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PubMed1991

Topical nasal anesthesia for flexible bronchoscopy. A comparison of four methods in normal subjects and in patients undergoing transnasal bronchoscopy.

We evaluated nasal anesthesia regimens by comparing, in seven normal men, four drug regimens: 1) 1 percent phenylephrine; 2) 4 percent lidocaine; 3) 1 percent phenylephrine + 4 percent lidocaine; and 4) 5 percent cocaine. After spraying each drug into the anterior nares, vasoconstriction, decongestion, and nasal anesthesia (measured as transnasal depth of nasogastric (NG) tube insertion before discomfort) were assessed. There were no significant differences in NG tube insertion depth between the regimens (p = 0.54). Insertion depth was significantly increased after 10 ml of 2 percent viscous lidocaine were sniffed (p less than 0.004), but again, differences between regimens were not significant (p = 0.051). One hundred bronchoscoped patients received one of the following sprayed into the nose: 1) placebo (P); 2) 1 percent phenylephrine + P; 3) 1 percent phenylephrine + 4 percent lidocaine; or 4) 5 percent cocaine + P. Each patient then sniffed viscous lidocaine. There were no significant differences between regimens for any of the following: 1) nasal resistance to bronchoscope insertion, 2) patient's nasal discomfort, or 3) bronchoscopist's perception of patient discomfort. We conclude that sprayed anesthetics contribute little to nasal anesthesia and any regimen appears acceptable when viscous lidocaine is used.

Administration, Intranasal↗
PubMed1997

Comparison of real-time virtual and fiberoptic bronchoscopy in patients with bronchial carcinoma: opportunities and limitations.

OBJECTIVE: Both helical CT and fiberoptic bronchoscopy are used in the staging of pulmonary tumors for therapeutic decision making. The improved resolution offered by helical CT has led to the clinical use of three-dimensional reconstruction techniques such as virtual bronchoscopy. We tested this new simulated endoscopic view of inner organ surfaces and compared it with corresponding fiberoptic examinations of the tracheobronchial system. SUBJECTS AND METHODS: Twenty patients with malignancies of the lung and mediastinum were examined with both virtual bronchoscopy and fiberoptic bronchoscopy. Both examinations were reviewed by radiologists and surgeons familiar with fiberoptic bronchoscopy. Virtual bronchoscopy was calculated and reconstructed from the cross-sectional images on a separate workstation. Stenoses and tumor infiltration were classified from the fiberoptic examination. These results were compared with the virtual bronchoscopy findings. RESULTS: Virtual bronchoscopy of diagnostic quality was achieved in 19 of 20 patients. High-grade stenoses were revealed equally well with virtual and fiberoptic techniques. Virtual bronchoscopy offered the advantage of being able to visualize areas beyond even high-grade stenoses. However, on virtual bronchoscopy discrete infiltration or extraluminal impression was not visible in five patients. In another patient, strong heart pulsation produced motion artifacts that prevented evaluation of the reconstruction. CONCLUSION: Virtual bronchoscopy represents a new noninvasive method for evaluating helical CT findings. In comparison with fiberoptic bronchoscopy, virtual bronchoscopy offers the advantage of being able to visualize areas beyond even high-grade stenoses. In addition to the limited view of fiberoptic bronchoscopy, extraluminal causes of lumen compressions can be analyzed in the cross-sectional images and evaluated together with the virtual representation. However, it was not possible to detect small infiltrations with virtual bronchoscopy. This new representation of helical CT data might be helpful for postoperative follow-up examinations, such as after stent implantation, and can be carried out without additional risk to the patient. Radiologists do need special fiberoptic bronchoscopy knowledge and experience with three-dimensional-reconstructions to differentiate between real stenoses and artificial stenoses that might be caused by pulsation artifacts.

Artifacts↗
PubMed2002

Virtual bronchoscopy for evaluation of malignant tumors of the thorax.

