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Original Research: Pulmonary Procedures |

Learning Experience of Linear Endobronchial Ultrasound Among Pulmonary TraineesEndobronchial Ultrasound Learning Experience FREE TO VIEW

Momen M. Wahidi, MD, MBA, FCCP; Cidney Hulett, MD, MPH; Nicholas Pastis, MD, FCCP; R. Wesley Shepherd, MD, FCCP; Scott L. Shofer, MD, PhD; Kamran Mahmood, MD, MPH; Hans Lee, MD, FCCP; Rajiv Malhotra, DO; Barry Moser, PhD; Gerard A. Silvestri, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine and Department of Medicine (Drs Wahidi, Shofer, Mahmood, and Moser), Duke University Medical Center, Durham, NC; the University of North Carolina (Dr Hulett), Chapel Hill, NC; the Medical University of South Carolina (Drs Pastis and Silvestri), Charleston, SC; and the Virginia Commonwealth University Medical Center (Drs Shepherd, Lee, and Malhotra), Richmond, VA.

Correspondence to: Momen M. Wahidi, MD, MBA, FCCP, Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Box 3683, Durham, NC 27710; e-mail: momen.wahidi@duke.edu


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(3):574-578. doi:10.1378/chest.13-0701
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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.

Figures in this Article

Linear endobronchial ultrasound (EBUS) was introduced over the last decade as an innovative tool that incorporated an ultrasound probe at the tip of a flexible bronchoscope, allowing real-time guidance of transbronchial needle aspiration (TBNA) of various mediastinal, hilar, and peribronchial structures. Data on EBUS quickly accumulated demonstrating its safety and efficacy in the diagnosis and staging of lung cancer, sarcoidosis, and other benign causes of mediastinal and hilar lymphadenopathy.1,2 The demonstrated efficacy of EBUS-guided TBNA (EBUS-TBNA) has fueled a widespread interest in EBUS among chest physicians, which, in turn, created an urgent need to understand the training required to achieve competency in this procedure for both established practitioners and trainees.

There is a paucity of literature that has specifically addressed EBUS-TBNA training.3 There is no consensus on how best to train clinicians in EBUS or how to assess procedural competency, including what is an appropriate minimum threshold number of procedures. National societies have published number-based guidelines for interventional pulmonology procedures; however, these were largely based on expert opinion and predated the availability of linear EBUS technology and, therefore, focused on radial EBUS, a fundamentally different type of EBUS procedure.4,5 Several studies evaluating the learning curve for EBUS-TBNA among established clinicians have been published.68 A small retrospective study evaluated the learning curve of EBUS-TBNA based on diagnostic sensitivity among two thoracic surgeons and found it to be about 10 procedures.8 A prospective Australian study demonstrated that the diagnostic performance of EBUS-TBNA among two pulmonologists improved significantly by 20 procedures but did not peak until after 50 procedures.6

An even more pressing need is the determination of the training requirements of EBUS-TBNA among pulmonary trainees to ensure adequate training of future chest physicians. A recent survey of Pulmonary and Critical Care Medicine Program Directors reported that 89.1% of institutions had EBUS equipment.9 Of those programs that did not currently have equipment, 100% were interested in obtaining it in the next 12 months. However, only 30% of these programs had a formal protocol in place to assess fellow competency in linear EBUS. The purpose of our study is to prospectively evaluate the learning experience of pulmonary trainees performing EBUS-TBNA and to determine the average required number of procedures to perform the essential steps of the procedure and successfully obtain a tissue diagnosis.

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 interest and prior experience in bronchoscopy, including experience with conventional flexible bronchoscopy, specific experience with EBUS-TBNA, and perceptions related to EBUS bronchoscopy.

Prior to performing their first EBUS-TBNA procedure, all fellows were required to complete 30 conventional bronchoscopies and participate in a didactic and hands-on training on EBUS-TBNA. This consisted of a standardized lecture on EBUS-TBNA provided by faculty with experience in EBUS bronchoscopy and an hour-long period of supervised practice of EBUS-TBNA on an inanimate plastic airway model (Olympus Corp).

Fellows performed EBUS procedures under the direct supervision of an attending physician with experience in EBUS-TBNA and were evaluated on EBUS-TBNA performance via a checklist. The checklist included five steps that were deemed essential for the successful performance of EBUS-TBNA. These steps included the following: ability to pass the EBUS bronchoscope through the vocal cords, ability to identify the appropriate lymph node for initial sampling (based on highest stage of staging procedure or ease of access in context of diffuse disease), ability to identify the target lymph node and/or mass with ultrasound on command without assistance, ability to guide the team in the bronchoscopy suite through the steps necessary to operate the needle and perform EBUS-TBNA, and ability to obtain adequate samples as determined by rapid on-site evaluation (ROSE). The fellow had to complete all five steps with no assistance to be recorded as successful EBUS-TBNA performance. If the fellow could not complete one of these steps independently or required assistance by the supervising attending physician, then the procedure was recorded as unsuccessful performance of EBUS-TBNA. The supervising attending physician was instructed to take over the procedure if any of these steps were missed by the fellows. Additionally, if ROSE determined that adequate sampling was not accomplished by the fellow, the attending physician completed the procedure to assure that adequate sampling occurred. Other data collected for each procedure included patient data (indication for procedure), procedural preparation data (presence or absence of artificial airway and agents for sedation/anesthesia), and sampling data (lymph node station sampled, estimated size of lymph node sampled, total number of TBNA passes attempted by the fellow and/or attending physician, preliminary diagnosis by ROSE, and final pathologic diagnosis).

