Bronchoscopy simulation training in the post-pandemic world

Vieira, Lais Meirelles Nicoliello; Camargos, Paulo Augusto Moreira; Ibiapina, Cássio da Cunha

doi:10.36416/1806-3756/e20210361

Lais Meirelles Nicoliello Vieira

. Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil.

https://orcid.org/0000-0003-3223-4293

Paulo Augusto Moreira Camargos

. Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil.

https://orcid.org/0000-0003-4731-291X

Cássio da Cunha Ibiapina

. Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil.

https://orcid.org/0000-0003-3607-8857

Correspondence to:
Lais Meirelles Nicoliello Vieira. Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, Santa Efigênia, CEP 30130-100, Belo Horizonte, Minas Gerais, Brasil. Tel.: 31 3409-9660. E-mail: laisnicoliello@hotmail.com

AUTHOR CONTRIBUTIONS

LMNV: literature review and drafting of the manuscript; PAMC and CCI: drafting of the manuscript and critical revision of the manuscript for important intellectual content; LMNV, PAMC, and CCI: final approval of the version to be published.

CONFLICTS OF INTEREST

None declared.

Study	Objective	Population	Sample	Method	Result	Conclusion
Crawford et al.⁹9 Crawford SW, Colt HG. Virtual reality and written assessments are of potential value to determine knowledge and skill in flexible bronchoscopy. Respiration. 2004;71(3):269-275. https://doi.org/10.1159/000077425 https://doi.org/10.1159/000077425...	To evaluate specific technical skills by means of a virtual reality bronchoscopy simulator	Pulmonology residents	5	A prospective study evaluating the participants during identification of and insertion of the bronchoscope in five specific bronchial segments	Trainees identified 71% of the bronchi correctly. Of those who had performed more than 200 bronchoscopies, 50% explored all segments Beginners were unable to identify all segments	Great variability was observed, suggesting that these abilities do not correlate with the years of training or the number of bronchoscopies performed
Colt et al.⁴4 Colt HG, Crawford SW, Galbraith O 3rd. Virtual reality bronchoscopy simulation: a revolution in procedural training. Chest. 2001;120(4):1333-1339. https://doi.org/10.1378/chest.120.4.1333 https://doi.org/10.1378/chest.120.4.1333...	To evaluate whether training beginners on a bronchoscopy simulator would allow the acquisition of basic skills, in comparison with experienced physicians, who received traditional training	Pulmonology and intensive care residents	5	A prospective study comparing a group of beginners receiving bronchoscopy simulator training and a group of experienced physicians who had performed more than 200 bronchoscopies	Beginners significantly improved their dexterity after training, equaling or even surpassing the performance of experts	The evaluation metrics provided by the simulator were able to distinguish among novice, intermediate-level, and expert bronchoscopists, suggesting that clinical skills are correlated with the simulator environment
Davoudi et al.¹¹11 Davoudi M, Osann K, Colt HG. Validation of two instruments to assess technical bronchoscopic skill using virtual reality simulation. Respiration. 2008;76(1):92-101. https://doi.org/10.1159/000126493 https://doi.org/10.1159/000126493...	To evaluate bronchoscopy abilities by means of two novel instruments: the BSTAT and the BSET	Medical students, pulmonology residents, intensive care residents, intensivists, and thoracic surgeons	22	A prospective cohort study in which two independent evaluators simultaneously scored participants during simulation bronchoscopy	A high correlation (0.86 for the BSTAT and 0.85 for the BSET) was found for both methods There were clear differences between beginners and experts	Both tools showed high reliability and simultaneous validity in distinguishing beginners from experts It was not possible to discriminate significantly among intermediate trainees
Konge et al.¹⁰10 Konge L, Arendrup H, von Buchwald C, Ringsted C. Using performance in multiple simulated scenarios to assess bronchoscopy skills. Respiration. 2011;81(6):483-490. https://doi.org/10.1159/000324452 https://doi.org/10.1159/000324452...	To explore the validity of an evaluation method for bronchoscopy simulation training	Medical specialists, resident physicians, and medical students	42	A prospective study that filmed the participants while they performed six simulated bronchoscopies, with increasing difficulty Their performance was scored by two blind evaluators using a checklist	High interexaminer reliability was found The evaluation method differentiated among the three groups in terms of their performance (p < 0.001)	The evaluation procedure differentiated among beginners, intermediate trainees, and experts
Colella et al.¹²12 Colella S, Søndergaard Svendsen MB, Konge L, Svendsen LB, Sivapalan P, Clementsen P. Assessment of competence in simulated flexible bronchoscopy using motion analysis. Respiration. 2015;89(2):155-161. https://doi.org/10.1159/000369471 https://doi.org/10.1159/000369471...	To evaluate whether there is a correlation between scope movements and operator experience by means of an automatic motion analysis system	Resident physicians and medical students	29	A prospective cohort study using an automatic motion analysis system to measure total scope deviation during simulation bronchoscopy	The deviations were greatest for beginners and smallest for more experienced trainees	The motion analysis system can discriminate among different levels of experience

