When Pulmonologists Are Novice to Navigational Bronchoscopy, What Predicts Diagnostic Yield?

Predicting factors of diagnostic yield in electromagnetic navigation bronchoscopy (ENB) have been explored in a number of previous studies based on data from experienced operators. However, little is known about predicting factors when the procedure is carried out by operators in the beginning of their learning curve. We here aim to identify the role of operators' experience as well as lesion- and procedure characteristics on diagnostic yield of ENB procedures in the hands of novice ENB operators. Four operators from three centers without prior ENB experience were enrolled. The outcome of consecutive ENB procedures was assessed and classified as either diagnostic or non-diagnostic and predicting factors of diagnostic yield were assessed. A total of 215 procedures were assessed. A total of 122 (57%) of the ENB procedures resulted in diagnostic biopsies. Diagnostic ENB procedures were associated with a minor yet significant difference in tumor size compared to non-diagnostic/inconclusive ENB procedures (28 mm vs. 24 mm; p = 0.03). Diagnostic ENB procedures were associated with visible lesions at either fluoroscopy (p = 0.003) or radial endobronchial ultrasound (rEBUS), (p = 0.001). In the logistic regression model, lesion visibility on fluoroscopy, but none of operator experience, the presence of a bronchus sign, lesion size, or location nor visibility on rEBUS significantly impacted the diagnostic yield. In novice ENB operators, lesion visibility on fluoroscopy was the only factor found to increase the chance of obtaining a diagnostic sample.

Learning Curves for Electromagnetic Navigation Bronchoscopy Using CUSUM Analysis.

BACKGROUND: Electromagnetic navigation bronchoscopy (ENB) is a relatively new and technically demanding procedure for the guidance of bronchoscopic biopsy to help locate small lung lesions. The results in experienced hands are well described. However, we do not know the results in unexperienced hands-in other words, we have no knowledge about how fast you can learn the procedure. AIM: The aim of this study was to draw learning curves for beginners in ENB using Cumulated Sum (CUSUM) analysis, a method for quantitative evaluation of the learning curves for clinical procedures. METHODS: Four operators from 3 centers without prior ENB experience were enrolled. The outcome of consecutive ENB procedures was assessed and classified as either diagnostic or nondiagnostic based on sample adequacy. Learning curves were drawn based on diagnostic yield. RESULTS: A total of 215 procedures were assessed. For 2 of the operators (operators 1 and 4), at least 25 to 30 procedures were necessary to obtain competency whereas operators 2 and 3 showed more horizontal learning curves indicating an overweight of diagnostic procedures from the beginning. CONCLUSION: Operators achieve competences in ENB at different paces. This must be taken in account when beginners start to learn the procedure. There is a huge need for a structured educational program and a validated test to determine competences.

Non-invasive ventilation is less efficient in pneumonia than in chronic obstructive pulmonary disease exacerbation.

INTRODUCTION: Non-invasive ventilation (NIV) is especially valid for acute exacerbation in chronic obstructive pulmonary disease (COPD), but the trend has been to use it for all types of patients with acute respiratory failure (ARF). Recent data suggest that treatment failure occurs more often in patients with ARF from pneumonia than from COPD. MATERIAL AND METHODS: This was a retrospective study using data from patients with ARF admitted into the intensive care unit in a university-affiliated hospital in the period from 1 January 2009 to 31 December 2012 and treated with NIV. Patients with ARF due to acute exacerbation in COPD or ARF due to pneumonia were included. The primary end-point was treatment failure (intubation). The secondary end-point was in-hospital mortality. A total of 107 patients were included, 42 in the COPD group and 65 in the pneumonia group. RESULTS: We found no significant difference between the two groups with regard to age (mean 65 ± 8 years (COPD) versus mean 64 ± 16 years (pneumonia)), sex (male/female 23/19 (COPD) versus male/female 26/39 (pneumonia)) or New Simplified Acute Physiology Score (SAPS II) (mean 47 ± 11 (COPD) versus mean 51 ± 15 (pneumonia)). Treatment failure occurred in five patients in the COPD group (12%) and in 32 patients in the pneumonia group (49%), p < 0.00001. In-hospital mortality occurred in six patients in the COPD group (14%) and in 21 patients in the pneumonia group (32%), p = 0.01. CONCLUSION: NIV is less effective in the treatment of ARF due to pneumonia than in the treatment of ARF due to acute exacerbation in COPD. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.