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Original Research: INTERVENTIONAL PULMONOLOGY |

The Safety of Bronchoscopy in a Pulmonary Fellowship Program* FREE TO VIEW

Daniel R. Ouellette, MD, FCCP
Author and Funding Information

*From the Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI.

Correspondence to: Daniel R. Ouellette, MD, FCCP, Senior Staff Physician, Pulmonary and Critical Care Medicine, Henry Ford Hospital, 2799 West Grand Ave, Detroit, MI 48202; e-mail: Douelle1@hfhs.org



Chest. 2006;130(4):1185-1190. doi:10.1378/chest.130.4.1185
Text Size: A A A
Published online

Study objective: To determine the complication rate from supervised training bronchoscopy in a single pulmonary fellowship program, and to examine the effects of fellow and faculty experience on this complication rate.

Design: A retrospective review of preexisting quality improvement data from one center for the time period July 1, 1991, until June 30, 2005, was performed. The data were stratified based on the fellow year group and the staff experience level. The types of complications were recorded.

Setting: The study was performed at an accredited pulmonary and critical care fellowship program at a military medical center in the United States.

Participants: Fifty-one pulmonary and critical care medicine fellows and 20 staff supervising physicians performed the bronchoscopies that were included in this study.

Results: A total of 3,538 training bronchoscopies were performed during the study period with 73 complications for a complication rate of 2.06%. The most common complication was pneumothorax. The overall complication rates for first-year fellows (1stYFs), second-year fellows, and third-year fellows were not significantly different from the total complication rate. Training bronchoscopies supervised by junior staff had a complication rate not significantly different from that of senior staff. The cumulative complication rate for the first trimester for 1stYFs was 3.1%, whereas the cumulative complication rate for the second plus the third trimester for 1stYFs was 1.57% (p < 0.05).

Conclusions: Training bronchoscopy performed during a pulmonary fellowship is a safe procedure in a supervised setting. Patients undergoing bronchoscopy performed by novice bronchoscopists have an increased complication rate during the first trimester of bronchoscopist training.

Bronchoscopy is a widely performed procedure that is generally considered to be safe and effective. Although bronchoscopy was first performed by Gustav Killian in 1897, it was the development of flexible fiberoptic bronchoscopy by Ikeda in 1964 that led to a revolution in the clinical science of bronchoscopy.1Survey data concerning flexible fiberoptic bronchoscopy24 suggest that complication rates are very low. The concept that flexible fiberoptic bronchoscopy is a safe procedure has been reinforced by studies of bronchoscopy complications in populations of patients that might be considered to be at high risk because of comorbidities or other factors. Patients with thrombocytopenia,5asthma,6pregnancy,7and COPD,8and those who are octogenarians9 have low rates of complications.

In the United States, training in bronchoscopy is generally accomplished in the context of pulmonary and critical care medicine fellowship programs. Guidelines have been established1011 concerning the number of supervised training bronchoscopies that must be performed for competency. Despite the fact that the numbers of bronchoscopies required for fellow competency have been established, there are few clinical outcome data supporting specific competency levels. One measure of procedural competency is patient safety and procedure complication rates. The safety of supervised training bronchoscopy has been the subject of several reports.1214 The purpose of this study was to assess the safety of training bronchoscopy at one teaching hospital, and to determine whether complication rates varied depending on fellow or staff experience levels.

Setting and Study Design

The data set used for this study included all complete and legible bronchoscopy reports and the associated complication data sheets for all training bronchoscopies performed between July 1, 1991, and June 30, 2005. These data were retrospectively reviewed. Bronchoscopy reports were not included in the data set if they were illegible or incomplete, or if the bronchoscopy did not meet the definition of a training bronchoscopy. The study protocol was approved as an exempt protocol by the Brooke Army Medical Center (BAMC) institutional review board. The need for informed consent was waived.

