Flexible Bronchoscopies Research Articles

The safety of flexible fibre‐optic bronchoscopy and proceduralist‐administered sedation: a tertiary referral centre experience

Flexible fibre-optic bronchoscopy has become an essential investigation and is widely regarded as safe, but wider published prospective data regarding delayed complications are limited. There is continuing debate concerning the safety of proceduralist-administered sedation. We evaluated complication rates of bronchoscopy and proceduralist-administered sedation at our tertiary institution, and their clinical significance. Prospective evaluation of all patients undergoing bronchoscopy over a 12-month period at a tertiary referral centre. Immediate minor and major complications were documented within 4 h of bronchoscopy, delayed complications at 48 h, case notes and bronchoscopy records were reviewed 1 month later. Five hundred and fifty-eight flexible fibre-optic bronchoscopies were performed, 216 with transbronchial biopsy or nodal aspiration, 19 had therapeutic airways intervention. The minor complication rate at 4 h was 4.12% (23), rising to 26% (145) at 48 h. All 2.2% (12) major complications occurred exclusively within 4 h of bronchoscopy. No complications could be attributed to proceduralist-administered sedation. Complication rates at 4 h were comparable with previously reported data. Delayed minor complications were greater than expected, and did not require additional medical input. There were no complications from proceduralist-administered sedation. Flexible fibre-optic bronchoscopy and proceduralist-administered sedation within our institution's guidelines are safe.

Análisis de 208 fibrobroncoscopias realizadas en una unidad de cuidados intensivos

ObjectiveTo describe the main indications, clinical results and complications associated with fibrobronchoscopy in the Intensive Care Unit (ICU). DesignA retrospective, single-center observational study was carried out.Setting. Seventeen beds in a medical/surgical ICU.Patients. Consecutive patients undergoing fibrobronchoscopy during their stay in the ICU over a period of 5 years. InterventionsFlexible bronchoscopy performed by an intensivist.Main variables of interest. Flexible bronchoscopy indications and complications derived from the procedure. ResultsA total of 208 flexible bronchoscopies were carried out in 192 patients admitted to the ICU. Most of the procedures (193 [92.8%]) were performed in mechanically ventilated patients. The average patient age was 58±16 years, with an APACHE II score at admission of 19±7. The most frequent indication for flexible bronchoscopy was diagnostic confirmation of initially suspected pneumonia (148 procedures), with positive bronchoalveolar lavage findings in 46%. The most frequent therapeutic indication was the resolution of atelectasis (28 procedures). Other indications were the diagnosis and treatment of pulmonary hemorrhage, the aspiration of secretions, control of percutaneous tracheotomy, and difficult airway management. The complications described during the procedures were supraventricular tachycardia (3.8%), transient hypoxemia (6.7%), and slight bleeding of the bronchial mucosal membrane (2.4%). ConclusionsA microbiological diagnosis of pneumonia and the resolution of atelectasis are the most frequent indications for flexible bronchoscopy in critically ill patients.Flexible bronchoscopy performed by an intensivist in ICU is a safe procedure.

An analysis of potential risk factors for early complications from fiberoptic bronchoscopy in lung transplant recipients

Several reviews exist describing the safety of bronchoscopy in lung transplant recipients. However, the incidence of bronchoscopic complications in lung transplant recipients in relation to trainee involvement, and clinical characteristics such as pre-transplant diagnosis and transplant type, has not been described. We performed a retrospective cohort study of all lung transplant recipients undergoing flexible fiberoptic bronchoscopy (n = 259) at the University of California, San Francisco, between January, 2003, and June, 2009. Complications included bleeding, pneumothorax, aspiration, oversedation, and hypoxemia. From 2003 to 2009, 3734 flexible fiberoptic bronchoscopies were performed, including 2111 (57%) with transbronchial biopsies. Trainees were involved in 2102 bronchoscopies (56%), including 1046 transbronchial biopsies (49.5%). Complications occurred in 27 bronchoscopies [0.7% (95% Confidence Interval [CI]: 0.4-1.0)], with 10 involving a trainee (37%). Twenty (74%) occurred during bronchoscopies with transbronchial biopsies. Six of these involved a trainee, while 14 involved an attending alone (P = 0.03). We did not find differences in pre-transplant diagnosis, transplant type, lung, or renal function between subjects who suffered a complication and those who did not (P ≥ 0.30). The involvement of trainees, pre-transplant diagnosis, and transplant type do not significantly impact the rate of bronchoscopic complications in lung transplant recipients.