OBJECTIVE: Virtual bronchoscopy is a novel technique making use of 3-dimensional reconstruction of 2-dimensional helical computed tomographic images for noninvasive evaluation of the tracheobronchial tree. This study was undertaken to evaluate the diagnostic potential of virtual bronchoscopy by comparing virtual bronchoscopic images with fiberoptic bronchoscopic findings in patients with thoracic malignant disease. METHODS: Thirty-two consecutive patients with thoracic malignant tumors underwent virtual bronchoscopy for evaluation of suspected tracheobronchial lesions. For each virtual bronchoscopic examination, 200 to 300 contiguous 1.25-mm images of the thorax were obtained in only one or two 17-second breath holds by using a multislice computed tomographic scanner. Virtual bronchoscopy images were reconstructed and interpreted blind to the actual endoscopic findings. Results of virtual bronchoscopy were compared with fiberoptic bronchoscopic findings in 20 patients. RESULTS: Anatomic computer simulation of the bronchial tree was successfully created in all patients. In 7 (35%) of 20 patients, results of fiberoptic bronchoscopy were found to be within normal limits. In all patients with normal anatomy, virtual bronchoscopy accurately correlated with the fiberoptic findings. Thirteen (65%) patients had a total of 22 abnormal findings on fiberoptic bronchoscopy. Virtual bronchoscopy detected 18 of 22 abnormal fiberoptic bronchoscopic findings: 13 of 13 obstructive lesions, 5 of 6 endoluminal lesions, and 0 of 3 mucosal lesions. The sensitivity of virtual bronchoscopy was 100% for obstructive lesions, 83% for endoluminal lesions, 0% for mucosal lesions, and 82% for all abnormalities; the specificity of virtual bronchoscopy was 100%. CONCLUSIONS: Preliminary evaluation indicates that virtual bronchoscopy may be a promising and noninvasive modality for identifying bronchial obstructions and endoluminal lesions, as well as for assessing the tracheobronchial tree beyond stenoses. However, at present, virtual bronchoscopy does not enable the detection of subtle mucosal lesions, and as such, this modality may not be appropriate for identifying premalignant lesions in the respiratory tract. Although fiberoptic bronchoscopy remains the standard modality for evaluating airway patency and mucosal lesions, virtual bronchoscopy may provide additional information that may be useful in the management of pulmonary malignant tumors.

Adult↗
PubMed2005

The influence of diagnostic bronchoscopy on clinical outcomes comparing adult autologous and allogeneic bone marrow transplant patients.

STUDY OBJECTIVES: To review our experience with diagnostic bronchoscopy in the evaluation of pulmonary infiltrates in adult hematopoietic stem cell transplantation (HSCT) recipients in the era of Pneumocystis prophylaxis and cytomegalovirus antigen testing. The study focused on diagnostic yields and the influence of bronchoscopic findings on pharmacologic therapy and mortality, comparing allogeneic (allo) HSCT patients to autologous (auto) HSCT patients. DESIGN: Case series review. SETTING: Tertiary care academic urban medical centers. PATIENTS: All adult allo-HSCT and auto-HSCT patients undergoing bronchoscopy for the evaluation of pulmonary infiltrates from January 1997 to September 2001. MEASUREMENTS AND RESULTS: The review identified 169 bronchoscopies that had been performed on HSCT patients, representing 12.5% of all HSCT patients (allo-HSCT patients, 125 bronchoscopies; auto-HSCT patients, 44 bronchoscopies). Bronchoscopy was requested more often in allo-HSCT patients (18.7%) compared to auto-HSCT patients (6.6%). Findings at bronchoscopy provided a specific diagnosis more frequently in allo-HSCT patients (50%) compared to auto-HSCT patients (34%). For both allo-HSCT and auto-HSCT patients, most diagnoses were obtained by BAL alone, whereas transbronchial biopsy (TBBx) provided additional specific information in < 10% of cases. For select patients (n = 27), surgical lung biopsy following bronchoscopy provided unique diagnoses in 47 to 50% of cases. Information from bronchoscopy influenced clinical decisions more often in allo-HSCT patients (50%) than in auto-HSCT patients (36%), and allowed for the discontinuation or addition of antimicrobial, corticosteroid, or antineoplastic agents to treatment. Complications from bronchoscopy occurred in 9% of all HSCT patients (n = 15), and were associated with higher in-hospital mortality rates in allo-HSCT patients (82%; n = 9) compared to auto-HSCT patients (50%; n = 2). The overall in-hospital mortality rates for allo-HSCT and auto-HSCT patients having bronchoscopy was similar (38% vs 27%, respectively; p = 0.25), and establishing a specific diagnosis by bronchoscopy did not improve the in-hospital mortality rate for allo-HSCT or auto-HSCT patients. CONCLUSIONS: Bronchoscopy may provide clinically useful information in the evaluation of adult allo-HSCT and auto-HSCT recipients with pulmonary infiltrates. The results of testing BAL fluid samples alone suggested an etiology in most cases, whereas the findings of TBBx provided unique diagnoses infrequently. Further studies are warranted to improve the utility of diagnostic bronchoscopy in the evaluation of HSCT patients.

