Learning Experience of Linear Endobronchial Ultrasound Among Pulmonary Trainees

doi:10.1378/chest.13-0701

Chest

Volume 145, Issue 3, March 2014, Pages 574-578

https://doi.org/10.1378/chest.13-0701 Get rights and content

Background

Linear endobronchial ultrasound (EBUS) allows real-time guidance of transbronchial needle aspiration of thoracic structures and has become an increasingly important diagnostic tool for chest physicians. Little has been published about the learning experience of operators with this technology. The purpose of this study was to define the learning experience of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) among pulmonary trainees.

Methods

This was a multicenter cohort study of fellows in pulmonary medicine over the first 2 years of their training. Prior to performing EBUS-TBNA, all participants had to complete 30 conventional bronchoscopies, an EBUS-specific didactic curriculum, and a simulation session with a plastic airway model. Each consecutive EBUS procedure was scored with a checklist that evaluated the ability to pass a bronchoscope through vocal cords, identify the appropriate node for sampling, acquire adequate ultrasound images, guide the bronchoscopy team through the technical steps of EBUS-TBNA, and obtain adequate tissue samples.

Results

Thirteen pulmonary trainees from three training programs were enrolled in the study and were observed over a 2-year period. The majority of trainees were able to perform all essential steps of EBUS-TBNA and obtain adequate tissue after performing an average of 13 (95% CI, 7-16) procedures.

Conclusions

Pulmonary trainees needed an average of 13 procedures to achieve first independent successful performance of EBUS-TBNA following a training protocol that included a didactic curriculum and simulation-based practice. Our findings could guide pulmonary fellowship directors in planning EBUS training and establishing a reasonable juncture to assess EBUS skills with validated assessment tools.

Section snippets

Materials and Methods

This was a multicenter cohort study of fellows in pulmonary medicine with an observation period of 2 years. Study protocols were approved by each institution's review board. Thirteen fellows from Duke University Medical Center, Medical University of South Carolina, and Virginia Commonwealth University Medical Center were followed for a 2-year period starting at the first day of their pulmonary fellowship. At the beginning of the study period, each participant completed a survey to assess their

Statistical Analysis

The primary survival analysis related the number of EBUS-TBNA procedures to the percentage of fellows completing all EBUS-TBNA steps. The procedures from 13 fellows were used in the analysis. Of the 13 fellows, 11 completed all EBUS-TBNA steps by the end of the study. The two fellows who did not complete all EBUS-TBNA steps by the end of the study had censored observations in the analysis. The two vertical hash marks on the graph (Fig 1) are plotted at the number of EBUS-TBNA steps completed by

Bronchoscopy Experience and Demographics

Table 1 summarizes the participating fellows' demographics. It also illustrates their prior experience in conventional and EBUS bronchoscopy and perception about EBUS bronchoscopy.

EBUS-TBNA Procedural Details

Indications for the EBUS-TBNA procedure consisted of undiagnosed hilar and/or mediastinal lymphadenopathy (46%), pulmonary nodule/lung mass/mediastinal mass (24%), additional sampling for lung cancer (4%), suspected sarcoidosis (3%), and lung cancer staging (3%). A number of extrathoracic malignancies were listed

EBUS-TBNA Fellow Learning Experience

Pulmonary trainees were able to complete the essential steps of EBUS-TNBA and perform the procedure successfully with adequate tissue sampling at variable rates: 25% of trainees did so after an average of five EBUS-TBNA procedures (95% CI, 2-7), 50% after nine procedures (95% CI, 4-13), and 75% after 13 procedures (95% CI, 7-16). Figure 1 illustrates the learning experience of EBUS-TBNA among pulmonary trainees.

Discussion

EBUS-TBNA has become an important clinical tool in the armamentarium of chest physicians in the diagnosis of malignant and benign mediastinal and hilar conditions. Very little has been published about the learning experience for EBUS-TBNA, and the existing literature does not specifically address physicians in training. To our knowledge, our prospective multicenter study was the first study to look at this cohort of learners.

In our checklist assessment of EBUS-TBNA performance, we outlined the

Acknowledgments

Author contributions: Dr Wahidi is guarantor of the manuscript and takes responsibility for the integrity of the work as a whole from inception to published article.

Dr Wahidi: contributed to the design and data analysis of this study and the review and editing of the manuscript.

Dr Hulett: contributed to the design and data analysis of this study and the review and editing of the manuscript.

Dr Pastis: contributed to data collection for this study and the review and editing of the manuscript.

References (10)

A Tremblay et al.
A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis
Chest
(2009)
P Gu et al.
Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis
Eur J Cancer
(2009)
NT Tanner et al.
Training for linear endobronchial ultrasound among US pulmonary/critical care fellowships: a survey of fellowship directors
Chest
(2013)
MA Unroe et al.
Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques
Curr Opin Pulm Med
(2010)
CT Bolliger et al.
ERS/ATS statement on interventional pulmonology
Eur Respir J
(2002)

There are more references available in the full text version of this article.