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 the two fellows with censored observations. The rate of missed data points was 16%, with the majority of missed procedures being related to two fellows who performed procedures at a VA Medical Center. Analysis calculations were performed using SAS Proc Lifetest, version 9.2 (SAS Institute Inc).

Figure Jump LinkFigure 1. Learning experience of EBUS-TBNA among pulmonary trainees. EBUS-TBNA = endobronchial ultrasound-guided transbronchial needle aspiration.Grahic Jump Location
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.

Table Graphic Jump Location
Table 1 —Demographics, Bronchoscopy Experience, and EBUS Bronchoscopy Experience and Perception Among Participating Pulmonary Trainees

EBUS = endobronchial ultrasound; EBUS-TBNA = endobronchial ultrasound-guided transbronchial needle aspiration.

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 infrequently as the indication, most common being breast cancer (3%) and head and neck cancer (2%). The majority of procedures were performed using moderate sedation with fentanyl and midazolam (99%). Other approaches to sedation and anesthesia included propofol, midazolam, and meperidine, and a combination of midazolam, fentanyl, and diphenhydramine.

The mean size of the sampled lymph node was 1.99 cm (± 1.16 cm). The location of EBUS-TBNA sampling was variable and included station 7 (40%), station 4R (30%), station 4L (9%), station 11R (8%), lung mass (3%), station 2R (2%), station 10L (1%), station 2L (1%), mediastinal mass (1%), station 10R (0.5%), and station 12R (0.5%). The mean number of EBUS-TBNA passes by the fellow was two (± 2), and mean passes by the attending physician was two (± 2). The most frequent preliminary diagnoses by ROSE were, in order: malignant cells (46%), lymphocytes (24%), granuloma (7%), and indeterminate/inadequate sample (7%). The rate of concordance between the ROSE preliminary diagnosis and final pathologic diagnosis was 84%. When the diagnosis was not concordant, 80% of the cases represented scenarios when no diagnosis was made by ROSE but a diagnosis was made by final pathology. In the other 20% of cases, a diagnosis was obtained by ROSE that differed from the final pathologic diagnosis (one case of small cell lung cancer changed to lymphocytes only, one case of small cell lung cancer changed to non-small cell lung cancer, one case of granuloma changed to lymphocytes and bronchial epithelium, and one case of non-small cell lung cancer changed to lymphocytes only).

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.

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 requisite steps one would need to accomplish to perform the procedure successfully: navigate the EBUS bronchoscope through the upper airways, recognize the appropriate lymph node for initial sampling, identify the target lymph node and/or mass with ultrasound, guide the team in the bronchoscopy suite through the steps necessary to operate the needle and perform TBNA, and obtain adequate samples as determined by ROSE. Our study found that the majority of learners were able to successfully navigate all of these steps after performing an average of 13 EBUS-TBNA procedures. We are not advocating this number as a threshold minimum number for attaining competency, as different learners will master skills at different times, as evident by our study. Instead, we believe that this number should guide pulmonary fellowship training directors’ plans for training their fellows in EBUS-TBNA, given the finite number of procedures performed in various institutions. This is particularly relevant in light of the recent survey of EBUS training among US pulmonary fellowships, which revealed that 44 programs that offered EBUS training averaged < 25 procedures per fellow.9 Additionally, 13 procedures may be a reasonable juncture to initiate testing of EBUS-TBNA technical skills with a validated skills assessment tool. One such tool is the EBUS Skills and Tests Assessment Tool, which was validated and shown to have the ability to discriminate between skills and knowledge of beginner, intermediate, and experienced EBUS operators.10 We believe that our study presents a reasonable path to standardized training in EBUS-TBNA for pulmonary trainees to include a didactic curriculum, simulation-based practice, and completion of a minimal number of procedures coupled with skills testing with validated tools.

Our study’s strengths lie in its prospective and multicenter design, longitudinal observational period of 2 years, and focus on pulmonary trainees. Weaknesses include the relatively small number of observed trainees and the inability of some trainees to reach the benchmark of completing all required procedural steps during the period of study. The latter was the result of the low volume of procedures at some centers or the structure of particular fellows’ schedules that exposed them to less clinical time in their first 2 years of training.