Adult↗
PubMed2001

Assessment of a bronchoscopy simulator.

The study objective was to validate a flexible bronchoscopy simulator by determining if it could differentiate between expert and novice bronchoscopists. A subsequent evaluation phase was then done to determine whether use of the simulator would improve the rate of bronchoscopy skill acquisition for new pulmonary fellows. A multicenter prospective cohort study was performed using a bronchoscopy simulator. Three cohorts were evaluated based on the number of bronchoscopies previously performed: "experts" (> 500, n = 9), "intermediates" (25 to 500, n = 8), and "novices" (none, n = 11). Each participant performed two simulated cases with performance measures being recorded by the simulator. Performance measures that distinguished between groups were then used to evaluate the learning curve for new fellows training on the simulator. A randomized-controlled trial was then conducted comparing the quality of bronchoscopy performance for new pulmonary fellows who were trained either with conventional methods or with the simulator. Expert bronchoscopists performed better on the simulator than intermediates who performed better than novices in terms of procedure time, percentage of segments visualized, time in red-out, and wall collisions. Training of new fellows demonstrated that after performing 20 bronchoscopic simulations, the skill level acquired with the simulator significantly improved in terms of speed, percentage of segments visualized, time in red-out, and collisions. Fellows trained on the simulator performed better than fellows trained using conventional methods during their first actual bronchoscopies as assessed by procedure time (815 versus 1,168 s, p = 0.001), a bronchoscopy nurse's subjective quality assessment score (7.7 +/- 0.3 versus 3.7 +/- 2.5, p = 0.05), and by a quantitative bronchoscopy quality score (percentage of segments correctly identified/procedure time, 0.119 +/- 0.015 versus 0.046 +/- 034, p = 0.03). In conclusion, the bronchoscopy simulator was able to accurately assess bronchoscopy experience level. Training new fellows on the bronchoscopy simulator leads to more rapid acquisition of bronchoscopy expertise compared with conventional training methods. This technology has the potential to facilitate bronchoscopy training and to improve objective evaluations of bronchoscopy skills.

Adult↗
PubMed2005

[Detection of airways stenoses: comparison of virtual and flexible bronchoscopy].

PURPOSE: To compare virtual with flexible bronchoscopy for the detection of bronchial stenoses. MATERIALS AND METHODS: In a retrospective study, we compared the results of 26 patients, who had clinical suspected pathologies of the tracheobronchial airways and underwent both flexible bronchoscopy and multislice CT with 3D surface rendering of the airways. Flexible bronchoscopy and virtual bronchoscopy were compared as to the rate of detecting bronchial stenoses. For statistical analysis, we divided the tracheobronchial tree in the following sections: trachea, 2 main bronchi, 6 lobar bronchi, 18 segmental bronchi and 36 subsegmental bronchi, corresponding to 63 bronchial sections for each patient (on average) and a total of 1638 bronchial sections for all 26 patients. We graded the bronchial stenosis as less than 50 %, as 50 to 95 % and as complete obstruction. RESULTS: Virtual bronchoscopy detected 25 bronchial stenoses, while flexible bronchoscopy only revealed 17 stenoses. Stenoses with a diameter less than 50 % were found with virtual bronchoscopy 14 times and with flexible bronchoscopy 10 times. Stenoses with a diameter between 50 and 95 % were detected 7 and 4 times, respectively, and complete obstructions 4 and 3 times, respectively. Tracheobronchial stenoses were well recognized with virtual bronchoscopy. Moreover, the virtual method enabled the visualization of high-grade stenoses and post-stenotic areas that could not be passed by the fiberoptic bronchoscope. Virtual bronchoscopy detected stenoses at a higher rate but the difference was not statistically significant (stenoses < 50 %: p = 0.352, 50 - 95 %: p = 0.339, complete obstruction: p = 0.696). CONCLUSION: Virtual bronchoscopy is a useful non-invasive method for the diagnostic evaluation of the tracheobronchial tree. In comparison with flexible bronchoscopy, virtual bronchoscopy is superior in revealing high-grade stenoses and visualizing post-stenotic areas.

Adult↗
PubMedDate not supplied

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↗