A randomised, controlled trial evaluating a low cost, 3D-printed bronchoscopy simulator

Evaluation of a 12-hole clock model for improving bronchoscopic skills in simulated normal and difficult airways among anesthesia residents: A randomized controlled study

BACKGROUND

Simulation-based training is used to improve fiberoptic bronchoscopic skills for novices. We developed a nonanatomical task trainer (named 12-hole clock model) that focused on training manipulation of bronchoscopes. The aim of this study was to evaluate the training effect of this model on bronchoscopic skills and learning interests in simulated normal and difficult airways among anesthesia residents.

METHODS

Forty-three anesthesia residents without experience in bronchoscopic intubation were randomly divided into control (n = 22) and intervention groups (n = 21). All participants received standard multimedia learning and a baseline test using a normal airway manikin. Then, the control and intervention groups engaged in 60 minutes of training via a traditional airway manikin or the clock model, respectively. After training, the participants completed bronchoscopic performance assessments in simulated normal and difficult airways, as well as an electronic questionnaire related to the course.

RESULTS

During training, the total hands-on time of bronchoscopic practice recorded by trainees' themselves was longer in the intervention group than in the control group (1568 ± 478 seconds vs 497 ± 172 s, P < .0001). Posttraining, the time required to visualize the carina in simulated normal airways was longer in the intervention group than in the control group (22.0 [18.0, 29.0] vs 14.0 [10.8, 18.3], P < .0001), while it was shorter for simulated difficult airways (24.0 [16.0, 32.0] s vs 27.0 [21.0, 35.5] s, P = .0425). The survey results indicated that confidence in bronchoscopic intubation increased in both groups, without significant differences in satisfaction, acceptance, or perceived difficulty between the groups. However, the interest ratings were higher in the intervention group than in the control group.

CONCLUSIONS

The 12-hole clock model is a simple and feasible method for improving bronchoscopic skills and promoting interest among trainees.

TRIAL REGISTRATION

NCT05327842 at Clinicaltrials.gov.

Innovations to Improve Lung Isolation Training for Thoracic Anesthesia: A Narrative Review

A double-lumen tube or bronchial blocker positioning using flexible bronchoscopy for lung isolation and one-lung ventilation requires specific technical competencies. Training to acquire and retain such skills remains a challenge in thoracic anesthesia. Recent technological and innovative developments in the field of simulation have opened up exciting new horizons and possibilities. In this narrative review, we examine the latest development of existing training modalities while investigating, in particular, the use of emergent techniques such as virtual reality bronchoscopy simulation, virtual airway endoscopy, or the preoperative 3D printing of airways. The goal of this article is, therefore, to summarize the role of existing and future applications of training models/simulators and virtual reality simulators for training flexible bronchoscopy and lung isolation for thoracic anesthesia.

Incorporating a Three-Dimensional Printed Airway into a Pediatric Flexible Bronchoscopy Curriculum

Background

Although hands-on simulation plays a valuable role in procedural training, there are limited tools available to teach pediatric flexible bronchoscopy (PFB). Fellowship programs rely on patient encounters, with inherent risk, or high-cost virtual reality simulators that may not be widely available and create education inequalities.

Objective

Our objective was to study the educational value and transferability of a novel, low-cost, three-dimensional-printed pediatric airway model (3D-AM) for PFB training. Our central hypothesis was that the 3D-AM would have high educational value and would be easily transferrable to learners at different teaching hospitals.

Methods

The 3D-AM was designed to teach technical bronchoscopy skills, airway anatomy, airway pathology, and bronchoalveolar lavage (BAL). The curriculum was offered to incoming fellows in pediatric pulmonology, pediatric surgery, and pediatric critical care across three different teaching institutions. After course completion, each participant assessed the simulation model(s) with a 5-point Likert scale across six domains: physical attributes, realism of experience, ability to perform tasks, value, relevance, and global impression. The expert instructors assessed the learners' competency using a modified version of the Bronchoscopy Skills and Tasks Assessment Tool.