Data were extracted from the bronchoscopy reports and complication data sheets and entered into a computerized database. Bronchoscopy reports were generally completed by the bronchoscopist at the time of the bronchoscopy. The patients were prospectively monitored following bronchoscopy for complications while the patient recovered from the bronchoscopy anesthesia, and the bronchoscopist completed the complication data sheet following discharge of the patient from the hospital to home. Patient identifiers were not included in the database. Data were stratified by fellow year group, staff experience level, academic year, and academic trimester. Data were collected on the number and types of complications that occurred. Data were also collected on ancillary procedures performed with bronchoscopy during selected academic years.

Definitions

Training bronchoscopy is defined as a bronchoscopy performed by a pulmonary fellow participating in an educational rotation at BAMC under the supervision of a staff physician. A bronchoscopy complication is a serious complication that requires a second invasive procedure to be performed or results in hospitalization or elevation of the level of care. Patients were monitored for complications in a recovery area following bronchoscopy by nursing personnel until the effects of topical and systemic anesthesia had resolved. Chest radiographs were routinely obtained in all patients undergoing transbronchial biopsies immediately following bronchoscopy, but were obtained in other patients at the bronchoscopist’s discretion. Academic year is defined as the period from July 1 of a given year until June 30 of the subsequent year. Academic trimester refers to a 4-month period of the educational cycle during an academic year. The first academic trimester is from July 1 until October 31 of a given academic year, the second academic trimester is from November 1 until February 27 or 28, and the third academic trimester is from March 1 until June 30.

Fellowship Training Program

Fellows at BAMC do not participate in formal training programs for bronchoscopy using simulators. Fellows have a mannequin with a model airway available for practice bronchoscopy. Fellows receive a lecture on bronchoscopy during their initial orientation to the hospital. Fellows receive significant exposure to didactic material concerning bronchoscopy from required reading and lectures during the fellowship program. Fellows also receive extensive hands-on experience and bedside teaching in bronchoscopic techniques. Fellows performed bronchoscopy on patients who they had personally seen in the clinic or in the hospital for the purposes of continuity of care, thus performing all bronchoscopic procedures on a continual basis throughout the fellowship period. A separate rotation for bronchoscopy did not exist.

Statistical Analysis

The Pearson χ2 test and the Pearson χ2 test with continuity correction were used for analysis. Statistical analysis was performed using a statistical software package (SPSS, version 13.0; SPSS Inc; Chicago IL). Differences were considered to be statistically significant when the p value was < 0.05.

Data were collected on bronchoscopies performed by pulmonary fellows at BAMC from July 1991, until June 2005. A total of 51 fellows performed bronchoscopies at BAMC during this period. All fellows had completed internal medicine residencies in the United States. Fifty fellows began their academic training in pulmonary and critical care medicine in July or August of their first training year. One fellow began her training in the mid-cycle of her first academic year. Faculty physicians were present and supervised training during all bronchoscopies reported in this study. A total of 20 faculty physicians participated in fellow training from 1991 to 2005 on either a full-time or part-time basis. All faculty physicians were board-certified or board-eligible in pulmonary medicine.

A total of 3,538 training bronchoscopies were reported between 1991 and 2005 (Table 1 ). There were 73 serious complications for a total complication rate of 2.06%. None of the fellow year groups had a complication rate that was statistically different from the total complication rate. Both junior staff and senior staff supervised the training bronchoscopies (Table 2 ). Neither junior staff nor senior staff had a complication rate that was significantly different from the total complication rate.

A total of 73 serious complications occurred with training bronchoscopies during the study period (Table 3 ). The most common complication reported was pneumothorax. One patient with respiratory decompensation was reported to have died during the 6 h immediately following bronchoscopy. Patient outcomes > 6 h following bronchoscopy were not studied.

In order to better understand the types of procedures being performed over the study period, training bronchoscopies and their associated ancillary procedures were compared for two different academic years 1 decade apart. Training bronchoscopies performed between July 1, 1993, and June 30, 1994, were compared with those performed between July 1, 2003, and June 30, 2004 (Table 4 ). Although the total number of transbronchial biopsies and endobronchial biopsies performed in each of the 2 years was very similar, the numbers of each of these two ancillary procedures relative to the total number of bronchoscopies per academic year was higher in the academic year from 2003 to 2004. The number of complications occurring from 2003 to 2004 was not significantly different from that from 1993 to 1994 (three and four, respectively).

