Assessment of Bronchoscopic Dexterity and Procedural Competency in a Low-fidelity Simulation Model

Simulation in airway management teaching and training

There is a gradual shift in training and teaching methods in the medical field. We are slowly moving from the traditional model and adopting active learning methods like simulation-based training. Airway management is an essential clinical skill for any anaesthesiologist, and a trained anaesthesiologist must perform quick and definitive airway management using various techniques. Airway simulations have been used for the past few decades. It ensures active involvement, upgrading the trainees' airway management knowledge and skills, including basic airway skills, invasive procedures, and difficult clinical scenarios. Trainees also learn non-technical skills such as communication, teamwork, and coordination. A wide range of airway simulators are available. However, texture surface characteristics vary from one type to another. The simulation-based airway management training requires availability, understanding, faculty development, and a structured curriculum for effective delivery. This article explored the available evidence on simulation-based airway management teaching and training.

Step-by-step development and evaluation of a 3D printed home-made low-cost pediatric tracheobronchial tree for foreign body aspiration extractions

OBJECTIVES

The management of foreign body aspirations (FBA) is dreaded by pediatric physicians due to the high risk of respiratory distress and a potential fatal outcome, favored by a lack of experience of young specialists. Furthermore, there has been an increasing requirement for low-cost simulation. The aim was to describe the step-by-step manufacturing process and to validate a low-cost, easily home-made training model of pediatric tracheo-bronchial tree (pTBT) for simulation-based training in order to teach young physicians to practice foreign body (FBA) extractions.

METHODS

A simulator was designed in order to reproduce the physical and esthetic properties of a pTBT. The production cost of a single simulator was estimated. The simulator was then tested by experienced physicians using a rigid bronchoscope. A manufacturing manual of the simulator is hereby presented. A group of 7 experienced pediatric otolaryngologists performed a FBA extraction in the conditions of installation of an operating room.

RESULTS

The result of the survey showed a high fidelity of the simulator in mimicking the biological esthetics and physical properties of a pTBT during a FBA extraction (mean 4.3 ± 0.8). The total cost of the custom-made simulator is about 20.5 € ($23.4) for the production of the first simulator.

CONCLUSIONS

A highly realistic and easily reproducible pediatric tracheo-bronchial tree simulator is presented and can therefore be used during simulation-based training.

Teaching Radial Endobronchial Ultrasound with a Three-Dimensional–printed Radial Ultrasound Model

Background

Peripheral pulmonary lesion (PPL) incidence is rising because of increased chest imaging sensitivity and frequency. For PPLs suspicious for lung cancer, current clinical guidelines recommend tissue diagnosis. Radial endobronchial ultrasound (R-EBUS) is a bronchoscopic technique used for this purpose. It has been observed that diagnostic yield is impacted by the ability to accurately manipulate the radial probe. However, such skills can be acquired, in part, from simulation training. Three-dimensional (3D) printing has been used to produce training simulators for standard bronchoscopy but has not been specifically used to develop similar tools for R-EBUS.

Objective

We report the development of a novel ultrasound-compatible, anatomically accurate 3D-printed R-EBUS simulator and evaluation of its utility as a training tool.

Methods

Computed tomography images were used to develop 3D-printed airway models with ultrasound-compatible PPLs of “low” and “high” technical difficulty. Twenty-one participants were allocated to two groups matched for prior R-EBUS experience. The intervention group received 15 minutes to pretrain R-EBUS using a 3D-printed model, whereas the nonintervention group did not. Both groups then performed R-EBUS on 3D-printed models and were evaluated using a specifically developed assessment tool.

Results

For the “low-difficulty” model, the intervention group achieved a higher score (21.5 ± 2.02) than the nonintervention group (17.1 ± 5.7), reflecting 26% improvement in performance (P = 0.03). For the “high-difficulty” model, the intervention group scored 20.2 ± 4.21 versus 13.3 ± 7.36, corresponding to 52% improvement in performance (P = 0.02). Participants derived benefit from pretraining with the 3D-printed model, regardless of prior experience level.

Conclusion

3D-printing can be used to develop simulators for R-EBUS education. Training using these models significantly improves procedural performance and is effective in both novice and experienced trainees.

Using structured progress to measure competence in flexible bronchoscopy

Background

Flexible bronchoscopy is a core invasive procedure in pulmonary medicine and training in the procedure is mandatory. Diagnostic completeness and procedure time have been identified as useful measures of competence. No outcome measures have been developed regarding navigational path in bronchoscopy to assess whether the bronchial segments have been identified in an arbitrary or structured order. We investigated whether a new outcome measure for structured progression could be used to assess competency in flexible bronchoscopy.