Results

A total of 14 incoming fellows participated in the course. The mean scores for the 3D-AM across all six domains and across the three institutions was between 4 and 5, suggesting that learners generally had a favorable impression and a similar experience across different institutions. All learners "agreed" or "strongly agreed" that the course was a valuable use of their time, helped teach technical skills and airway anatomy, and would be useful for extra training during fellowship. Most of the learners correctly identified anatomy, bronchomalacia, and performed a BAL. Wall trauma was observed in 36% of learners.

Conclusion

The utility, low cost, and transferability of this model may create opportunities for PFB training across different institutions despite resource limitations in the United States and abroad.

Creation and Validation of a Massive Hemoptysis Simulator

BACKGROUND

Simulation for the management of massive hemoptysis is limited by the absence of a commercially available simulator to practice procedural skills necessary for management.

RESEARCH QUESTION

Is it feasible to create and validate a hemoptysis simulator with high functional task alignment?

STUDY DESIGN AND METHODS

Pulmonary and critical care medicine (PCCM) attending physicians from four academic institutions in the Denver, Colorado, area and internal medicine residents from the University of Colorado participated in this mixed-methods study. A hemoptysis simulator was constructed by connecting a 3-D-printed airway model to a manikin that may be intubated. Attending PCCM physicians evaluated the simulator through surveys and qualitative interviews. Attendings were surveyed to determine simulation content and appropriate assessment criteria for a hemoptysis simulation. Based on these criteria, expert and novice performance on the simulator was assessed.

RESULTS

The manikin-based hemoptysis simulator demonstrated adequate physical resemblance, high functional alignment, and strong affective fidelity. It was universally preferred over a virtual reality simulator by 10 PCCM attendings. Twenty-seven attendings provided input on assessment criteria and established that assessing management priorities (eg, airway protection) was preferred to a skills checklist for hemoptysis management. Three experts outperformed six novices in hemoptysis management on the manikin-based simulator in all management categories assessed, supporting construct validity of the simulation.

INTERPRETATION

Creation of a hemoptysis simulator with appropriate content, high functional task alignment, and strong affective fidelity was successful using 3-D-printed airway models and existing manikins. This approach can overcome barriers of cost and availability for simulation of high-acuity, low-occurrence procedures.

Development and Evaluation of An In-House Lumbar Puncture Simulator for First-Year Resident Lumbar Puncture Procedure Learning

INTRODUCTION

Lumbar puncture (LP) is a common invasive technique considered an essential learning milestone for anesthesiologists due to its application in spinal anesthesia. We aimed to develop an in-house LP simulator, test its effectiveness in learning the steps to perform an LP and analyze its impact on the first-year residents' self-confidence at our hospital.

METHODS

 We used 3D printing and silicone casting to create an LP simulator based on a lumbar spine computed tomography (CT). We divided 12 first-year anesthesiology residents into control and experimental groups. The control group received traditional training, while the experimental group practiced with the simulator for three months. We used a procedure checklist and a Likert scale survey to evaluate their procedural knowledge and self-confidence at baseline, three, and six months. Eighteen months later, we evaluated their LP performance skills.

RESULTS

Both groups showed a significant improvement in their knowledge scores over time. After three months, the experimental group had a higher median knowledge score (10 (10 - 10) median (min-max)) than the control group (9 (8 - 9.5) median (min-max)) (p = 0.03). While there were no apparent differences in median self-confidence scores between the groups at any time point, the experimental group had a significant increase in their self-confidence for performing an unassisted LP, with a median score of 1/5 (1 - 2.3) at baseline and 5/5 (4.8 - 5) after six months (p = 0.006). In contrast, the control group's self-confidence scores decreased from 4/5 (3 - 4) after three months to 3/5 (2 - 5) after six months. The evaluation of performance skills did not yield statistically significant results.

CONCLUSION

Our study demonstrates that an in-house LP simulator is an effective and practical approach for first-year anesthesiology residents to learn the LP procedure. This approach could be particularly useful in settings with limited resources and a lack of sufficient patients to practice on, as it provides an opportunity for faster learning and increased self-confidence.

