EBUS-STAT Subscore Analysis to Predict the Efficacy and Assess the Validity of Virtual Reality Simulation for EBUS-TBNA Training Among Experienced Bronchoscopists

A Novel Simulator for Teaching Endobronchial Ultrasound-guided Needle Biopsy

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become standard for the diagnosis of lung cancer, and there is an increasing need for procedural competence in trainees. We evaluate a low-cost, gelatin-based EBUS-TBNA training simulator to assess pulmonary fellows' baseline skills and facilitate procedural development.

METHODS

A low-cost ($30) gelatin-based, high-fidelity simulator was created to represent the airways, major vessels, and lymph node stations essential to identify for EBUS-TBNA. Trainees had a baseline skills assessment using the simulator and were then provided a 1-hour didactic session on EBUS-TBNA and additional practice time with the simulator. Trainees then underwent a postsimulation skills assessment using a modified endobronchial ultrasound (EBUS)-Skills and Tasks Assessment Tool (STAT) performance assessment tool. Simulator fidelity and trainee procedural confidence was assessed using a 10-point scale.

RESULTS

Ten fellows received training on the EBUS-TBNA simulator. First-year trainees scored the lowest on the 18-point performance scale with a mean score of 9, while third-year trainees scored highest with a mean score of 17.5. Mean 18-point performance score improvement after simulator training and didactics was 4.31 points for all trainees with the largest change in first-year trainees amounting to 8.25 points. First-year trainees experienced the greatest improvement in EBUS procedural confidence by a mean of 2.5 points on a 10-point confidence survey.

CONCLUSION

A low-cost EBUS simulator effectively differentiated early and advanced learners based on graded procedural performance scores. Simulation-based practice significantly improved learners' procedural performance, and the degree of improvement correlated with learner inexperience. The simulation significantly increased early learner confidence in EBUS-TBNA technique.

Endobronchial Ultrasound Image Simulation for Image-Guided Bronchoscopy

BACKGROUND/OBJECTIVE

Accurate disease diagnosis and staging are essential for patients suspected of having lung cancer. The state-of-the-art minimally invasive tools used by physicians to perform these operations are bronchoscopy, for navigating the lung airways, and endobronchial ultrasound (EBUS), for localizing suspect extraluminal cancer lesions. While new image-guided systems enable accurate bronchoscope navigation close to a lesion, no means exists for guiding the final EBUS localization of an extraluminal lesion. We propose an EBUS simulation method to assist with EBUS localization.

METHODS

The method draws on a patient's chest computed-tomography (CT) scan to model the ultrasound signal propagation through the tissue media. The method, which is suitable for simulating EBUS images for both radial-probe and convex-probe EBUS devices, entails three steps: 1) image preprocessing, which generates a 2D CT equivalent of the EBUS scan plane; 2) EBUS scan-line computation, which models ultrasound transmission to map the CT plane into a preliminary simulated EBUS image; and 3) image post-processing, which increases realism by introducing simulated EBUS imaging effects and artifacts.

RESULTS

Results show that the method produces simulated EBUS images that strongly resemble images generated live by a real device and compares favorably to an existing ultrasound simulation method. It also produces images at a rate greater than real time (i.e., 53 frames/sec). We also demonstrate a successful integration of the method into an image-guided EBUS bronchoscopy system.

CONCLUSION/SIGNIFICANCE

The method is effective and practical for procedure planning/preview and follow-on live guidance of EBUS bronchoscopy.

Impact of a Multimodal Simulation-based Curriculum on Endobronchial Ultrasound Skills

Background

Currently there is no consensus on ideal teaching method to train novice trainees in EBUS. Simulation-based procedure training allows direct observation of trainees in a controlled environment without compromising patient safety.

Objective

We wanted to develop a comprehensive assessment of endobronchial ultrasound (EBUS) performance of pulmonary fellows and assess the impact of a multimodal simulation-based curriculum for EBUS-guided transbronchial needle aspiration.

Methods

Pretest assessment of 11 novice pulmonary fellows was performed using a three-part assessment tool, measuring EBUS-related knowledge, self-confidence, and procedural skills. Knowledge was assessed by 20 multiple-choice questions. Self-confidence was measured using the previously validated EBUS–Subjective Assessment Tool. Procedural skills assessment was performed on Simbionix BRONCH Express simulator and was modeled on a previously validated EBUS–Skills and Task Assessment Tool (EBUS-STAT), to create a modified EBUS-STAT based on internal faculty input via the Delphi method. After baseline testing, fellows participated in a structured multimodal curriculum, which included simulator training, small-group didactics, and interactive problem-based learning sessions, followed by individual debriefing sessions. Posttest assessment using the same three-part assessment tool was performed after 3 months, and the results were compared to study the impact of the new curriculum.

