Journal Mobile Options
Table of Contents
Vol. 77, No. 3, 2009
Issue release date: April 2009
Respiration 2009;77:325–330
(DOI:10.1159/000188788)

Flexible Bronchoscope Damage and Repair Costs in a Bronchoscopy Teaching Unit

Rozman A. · Duh S. · Petrinec-Primozic M. · Triller N.
University Clinic for Pulmonary and Allergic Diseases Golnik, Golnik, Slovenia
email Corresponding Author

Abstract

Background: A significant part of the budget of our bronchoscopy unit represents repair costs for damaged bronchoscopes. Objectives: The purpose of this study was to determine the frequency, type and cause of damage to the bronchoscope as well as the repair costs. Methods: Frequency, type and cause of bronchoscope damage and repair costs of 13 new bronchoscopes that were used between August 1, 2001, and December 31, 2006, were retrospectively studied. Results: We recorded 47 instances of bronchoscope damage during the study, which is 1 instance of damage/141.6 procedures. Six instances of damage (12.7%) were potentially preventable. The most frequent wear and tear damage was to the rubber sheath on the distal bending portion of flexible bronchoscopes, and the most frequently preventable damage was that of the suction channel of the bronchoscope. The repair costs totaled 34,950.00 EUR or 5.25 EUR/procedure. 17,781.00 EUR (50.9%) can be attributed to preventable damage. The use of bronchoscopes for educational purposes was not associated with a higher rate of bronchoscope damage at our institution. Conclusions: Only a small number of occurrences of bronchoscope damage in our unit are potentially preventable, but they still represent an important expense. The relatively low occurrence of preventable damage is a result of the successful bronchoscopy training program.


 Outline


 goto top of outline Key Words

  • Endoscopy/surgery, assessment
  • Bronchoscopy, cost-benefit analysis
  • Bronchoscopy, diagnostic and therapeutic
  • Endoscopy and training

 goto top of outline Abstract

Background: A significant part of the budget of our bronchoscopy unit represents repair costs for damaged bronchoscopes. Objectives: The purpose of this study was to determine the frequency, type and cause of damage to the bronchoscope as well as the repair costs. Methods: Frequency, type and cause of bronchoscope damage and repair costs of 13 new bronchoscopes that were used between August 1, 2001, and December 31, 2006, were retrospectively studied. Results: We recorded 47 instances of bronchoscope damage during the study, which is 1 instance of damage/141.6 procedures. Six instances of damage (12.7%) were potentially preventable. The most frequent wear and tear damage was to the rubber sheath on the distal bending portion of flexible bronchoscopes, and the most frequently preventable damage was that of the suction channel of the bronchoscope. The repair costs totaled 34,950.00 EUR or 5.25 EUR/procedure. 17,781.00 EUR (50.9%) can be attributed to preventable damage. The use of bronchoscopes for educational purposes was not associated with a higher rate of bronchoscope damage at our institution. Conclusions: Only a small number of occurrences of bronchoscope damage in our unit are potentially preventable, but they still represent an important expense. The relatively low occurrence of preventable damage is a result of the successful bronchoscopy training program.

Copyright © 2008 S. Karger AG, Basel


goto top of outline Introduction

Respiratory endoscopy equipment continuously undergoes technological updating and improvement. At the same time, there are concomitant increases in purchase prices of endoscopy instruments. The repair costs and maintenance of this equipment represent an important share of the total budget of the endoscopy unit. Bronchoscopes get damaged as a result of routine wear and tear during procedures, as well as the use of aggressive cleaning and disinfection processes; however, a significant amount of damage results from inattentive or inexperienced use of instruments [1,2,3].

Bronchoscopists and their assisting nurses need to have a profound knowledge of the components of an instrument and its most sensitive parts. They need to be familiar with preparing the instrument for the procedure, handling the instrument during the procedure, and cleaning, disinfecting and storing the instrument properly after the procedure. The bronchoscopy team in our endoscopy unit practices the above-mentioned skills in accordance with specifically defined responsibilities for each member of the bronchoscopy team [4].

Another factor that might influence bronchoscope damage is doctors who are still learning bronchoscopy and have yet to sufficiently develop their instrument handling skills. It was already established that a training program on proper handling of equipment significantly reduces repair costs in a bronchoscopy unit [3]. Therefore, trainees in a bronchoscopy unit should start with the theoretical study of the structure and proper handling of the bronchoscope, as well as aspects of proper cleaning, storing and transporting of the flexible bronchoscope. The practical part of the training in our bronchoscopy unit starts with the candidate practicing on a model with a bronchoscope that is used for educational purposes. Only after this has been completed are they allowed to perform the procedure on a patient under the direct supervision of their mentor.