Development and Validation of a Hybrid Bronchoscopy Trainer Using Three-Dimensional Printing

INTRODUCTION

Simulation is an essential component of medical education. Commercially available intubation simulators often lack anatomical fidelity of the lower airway and are therefore not suitable for teaching bronchoscopy or lung isolation. By using a desktop 3-dimensional (3D) printer, we aimed to create and validate a hybrid simulator from an existing mannequin with a 3D-printed lower airway that has anatomical fidelity and is financially affordable compared with commercially available models.

METHODS

Using an anonymized computed tomography scan of an adult male patient, we developed a 3D model of the airway from below the larynx to the 3rd generation bronchi, which was then printed on a desktop 3D printer. The printed airway was attached to an existing mannequin below the larynx via a universal adaptor. Ten anesthesiology attendings performed a blinded comparison of the hybrid mannequin with a commercially available mannequin for tactile and visual fidelity when performing intubation, bronchoscopy, and lung isolation. They were also asked to assess the models for educational suitability.

RESULTS

The 3D printed model was judged more suitable for teaching double-lumen tube insertion to novice physicians compared with the commercial model, with median (interquartile range) scores of 5 (4-5) versus 3 (2-4), P = 0.017. Similar results were found for bronchial blocker insertion and bronchoscopy. The visual fidelity of the bronchial anatomy was scored as 5 (4-5) and 2 (1-3) for the 3D-printed and the commercial models, respectively ( P = 0.007).

CONCLUSION

By creating a hybrid model combining an existing commercially available mannequin with a 3D-printed trachea and bronchial tree, we have created an affordable training simulator suitable for teaching lung isolation and bronchoscopy. Enhancing existing mannequins with 3D-printed parts may be of particular interest to institutions that do not have the funds to buy models with anatomical fidelity but do have access to a 3D printer.

Role of simulation-based training in thoracic anaesthesia

Simulation-based training (SBT) aims to acquire technical and non-technical skills in a simulated fashion without harming the patient. Simulation helps the anaesthesiologist acquire procedural competence and non-technical abilities. In thoracic anaesthesia, various simulators are available with varying degrees of fidelity and costs. Apart from improving bronchoscopy-related skills, other potential applications of SBT include the practice of lung isolation in normal and difficult airway scenarios, troubleshooting complications during surgeries, and certification of the proficiency of anaesthesiologists. A pragmatic approach is required for choosing the simulator based on its availability, cost, and benefits. Although the literature supports SBT to improve procedural skills, retention of the skills and their translation into improving clinical outcomes remain largely unproven. Randomised, controlled studies targeting the effect of SBT on the improvement of clinical outcomes of patients are needed to prove their worth.

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.

Deep learning for anatomical interpretation of video bronchoscopy images

Anesthesiologists commonly use video bronchoscopy to facilitate intubation or confirm the location of the endotracheal tube; however, depth and orientation in the bronchial tree can often be confused because anesthesiologists cannot trace the airway from the oropharynx when it is performed using an endotracheal tube. Moreover, the decubitus position is often used in certain surgeries. Although it occurs rarely, the misinterpretation of tube location can cause accidental extubation or endobronchial intubation, which can lead to hyperinflation. Thus, video bronchoscopy with a decision supporting system using artificial intelligence would be useful in the anesthesiologic process. In this study, we aimed to develop an artificial intelligence model robust to rotation and covering using video bronchoscopy images. We collected video bronchoscopic images from an institutional database. Collected images were automatically labeled by an optical character recognition engine as the carina and left/right main bronchus. Except 180 images for the evaluation dataset, 80% were randomly allocated to the training dataset. The remaining images were assigned to the validation and test datasets in a 7:3 ratio. Random image rotation and circular cropping were applied. Ten kinds of pretrained models with < 25 million parameters were trained on the training and validation datasets. The model showing the best prediction accuracy for the test dataset was selected as the final model. Six human experts reviewed the evaluation dataset for the inference of anatomical locations to compare its performance with that of the final model. In the experiments, 8688 images were prepared and assigned to the evaluation (180), training (6806), validation (1191), and test (511) datasets. The EfficientNetB1 model showed the highest accuracy (0.86) and was selected as the final model. For the evaluation dataset, the final model showed better performance (accuracy, 0.84) than almost all human experts (0.38, 0.44, 0.51, 0.68, and 0.63), and only the most-experienced pulmonologist showed performance comparable (0.82) with that of the final model. The performance of human experts was generally proportional to their experiences. The performance difference between anesthesiologists and pulmonologists was marked in discrimination of the right main bronchus. Using bronchoscopic images, our model could distinguish anatomical locations among the carina and both main bronchi under random rotation and covering. The performance was comparable with that of the most-experienced human expert. This model can be a basis for designing a clinical decision support system with video bronchoscopy.