Flexible bronchoscopy for children on extracorporeal membrane oxygenation for cardiac failure*

To describe the safety and use of flexible bronchoscopy in the management of respiratory complications in patients on extracorporeal membrane oxygenation for cardiac failure. Retrospective cohort study. Pediatric intensive care unit at a tertiary care university hospital. Patients requiring extracorporeal membrane oxygenation for cardiac failure in the pediatric intensive care unit between 2003 and 2008. None. Forty-eight patients required extracorporeal membrane oxygenation for cardiac failure (32 after surgery for congenital heart disease, 16 for acquired heart disease) during the study period. Seven patients (15%) underwent 17 flexible bronchoscopies. Median age and weight at extracorporeal membrane oxygenation cannulation was 10 days (range, 4 days to 27 yrs) and 3.2 kg (range, 2.8-66 kg), respectively. Median duration of extracorporeal membrane oxygenation in this group was longer than those not undergoing flexible bronchoscopy (314 vs. 114 hrs, p < .001). In all cases, flexible bronchoscopy indication was persistent atelectasis despite conventional ventilator adjustments. Activated clotting time during flexible bronchoscopy was maintained between 180 and 220 secs (normal, 80-150 secs) in all patients. No major complications occurred. A minor complication occurred in one of 17 flexible bronchoscopies (6%), scant oozing that stopped with epinephrine lavage. Findings included bronchus compression or narrowing in four patients and mucous plugging in three patients. Bronchoalveolar lavage specimens identified new ventilator-associated infections in three patients. In two patients with mucous plugging, serial bronchoscopies were accompanied by stepwise decreases in extracorporeal membrane oxygenation flow, thereby facilitating discontinuation from extracorporeal membrane oxygenation support. In patients requiring extracorporeal membrane oxygenation for cardiac failure, flexible bronchoscopy can be performed safely, provide important diagnostic information to the bedside clinician, and, perhaps, therapeutic benefit to the patient.

Empfehlungen zu Trainingskursen in der Bronchoskopie

Bronchoscopic training courses are an essential part of the education in bronchoscopy for all kinds of specialisations and professions performing such investigations. All aspects of the application should be mentioned during a course. These recommendations are necessary because the number of bronchoscopies performed in the last years has increased due to the increasing number of patients, improved equipment and better availability. Courses should provide the basic knowledge including main points of indications, preconditions for the procedure and decisions of consequence after bronchoscopy. Participants should be trained in the skills of correct handling and performing flexible bronchoscopies in training dummies. Necessary competence requirements on the course instructor are adequate professional qualifications, paedagogic skills and the availability of appropriate teaching material. Quality assurance of the course should be achieved by consequent evaluation. A widely spread field of bronchoscopic applications can improve patient care in many medical specialisations.

Using Performance in Multiple Simulated Scenarios to Assess Bronchoscopy Skills

Background: International guidelines suggest that trainees should perform at least 100 flexible bronchoscopies in a supervised setting, but this number is not evidence based. An objective assessment method could provide educational feedback to trainees and help supervisors decide when basic competency is established. No former assessment instrument has been able to distinguish between trainees and experts. Objectives: The aim of this study was to explore the validity and reliability of a new assessment procedure relating to testing operators across multiple tasks with increasing difficulty using a standardized scoring form. Methods: The test was administered on a virtual reality bronchoscopy simulator to a total of 42 test subjects (14 senior consultants, 14 trainees and 14 medical students). The inter-rater reliability of the test procedure was explored according to examination of test results from 10 subjects using 3 raters (2 blinded). Results: We found a high inter-rater reliability (Cronbach’s α = 0.90). The assessment procedure sufficiently differentiated the performance of the 3 groups (p < 0.001). Assessment of 6 procedures was necessary to secure a generalizability coefficient >0.80. Conclusions: The new assessment procedure proved both valid and reliable.

