Anatomical model broncho-trainer: A new training device.

INTRODUCTION

Flexible fibreoptic bronchoscopy (FFB) is an indispensable tool for optimal management of intensive care unit (ICU) patients having both diagnostic as well as therapeutic goals.[1] FFB should be performed by experienced individuals as it requires good hand and eye coordination, which can be achieved only by repeated practicing.[2] Practicing the procedure on patients by inexperienced physicians is unethical and harmful to the patient. It is seen that trainees who practiced on cadavers grasped the skill of bronchoscopy earlier in comparison with those who learnt the skill through textbooks.[3] Experienced operators can teach the basic skills of FFB on intubated patients in ICU, but the time spent in examination, and the number of FFBs performed could be insufficient for a satisfactory training. Hence, alternative methods to train the residents before they are allowed to attempt FFB on patients is essential.[4] There are several models and mannequins available to teach resident doctors how to manipulate the fibreoptic bronchoscope.[5] However, these simulators are expensive and have some limitations for wide utilisation. In order to overcome the limitations such as high cost, difficulty in handling by inexperienced persons, and to promote external visualisation, we designed a very low cost, easily made anatomical simulator, for bronchoscopy in ventilated patients.[6]

METHODS

We used double coloured (white and blue) corrugated tubing of ventilator circuit. This circuit was cut into several pieces of equal length; pieces were rearranged and connected to each other through Y-connector giving an anatomical appearance of tracheobronchial tree. We created two different types of branching; one simpler for beginners and the other one for the second phase of training [Figures 1 and 2]. Two different colours of tubing (white for right, blue for left) in our simulator helps residents in better guidance of direction of bronchoscope. Three-generation branching was achieved in this simulator. The simulator is designed in such a way that disassembly is easy and quick, (approximately 45 s.) for cleaning, repairing, and for trouble-free transport.

Figure 1

AM broncho-trainer

Figure 2

Endoscopic view of anatomical tracheal ring with carina and view of this model

The complete model requires approximately 30 min of work time. It is possible to increase the difficulty level by attaching the Y-connector for more branching at different levels of the broncho-trainer through which the tubings are attached.

DISCUSSION

There are several models for the training of bronchoscopy, e.g. Oxford Fibreoptic Teaching Box, cadavers for learning, choose-the-hole model, inexpensive anatomical trainer, high-fidelity systems and many more. These broncho-trainers are compared on the basis of their cost, simulation to bronchial tree, external visualisation, chances of damage to bronchoscope, colour coding, and options of increasing difficulty level, handling and cleaning. In comparison to other broncho-trainers, the reported one is a very cheap and useful tool for easy learning of bronchoscopy when there is limitation of resources.[5678]

Oxford Fibre optic Teaching Box is a simple model, in which multiple discs are arranged over one another having holes at different points.

Choose-the-hole model is a simple model that can be developed locally. Three wooden panels with holes are mounted on a wooden base. Syringe barrels are inserted into the holes in different combinations. This is simple and inexpensive non-anatomical model for improving manipulation skills.

High-fidelity systems can create a more realistic environment, but are expensive. Multiple types of clinical situations can be simulated and can be repeated. In addition, a wide range of data and pictures can be automatically recorded and stored. One example is “The AccuTouch Bronchoscopy Simulator” (Immerson Medical, Giathersberg, MD, USA), which has an inbuilt comprehensive software capable of creating multiple clinical scenarios.

Inexpensive anatomical trainer (AM) was made by using iron wire and newspaper to construct the bronchial tree scaffold based on anatomical pictures. The iron wire scaffold was fixed to a wooden stick on a wood base. They were used strips of newspaper sheet to cover the model in several layers (6-7 layers). The model completely dried up in ambient temperature. Once the model got dried up, it was painted.

In comparison to the other quoted models, our model, A M Broncho-trainer (ANIL- MANOJ. Broncho-trainer) is very low cost, easy to disassemble, easy to clean, ‘learning difficulty level’ can be increased, transparent material is used for external visibility, and trainee can practice for foreign body removal [Tables 1 and 2].

Table 1

Advantages and disadvantages of AM the broncho-trainer

Table 2

Comparison between AM broncho-trainer to other models

With many advantages this broncho-trainer has some limitations like it doesn’t mimic the actual bronchial tree and learning of intubation through this model is not possible.

By adding a mannequin of head and face at the top of our model, we can simulate and overcome the limitation of intubation learning through our broncho-trainer but this will increase the cost.

CONCLUSION

An excellent hand and eye coordination is needed for the bronchoscopy and this skill can be learned only by practicing repeatedly. We designed this simulator for easy learning of bronchoscopy. Residents can practice for unlimited number of times through our broncho-trainer. Through our simulator resident can learn how to keep the scope in the centre of field under the guidance of the skilled trainer and this will minimise the risk of mucosal injury and damage to bronchoscope [Figure 2]. AM broncho-trainer is highly effective simulator in comparison to other simulator.[4578] It is a useful tool for training of residents before they have their first exposure on patients. It is very cheap, with potential application in hospitals with limited resources for medical training.