Bronchoscopy complication rates during the first, second, and third trimesters of the academic year were investigated to determine whether a training effect on complication rates was apparent. The cumulative total number of training bronchoscopies and the associated complication rate occurring between July 1 and October 31 of each year for the study period was compared with the cumulative total number of training bronchoscopies and the associated complication rate occurring between November 1 and June 30 of each year for the study period (Table 5 ). The difference between the complication rate for first-trimester bronchoscopies and second-plus-third-trimester bronchoscopies did not reach statistical significance (p = 0.078 [Pearson χ2 analysis with continuity correction]).

Because of the trend toward a higher complication rate during the first trimester for training bronchoscopies, these data were analyzed for just first year fellows (1stYFs) [Table 5]. The cumulative first-trimester complication rate for 1stYFs was significantly different from the second-plus-third-trimester complication rate (p = 0.025 [Pearson χ2 analysis with continuity correction]).

The type of complication occurring with training bronchoscopy performed by 1stYFs during the first trimester was investigated (Table 3). There were 22 total first-trimester complications by 1stYFs during the study period. The most common complication was pneumothorax (five complications). None of these individual complications occurred significantly more frequently during first-trimester bronchoscopies performed by 1stYFs than they did overall during training bronchoscopies.

Bronchoscopy is generally considered to be a safe procedure. Data concerning complications associated with bronchoscopy have been predominantly obtained by survey and retrospective studies. Credle and coworkers15 developed a questionnaire concerning bronchoscopy that was sent to 250 physicians. The incidence of major complications reported by these physicians was 0.08%. Suratt et al2also conducted a survey of 1,041 bronchoscopists and reported a bronchoscopy complication rate of 0.3%, and a mortality rate of 0.03%. In 1991, the American College of Chest Physicians reported3 the results of a mail survey conducted in the United States. The median rate of serious complications from bronchoscopy was reported to be between 0.1 and 1.0%. Only 3.5% of the physicians surveyed reported a complication rate of > 5%.

Dreisin and coworkers12 prospectively studied 205 consecutive bronchoscopies performed at a teaching hospital. The mortality rate in this report was 0.5%, and the incidence of major or serious complications was 5%. Dreisin et al12 described the complications that occurred, which included the following: bronchospasm; laryngospasm; pneumothorax; and hemoptysis. Minor complications in this study occurred at a rate of 6%, and included the following: pulmonary infiltrates; dyspnea; epistaxis; subcutaneous emphysema; maxillary sinusitis; and an acute hysterical reaction.

Pue and Pacht13 retrospectively studied the indications and complications associated with bronchoscopy at a teaching hospital. They reviewed 4,273 consecutive bronchoscopies, which included 2,493 BAL procedures and 173 transbronchial biopsies. Seventy-two percent of bronchoscopies were performed by a pulmonary fellow with staff supervision; the rest were performed by staff pulmonary physicians. Pue and Pacht13 reported a minor complication rate of 0.5% and a major complication rate of 0.8%. Major complications included pneumothorax, pulmonary hemorrhage, and respiratory failure.

Reinoso and coworkers14 retrospectively studied consecutive training bronchoscopies at a teaching hospital. Using methodology similar to the present study, they reviewed 3,572 training bronchoscopies and examined the frequency and type of complications. Reinoso and colleagues14 reported 57 complications for a complication rate of 1.60%. There were six deaths reported in this study. The most common complications reported were pneumothorax and hemorrhage.

