John Conforti

A Prospective Multicenter Study of Competency Metrics and Educational Interventions in the Learning of Bronchoscopy Among New Pulmonary Fellows

BACKGROUND Learning medical procedures relies predominantly on the apprenticeship model, and competency is established based on the number of performed procedures. Our study aimed to establish bronchoscopy competency metrics based on performance and enhanced learning with educational interventions. METHODS We conducted a prospective study of the acquisition of bronchoscopy skills and cognitive knowledge in two successive cohorts of new pulmonary fellows between July 5, 2006, and June 30, 2008. At prespecified milestones, validated tools were used for testing: the Bronchoscopy Skills and Tasks Assessment Tool (BSTAT), an objective evaluation of bronchoscopy skills with scores ranging from 0 to 24, and written multiple-choice questions examinations. The first cohort received training in bronchoscopy as per the standards set by each institution, whereas the second cohort received educational interventions, including training in simulation bronchoscopy and an online bronchoscopy curriculum. RESULTS There was significant variation among study participants in bronchoscopy skills at their 50th bronchoscopy, the minimum number previously set to achieve competency in bronchoscopy. An educational intervention of incorporating simulation bronchoscopy enhanced the speed of acquisition of bronchoscopy skills, as shown by the statistically significant improvement in mean BSTAT scores for seven of the eight milestone bronchoscopies (P < .05). The online curriculum did not improve the performance on the written tests; however, compliance of the learners with the curriculum was low. CONCLUSIONS Performance-based competency metrics can be used to evaluate bronchoscopy skills. Educational interventions, such as simulation-based training, accelerated the acquisition of bronchoscopy skills among first-year pulmonary fellows as assessed by a validated objective assessment tool.

Pulmonary Extramedullary Hematopoiesis

Extramedullary hematopoiesis (EMH) is the formation and development of blood cells outside of the bone marrow. Of particular interest to chest physicians and radiologists is the occurrence of EMH in the lungs and pleura. There have been several reports of patients presenting with pulmonary EMH published in the literature and the majority are due to a secondary process, such as myeloproliferative disorders, hemolytic anemias, hereditary spherocytosis, and Gaucher disease. We present a case report of pulmonary EMH and a review of the literature concentrating on the etiology, clinical presentation, pathophysiology, diagnosis, and therapy for this uncommon disorder.

Reproducibility of the 6-Minute Walk Test for Ambulatory Oxygen Prescription

Background: Ambulatory oxygen is frequently prescribed for patients with chronic obstructive pulmonary disease (COPD) who have oxygen desaturation ≤88% during exercise. The 6-min walk test (6MWT) with continuous pulse oximetry monitoring is a common method to document this oxygen desaturation, but the reproducibility of this test in determining the need for ambulatory oxygen in patients with COPD is not well documented. Objective:The aim of this study was to establish the reproducibility of the 6MWT in determining the need for ambulatory oxygen prescription in stable COPD patients using the Centers for Medicare and Medicaid (CMS) criteria for ambulatory oxygen prescription. Methods:The study was designed as a prospective observational study in an academic health center and associated pulmonary rehabilitation program. Eighty-eight COPD patients referred to pulmonary rehabilitation underwent continuous pulse oximetry while performing standard 6MWT on 3 separate days. Results: Fifty-one (58%) of these patients desaturated by continuous pulse oximetry to an SpO2 ≤88% on a least one of the 6MWTs. Only 26 patients (30%) demonstrated consistency in meeting the criteria for ambulatory oxygen set forth by the CMS on all three 6MWT with a κ statistic of 0.62. The percent agreement between 6MWTs for ambulatory oxygen prescription was 72% and the paired observation was 51%. Conclusions: The 6MWT distance is simple and widely used as a consistent measure of functional capacity in patients with COPD; however, the 6MWT oxygen saturation has only modest reproducibility in determining the need for ambulatory oxygen in stable COPD patients undergoing pulmonary rehabilitation.

Endobronchial ultrasound in the evaluation of lung cancer: a practical review and cost analysis for the practicing pulmonologist.

Flexible bronchoscopy remains an important tool in the staging, diagnosis, and treatment of primary and metastatic lung malignancies. Endobronchial ultrasound is a new technology utilized with bronchoscopy that has been shown to identify bronchial wall invasion by malignant tumors, aid in the fine needle aspiration of peripheral lung lesions and mediastinal/hilar lymph nodes, and determine the course of treatment in patients with pulmonary carcinoma in situ. The decision to invest both time and money in this technology is determined by several factors such as the cost of the equipment, reimbursement for the procedure, availability of training, the number of bronchoscopies one performs in a year, and access to endoscopic ultrasound and mediastinoscopy. This article reviews the literature to determine the utility of endobronchial ultrasound in the management of patients with lung cancer and to provide information to practicing pulmonologists that may aid in determining whether and where this technology fits into their clinical armamentarium.

Conventional and endobronchial ultrasound-guided transbronchial needle aspiration: complementary procedures.