Teaching the technical performance of bronchoscopy to residents in a step-wise simulated approach: factors supporting learning and impacts on clinical work - a qualitative analysis

BACKGROUND

The ability to perform a bronchoscopy is a valuable clinical skill for many medical specialities. Learning this skill is demanding for residents, due to the high cognitive load. Lessons learned from cognitive load theory might provide a way to facilitate this learning. The aim of this study was to investigate residents' perception of factors that support and hinder learning, as well as outcome and acceptance of a workshop on flexible bronchoscopy.

METHODS

Three half-day workshops were designed to teach 12 residents the basics of handling a flexible bronchoscope. They consisted of four phases that alternated between short theoretical aspects and longer practical situations. The practical phases focussed initially on manoeuvring a bronchoscope through holes in panels inside a box, and then on examination and practice using a three-dimensional printed model of the bronchial tree. Afterwards, three audio- and video-recorded focus groups were conducted, transcribed and coded, and underwent reflexive thematic analysis.

RESULTS

Analysis of the focus groups defined two themes: (1) factors that supported a safe and positive learning environment were optimised for intrinsic load, simulated setting, absence of pressure, dyad practice (working in pairs), small group sizes and playful learning; and (2) impacts on clinical work were perceived as high levels of learning and improved patient safety. The residents did not report factors that hindered their learning. Some suggestions were made to improve the set-up of the wooden box.

CONCLUSIONS

The half-day workshop was designed according to several factors, including cognitive load theory in a simulated setting, and creation of a safe and positive learning environment. The residents perceived this as supporting learning and patient safety. Further studies can be designed to confirm these results in a quantitative setting.

TRIAL REGISTRATION

This study was not interventional, therefore was not registered.

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.

[Comprehensive review of 3D printing use in medicine: Comparison with practical applications in urology]

INTRODUCTION

Over the past few years, 3D printing has evolved rapidly. This has resulted in an increasing number of scientific publications reporting on the medical use of 3D printing. These applications can range from patient information, preoperative planning, education, or 3D printing of patient-specific surgical implants. The objective of this review was to give an overview of the different applications in urology and other disciplines based on a selection of publications.

METHODS

In the current narrative review the Medline database was searched to identify all the related reports discussing the use of 3D printing in the medical field and more specifically in Urology. 3D printing applications were categorized so they could be searched more thoroughly within the Medline database.

RESULTS

Three-dimensional printing can help improve pre-operative patient information, anatomy and medical trainee education. The 3D printed models may assist the surgeon in preoperative planning or become patient-specific surgical simulation models. In urology, kidney cancer surgery is the most concerned by 3D printing-related publications, for preoperative planning, but also for surgical simulation and surgical training.

CONCLUSION

3D printing has already proven useful in many medical applications, including urology, for patient information, education, pre-operative planning and surgical simulation. All areas of urology are involved and represented in the literature. Larger randomized controlled studies will certainly allow 3D printing to benefit patients in routine clinical practice.

Systematic review of three-dimensional printing for simulation training of interventional radiology trainees

RATIONALE AND OBJECTIVES

Three-dimensional (3D) printing has been utilized as a means of producing high-quality simulation models for trainees in procedure-intensive or surgical subspecialties. However, less is known about its role for trainee education within interventional radiology (IR). Thus, the purpose of this review was to assess the state of current literature regarding the use of 3D printed simulation models in IR procedural simulation experiences.

MATERIALS AND METHODS

A literature query was conducted through April 2020 for articles discussing three-dimensional printing for simulations in PubMed, Embase, CINAHL, Web of Science, and the Cochrane library databases using key terms relating to 3D printing, radiology, simulation, training, and interventional radiology.