Results

The mean knowledge score improved significantly from baseline to posttest (52.7% vs. 67.7%; P = 0.002). The mean EBUS–Subjective Assessment Tool confidence scores (maximum score, 50) improved significantly from baseline to posttest (26 ± 7.6 vs. 35.2 ± 6.3 points; P < 0.001). The mean modified EBUS-STAT (maximum score, 105) improved significantly from baseline to posttest (44.8 ± 10.6 [42.7%] vs. 65.3 ± 11.4 [62.2%]; P < 0.001). There was a positive correlation (r = 0.81) between the experience of the test participants and the modified EBUS-STAT scores.

Conclusion

This study suggests a multimodal simulation-based curriculum can significantly improve EBUS-guided transbronchial needle aspiration–related knowledge, self-confidence, and procedural skills among novice pulmonary fellows. A validation study is needed to determine if skills attained via a simulator can be replicated in a clinical setting.

Time between endobronchial ultrasound needle passes as a metric to monitor progress of trainees

BACKGROUND

Methods to assess and track progress of new endobronchial ultrasound (EBUS) operators and trainees is desirable to ensure training goals and procedural competence are achieved. Relying on the diagnostic yield or on question-based assessments alone is not sufficient. This study examined the longitudinal change in times taken between needle passes (needle pass time; NPT) during EBUS lymph node sampling as a metric to monitor progress.

RESEARCH DESIGN AND METHODS

:The EBUS database of a tertiary hospital was accessed to extract data on the first 50 EBUS procedures for three trainees. The NPT was derived using PACS images that are stored to document every needle pass during an EBUS procedure and an average NPT was calculated.

RESULTS

Between the three trainees, 157 procedures were carried out within the study period with 302 nodal stations sampled. The mean NPT (n = 204 stations) was 2:49 ± 0:49 mins. The mean node short axis diameter was 15.5 ± 8.7 mm. There was a negative correlation between node size and time per pass (r - 0.146, p = 0.045).The average NPT showed a negative correlation with procedure order through the first 50 procedures. Less variation between procedures was noted for the three trainees from the 30^th procedure onward. On multivariate regression, NPT was significantly associated with procedure order regardless of station sampled or lymph node diameter.

CONCLUSION

NPT is novel, easy, and robust metric that can potentially help ensure EBUS trainees are advancing in a given training program.

Standardizing education in interventional pulmonology in the midst of technological change

Interventional pulmonology (IP) is a maturing subspecialty of pulmonary medicine. The robust innovation in technology demands standardization in IP training with both disease and technology driven training. Simulation based training should be considered a part of IP training as seen in other procedural and surgical subspecialties. Procedure volume is a component of training; however, this does not guarantee or translate into competency for learners. Basic competency skills can be assessed using standardized well validated assessment tools designed for various IP procedures including flexible bronchoscopy, endobronchial ultrasound guided transbronchial needle aspiration (EBUS TBNA), rigid bronchoscopy and chest tube placement; however, further work is needed to validate tools in all procedures as new technologies are introduced beyond fellowship training. Currently there are at least 39 IP fellowship programs in the United States (US) and Canada which has led to improved training by accreditation of programs who meet rigorous requirements of standardized curriculum and procedural volume. The challenge is to be innovative in how we teach globally with intention and how to best integrate new evolving technology training for those not only during fellowship training but also beyond fellowship training.

A novel biosimulator based on ex vivo porcine lungs for training in peripheral tissue sampling using endobronchial ultrasonography with a guide sheath

Background

Although radial probe endobronchial ultrasonography (EBUS) with a guide sheath (GS; EBUS-GS) is widely used for sampling peripheral pulmonary lesions (PPLs), a standard training model for EBUS-GS remains to be developed. The purpose of this study was to evaluate the feasibility of a novel pulmonary biosimulator for hands-on training in peripheral tissue sampling using EBUS-GS.

Methods

We established a novel biosimulator for EBUS-GS using porcine lungs. The simulator was equipped with multiple pseudo PPLs that were created using blue agar solution injected through GS inserted in a bronchoscope. A total of 12 voluntary trainees participated in a hands-on training course using the biosimulator. The size of samples acquired using biopsy forceps were compared between initial and post-training biopsies, and trainee satisfaction with the biosimulator and training program were evaluated using a questionnaire.