Study	Objective	Population	Sample	Method	Result	Conclusion
Colt et al.⁴4 Colt HG, Crawford SW, Galbraith O 3rd. Virtual reality bronchoscopy simulation: a revolution in procedural training. Chest. 2001;120(4):1333-1339. https://doi.org/10.1378/chest.120.4.1333 https://doi.org/10.1378/chest.120.4.1333...	To evaluate whether training beginners on a bronchoscopy simulator would allow the acquisition of basic skills, in comparison with experienced physicians, who received traditional training	Pulmonology and intensive care residents	5	A prospective study comparing a group of beginners receiving bronchoscopy simulator training and a group of experienced physicians who had performed more than 200 bronchoscopies	After training, beginners significantly improved their dexterity, with fewer contacts with the bronchial wall (p = 0.022), and precision, with more segments identified (p = 0.029), equaling or even surpassing the performance of experts.	Virtual simulator training was effective.
Colt et al.¹³13 Colt HG, Davoudi M, Murgu S, Zamanian Rohani N. Measuring learning gain during a one-day introductory bronchoscopy course. Surg Endosc. 2011;25(1):207-216. https://doi.org/10.1007/s00464-010-1161-4 https://doi.org/10.1007/s00464-010-1161-...	To evaluate an introductory one-day bronchoscopy simulation training course.	Pulmonology and intensive care residents	24	A multicenter prospective study evaluating pre-test and post-test trainees on the simulator	After training, the mean scores for the technical skill tests on the simulator improved significantly, from 43% to 77% (p = 0.017).	Virtual simulator training was effective.
Veaudor et al.¹⁴14 Veaudor M, Gérinière L, Souquet PJ, Druette L, Martin X, Vergnon JM, et al. High-fidelity simulation self-training enables novice bronchoscopists to acquire basic bronchoscopy skills comparable to their moderately and highly experienced counterparts. BMC Med Educ. 2018;18(1):191. https://doi.org/10.1186/s12909-018-1304-1 https://doi.org/10.1186/s12909-018-1304-...	To evaluate whether a self-driven training program on a high-fidelity simulator would allow beginner residents to acquire skills similar to those of experienced bronchoscopists	Pulmonology residents	34	A prospective cohort study comparing the performance of bronchoscopists trained on a high-fidelity simulator with that of experienced bronchoscopists	There was a significant reduction in mean procedure time (p = 0.002) and an improvement in overall performance (p = 0.002) among beginners, comparable to the general performance of experienced professionals.	The simulator was effective in bronchoscopy training.
Wahidi et al.¹⁵15 Wahidi MM, Silvestri GA, Coakley RD, Ferguson JS, Shepherd RW, Moses L, et al. A prospective multicenter study of competency metrics and educational interventions in the learning of bronchoscopy among new pulmonary fellows. Chest. 2010;137(5):1040-1049. https://doi.org/10.1378/chest.09-1234 https://doi.org/10.1378/chest.09-1234...	To evaluate trainees performing bronchoscopy on real patients after receiving bronchoscopy simulator training.	Pulmonology residents	47	A multicenter prospective study comparing the performance of simulator-trained participants with that of participants who had received traditional training The BSTAT was used	The incorporation of simulated bronchoscopy increased the speed of acquisition of bronchoscopy skills, and there was a statistically significant improvement in the mean BSTAT scores of trainees (p < 0.05)	The use of simulators prior to performing bronchoscopy on real patients allows the improvement of bronchoscopy skills