RESULTS

We identified a scarcity of published sources, 4 total articles, that appraised the use of three-dimensional printing for simulation training in IR. While trainee feedback is generally supportive of the use of three-dimensional printing within the field, current applications utilizing 3D printed models are heterogeneous, reflecting a lack of best practices standards in the realm of medical education.

CONCLUSIONS

Presently available literature endorses the use of three-dimensional printing within interventional radiology as a teaching tool. Literature documenting the benefits of 3D printed models for IR simulation has the potential to expand within the field, as it offers a straightforward, sustainable, and reproducible means for hands-on training that ought to be standardized.

Applications of 3D printing in critical care medicine: A scoping review

Although a wide range of medical applications for three-dimensional printing technology have been recognised, little has been described about its utility in critical care medicine. The aim of this review was to identify three-dimensional printing applications related to critical care practice. A scoping review of the literature was conducted via a systematic search of three databases. A priori specified themes included airway management, procedural support, and simulation and medical education. The search identified 1544 articles, of which 65 were included. Ranging across many applications, most were published since 2016 in non - critical care discipline-specific journals. Most studies related to the application of three-dimensional printed models of simulation and reported good fidelity; however, several studies reported that the models poorly represented human tissue characteristics. Randomised controlled trials found some models were equivalent to commercial airway-related skills trainers. Several studies relating to the use of three-dimensional printing model simulations for spinal and neuraxial procedures reported a high degree of realism, including ultrasonography applications three-dimensional printing technologies. This scoping review identified several novel applications for three-dimensional printing in critical care medicine. Three-dimensional printing technologies have been under-utilised in critical care and provide opportunities for future research.

Can we improve teaching and learning of percutaneous dilatational tracheostomy's bronchoscopic guidance?

Percutaneous dilatational tracheostomy has become the technique of choice in multiple intensive care units. Among innovations to improve procedural safety and success, bronchoscopic guidance of percutaneous dilatational tracheostomy has been advocated and successfully implemented by multiple groups. Most published literature focuses on the percutaneous dilatational tracheostomy operator, with scarce descriptions of the bronchoscopic particularities of the procedure. In this article, we provide 10 suggestions to enhance specific procedural aspects of bronchoscopic guidance of percutaneous dilatational tracheostomy, and strategies to optimize its teaching and learning, in order to promote learners' competence acquisition and increase patient safety.

Man or machine? Impact of tutor-guided versus simulator-guided short-time bronchoscopy training on students learning outcomes

BACKGROUND

Simulation based medical education is efficient for the acquisition of flexible bronchoscopy navigational skills and the knowledge of the tracheobronchial anatomy. However, bronchoscopy simulator training is not routinely integrated into pneumologic fellowship programs or undergraduate medical education for time and/or cost reasons. Our study compares the effect of self-guided bronchoscopy simulator training versus tutor guided training on the acquisition of navigational skills and knowledge of the bronchial anatomy.

METHODS

Third-year undergraduate medical students were randomized to either a tutor- or simulator guided bronchoscopy simulator training focusing on the acquisition of navigational skills and the knowledge of the tracheobronchial anatomy. Every student performed a baseline bronchoscopy followed by a structured bronchoscopy simulator training and finally an assessment bronchoscopy at the end of the training program. Groups were compared by means of a repeated measurement ANOVA and effect sizes calculated as Cohens' d.

RESULTS

Fifty-four eligible students participated in the study. Knowledge of the tracheobronchial anatomy significantly increased from pre- to post training (all p < 0.001; all d > 2), navigational skills significantly decreased (all p < 0.005; all d < 1). There were no significant differences between groups. Instruction by the simulator as well as by the tutor was rated as helpful by the students. Twenty-two (84.6%) of the participants of the simulator guided group would have appreciated an additional instruction by a tutor.

CONCLUSION

Short-time simulator guided bronchoscopy training improves knowledge of the tracheobronchial anatomy in novice bronchoscopists as much as tutor guided training, but navigational skills seem to worsen in both groups. Further studies assessing transfer to clinical practice are needed to find the optimal teaching method for basic flexible bronchoscopy.