The economics of work in an endoscopy unit are important because they include equipment servicing and purchasing, planning of new activities and the costs of new investments or the implementation of new methods. The available literature does not say much about these issues. This is why our analysis here attempts to address the financial aspects of maintaining bronchoscopes. In doing this, we tried to obtain the basic data for the preparation of the record of expenses of the bronchoscopy unit and the plan for improvements in working with these instruments.

The purpose of the analysis was to define:

– The frequency of bronchoscope damage

– Types of bronchoscope damage

– Causes for bronchoscope damage

– Prevention of bronchoscope damage

– The influence of a novice’s use of a bronchoscope on the frequency and the type of bronchoscope damage

– The comparability of damage in fiberoptic bronchoscopes and video bronchoscopes

– Period of duration for damaged bronchoscopes that are out of service

– Repair costs

– Possibilities of cost reduction and improvements in working with bronchoscopes.

 

goto top of outline Methods

A retrospective analysis of bronchoscope damage and repair costs between August 1, 2001, and December 31, 2006, was performed at the Respiratory Endoscopy Unit of the University Clinic of Respiratory and Allergic Diseases Golnik. The study protocol was approved by the institutional review board.

The analysis included bronchoscopes that were new and introduced into regular use after the study had begun. Those that were used before the study were not included.

Our Respiratory Endoscopy Unit is a tertiary teaching center where diagnostic and interventional bronchoscopies are performed along with the training of new bronchoscopists. In diagnostic bronchoscopies, all methods of sample collection including transbronchial needle aspiration are used. In interventional procedures with a flexible bronchoscope, argon plasma coagulation, electrocautery and cryoprobes are used.

At the time of the analysis, the following fiberoptic bronchoscopes and video bronchoscopes were in use: Olympus BF XT40, Olympus BF XT160, Olympus BF 1T40 and Olympus BF 1T60.

Data were collected with the help of a protocol manual with information about previously performed procedures, which enabled us to trace the use of these instruments. In addition to patients’ identification data (name, registration number, birth data), the protocol manual also included information about the type of procedure, names of the bronchoscopist (with the name of the training program mentor) and of the assistants (nurses), as well as the code number of the bronchoscope with which the procedure was performed. The code number of the bronchoscope was given to each new instrument and was inscribed on the venting connector after that.

Apart from the protocol manual, each flexible bronchoscope was also registered in a service book with the following data: production year, year of purchase, type and serial number of the bronchoscope, code number, type of bronchoscope damage, the date when the bronchoscope was sent for service and the date when it was returned.

The research included all flexible fiberoptic bronchoscopes and video bronchoscopes that were used in procedures at the time of the study and that were used for the first time only after the study had begun. Preventable damage was defined as damage resulting from inappropriate handling. We arbitrarily separated this type of damage from damage resulting from wear and tear.

Teaching bronchoscopy procedure was defined as a procedure where the whole procedure or part of it was performed by a bronchoscopist in training. Apprentices were involved in both diagnostic and interventional procedures. Data on repair costs were obtained from the archive of the invoices of bronchoscope repairs and were then compared to the invoice copies from the service company.

Incidents of bronchoscope damage were analyzed with the help of descriptive statistical methods. Comparison was made with the χ2 test. p < 0.05 was accepted as statistically significant.

 

goto top of outline Results

The analysis included 13 flexible bronchoscopes, which were used for the first time after August 1, 2001. Four of these were video bronchoscopes (code No. 6, 7, 8 and 11) and 9 were fiberoptic bronchoscopes (code No. 1–5, 9, 10, 12, 13).

The average age of the instruments was 35.2 months (ranging from 5 to 65 months). We performed a total of 6,654 bronchoscopies with these instruments, including 623 (9.4%) interventional procedures. Transbronchial needle aspiration was performed in 2,559 (38.5%) procedures. The instruments were used as a teaching tool 1,347 times (20.2%). Each individual bronchoscope was used to perform between 44 and 1,328 procedures. The data are presented in table 1.

TAB01
Table 1. Bronchoscope use and frequency of damage

Bronchoscopes were damaged 47 times (table 2). The frequency of damage was as follows: damage of the rubber coat on the distal bending section, damage of the venting connector, suction channel damage, damage of the bending apparatus, ocular damage, damage of the external sheath and damage of the covering on the distal tip of the bronchoscope.

TAB02
Table 2. Types and costs of bronchoscope damage

The most frequent type of damage was wear and tear which included damage of the rubber coat on the distal bending section, damage of the venting connector, damage of the bending apparatus, ocular damage and damage of the covering on the distal tip of the bronchoscope. Damage of the rubber coat on the distal bending section was the most frequent type of damage in this group. Wear and tear damage resulted from repeated stress on the instruments’ materials during procedures and cleaning and maintenance processes.

Two types of preventable damage were noted: suction channel damage and damage of the external sheath. In 4 cases, suction channel damage resulted from inappropriate handling of the needle used for transbronchial needle aspiration. In the remaining case, damage was caused by biopsy forceps that did not close due to a handle malfunction; the suction channel was damaged when the forceps were drawn out. A single incident of damage to the external sheath was due to rough manipulation of the bronchoscope with an endotracheal tube during the interventional procedure.