Induction Therapy With Antithymocyte Globulin Before Reperfusion

The use of induction immunosuppressive agents in pediatric lung transplantation is not universal. The rationale of induction therapy is to use the strongest immunosuppressive drugs at the time when the risk of acute cellular rejection (ACR) is highest. The timing of induction is not universal. We hypothesize that early treatment with antilymphocyte globulin (ATG) prior to reperfusion of the first donor lung will decrease the incidence of ACR. The initial dose of ATG was given during the operative procedure when the recipient was on cardiopulmonary bypass after removal of the recipient lungs and prior to implantation. Patients received additional doses daily for four days. All children were monitored for ACR during the first 6 months posttransplant with transbronchial biopsies at defined intervals (weeks-months) and when clinically indicated. Presence of ACR was defined by International Society for Heart & Lung Transplantation guidelines. Recipients from two pediatric centers received ATG based on this protocol. A total of 18 patients were treated with this protocol, and the follow-up period was 6 to 45 months. A total of 63 flexible bronchoscopies with transbronchial biopsies were performed during the first 6 months. A single episode of ACR (≥ grade A2) was identified in this patient population for an incidence of 5.2% ACR grade A2 or above in this patient population. Induction therapy with ATG prior to donor lung reperfusion is associated with a low incident of ACR during the first 6 months posttransplant in our patient cohort. Long-term follow-up is needed to ascertain the full effect of this treatment protocol.

Repair Costs for Endobronchial Ultrasound Bronchoscopes

The development of endobronchial ultrasound (EBUS) has revolutionized the diagnostic approach to lung cancer and mediastinal lymphadenopathy. The capital costs associated with implementing EBUS are easily obtained from manufacturers, but the ongoing maintenance and repair costs are unknown. The purpose of this study was to delineate the maintenance and repair costs associated with EBUS. For the period between October 2005 and June 30, 2009, the number of procedures and the maintenance and repair costs for both EBUS and flexible bronchoscopes were recorded. Two BF-160UCF-OL8 (Olympus, Canada) linear convex EBUS bronchoscopes were used for EBUS procedures during the course of the study. Total costs were calculated on a yearly basis and on a per procedure basis for EBUS and standard bronchoscopes and are presented in Canadian and US dollars ($1 CAN=$0.88 USD). During the period of October 2005 and June 2009, a total of 949 linear convex EBUS procedures and 2767 flexible bronchoscopies were carried out. During this period, 13 separate repair issues were encountered with the EBUS bronchoscopes and control unit. The total cost for maintenance and repair of the EBUS and flexible bronchoscopes was $110,151.46 ($96,933.28 USD) and $67,301.49 ($59,225.31 USD), respectively. The average cost per procedure for EBUS and flexible bronchoscopy was $116.00 ($102.08 USD) and $24.32 ($21.42 USD), respectively. The cost of EBUS repairs per procedure is significant and illustrates the importance of understanding the ongoing maintenance issues inherent in these delicate pieces of medical equipment.