Ost et al.⁵5 Ost D, DeRosiers A, Britt EJ, Fein AM, Lesser ML, Mehta AC. Assessment of a bronchoscopy simulator. Am J Respir Crit Care Med. 2001;164(12):2248-2255. https://doi.org/10.1164/ajrccm.164.12.2102087 https://doi.org/10.1164/ajrccm.164.12.21...	To validate a virtual bronchoscopy simulator	Pulmonology and intensive care residents	28	A multicenter prospective cohort study evaluating participants performing bronchoscopy on real patients after receiving simulator training or traditional training	The participants who underwent simulation training significantly improved their abilities after 20 simulations, with a reduction in time (p = 0.001) and an increase in the number of bronchi inspected (p = 0.03) In addition, they obtained better results on real patients than did those who received traditional training	Bronchoscopy simulation training allowed faster acquisition of bronchoscopy skills in comparison with traditional training
Rowe et al.¹⁶16 Rowe R, Cohen RA. An evaluation of a virtual reality airway simulator. Anesth Analg. 2002; 95(1):62-66. https://doi.org/10.1097/00000539-200207000-00011 https://doi.org/10.1097/00000539-2002070...	To evaluate the efficacy of a single short training session in pediatric endotracheal intubation on a bronchoscopy simulator	Pediatrics residents	20	A prospective study comparing the performance of residents on real patients before and after simulator training	After simulator training, there was a reduction in the time to complete intubation with a bronchoscope (p < 0.001), in the number of contacts with the mucosa (p < 0.001), and in the time spent to view the mucosa adequately (p < 0.001), as well as an increase in the percentage of airway visualization (p = 0.004)	Even a single short simulator training session improved the ability to perform pediatric endotracheal intubation with a bronchoscope
Sokouti et al.¹⁷17 Sokouti M, Rezaei P, Ghojazadeh M, Sokouti M, Sadeghi R, Pashazadeh S, et al. 195: Systematic review and meta-analysis on the study of bronchoscopy training based on visual reality simulation. BMJ Open. 2017;7(Suppl 1).	To conduct a systematic review of studies on virtual reality bronchoscopy simulator training	Database searching (MEDLINE/PubMed, Scopus, and Google Scholar)	-	A meta-analysis including original articles published between 2000 and 2016 and examining virtual reality bronchoscopy simulator training in rigid and flexible bronchoscopy	Eight studies of virtual reality bronchoscopy simulator training were retrieved	Bronchoscopy simulation training improved technical skills and should be considered an important learning tool
Nilsson et al.¹⁸18 Nilsson PM, Naur TMH, Clementsen PF, Konge L. Simulation in bronchoscopy: current and future perspectives. Adv Med Educ Pract. 2017;8:755-760. https://doi.org/10.2147/AMEP.S139929 https://doi.org/10.2147/AMEP.S139929...	To conduct an extensive bibliographic review of bronchoscopy simulation training	Database searching in July of 2016	-	Systematic review of studies of bronchoscopy simulation training, covering training structure, evaluation of skills, and inexpensive alternatives	It was reported that bronchoscopy simulation training should be structured, that practicing in pairs is feasible and allows for more efficient use of the equipment, and that the performance of trainees should be evaluated by validated tools	Bronchoscopy simulation training is effective