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Hence, the real EBUS views have been blank, as Figs. 6a–c show. Fig. 6d illustrates system state after the EBUS push — clearly, the real EBUS view indicates that the physician has immediately hit the target lymph node, without the usual guesswork encountered in standard EBUS practice [11]. The Multimodal Virtual Bronchoscope has now reached the preplanned destination for optimal EBUS ROI localization in virtual space.
The staging of the central-chest lymph nodes is a major step in the management of lung-cancer patients. For this purpose, the physician uses a device that integrates videobronchoscopy and an endobronchial ultrasound (EBUS) probe. To biopsy a lymph node, the physician first uses videobronchoscopy to navigate through the airways and then invokes EBUS to localize and biopsy the node. Unfortunately, this process proves difficult for many physicians, with the choice of biopsy site found by trial and error. We present a complete image-guided EBUS bronchoscopy system tailored to lymph-node staging. The system accepts a patient’s 3D chest CT scan, an optional PET scan, and the EBUS bronchoscope’s video sources as inputs. System workflow follows two phases: (1) procedure planning and (2) image-guided EBUS bronchoscopy. Procedure planning derives airway guidance routes that facilitate optimal EBUS scanning and nodal biopsy. During the live procedure, the system’s graphical display suggests a series of device maneuvers to perform and provides multimodal visual cues for locating suitable biopsy sites. To this end, the system exploits data fusion to drive a multimodal virtual bronchoscope and other visualization tools that lead the physician through the process of device navigation and localization. A retrospective lung-cancer patient study and follow-on prospective patient study, performed within the standard clinical workflow, demonstrate the system’s feasibility and functionality. For the prospective study, 60/60 selected lymph nodes (100%) were correctly localized using the system, and 30/33 biopsied nodes (91%) gave adequate tissue samples. Also, the mean procedure time including all user interactions was 6 min 43 s All of these measures improve upon benchmarks reported for other state-of-the-art systems and current practice. Overall, the system enabled safe, efficient EBUS-based localization and biopsy of lymph nodes.
Development of Learning Curves for Bronchoscopy: Results of a Multicenter Study of Pulmonary Trainees
2020, Chest
There are currently no reference standards for the development of competence in bronchoscopy.
The aims of this study were to (1) develop learning curves for bronchoscopy skill development and (2) estimate the number of bronchoscopies required to achieve competence.
Trainees from seven North American academic centers were enrolled at the beginning of their pulmonology training. Performance during clinical bronchoscopies was assessed by supervising physicians using the Ontario Bronchoscopy Assessment Tool (OBAT). Group-level learning curves were modeled using a quantile regression growth model, where the dependent variable was the mean OBAT score and the independent variable was the number of bronchoscopies performed at the time the OBAT was completed.
A total of 591 OBAT assessments were collected from 31 trainees. The estimated regression quantiles illustrate significantly different learning curves based on trainees’ performance percentiles. When competence was defined as the mean OBAT score for all bronchoscopies rated as being completed without need for supervision, the mean OBAT score associated with competence was 4.54 (95% CI, 4.47-4.58). Using this metric, the number of bronchoscopies required to achieve this score varied from seven to 10 for the 90th percentile of trainees and from 109 to 126 for the lowest 10th percentile of trainees. When competence was defined as the mean OBAT score for the first independent bronchoscopy, the mean was 4.40 (95% CI, 4.20-4.60). On the basis of this metric, the number of bronchoscopies required varied from one to 11 for the 90th percentile of trainees and from 83 to 129 for the lowest 10th percentile of trainees.
We were able to generate learning curves for bronchoscopy across a range of trainees and centers. Furthermore, we established the average number of bronchoscopies required for the attainment of competence. This information can be used for purposes of curriculum planning and allows a trainee’s progress to be compared with an established norm.
An Evaluation of Diagnostic Yield From Bronchoscopy: The Impact of Clinical/Radiographic Factors, Procedure Type, and Degree of Suspicion for Cancer
2020, Chest
Citation Excerpt :
The surgical literature has previously established that undergoing procedures performed by high-volume clinicians or high-volume institutions had significantly better outcomes compared with their low-volume counterparts.9,10 Although the pulmonary community has established competency metrics for both standard bronchoscopy and EBUS-TBNA,11,12 there are no similar studies showing a correlation between diagnostic yield from bronchoscopy and procedural volume. To complicate matters further, published meta-analyses have combined these single-site, retrospective, high-volume, expert proceduralist studies, with the result being reports that tout high aggregate diagnostic yields.3
Bronchoscopy is commonly used to evaluate suspicious lung lesions. The yield is likely dependent on patient, radiographic, and bronchoscopic factors. Few studies have assessed these factors simultaneously while also including the preprocedure physician-assessed probability of cancer (pCA) when assessing yield.