Idiopathic Progressive Tracheobronchial Stenosis of 20 Years' Duration: Response to Anti-inflammatory Treatment

We report a unique case of progressive tracheobronchial stenosis in a 52-year-old woman who presented to us with stridor and dyspnea at rest. Her initial symptoms began 20 years earlier, at which time subglottic stenosis of ill-defined etiology necessitated tracheal resection with end-to-end anastomosis. Tracheal biopsy at the time revealed nonspecific inflammation without granulomas, vasculitis, infection, amyloidosis, or malignancy. Over subsequent years, she underwent multiple endobronchial laser resections of the trachea for recurrent disease. On presentation to us, flexible bronchoscopy showed inflammatory stenoses of the left mainstem bronchus and bronchus intermedius. Bronchial biopsy showed acute and chronic stromal inflammation with scattered plasma cells and myofibroblasts against a background of dense fibrosis. Review of the initial tracheal resection specimens and subsequent bronchial specimens revealed areas of high collagenous content with a relatively scant overall myofibroblastic cellular infiltrate; stains for S-100 and anaplastic lymphoma kinase were negative. A diagnosis of idiopathic tracheal stenosis was made with unusual accompanying bronchial involvement, that is, idiopathic tracheobronchial stenosis. Inflammatory airway bronchostenoses were stabilized by high-dose steroids followed by weekly methotrexate therapy, as evidenced by serial flexible bronchoscopies and sequential chest computed tomography with 3-dimensional reconstruction imaging. To our knowledge, this is the first reported case of combined idiopathic tracheal and bronchial stenosis stabilized with anti-inflammatory treatment.

Extraction of airway foreign bodies in adults: experience from 1987–2008☆

To determine the incidence and the clinical, radiographic, and endoscopic characteristics of adult patients in our area diagnosed with tracheobronchial foreign bodies (FBs), we have performed a descriptive retrospective study analysing rigid and flexible bronchoscopies practised at our department between 1987 and 2008 in patients older than 14 years. Of the 9781 bronchoscopies performed, 32 involved cases of bronchoaspiration of FBs. The mean age of the patients was 43.81 years (S.D. 21.43); 65.6% were male and 34.4% were female. Acute or recurrent infection was the most frequent clinical presentation. Chest radiographs provided data for diagnosis in 68% of the cases. The most common FB aspirated were inorganic (pins and plastic devices 21.4%, respectively). In conclusion, we can state that in our area tracheobronchial aspiration of FBs by adults is not common. The clinical symptoms are highly variable and the FBs are usually lodged in the right bronchial tree.

Tracheobronchoscopy and esophagoscopy in current ear–nose–throat practice: an update

Rigid and flexible bronchoscopies and upper aerodigestive endoscopy are important diagnostic and therapeutic tools in ENT. The use of flexible upper aerodigestive endoscopy allows simultaneous percutaneous endoscopic gastrostomy (PEG) placement. Based on a similar study analyzing endoscopies performed in 1995, an anonymous questionnaire was developed by the Arbeitsgemeinschaft Endoskopie of the German Society of Oto-Rhino-Laryngology Head and Neck Surgery to determine current trends in the use of bronchoscopy and upper aerodigestive endoscopy. Questionnaires were sent to 165 different ENT institutions in Germany. 57 questionnaires were evaluated. 4,294 rigid and 3,965 flexible bronchoscopies were performed as well as 8,897 rigid and 2,211 flexible upper aerodigestive endoscopies. These results are shown according to the size (number of beds) of the performing institutions. Foreign body removals and PEG placements were also analyzed and compared with previous studies. In conclusion, the survey shows that the total number of procedures performed is comparable to the number performed in 1995. There is, however, a considerable increase in the number of flexible procedures performed, especially in upper aerodigestive endoscopies. It is commendable that all 57 institutions provide PEGs for their patients. However, only about one-fifth of these is placed by the treating ENT, despite the fact that panendoscopies provide an ideal setting for the performance of this procedure. An improvement of this situation would be desirable.