Computer-Generated Three-Dimensional Airway Models as a Decision-Support Tool for Preoperative Evaluation and Procedure-Planning in Pediatric Anesthesiology

Technology improvements have rapidly advanced medicine over the last few decades. New approaches are constantly being developed and utilized. Anesthesiology strongly relies on technology for resuscitation, life-support, monitoring, safety, clinical care, and education. This manuscript describes a reverse engineering process to confirm the fit of a medical device in a pediatric patient. The method uses virtual reality and three-dimensional printing technologies to evaluate the feasibility of a complex procedure requiring one-lung isolation and one-lung ventilation. Based on the results of the device fit analysis, the anesthesiology team confidently proceeded with the operation. The approach used and described serves as an example of the advantages available when coupling new technologies to visualize patient anatomy during the procedural planning process.

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.

Comparison of Flexible 3D Printed Stenotic Airway Model Versus Standard Model for Therapeutic Bronchoscopy Training a Proof of Concept

AIM

This study aimed to determine operator impressions of an airway obstruction procedure using a custom silicone model of low cost and high accuracy.

BACKGROUND

Current procedural education for therapeutic bronchoscopy relies on animal models, supervised in-patient training, and inanimate artificial models. Model manufacturing via lost-wax casting allows for the flexibility of the material selection and reproduction of complex airway shapes.

METHODS

A patient computed tomography scan was anonymized and segmented into a stereolithographic (STL) file. The water dissolvable interior airway mold was 3-dimensional (D) printed using polyvinyl alcohol and the exterior mold was printed with polylactic acid. Flexible silicone was injected into the mold. During advanced bronchoscopy courses (2017-2018) at Beth Israel Deaconess Medical Center, participants were asked to evaluate both standard bronchoscopy manikin and the manikin with 3D customization.

RESULTS

We evaluated 17 participants with different levels in training in the pulmonary field. All of them reported that they previously have performed >100 bronchoscopies, 88% having treated patients with airway stenosis. In total, 77% of participants thought the 3D model was better or much better for airway inspection when compared with Broncho-Boy. Overall, 94% of participants reported the 3D model was accurate or very accurate for realism. In total, 69% of trainees reported the overall experience as excellent. All of them reported 3D model would improve their skills on stent placement.

CONCLUSION

3D printing with silicone lost wax casting can be used to reproduce airway abnormalities for tactile simulation bronchoscopy. Reproducible custom airway models can be created for a relatively low cost.

Patient-specific and hyper-realistic phantom for an intubation simulator with a replaceable difficult airway of a toddler using 3D printing

Difficult tracheal intubation is the third most common respiratory-related adverse co-morbid episode and can lead to death or brain damage. Since difficult tracheal intubation is less frequent, trainees have fewer opportunities to perform difficult tracheal intubation; this leads to the need to practice with a hyper-realistic intubation simulator. However, conventional simulators are expensive, relatively stiffer than the human airway, and have a lack of diversity in terms of disease variations and anatomic reproducibility. Therefore, we proposed the development of a patient-specific and hyper-realistic difficult tracheal intubation simulator using three-dimensional printing technology and silicone moulding and to test the feasibility of patient-specific and hyper-realistic difficult intubation simulation using 3D phantom for the trainee. This difficult tracheal intubation phantom can provide a realistic simulation experience of managing various difficult tracheal intubation cases to trainees, which could minimise unexpected tissue damage before anaesthesia. To achieve a more realistic simulation, a patient-specific phantom was fabricated to mimic human tissue with realistic mouth opening and accurate difficult airway shape. This has great potential for the medical education and training field.

A three-dimensional (3D) printed paediatric trachea for airway management training

There is a deficit of commercially available paediatric airway models for anaesthesia airway management training, particularly for infant front-of-neck access and customised airway planning. Acknowledging this, we created a three-dimensional printed prototype for an affordable, high-fidelity training device, incorporating realistic tactile feedback, reproducibility and potential for modification for specific patient pathologies. Our model, created on a Stratasys Polyjet J750™ (Rehovot, Israel) printer, is a novel and useful educational tool in paediatric airway management, and we are pleased to share access to this resource with readers. Our work adds credence to three-dimensional printing as an accessible, reproducible and pluripotent technology in clinical anaesthesia.