This study is a secondary data analysis from a prospective multicenter trial. Diagnostic yield of standard bronchoscopy with biopsy ± fluoroscopy, endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), electromagnetic navigation, and combination bronchoscopies was assessed. Definitions for diagnostic and nondiagnostic bronchoscopies were rigorously predefined. The association of diagnostic yield with individual variables was examined by using univariate and multivariate logistic regression analyses where appropriate.
A total of 687 patients were included from 28 sites. Overall diagnostic yield was 69%; 80% for EBUS, 55% for bronchoscopy with biopsy ± fluoroscopy, 57% for electromagnetic navigation, and 74% for combination procedures (P < .001). Patients with larger, central lesions with adenopathy were significantly more likely to undergo a diagnostic bronchoscopy. Patients with pCA < 10% and 10% to 60% had lower yields (44% and 42%, respectively), whereas pCA > 60% yielded a positive result in 77% (P < .001). In multivariate logistic regression, the use of EBUS-TBNA, larger sized lesions, and central location were significantly associated with a diagnostic bronchoscopy. Seventeen percent of those with a malignant diagnosis and 28% of those with a benign diagnosis required secondary procedures to establish a diagnosis.
This study is the first to assess the yield of bronchoscopy according to physician-assessed pCA in a large, prospective multicenter trial. The yield of bronchoscopy varied greatly according to physician suspicion that cancer is present, the patients’ clinical/radiographic features, and the type of procedure performed. Of the procedures performed, EBUS-TBNA was the most likely to provide a diagnosis.
Optimal route planning for image-guided EBUS bronchoscopy
2019, Computers in Biology and Medicine
Citation Excerpt :
In addition, reliable bronchoscopic methods for adequate tissue sampling are being called upon for evidence-based lung-cancer treatment planning, lung precision medicine, and the search for airway biomarkers aiding early lung-cancer detection/monitoring [48–50]. Unfortunately, skill variations in interpreting patient chest CT scans and in using EBUS limit staging effectiveness [11]. In particular, the accuracy of localizing target lymph nodes and the selection of safe, effective biopsy sites is inadequate, as it involves manual trial-and-error methods.
The staging of the central-chest lymph nodes is a major lung-cancer management procedure. To perform a staging procedure, the physician first uses a patient's 3D X-ray computed-tomography (CT) chest scan to interactively plan airway routes leading to selected target lymph nodes. Next, using an integrated EBUS bronchoscope (EBUS = endobronchial ultrasound), the physician uses videobronchoscopy to navigate through the airways toward a target node's general vicinity and then invokes EBUS to localize the node for biopsy. Unfortunately, during the procedure, the physician has difficulty in translating the preplanned airway routes into safe, effective biopsy sites. We propose an automatic route-planning method for EBUS bronchoscopy that gives optimal localization of safe, effective nodal biopsy sites. To run the method, a 3D chest model is first computed from a patient's chest CT scan. Next, an optimization method derives feasible airway routes that enables maximal tissue sampling of target lymph nodes while safely avoiding major blood vessels. In a lung-cancer patient study entailing 31 nodes (long axis range: [9.0 mm, 44.5 mm]), 25/31 nodes yielded safe airway routes having an optimal tissue sample size = 8.4 mm (range: [1.0 mm, 18.6 mm]) and sample adequacy = 0.42 (range: [0.05, 0.93]). Quantitative results indicate that the method potentially enables successful biopsies in essentially 100% of selected lymph nodes versus the 70–94% success rate of other approaches. The method also potentially facilitates adequate tissue biopsies for nearly 100% of selected nodes, as opposed to the 55–77% tissue adequacy rates of standard methods. The remaining nodes did not yield a safe route within the preset safety-margin constraints, with 3 nodes never yielding a route even under the most lenient safety-margin conditions. Thus, the method not only helps determine effective airway routes and expected sample quality for nodal biopsy, but it also helps point out situations where biopsy may not be advisable. We also demonstrate the methodology in an image-guided EBUS bronchoscopy system, used successfully in live lung-cancer patient studies. During a live procedure, the method provides dynamic real-time sample size visualization in an enhanced virtual bronchoscopy viewer. In this way, the physician vividly sees the most promising biopsy sites along the airway walls as the bronchoscope moves through the airways.
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Funding/Support: The authors have reported to CHEST that no funding was received for this study.

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Chest

Original Research: Pulmonary ProceduresLearning Experience of Linear Endobronchial Ultrasound Among Pulmonary Trainees

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Statistical Analysis

Bronchoscopy Experience and Demographics

EBUS-TBNA Procedural Details

EBUS-TBNA Fellow Learning Experience

Discussion

Acknowledgments

Chest

Eur J Cancer

Chest

Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques

Curr Opin Pulm Med

ERS/ATS statement on interventional pulmonology

Eur Respir J

Original Research: Pulmonary Procedures
Learning Experience of Linear Endobronchial Ultrasound Among Pulmonary Trainees