In summary, our study showed that 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. We hope that our findings can help pulmonary fellowship directors in designing training pathways for linear EBUS and identifying appropriate junctures for testing EBUS skills with validated tests.

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.

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

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

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

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

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

Dr Moser: contributed to providing statistical analysis for this study and the review and editing of the manuscript.

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

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Wahidi has received educational grants from Olympus Corp and Pentax of America, Inc and served as a consultant with Olympus Corp. Dr Pastis has received consulting fees from Olympus Corp for preparing and delivering an educational webinar to the Olympus EBUS sales force. Dr Silvestri has received grant funding from Olympus Corp and has served as a consultant with Olympus Corp. Drs Hulett, Shepherd, Shofer, Mahmood, Lee, Malhotra, and Moser have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

EBUS

endobronchial ultrasound

EBUS-TBNA

endobronchial ultrasound-guided transbronchial needle aspiration

ROSE

rapid on-site evaluation

TBNA

transbronchial needle aspiration

Tremblay A, Stather DR, Maceachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest. 2009;136(2):340-346. [CrossRef] [PubMed]
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389-1396. [CrossRef] [PubMed]
 
Unroe MA, Shofer SL, Wahidi MM. Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques. Curr Opin Pulm Med. 2010;16(4):295-300. [CrossRef] [PubMed]
 
Bolliger CT, Mathur PN, Beamis JF, et al; European Respiratory Society/American Thoracic Society. ERS/ATS statement on interventional pulmonology. Eur Respir J. 2002;19(2):356-373. [CrossRef] [PubMed]
 
Ernst A, Silvestri GA, Johnstone D; American College of Chest Physicians. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717. [CrossRef] [PubMed]
 
Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital. Intern Med J. 2011;41(12):815-824. [CrossRef] [PubMed]
 
Kemp SV, El Batrawy SH, Harrison RN, et al. Learning curves for endobronchial ultrasound using cusum analysis. Thorax. 2010;65(6):534-538. [CrossRef] [PubMed]
 
Groth SS, Whitson BA, D’Cunha J, Maddaus MA, Alsharif M, Andrade RS. Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution’s early learning curve. Ann Thorac Surg. 2008;86(4):1104-1109. [CrossRef] [PubMed]
 
Tanner NT, Pastis NJ, Silvestri GA. Training for linear endobronchial ultrasound among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest. 2013;143(2):423-428. [CrossRef] [PubMed]
 
Davoudi M, Colt HG, Osann KE, Lamb CR, Mullon JJ. Endobronchial ultrasound skills and tasks assessment tool: assessing the validity evidence for a test of endobronchial ultrasound-guided transbronchial needle aspiration operator skill. Am J Respir Crit Care Med. 2012;186(8):773-779. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Learning experience of EBUS-TBNA among pulmonary trainees. EBUS-TBNA = endobronchial ultrasound-guided transbronchial needle aspiration.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Demographics, Bronchoscopy Experience, and EBUS Bronchoscopy Experience and Perception Among Participating Pulmonary Trainees

EBUS = endobronchial ultrasound; EBUS-TBNA = endobronchial ultrasound-guided transbronchial needle aspiration.

References

Tremblay A, Stather DR, Maceachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest. 2009;136(2):340-346. [CrossRef] [PubMed]
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389-1396. [CrossRef] [PubMed]
 
Unroe MA, Shofer SL, Wahidi MM. Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques. Curr Opin Pulm Med. 2010;16(4):295-300. [CrossRef] [PubMed]
 
Bolliger CT, Mathur PN, Beamis JF, et al; European Respiratory Society/American Thoracic Society. ERS/ATS statement on interventional pulmonology. Eur Respir J. 2002;19(2):356-373. [CrossRef] [PubMed]
 
Ernst A, Silvestri GA, Johnstone D; American College of Chest Physicians. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717. [CrossRef] [PubMed]
 
Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital. Intern Med J. 2011;41(12):815-824. [CrossRef] [PubMed]
 
Kemp SV, El Batrawy SH, Harrison RN, et al. Learning curves for endobronchial ultrasound using cusum analysis. Thorax. 2010;65(6):534-538. [CrossRef] [PubMed]
 
Groth SS, Whitson BA, D’Cunha J, Maddaus MA, Alsharif M, Andrade RS. Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution’s early learning curve. Ann Thorac Surg. 2008;86(4):1104-1109. [CrossRef] [PubMed]
 
Tanner NT, Pastis NJ, Silvestri GA. Training for linear endobronchial ultrasound among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest. 2013;143(2):423-428. [CrossRef] [PubMed]
 
Davoudi M, Colt HG, Osann KE, Lamb CR, Mullon JJ. Endobronchial ultrasound skills and tasks assessment tool: assessing the validity evidence for a test of endobronchial ultrasound-guided transbronchial needle aspiration operator skill. Am J Respir Crit Care Med. 2012;186(8):773-779. [CrossRef] [PubMed]
 
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