This study confirms and extends the results noted by Reinoso and associates.14 Both reports were retrospective analyses of training bronchoscopy data reviewing similar numbers of bronchoscopies. Both studies had similar types and numbers of associated ancillary procedures and reported similar complication rates (this study, 2.06%; Reinoso et al,14 1.60%). The most frequent complication reported in each study was pneumothorax. These two studies differ from several reports based on surveys23,15 in that a higher complication rate is reported in the two retrospective training bronchoscopy studies. This difference may be because training bronchoscopies are associated with a higher complication rate due to the inexperience and lack of dexterity of the trainees. It is also possible that the methodological nature of the surveys led to an underreporting of complications. The study by Pue and Pacht13reported a lower complication rate associated with training bronchoscopies than that reported by Reinoso et al14 or this study. The report by Pue and Pacht13 also differed from the latter two studies in that not all of the reported bronchoscopies were training bronchoscopies, there were different definitions for complications, and there were many fewer transbronchial biopsies performed. The study by Dreisin et al12 reported a high bronchoscopy complication rate at a training hospital. Dreisin and coworkers12 reviewed a much smaller data set than the other noted studies and was published > 25 years ago at a time when bronchoscopy and bronchoscopy training might be considered to have been in an early stage of evolution.

One goal of this study was to evaluate specific clinical outcomes (complication rates) in relation to the experience level of the trainee and the supervisor of bronchoscopies. The data presented in this report suggest that at our institution complication rates and patient safety were similar during training bronchoscopy regardless of the level of supervisor experience. One might imply from these data that a properly trained and credentialed faculty supervisor is able to ensure a safe procedure irrespective of the amount of postfellowship experience. It is not possible from this study to determine the minimum staff requirements in terms of training and experience that will guarantee safety with bronchoscopy. Because all physician-supervisors in this study were either board-certified or board-eligible in pulmonary disease, as defined by the American Board of Internal Medicine,10 these standards would seem to provide an appropriate point of reference for staff and faculty experience in regard to bronchoscopy.

Learning during a subspecialty training program is a continuous process, and one might expect that trainees would be more likely to perform bronchoscopy associated with complications very early in their training program when they were the most inexperienced. The academic year at our institution begins on July 1 of each year and ends on June 30 of the subsequent year. The first trimester, or first 4 months, of the academic year was compared with the remainder of the year as a 4-month period permitted almost all initiate fellows (one exception, as noted previously) in each academic year of the study to have sufficient clinical exposure to have performed at least a few bronchoscopies. We found that 1stYFs had a significantly higher complication rate during the first trimester than during the remainder of the year. To the best of our knowledge, this is the first report in the literature suggesting that initiate bronchoscopists have increased complication rates that are ameliorated by continued training and experience. It did not appear that there was a change in the frequency of any one type of complication experienced by 1stYFs compared with the group of trainees as a whole. Thus, it appears that at our institution the increased number of complications experienced by initiate bronchoscopists cannot be attributed to an inability to perform any one specific aspect of the bronchoscopy procedure.

Fellows in training in pulmonary and critical care medicine at BAMC attended lectures concerning bronchoscopy, were given selected reading material, and had supervised clinical experience. A survey16conducted at the 1998 American College of Chest Physicians annual meeting emphasized that experiences in bronchoscopy training varied significantly among different programs in the United States. Highly ranked programs were more likely to use lectures, a bronchoscopy text, and one-on-one instruction. There is considerable variation across the United States in the educational programs available to fellows in interventional bronchoscopy. Pastis et al17 published the results of a survey of training program directors in the United States and found that the presence of an interventional pulmonologist on the faculty of a training program increased the likelihood that advanced procedural training would be offered. Pastis and coworkers17found that most fellowship programs did not reach the recommended competency numbers for interventional bronchoscopy procedures. Advances in educational tools and techniques might facilitate training in bronchoscopy in the future. Colt and coworkers18demonstrated that a virtual reality bronchoscopy simulator led to improved dexterity and accuracy in a small group of novice bronchoscopists. Ost et al19 evaluated a bronchoscopy simulator. They were able to show that the simulator could differentiate among novice bonchoscopists, those with intermediate experience, and expert bronchoscopists. The training of new pulmonary fellows using this simulator led to a more rapid acquisition of bronchoscopy skills than did traditional teaching methods.