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.

Evaluation of a bronchoscopy guidance system for bronchoscopy training, a randomized controlled trial

BACKGROUND

Conventional training in bronchoscopy is performed either on patients (apprenticeship model) or phantoms. While the former is associated with increased rate of patient complications, procedure time, and amount of sedation, the latter does not offer any form of feedback to the trainee. This paper presents a study which investigates whether a bronchoscopy guidance system may be a helpful tool for training of novice bronchoscopists.

METHODS

A randomized controlled study with 48 medical students was carried out with two different groups (control and test group, each N = 24). Whereas the control group performed a conventional bronchoscopy on phantom the test group carried out an Electromagnetic Navigation Bronchoscopy (ENB) for tracking of the bronchoscopal tip in the bronchial system. All volunteers had a common task: to perform a complete and systematic diagnostic bronchoscopy within 10 min.

RESULTS

The test group examined significantly more lobes than the control group (p = 0.009). Due to the real-time feedback of the system, all students of test group felt more confident having analyzed the entire lung. Additionally, they were unanimous that the system would be helpful during the next bronchoscopy.

CONCLUSIONS

In sum, this technology may play a major role in unsupervised learning by improving accuracy, dexterity but above all by increasing the confidence of novices, students as well as physicians. Due to good acceptance, there may be a great potential of this tool in clinical routine.

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.

Development and evaluation of 3-dimensional printed models of the human tracheobronchial system for training in flexible bronchoscopy

OBJECTIVES

Training and assessment of proper skills in flexible bronchoscopy are major educational goals for cardiothoracic residents. Therefore, we developed 3-dimensional (3D) printed models of the human tracheobronchial system for training and assessment of cardiothoracic residents in flexible bronchoscopy.

METHODS

Three models of normal (size/shape) human tracheobronchial anatomy were generated using a commercially available 3D printer. Ten residents (inexperienced: Group 1; experienced: Group 2) participated in this study with an experimental setting of initial assessment (Model 1), training (15 min, Model 2) and post-training assessment (Model 3). The time needed for flexible bronchoscopy assessment of randomly assigned ostia was recorded before and after training. Additionally, the time for retrieval of a foreign body from the tracheobronchial system was measured before and after training.

RESULTS

The average time for intubation of a given ostium (Model 1) at initial assessment was 88 s for Group 1 and 38 s for Group 2 (P < 0.0001). Following training, there was a significant reduction in time for intubation of a given ostium (Model 3) in both groups (P < 0.0001). However, the initial difference between experienced and inexperienced residents was no longer present following training. Additionally, the time for retrieval of a foreign body (cotton wool plug) from the tracheobronchial system was significantly reduced following training in both groups.

CONCLUSIONS

Accurate models of the human tracheobronchial system can be generated from representative patient images using 3D engineering software and 3D printing technology. With these models, residents can be effectively trained in flexible bronchoscopy with significant improvement in their proficiency and handling capability.

Multi-material three dimensional printed models for simulation of bronchoscopy

Background

Bronchoscopy involves exploration of a three-dimensional (3D) bronchial tree environment using just two-dimensional (2D) images, visual cues and haptic feedback. Sound knowledge and understanding of tracheobronchial anatomy as well as ample training experience is mandatory for technical mastery. Although simulated modalities facilitate safe training for inexperienced operators, current commercial training models are expensive or deficient in anatomical accuracy, clinical fidelity and patient representation. The advent of Three-dimensional (3D) printing technology may resolve the current limitations with commercial simulators. The purpose of this report is to develop and test the novel multi-material three-dimensional (3D) printed airway models for bronchoscopy simulation.

Methods

Using material jetting 3D printing and polymer amalgamation, human airway models were created from anonymized human thoracic computed tomography images from three patients: one normal, a second with a tumour obstructing the right main bronchus and third with a goitre causing external tracheal compression. We validated their efficacy as airway trainers by expert bronchoscopists. Recruited study participants performed bronchoscopy on the 3D printed airway models and then completed a standardized evaluation questionnaire.