Objective The diagnosis of mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are on the rise. Most reports have demonstrated high yields with EBUS-TBNA and superiority of this procedure over conventional TBNA (cTBNA), but the relative roles of these procedures remain undefined. We present a comprehensive comparison of EBUS-TBNA to cTBNA. Methods We reviewed all of the bronchoscopies performed at our medical center from January 2009 through December 2010. We collected data on 82 EBUS-TBNAs and 209 cTBNAs performed. A cost analysis was subsequently performed. Results EBUS-TBNA was performed more often in patients with known prior cancer and suspicion of recurrence or staging compared with cTBNA (42% vs 18%, P < 0.001). cTBNA was more likely to be performed in patients suspected of having malignancy and needing diagnostic specimens (70% vs 46%, P = 0.009). The overall yield in which a diagnostic specimen or lymphoid tissue was obtained was not different in each group: EBUS 84% vs cTBNA 86% (P = 0.75). The cancer yield was 57% in cTBNAs compared with 44% in EBUS-TBNAs (P < 0.0001), with EBUS-TBNA more often targeting smaller nodes (mean 15 ± 7 mm vs 21 ± 11 mm; P < 0.0001) and paratracheal sites (67% vs 49%, P = 0.003). Per-procedure cost using a Medicare scale was higher for EBUS than it was for cTBNA (

Prevalence of flexible bronchoscopic removal of foreign bodies in the advanced elderly

1195 vs

Perception versus Reality: The Measuring of Pleural Fluid pH in the United States

808; P < 0.001). Conclusions EBUS-TBNA and cTBNA are complementary bronchoscopic procedures, and the appropriate diagnostic modality can be selected in a cost-effective manner based upon the primary indication for TBNA, lymph node size, and lymph node location.

Bronchoscopic Myths and Legends: Anti-Platelet Medications

OBJECTIVES to define the likelihood and establish the overall safety and effectiveness of flexible bronchoscopy in the removal of foreign bodies in the advanced elderly compared to those younger. DESIGN a retrospective case-control analysis. SETTING tertiary care academic hospital. POPULATION 7,089 adults (age >18 years), including 949 (15%) advanced elderly (age >75 years), who underwent flexible bronchoscopy between January 1995 and June 2007. MEASUREMENTS in those patients with foreign body aspiration (FBA) (n = 20), a comparison of multiple clinical characteristics based on defined age groups (group 1, age <75 years and group 2, age >75 years) was performed. RESULTS FBA requiring bronchoscopic removal was greater than three and a half times more likely in patients aged >75 years compared to those younger (OR 3.78, CI 1.4-10: P <0.05). Flexible bronchoscopy was 87.5% effective in the removal of foreign bodies in the advanced elderly and associated with no increase in adverse events. CONCLUSION bronchoscopic removal of foreign bodies is more likely in the advanced elderly when compared to those younger. This implies that this population may be most at risk. Flexible bronchoscopy is a safe and effective initial diagnostic and therapeutic approach in this age group.

Bronchoscopy in the Diagnosis of Wegener Granulomatosis

Background: Pleural fluid pH measured by a blood gas analyzer is the only recommended method of pH measurement to guide management for patients with parapneumonic pleural effusions. Not all hospitals use blood gas analyzers for pleural fluid pH determination and it is unknown if physicians are aware of this problem. Objective: To determine if a discrepancy exists between the modality used for measuring pleural fluid pH and how physicians believe it is measured. Methods: We surveyed pulmonologists randomly across the USA by e-mail inquiring how they thought pleural fluid pH was measured at their laboratory. We then independently contacted the laboratory and asked how pleural fluid pH was actually measured. Results: Two hundred and sixty-seven pulmonologists completed the survey. Eighty-six percent of the pulmonologists use pleural fluid pH to manage complicated parapneumonic effusions. Forty-three percent did not recognize blood gas analyzer solely as the most accurate and validated method. Thirty-nine percent of the physicians who use pleural pH to manage effusions and believe that blood gas analyzers are the most accurate were wrong in their assumption that their laboratory was using this tool for pleural pH measurement. Conclusions: Whether it is due to inaccurate knowledge or a perception of how pleural fluid pH is tested, a significant number of pulmonologists, when treating complicated parapneumonic effusions, may be making management decisions based on erroneous information.

Bronchoscopic Myths and Legends: Bronchoscopy in the Diagnosis of Pulmonary Tuberculosis

Transbronchial lung biopsy is an important tool for the bronchoscopist in the evaluation of lung disease. It has, however, been associated with increased rates of major complications including bleeding and pneumothorax. It has been suggested that platelet dysfunction, potentially from antiplatelet medications, contributes to this increased risk. Additionally, although no recommendations exist, physician surveys have found that the majority of pulmonologists withhold antiplatelet pharmacotherapy before bronchoscopy when biopsies are planned. We reviewed the existing literature to determine whether antiplatelet medications contribute to an increased bleeding risk and provide recommendations on their use. Antiplatelet pharmacotherapy should be withheld at least 5 days before bronchoscopy to minimize the risk of bleeding when transbronchial lung biopsies are planned.