There are several limitations to this study. The training bronchoscopies performed in this study were performed at only one institution, which limits the ability to generalize the conclusions to other institutions. The data in this study were obtained in a retrospective manner. Finally, the complication rate is only one of a number of clinical outcomes that might be used to assess the adequacy of the bronchoscopy education process and competency. Other potential outcomes that could be studied include manual dexterity, clinical judgment, bronchoscopy duration, requirement for sedative agents, and diagnostic yield.1820

This work has demonstrated that the complication rate for training bronchoscopy over a 14-year period between 1991 and 2005 was 2.06% at one institution. This result is consistent with previous similar studies. Bronchoscopy complication rates were similar for all fellow year groups. Evidence has been presented that there may be an increased rate of bronchoscopy complications during initial training. These results should be confirmed by acquiring prospective information from a variety of centers. Practices that might improve bronchoscopy safety by novice bronchoscopists include the following: the use of simulators in training; closely monitored protocols for conscious sedation; and the gradual introduction of training in invasive techniques only after basic skills have been mastered. Data are needed on a variety of clinical outcomes from bronchoscopy in addition to complication rates in the assessment of the effectiveness of bronchoscopy education and the determination of competency in performing bronchoscopies. Future research is needed to determine the role of advanced educational techniques, including the use of simulators, in facilitating bronchoscopy education.

Abbreviations: BAMC = Brooke Army Medical Center; 1stYF = first-year fellow

The author is on the speakers bureaus of Ortho Biotech, Pfizer, and Boehringer-Ingleheim.

The opinions or assertions contained herein are the private views of the author and are not to be construed as reflecting the views of the Departments of the Army or Defense.

Table Graphic Jump Location
Table 1. Training Bronchoscopies Performed by Fellows*
* 

NS = not significant; 2ndYF = second-year fellow; 3rdYF = third-year fellow.

 

Fellow year group complications compared with the total number of complications.

Table Graphic Jump Location
Table 2. Staff Supervision of Training Bronchoscopies by Experience Level*
* 

See Table 1 for abbreviation not used in the text.

 

Staff complications compared with the total number of complications.

Table Graphic Jump Location
Table 3. Types of Complications With Training Bronchoscopy
Table Graphic Jump Location
Table 4. Comparison of Ancillary Procedures Performed With Bronchoscopy in Two Academic Years a Decade Apart*
* 

Values are given as the No. (%), unless otherwise indicated. Tbbx = transbronchial biopsy; Ebbx = endobronchial biopsy; TBNA = transbronchial needle aspiration; APC = argon plasma coagulation. See Table 1 for abbreviation not used in the text.

 

Comparison between the relative numbers of each procedure performed per year by χ 2 analysis.

Table Graphic Jump Location
Table 5. Comparison of Cumulative Bronchoscopy Complications by Fellows During the First Academic Trimester With the Complications During the Second and Third Trimesters*
* 

See Table 1 for abbreviation not used in the text.

 

p = 0.078 (Pearson χ 2; first trimester complication rate vs second and third trimester complication rates).

 

p = 0.025 (Pearson χ 2; first trimester complication rate vs second and third trimester complication rates).

Prakesh, UBS (1997) Gustav Killian centenary: the celebration of a century of progress in bronchoscopy.J Bronchol4,1-2. [CrossRef]
 
Suratt, PM, Smiddy, JF, Gruber, B Deaths and complications associated with fiberoptic bronchoscopy.Chest1976;69,747-751. [CrossRef] [PubMed]
 
Prakesh, UBS, Offord, KP, Stubbs, SE Bronchoscopy in North America: the ACCP survey.Chest1991;100,1668-1675. [CrossRef] [PubMed]
 
Colt, HG, Prakesh, UBS, Offord, KP Bronchoscopy in North America: survey by the American Association for Bronchology, 1999.J Bronchol2000;7,8-25. [CrossRef]
 
Weiss, SM, Hert, RC, Gianola, FJ, et al Complications of fiberoptic bronchoscopy in thrombocytopenic patients.Chest1993;104,1025-1028. [CrossRef] [PubMed]
 