Results

The models are flexible, life size, anatomically accurate and patient specific. Five expert respiratory physicians participated in validation of the airway models. All the participants agreed that the models were suitable for training bronchoscopic anatomy and access. Participants suggested further refinement of colour and texture of the internal surface of the airways. Most respondents felt that the models are suitable simulators for tracheal pathology, have a learning value and recommend it to others for use in training.

Conclusion

Using material jetting 3D printing to create patient-specific anatomical models is a promising modality of simulation training. Our results support further evaluation of the printed airway model as a bronchoscopic trainer, and suggest that pathological airways may be simulated using this technique.

Process of medical simulator development: An approach based on personal experience

With increasing demand for simulators from the healthcare community and increasingly sophisticated technology being used in the manufacture of medical simulators, the manufacture of healthcare simulators has become a multifaceted undertaking. Based on our experience in the field and our diverse backgrounds, we explore the processes and issues related to the development of these simulators and suggest ways for the developing teams to collaborate and coordinate with each other to achieve a successful outcome.

Three-dimensional Printing in Maxillofacial Surgery: Hype versus Reality

Three-dimensional printing technology is getting more attention recently, especially in the craniofacial region. This is a review of literature enlightening the materials that have been used to date and the application of such technology within the scope of maxillofacial surgery.

Bronchoscopy Simulation Training as a Tool in Medical School Education

BACKGROUND

Procedural simulation training is rare at the medical school level and little is known about its usefulness in improving anatomic understanding and procedural confidence in students. Our aim is to assess the impact of bronchoscopy simulation training on bronchial anatomy knowledge and technical skills in medical students.

METHODS

Medical students were recruited by email, consented, and asked to fill out a survey regarding their baseline experience. Two thoracic surgeons measured their knowledge of bronchoscopy on a virtual reality bronchoscopy simulator using the Bronchoscopy Skills and Tasks Assessment Tool (BSTAT), a validated 65-point checklist (46 for anatomy, 19 for simulation). Students performed four self-directed training sessions of 15 minutes per week. A posttraining survey and BSTAT were completed afterward. Differences between pretraining and posttraining scores were analyzed with paired Student's t tests and random intercept linear regression models accounting for baseline BSTAT score, total training time, and training year.

RESULTS

The study was completed by 47 medical students with a mean training time of 81.5 ± 26.8 minutes. Mean total BSTAT score increased significantly from 12.3 ± 5.9 to 48.0 ± 12.9 (p < 0.0001); mean scores for bronchial anatomy increased from 0.1 ± 0.9 to 31.1 ± 12.3 (p < 0.0001); and bronchoscopy navigational skills increased from 12.1 ± 5.7 to 17.4 ± 2.5 (p < 0.0001). Total training time and frequency of training did not have a significant impact on level of improvement.

CONCLUSIONS

Self-driven bronchoscopy simulation training in medical students led to improvements in bronchial anatomy knowledge and bronchoscopy skills. Further investigation is under way to determine the impact of bronchoscopy simulation training on future specialty interest and long-term skills retention.

A novel 3D-printed hybrid simulation model for robotic-assisted kidney transplantation (RAKT)

Robotic-assisted kidney transplantation (RAKT) offers key benefits for patients that have been demonstrated in several studies. A barrier to the wider uptake of RAKT is surgical skill acquisition. This is exacerbated by the challenges of modern surgery with reduced surgical training time, patient safety concerns and financial pressures. Simulation is a well-established method of developing surgical skill in a safe and controlled environment away from the patient. We have developed a 3D printed simulation model for the key step of the kidney transplant operation which is the vascular anastomosis. The model is anatomically accurate, based on the CT scans of patients and it incorporates deceased donor vascular tissue. Crucially, it was developed to be used in the robotic operating theatre with the operating robot to enhance its fidelity. It is portable and relatively inexpensive when compared with other forms of simulation such as virtual reality or animal lab training. It thus has the potential of being more accessible as a training tool for the safe acquisition of RAKT specific skills. We demonstrate this model here.