Bronchoscopy in Japan: A survey by the Japan Society for Respiratory Endoscopy in 2006

In order to obtain information on the clinical application of bronchoscopy in Japan, the Japan Society for Respiratory Endoscopy (JSRE) conducted a postal survey. A questionnaire was sent to 526 authorized institutes of the JSRE. The subject was bronchoscopy procedures performed during 2006. The response rate was 71.3%. The total number of bronchoscopies performed was 74,770. Of these, 74,412 were flexible bronchoscopies and 358 were rigid bronchoscopies. At least one JSRE-authorized specialist had worked with 97% of respondents. Eighty-five per cent of respondents performed bronchoscopy under topical anaesthesia for almost all patients. Seventy-five per cent of respondents routinely used the oral route. The reported numbers of diagnostic bronchoscopies was 12,509 for simple bronchoscopy, 25,971 for forceps biopsy, 26,289 for brush biopsy, 25,659 for bronchial washing, 1387 for transbronchial needle aspiration and 6716 for BAL. Three deaths were caused by forceps biopsy (0.012%). The morbidity rates for these diagnostic procedures ranged from 0.14% to 2.5%. The reported numbers of therapeutic bronchoscopies was 476 for tracheobronchial stent, 164 for neodymium (Nd): yttrium-aluminium garnet (YAG) laser photoresection (LPR), 40 for photodynamic therapy, 81 for balloon dilatation, 145 for endobronchial electrocautery, 120 for argon plasma coagulation, 109 for microwave coagulation (MWC), 116 for ethanol injection, 110 for foreign body removal and 89 for bronchial occlusion. Deaths occurred only as a consequence of Nd : YAG LPR (0.61%). The morbidity rates for these therapeutic procedures ranged from 0% to 5%. The preparation for, and practice of, bronchoscopy varied greatly between respondents. Diagnostic bronchoscopy was well tolerated and safe. Therapeutic procedures did not appear to be practised widely or frequently.

A Case of Tracheal Carcinoma Diagnosed by Rigid Bronchoscopy in Lidocaine Anaphylaxis Patient

The majority of flexible bronchoscopies are performed under topical anesthesia with lidocaine being the most commonly used agent. Anaphylaxis rarely occurs after local administration of lidocaine, but can be a fatal complication. We experienced a case of unexpected anaphylaxis. A 66-year-old woman was scheduled for flexible bronchoscopy to evaluate a tracheal mass and stenosis. The oral and nasal mucosa were pretreated with lidocaine. About 2 ∼3 minutes later, the patient developed hypotension and we treated for anaphylaxis in the emergency room. Then, we decided to perform rigid bronchoscopy in this patient, under conditions of general anesthesia. A rigid bronchoscopy was performed in this patient, safely and successfully. The tracheal mass was determined to be squamous cell carcinoma.

Flexible Bronchoscopy for Diagnosis and Follow Up of Childhood Endobronchial Tuberculosis

In this study, our aim was to determine the clinical and bronchoscopic outcome of the endobronchial tuberculosis (ETB). Patients with suspected tuberculosis (TB) or TB patients with an inadequate response to 8 weeks of antituberculosis treatment were enrolled in the study. Seventy patients were included to the study and 118 flexible bronchoscopies were performed. ETB was present in 33 (47%) patients. There was isolated compression in 14 cases, caseous lesions in 13, granuloma formation in 6, polypoid lesions in 2, adenopathy protrusion in 1, and mucosal erosion in 1 case. The mean duration of bronchoscopic resolution of endobronchial lesions was 5.50 +/- 2.74 months. Mycobacterium tuberculosis was isolated from gastric lavage in 10% and from bronchoalveolar lavage in 12.8% of 70 cases. When both of the procedures were performed concurrently, the isolation rate increased to 20%. Transient hypoxia resolving with nasal O2 was observed in 3 patients as a complication of bronchoscopy. Bronchoscopy offered a safe and rapid means of confirming the diagnosis of ETB.

Bronchoscopy simulation: a brief review

More than 500,000 flexible bronchoscopies are performed annually by chest physicians in the United States (Ernst et al., Chest 123:1693-1717, 2003). Indications include diagnosis of lung cancer and airway tumors, benign strictures, pulmonary infections, and treatment of central airway obstruction, emphysema, and intraepithelial lesions such as carcinoma in-situ. Anesthesiologists, cardiothoracic and trauma surgeons, otolaryngologists, and critical are physicians also perform this procedure as part of difficult airway management, intubation or airway inspection and bronchial toilet. Compared to the expanding body of simulation-related literature that is available in other procedural fields, however, the volume of published work relating to bronchoscopy is scant. The purpose of this paper is to provide an overview of the available literature pertaining to the use of simulation in bronchoscopy education, and to demonstrate how this limited yet valuable body of work lays a foundation for the future use of simulator-based bronchoscopy training.