Methods

The study was designed as a prospective comparative study. Twelve novices, eleven intermediates, and ten expert bronchoscopy operators completed three full bronchoscopies in a simulated setting on a phantom. The following outcome measures were collected through a checklist evaluation by a trained rater: Diagnostic Completeness as amount of visualized bronchial segments, Structured Progress between the bronchial segments in ascending order, and average intersegmental time (AIT).

Results

The ability to follow a structured ascending path through the bronchial tree correlated with a higher amount of identified bronchial segments (Pearson’s correlation, r=0.62, P<0.001) and a lower AIT (Pearson’s correlation, r=−0.52, P<0.001).

Conclusions

Operators should advance through the bronchial tree in a structured ascending order to ensure systematic progress with the highest level of diagnostic yield and the lowest procedure time. Structured progression is a useful measure to evaluate competency in flexible bronchoscopy.

3D printing in critical care: a narrative review

BACKGROUND

3D printing (3DP) has gained interest in many fields of medicine including cardiology, plastic surgery, and urology due to its versatility, convenience, and low cost. However, critical care medicine, which is abundant with high acuity yet infrequent procedures, has not embraced 3DP as much as others. The discrepancy between the possible training or therapeutic uses of 3DP in critical care and what is currently utilized in other fields needs to be addressed.

OBJECTIVE

This narrative literature review describes the uses of 3DP in critical care that have been documented. It also discusses possible future directions based on recent technological advances.

METHODS

A literature search on PubMed was performed using keywords and Mesh terms for 3DP, critical care, and critical care skills.

RESULTS

Our search found that 3DP use in critical care fell under the major categories of medical education (23 papers), patient care (4 papers) and clinical equipment modification (4 papers). Medical education showed the use of 3DP in bronchoscopy, congenital heart disease, cricothyroidotomy, and medical imaging. On the other hand, patient care papers discussed 3DP use in wound care, personalized splints, and patient monitoring. Clinical equipment modification papers reported the use of 3DP to modify stethoscopes and laryngoscopes to improve their performance. Notably, we found that only 13 of the 31 papers were directly produced or studied by critical care physicians.

CONCLUSION

The papers discussed provide examples of the possible utilities of 3DP in critical care. The relative scarcity of papers produced by critical care physicians may indicate barriers to 3DP implementation. However, technological advances such as point-of-care 3DP tools and the increased demand for 3DP during the recent COVID-19 pandemic may change 3DP implementation across the critical care field.

Training in interventional pulmonology: What we have learned and a way forward

IP encompasses a complex list of procedures requiring knowledge, technical skills and competence. Modern, learner-centric educational philosophies and an explosion of multidimensional educational tools including manikins, simulators, online resources, social media and formal programs can foster learning in IP, promoting professionalism and a culture of lifelong learning. This paper provides background and guidance to a structured, multidimensional and learner-centric strategy for medical procedural education. Focusing on our experience in IP, we describe how competency-based measures, simulation technology and various teaching modalities contribute to a more uniform learning environment in which patients do not suffer the burdens of procedure-related training.

Learning Gain and Skill Retention Following Unstructured Bronchoscopy Simulation in a Low-fidelity Airway Model

BACKGROUND

Simulation is invaluable for bronchoscopy training. Studies report improved procedure time, dexterity/technique, and trainee satisfaction supported by low-fidelity and high-fidelity simulators in structured-training programs. We sought to determine (1) Learning-gain in bronchoscopic dexterity after a single 45-minute unstructured exposure using a low-fidelity simulator. (2) Whether acquired skills are maintained 8 weeks later, during which trainees receive no interim exposure to simulation or clinical bronchoscopy.

METHODS

Using a low-fidelity model, medical students were assessed for bronchoscopicdexterity before and after an unstructured, self-directed 45-minute simulation. Bronchoscopic dexterity was assessed according to: (1) Ability to enter a target-bronchus within a specified time. (2) The modified Bronchoscopy Skills and Tasks Assessment Tool (mBSTAT). Scores were compared at baseline, postsimulation, and 8 weeks postsimulation. Individual domains of the mBSTAT were compared with identify specific skills demonstrating more significant deterioration.

RESULTS

Twenty-eight medical students completed the initial-simulation session. Fifteen returned at 8 weeks. Statistically significant improvement in bronchoscopic-skills was observed immediately following the simulation session (mBSTAT scores 3.7±1.2 pretest vs. 7.0±0.9 posttest, P<0.001). mBSTAT scores had deteriorated significantly at 8 weeks (5.7±1.8, P=0.03) but remained superior to baseline scores (P=0.002). Of the 4 domains assessed, only Precision did not demonstrate any change between post-test and review assessments (P=0.14). All other domains demonstrated trends towards significant deterioration between posttest and review.

CONCLUSION

A single 45-minute unstructured bronchoscopy simulation session resulted in significant improvement in bronchoscopic dexterity. Significant decay in bronchoscopic dexterity is observed, suggesting repeat simulation may be valuable following periods without bronchoscopy exposure.