Elston, WJ, Whittaker, AJ, Khan, LN, et al Safety of research bronchoscopy, biopsy, and bronchoalveolar lavage in asthma.Eur Respir J2004;24,375-377. [CrossRef] [PubMed]
 
Bahhady, IJ, Ernst, A Risks and recommendations for flexible bronchoscopy in pregnancy: a review.Chest2004;126,1974-1981. [CrossRef] [PubMed]
 
Hattotuwa, K, Gamble, EA, O’Shaughnessy, T, et al Safety of bronchoscopy, biopsy, and BAL in research patients with COPD.Chest2002;122,1909-1912. [CrossRef] [PubMed]
 
Allan, PF, Ouellette, D Bronchoscopic procedures in octogenarians: a case-control analysis.J Bronchol2003;10,112-117. [CrossRef]
 
American Board of Internal Medicine. Certification policies/subspecialty policies. Available at: http://www.abim.org. Accessed November 26, 2005.
 
Accreditation Council for Graduate Medical Education. RRC Program requirements/Internal Medicine. Available at: http://www.acgme.org. Accessed November 26, 2005.
 
Dreisin, RB, Albert, RK, Talley, PA, et al Flexible fiberoptic bronchoscopy in the teaching hospital: yield and complications.Chest1978;74,144-149. [CrossRef] [PubMed]
 
Pue, CA, Pacht, ER Complications of fiberoptic bronchoscopy at a university hospital.Chest1995;107,430-432. [CrossRef] [PubMed]
 
Reinoso, MA, Lechin, A, Varon, J, et al Complications from flexible bronchoscopy in a training program.J Bronchol1996;3,177-181. [CrossRef]
 
Credle, WF, Smiddy, JF, Elliott, RC Complications of fiberoptic bronchoscopy.Am Rev Respir Dis1974;109,67-72. [PubMed]
 
Haponik, EF, Russell, GB, Beamis, JF, Jr, et al Bronchoscopy training: current fellows’ experiences and some concerns for the future.Chest2000;118,625-630. [CrossRef] [PubMed]
 
Pastis, NJ, Nietert, PJ, Silvestri, GA Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships.Chest2005;127,1614-1621. [CrossRef] [PubMed]
 
Colt, HG, Crawford, SW, Galbraith, O Virtual reality bronchoscopy training: a revolution in procedural training.Chest2001;120,1333-1339. [CrossRef] [PubMed]
 
Ost, D, DeRosiers, A, Britt, EJ, et al Assessment of a bronchoscopy simulator.Am J Respir Crit Care Med2001;164,2248-2255. [PubMed]
 
Rodriguez de Castro, F, Diaz Lopez, F, Serda, GJ, et al Relevance of training in transbronchial fine-needle aspiration technique.Chest1997;111,103-105. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1. Training Bronchoscopies Performed by Fellows*
* 

NS = not significant; 2ndYF = second-year fellow; 3rdYF = third-year fellow.

 

Fellow year group complications compared with the total number of complications.

Table Graphic Jump Location
Table 2. Staff Supervision of Training Bronchoscopies by Experience Level*
* 

See Table 1 for abbreviation not used in the text.

 

Staff complications compared with the total number of complications.

Table Graphic Jump Location
Table 3. Types of Complications With Training Bronchoscopy
Table Graphic Jump Location
Table 4. Comparison of Ancillary Procedures Performed With Bronchoscopy in Two Academic Years a Decade Apart*
* 

Values are given as the No. (%), unless otherwise indicated. Tbbx = transbronchial biopsy; Ebbx = endobronchial biopsy; TBNA = transbronchial needle aspiration; APC = argon plasma coagulation. See Table 1 for abbreviation not used in the text.

 

Comparison between the relative numbers of each procedure performed per year by χ 2 analysis.

Table Graphic Jump Location
Table 5. Comparison of Cumulative Bronchoscopy Complications by Fellows During the First Academic Trimester With the Complications During the Second and Third Trimesters*
* 

See Table 1 for abbreviation not used in the text.