Complications of Silicone Stent Insertion in Patients With Expiratory Central Airway Collapse

Silicone stent insertion is an alternative treatment for expiratory central airway collapse. This study evaluates the complications (mucus plugging, migration, and granulation tissue) associated with stenting in patients who failed medical therapy and were not surgical candidates. Chart review from 15 consecutive patients treated by silicone stent insertion was done over a 2-year period. Outcomes included (1) changes in functional class, extent and severity of airway collapse (graded from 1 to 4 by using a multidimensional system), procedure- and stent-related complications at 48 hours after stent insertion; (2) frequency of stent-related complications; and (3) frequency of emergent flexible and rigid bronchoscopy (scheduled or emergent) over the follow-up period. Mean functional class and severity and extent of airway collapse significantly improved within 48 hours after treatment (p < 0.05). There were no perioperative deaths. Stent-related complications within 48 hours after stent insertion occurred in 3 patients (1 granulation, 1 migration, and 1 mucus plugging). The mean duration of follow-up for the 12 patients who underwent clinical and bronchoscopic follow-up was 188 days. Twenty-six stent-related complications (12 mucus plugs, 8 migrations, and 6 granulation tissues) were seen in 10 of the 12 patients. Five emergent flexible bronchoscopies and 14 rigid bronchoscopies (6 of which were emergent) were performed during the follow-up period. Silicone stent insertion improves functional status immediately after intervention in patients with expiratory central airway collapse, but is associated with a high rate of stent-related complications and need for repeat bronchoscopic interventions.

Retrospective evaluation of a paediatric intensivist-led flexible bronchoscopy service

To demonstrate the diagnostic yield, therapeutic role and safety of flexible bronchoscopy via an intensivist-led service in critically ill children. Retrospective chart review. Regional paediatric intensive care unit. One hundred forty-eight flexible bronchoscopies were performed by two intensivists on 134 patients (median age 16.5 months) over a 2.5-year period. Eighty-eight percent of patients required mechanical ventilation, and 22% were receiving inotropes. Case mix included general (n = 77), cardiac surgery (n = 18), cardiology (n = 13), ear-nose-and-throat surgery (n = 17), oncology (n = 8) and renal (n = 1). The indication for bronchoscopy was defined a priori according to one of four categories: suspected upper airway disease (n = 32); lower airway disease (n = 70); investigation of pulmonary disease (n = 25); and extubation failure (n = 21). Bronchoscopy was generally performed soon after PICU admission, at a median time of 1.5 days for the former three categories, and 4 days for extubation failure group. A positive yield from bronchoscopy (diagnosis that explained the clinical condition or influenced patient management) was present in 113 of 148 (76%) procedures, varying within groups from 44% (pulmonary disease) to 90% (extubation failure). Ten percent of patients developed a fall in oxygen saturations > 20% during the procedure and 17% required a bolus of at least 10 ml/kg of 0.9% saline for hypotension. Critically ill patients with respiratory problems may benefit from a PICU-led bronchoscopy service as the yield for positive bronchoscopic finding is high, particularly for upper airway problems or extubation failure.