Results

Under the guidance of a trainer, all trainees successfully detected pseudo PPLs using radial probe EBUS before the initial biopsy, and 11 trainees acquired samples from the target lesions during the initial biopsy. Post-training biopsy samples were larger than the initial samples for eight trainees. The results of the questionnaire revealed that all trainees were satisfied with the biosimulator. Moreover, eight trainees who had previously participated in another hands-on EBUS-GS training program involving a synthetic phantom model showed greater satisfaction for the biosimulator.

Conclusions

A hands-on training program using the novel biosimulator assessed in this study could aid clinicians in improving their skills for EBUS-GS and acquiring larger peripheral tissue samples using biopsy forceps inserted through GS.

Bronchoscopy Education: An Experiential Learning Theory Perspective

Bronchoscopy programs implementing the experiential learning model address different learning styles. Problem-based learning improves knowledge retention, critical decision making, and communication. These modalities are preferred by learners and contribute to their engagement, in turn leading to durable learning. Follow-up after live events is warranted through spaced education strategies. The objectives of this article are to (1) summarize and illustrate the implementation of experiential learning theory for bronchoscopy courses, (2) discuss the flipped classroom model and problem-based learning, (3) illustrate bronchoscopy checklists implementation in simulation, and (4) discuss the importance of feedback and spaced learning for bronchoscopy education programs.

Competence and training in interventional pulmonology

Interventional pulmonology (IP) is experiencing a rapid evolution of new technologies. There is a need to develop structured training programs, organized in high volume expert centers in order to improve trainee education, and including the development of validated metrics for their competency assessment. Concerning teaching methods, a gradual progression from theory to practice, using new teaching techniques, including live sessions and low and high-fidelity simulation, flipped classroom models and problem-based learning (PBL) exercises would provide a training setting more suitable for our current need to improve skills and update professionals. Training programs should be learner-centered and competence-oriented, as well as being based on a spiral-shaped approach in which the same subject is addressed many times, from new and different perspectives of knowledge, ability, behavior and attitude, until the trainee has demonstrated a high degree of skill and professionalism. Furthermore there is a need to standardize the training programs as guide for physicians wishing to undertake a gradual and voluntary improvement of their own competencies, and assist those planning and organizing training programs in IP. The article includes a general part on core curriculum contents, innovative training methods and simulation, and introduces the following articles on the skills that the Interventional Pulmonologist must master in order to perform the different procedures. This monography should be considered a starting point that will evolve over time and results in better training for practitioners and better care for our patients. The task of establishing a trainee's competence to practice independently as an Interventional Pulmonologist remains the responsibility of the IP fellowship program director and faculty, who validate logbooks and assess competence for each procedure. These standards need to be reviewed and approved by national and International Scientific Societies and Healthcare Institutions with the aim to improve, disseminate and incorporate them in healthcare programs.

Training and proficiency in endobronchial ultrasound-guided transbronchial needle aspiration: A systematic review

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is currently the modality of choice for evaluation of mediastinal lymphadenopathy. However, there is still uncertainty regarding the training methodology and the number of procedures required to attain proficiency in EBUS. Herein, we performed a systematic review of studies selected from PubMed, EmBase and Scopus databases describing the training and assessment of proficiency during EBUS, specifically studies investigating various methods for training, its outcome and the number of procedures required to overcome the learning curve for EBUS. Twenty-seven (simulator-based learning (n = 8), tools for assessing competence in EBUS-TBNA (n = 5) and threshold numbers needed to attain proficiency in EBUS-TBNA (n = 16)) studies were identified. An EBUS simulator accurately stratified individuals based on the level of experience in performing EBUS. Training received on a simulator was comparable with traditional apprentice-based training. Importantly, skills acquired on a simulator could be transferred to real-world patients. The number needed to overcome the initial learning curve of EBUS varied from 10 to 100 in individual studies with a mean of 37-44 procedures. Tools such as EBUS-STAT (EBUS skill and task assessment tool) and EBUSAT (EBUS skill and assessment tool) were effective in evaluating the EBUS trainees. We conclude that an EBUS simulator or EBUS assessment tools can objectively assess the training of an EBUS trainee. Simulator-based training is a useful modality in EBUS training. The number of procedures needed to overcome the initial learning curve is about 40. Centres involved in EBUS training could incorporate simulator-based training in their curriculum before allowing operators to perform EBUS on patients.