 

p = 0.078 (Pearson χ 2; first trimester complication rate vs second and third trimester complication rates).

 

p = 0.025 (Pearson χ 2; first trimester complication rate vs second and third trimester complication rates).

References

Prakesh, UBS (1997) Gustav Killian centenary: the celebration of a century of progress in bronchoscopy.J Bronchol4,1-2. [CrossRef]
 
Suratt, PM, Smiddy, JF, Gruber, B Deaths and complications associated with fiberoptic bronchoscopy.Chest1976;69,747-751. [CrossRef] [PubMed]
 
Prakesh, UBS, Offord, KP, Stubbs, SE Bronchoscopy in North America: the ACCP survey.Chest1991;100,1668-1675. [CrossRef] [PubMed]
 
Colt, HG, Prakesh, UBS, Offord, KP Bronchoscopy in North America: survey by the American Association for Bronchology, 1999.J Bronchol2000;7,8-25. [CrossRef]
 
Weiss, SM, Hert, RC, Gianola, FJ, et al Complications of fiberoptic bronchoscopy in thrombocytopenic patients.Chest1993;104,1025-1028. [CrossRef] [PubMed]
 
Elston, WJ, Whittaker, AJ, Khan, LN, et al Safety of research bronchoscopy, biopsy, and bronchoalveolar lavage in asthma.Eur Respir J2004;24,375-377. [CrossRef] [PubMed]
 
Bahhady, IJ, Ernst, A Risks and recommendations for flexible bronchoscopy in pregnancy: a review.Chest2004;126,1974-1981. [CrossRef] [PubMed]
 
Hattotuwa, K, Gamble, EA, O’Shaughnessy, T, et al Safety of bronchoscopy, biopsy, and BAL in research patients with COPD.Chest2002;122,1909-1912. [CrossRef] [PubMed]
 
Allan, PF, Ouellette, D Bronchoscopic procedures in octogenarians: a case-control analysis.J Bronchol2003;10,112-117. [CrossRef]
 
American Board of Internal Medicine. Certification policies/subspecialty policies. Available at: http://www.abim.org. Accessed November 26, 2005.
 
Accreditation Council for Graduate Medical Education. RRC Program requirements/Internal Medicine. Available at: http://www.acgme.org. Accessed November 26, 2005.
 
Dreisin, RB, Albert, RK, Talley, PA, et al Flexible fiberoptic bronchoscopy in the teaching hospital: yield and complications.Chest1978;74,144-149. [CrossRef] [PubMed]
 
Pue, CA, Pacht, ER Complications of fiberoptic bronchoscopy at a university hospital.Chest1995;107,430-432. [CrossRef] [PubMed]
 
Reinoso, MA, Lechin, A, Varon, J, et al Complications from flexible bronchoscopy in a training program.J Bronchol1996;3,177-181. [CrossRef]
 
Credle, WF, Smiddy, JF, Elliott, RC Complications of fiberoptic bronchoscopy.Am Rev Respir Dis1974;109,67-72. [PubMed]
 
Haponik, EF, Russell, GB, Beamis, JF, Jr, et al Bronchoscopy training: current fellows’ experiences and some concerns for the future.Chest2000;118,625-630. [CrossRef] [PubMed]
 
Pastis, NJ, Nietert, PJ, Silvestri, GA Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships.Chest2005;127,1614-1621. [CrossRef] [PubMed]
 
Colt, HG, Crawford, SW, Galbraith, O Virtual reality bronchoscopy training: a revolution in procedural training.Chest2001;120,1333-1339. [CrossRef] [PubMed]
 
Ost, D, DeRosiers, A, Britt, EJ, et al Assessment of a bronchoscopy simulator.Am J Respir Crit Care Med2001;164,2248-2255. [PubMed]
 
Rodriguez de Castro, F, Diaz Lopez, F, Serda, GJ, et al Relevance of training in transbronchial fine-needle aspiration technique.Chest1997;111,103-105. [CrossRef] [PubMed]
 
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