Tracheomalacia and Bronchomalacia in Children: Incidence and Patient Characteristics

Congenital airway malacia is one of the few causes of irreversible airways obstruction in children, but the incidence in the general population is unknown. Severe airway malacia or malacia associated with specific syndromes is usually recognized and diagnosed early in infancy, but information about clinical features of children with primary malacia, often diagnosed only later in childhood, is scarce.We analyzed all flexible bronchoscopies performed between 1997 and 2004 in the Sophia Children's Hospital, summarized clinical features of children with primary airway malacia, estimated the incidence of primary airway malacia, and calculated the predictive value of a clinical diagnosis of airway malacia by pediatric pulmonologists.In a total of 512 bronchoscopies, airway malacia was diagnosed in 160 children (94 males) at a median age of 4.0 years (range, 0 to 17 years). Airway malacia was classified as primary in 136 children and secondary in 24 children. The incidence of primary airway malacia was estimated to be at least 1 in 2,100. When pediatric pulmonologists expected to find airway malacia (based on symptoms, history, and lung function) prior to bronchoscopy, this was correct in 74% of the cases. In 52% of the airway malacia diagnoses, the diagnosis was not suspected prior to bronchoscopy. Presenting clinical features of children with airway malacia were variable and atypical, showing considerable overlap with features of allergic asthma. Peak expiratory flow was more reduced than FEV(1).Primary airway malacia is not rare in the general population, with an estimated incidence of at least 1 in 2,100 children. Airway malacia is difficult to recognize based on clinical features that show overlap with those of more common pulmonary diseases. We recommend bronchoscopy in patients with impaired exercise tolerance, recurrent lower airways infection, and therapy-resistant, irreversible, and/or atypical asthma to rule out airway malacia.

Virtual Reality and Written Assessments Are of Potential Value to Determine Knowledge and Skill in Flexible Bronchoscopy

Background: Technically challenging professions such as those of the defense and transportation industries increasingly use computer-based simulation and written self-learning instruments for education and to determine competency. A structured learning curriculum does not exist, however, for flexible bronchoscopy, a minimally invasive diagnostic procedure performed on thousands of patients by respiratory specialists, otolaryngologists, anesthesiologists, and surgeons worldwide. Objective: To explore an analogous strategy of measuring theoretical knowledge in flexible bronchoscopy and specific technical skills using written knowledge assessments and a virtual reality bronchoscopy simulator. Methods: Twelve trainees from a university pulmonary medicine training program were asked to identify and enter five specific bronchial segments on command using a virtual reality bronchoscopy skill station, and to complete a 50-question examination pertaining to bronchoscopy theory. Their performance scores and opinions pertaining to the use of these methods of assessment were then recorded. Results: Trainees correctly identified and entered 71% of the bronchial segments required on command (median 60%, range 40–100%). Fifty percent (3/6) of the trainees who had performed more than 200 flexible bronchoscopies successfully entered all segments required. None (0/6) of those who had performed less than 200 flexible bronchoscopies correctly located, identified and entered all required segments. Despite disparate performance, all trainees believed that technical skills could be improved through practice and instruction using computer-based simulation. On the written assessment, only 51% of questions were answered correctly (median 52%, range 32–60%). No relationship between technical skill and theoretical knowledge was noted. In addition, neither bronchoscopy skill nor theoretical knowledge were associated with years of training or number of bronchoscopies previously performed. Conclusions: Trainees concluded that (1) bronchoscopy simulation was realistic, (2) simulator-based practice would help improve technical skills, and (3) a written questionnaire would benefit theoretical knowledge acquisition if designed as a learning instrument. The wide variability noted in this study as well as the lack of a relationship between technical skill, knowledge of bronchoscopy theory, extent of training, and bronchoscopy experience suggest that competency should not be assumed based on years of bronchoscopy training or on an arbitrary number of procedures performed.

Bronchoscopy--how and when?

At the Royal Brompton Hospital, we perform over 200 flexible bronchoscopies per year in children. We will be presenting a series of five articles describing various aspects of our clinical and research practice. This first article is about the basics of how and when to perform flexible bronchoscopy. It highlights aspects of training, preparation of the patient and the equipment required. It discusses anaesthesia and gives practical details on how to actually use the bronchoscope, as well as detailing techniques of lavage, brushings and biopsy. Particular attention is paid to indications and contraindications, as well as potential complications.