Study	Objective	Population	Sample	Method	Result	Conclusion
Bjerrum et al.¹⁹19 Bjerrum AS, Eika B, Charles P, Hilberg O. Distributed practice. The more the merrier? A randomised bronchoscopy simulation study. Med Educ Online. 2016;21:30517. https://doi.org/10.3402/meo.v21.30517 https://doi.org/10.3402/meo.v21.30517...	To compare the efficacy of bronchoscopy simulation training on a single day with that of training distributed over one week	Pulmonology residents	20	A randomized study evaluating bronchoscopy simulation training on a single day vs. over one week Pre-test, post-test, and retention test performance was evaluated after four weeks	No interaction was found between groups and test scores (p > 0.16), except for the percentage of explored segments No major group effect was found for any of the evaluated measurements (p > 0.36)	Training can be conducted in a format that best fits the clinical practice of trainees and the availability of training centers
Veaudor et al.¹⁴14 Veaudor M, Gérinière L, Souquet PJ, Druette L, Martin X, Vergnon JM, et al. High-fidelity simulation self-training enables novice bronchoscopists to acquire basic bronchoscopy skills comparable to their moderately and highly experienced counterparts. BMC Med Educ. 2018;18(1):191. https://doi.org/10.1186/s12909-018-1304-1 https://doi.org/10.1186/s12909-018-1304-...	To evaluate the efficacy of self-driven bronchoscopy simulation training	Pulmonology residents	34	A prospective cohort study comparing the performance of beginner bronchoscopists receiving simulation training with that of experienced bronchoscopists	There was a significant reduction in the mean procedure time and a significant improvement in overall performance (p = 0.002) among beginners, comparable to the general performance of experienced professionals	Self-driven training on a bronchoscopy simulator was effective, allowing trainees to acquire basic skills similar to those of experienced bronchoscopists
Gopal et al.²2 Gopal M, Skobodzinski AA, Sterbling HM, Rao SR, LaChapelle C, Suzuki K, et al. Bronchoscopy Simulation Training as a Tool in Medical School Education. Ann Thorac Surg. 2018;106(1):280-286. https://doi.org/10.1016/j.athoracsur.2018.02.011 https://doi.org/10.1016/j.athoracsur.201...	To evaluate the impact of bronchoscopy simulation training on the knowledge of anatomy and on the technical skills of medical students	Medical students	47	A prospective study in which two surgeons evaluated the performance of participants receiving bronchoscopy simulation training The BSTAT was used	After training, there was a significant increase in BSTAT scores (p < 0.0001), visualization of bronchial anatomy (p < 0.0001), and bronchoscopy navigational skills (p < 0.0001)	Self-driven bronchoscopy simulation training was effective in medical students
Bjerrum et al.²⁰20 Bjerrum AS, Eika B, Charles P, Hilberg O. Dyad practice is efficient practice: a randomised bronchoscopy simulation study. Med Educ. 2014;48(7):705-712. https://doi.org/10.1111/medu.12398 https://doi.org/10.1111/medu.12398...	To compare the effectiveness of bronchoscopy simulation training performed in pairs and individually	Medical students	36	A randomized study comparing bronchoscopy simulation training performed in pairs and individually, by means of a pre-test, a post-test, and a retention test three weeks later	The two groups showed significantly improved performance after simulation training (p < 0.001) There was no difference in the efficacy of acquiring bronchoscopy skills between the two groups (p < 0.16)	Training in pairs can be considered more effective because the same resources used individually can be used in pairs
Latif et al.²¹21 K Latif R, Bautista A, Duan X, Neamtu A, Wu D, Wadhwa A, et al. Teaching basic fiberoptic intubation skills in a simulator: initial learning and skills decay. J Anesth. 2016;30(1):12-19. https://doi.org/10.1007/s00540-015-2091-z https://doi.org/10.1007/s00540-015-2091-...	To establish the time and number of attempts required to train beginners in fiberoptic bronchoscopy and intubation using simulators	Medical students	15	A prospective study in which participants received guidance from an experienced instructor and then started supervised training on a virtual simulator They returned after two months for a new evaluation	After training, the trainees’ technical skills were compared with those of experts. In the evaluation performed after two months, a longer time was needed to view the anatomy; however, when this performance was compared with the pre-test performance, retention of knowledge was observed	Training in fiberoptic bronchoscopy and intubation on simulators was effective, with knowledge retention
Bjerrum et al.²²22 Bjerrum AS, Hilberg O, van Gog T, Charles P, Eika B. Effects of modelling examples in complex procedural skills training: a randomised study. Med Educ. 2013;47(9):888-898. https://doi.org/10.1111/medu.12199 https://doi.org/10.1111/medu.12199...	To evaluate the effectiveness of integrating modeling examples into bronchoscopy simulation training	Medical students	48	A randomized study evaluating the effectiveness of integrating modeling examples into bronchoscopy simulation training, by means of a pre-test, a post-test, and a retention test after three weeks	Both groups showed significant improvement after training However, the modeling example group was significantly better than the control group (p < 0.0001)	The use of modeling examples in bronchoscopy simulation training was effective

[1] Correspondence to:
Lais Meirelles Nicoliello Vieira. Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, Santa Efigênia, CEP 30130-100, Belo Horizonte, Minas Gerais, Brasil. Tel.: 31 3409-9660. E-mail: laisnicoliello@hotmail.com

Brasil

Brasil

Bronchoscopy simulation training in the post-pandemic world

ABSTRACT