than on patients. But as we swallow this hook of simulation technology and the wonders of computer applications to this field, it is vital that we as surgeons validate that clinically useful learning is resulting from the use of a simulator.

So, Dr Blum, I have a few specific questions. The bronchoscopy simulator is a wonderful learning tool. I have used it. I have taught residents bronchoscopy with it. Can you comment on the cost of this equipment for the audience?

In addition, can you comment on the statistical validity of your study? In the abstract the N was four. It has now grown to five residents receiving preprocedural bronchoscopy training. I am concerned that the small number of the study group might negate the value of the reported data and will need to be defended under the scrutiny of peer review. So I assume your experience with this continues to grow.

I commend you on your methodical attempt to validate the usefulness of the bronchoscopy simulator in resident education. We are really at the dawning of a new age, not only in resident education, and certainly not just for bronchoscopy, but in our own continuing surgical education for the specialty at large as well. Thank you.

DR CHARLES R. BRIDGES (Philadelphia, PA): One of my concerns about the methodology also, to add to Dr Orringer's point, were the examiners blinded? Obviously you may not be able to be blinded with respect to the experienced residents because I would imagine they would be people you might know, but with respect to those who either had undergone the training or those who hadn't, it would seem to me it would be an important adjunct to your methodology to ensure that the examiner didn't know which type of student he was evaluating.

DR BLUM: I will take the last question first. The randomization was done by the technologist in the laboratory. The residents were specifically instructed not to tell the examiner in the operating room, which was me, to which group they had been randomized. However, usually within about 30 seconds to a minute of the performing bronchoscopy I could tell whether or not they had used the simulator just because the trained group had obviously superior skills.

The obvious difference in bronchoscopic skills goes back to the idea of the statistical validity. I think statistically certainly the numbers are small. We have been adding to those numbers and I would like to continue to add to them. The interns may be pulled off of our service, so we may have some troubles getting higher numbers. Certainly while the statistics on a subject that is difficult to objectively quantify with small number of subjects are going to be weak, the subjective difference in terms of the ability of people to handle a bronchoscope after having worked with this trainer is very obvious. A similar study involving pulmonary fellows training with a simulator for 4 hours, and comparing them to pulmonologists who had performed over 200 bronchoscopies, showed basically the same thing. The comparison between these two groups was done using a separate simulator system (not actual patients), but they found no difference between those groups. So I think even though the statistical power of the study is small, the actual power of the simulator is high, and we will just have to continue to do what I can with the statistics.

The cost of the equipment is somewhere in the neighborhood of $40,000 to $45,000. This system can also be used with the proper software and a different anatomic simulator plate (not a face plate) to simulate sigmoidoscopy. There is not an esophagoscopy or a colonoscopy tool yet, but that probably will be forthcoming.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 Discussion
 References
 

  1. Issenberg S.B., McGaghie W.C., Hart I.R., et al. Simulation technology for health care professional skills training, and assessment. JAMA 1999;282:861-866.[Abstract/Free Full Text]
  2. Bone R.C., et al. (American College of Chest Physicians, Section on Bronchoscopy). Guidelines for competency and training in fiberoptic bronchoscopy. Chest 1982;81:739.[Medline]
  3. Colt H.G., Crawford S.W., Galbraith O. Virtual reality bronchoscopy simulation: a revolution in procedural training. Chest 2001;120:1333-1339.[Abstract/Free Full Text]
  4. Rowe R., Cohen R.A. An evaluation of a virtual reality airway simulator. Anesth Analg 2002;95:62-66.[Abstract/Free Full Text]



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