None of the episodes of damage happened during reprocessing or storage. All damage occurred during procedures or during connection of the instrument before the procedure.

The influence of the instrument use in teaching on the frequency of damage was studied with two methods: by comparing the number of preventable occurrences of damage caused during learning procedures with those caused during regular procedures, and by comparing the number of all occurrences of damage caused during learning procedures with those caused during regular procedures. All six preventable occurrences of damage did not occur in procedures where apprentices worked with the instruments. In total, 14 occurrences of damage occurred during learning procedures and 33 occurred during regular procedures in which doctors learning to perform bronchoscopic procedures were not involved. The difference is statistically insignificant (p = 0.1).

The difference between the number of occurrences of damage in video bronchoscopes and fiberoptic bronchoscopes per number of performed procedures is also statistically insignificant (p = 0.99).

The average time period (mean, SD) during which bronchoscopes were out of service due to damage was 24.8 (±19.5) days per episode. The total time of not being in use was 1,165 days.

The total repair costs were 34,950.00 EUR, which is approximately 5.25 EUR per procedure. Predictable damage that resulted from wear and tear cost 17,169.00 EUR and preventable damage cost 17,781.00 EUR. The total financial burden of preventable damage amounted to 50.9% of all financial expenses for bronchoscope repair.

 

goto top of outline Discussion

Flexible bronchoscopes have been in use in Slovenia since 1974. However, to our knowledge, thus far no analysis of damage, its causes and repair costs has been presented in our medical literature [5]. Moreover, we found only a few reports on this topic in the entire global literature [1,2,3].

During this study at the Respiratory Endoscopy Unit of Golnik Hospital, 47 occurrences of bronchoscope damage were recorded, which is the equivalent of 1 occurrence of damage/every 141.6 procedures on average. This number of occurrences of damage is considerably lower than that in comparable analyses by Mehta et al. [1], who recorded 1 occurrence of damage/91.1 bronchoscopies performed, and by Kirkpatrick et al. [2], who recorded 1 occurrence of damage/97.3 procedures.

An interesting study by Lunn et al. [3] showed that the implementation of interventional methods in a bronchoscopy unit does not considerably influence the number of occurrences of bronchoscope damage. The authors stated that they recorded 1 occurrence of damage/41.9 procedures before the implementation of interventional methods, and 1 occurrence of damage/36.4 procedures after the implementation of interventional methods. An important fact is that after the introduction of an additional one-day training program that consisted of theoretical instruction about proper handling of the bronchoscopic equipment as well as practical instruction, the number of occurrences of damage fell to 1 occurrence/159.9 procedures [3]! However, this incidence of damage is not statistically different from the incidence of damage in our unit (p = 0.67).

The most frequent damage in our study was to the rubber coat on the distal bending section (59.6%). Extreme bending during bronchoscopic procedures puts the distal bending section and angulation control lever under great mechanical stress, which is a predisposition to wear and tear. The next most frequent type of damage was to the connecting parts of the bronchoscope, usually as seal damage in the venting connector and in the ocular. Inner channel damage resulted from inattentive handling during biopsies. Another preventable type of damage was to the external sheath.

In our unit, 87.3% of bronchoscope damage resulted from heavy workloads for some of the bronchoscope parts and, consequently, from wear and tear of material. This type of damage could not be prevented by changing procedural techniques or using different cleaning and maintenance processes. Only a relatively small portion of all damage was preventable (12.7%). This number is again lower than that reported by Kirkpatrick et al. [2] who analyzed that 64.1% of all damage could be prevented, while Mehta et al. [1 ] found that 69.0% of all damage could be prevented.

Lunn et al. [3] stated that as much as 45.6% of all damage could be prevented with more attentive handling prior to the additional bronchoscopy training program. After the training, only 29.4% of all damage was preventable, which is statistically not different from preventable damage in our unit (p = 0.12).

There was no statistical difference in the number of occurrences of damage to video bronchoscopes or fiberoptic bronchoscopes. Damaged bronchoscopes were not in use for 1,165 days or 24.8 (±19.5) days per damage occurrence on average. This is comparable to the study by Kirkpatrick et al. [2] who calculated a mean number of 3.5 (±3.9) weeks out of service for damaged bronchoscopes.

At the time of this study, the repair costs for bronchoscopes were 34,950.00 EUR which is approximately 5.25 EUR per procedure. Average repair costs were 743.61 EUR per damage incident, repair of the usual wear and tear cost 471.76 EUR on average, and repair of preventable damage cost as much as 2,963.50 EUR on average per damage incident. Of all costs, 50.9% was spent on repairing preventable damage.

In the study by Kirkpatrick et al. [2], 64.1% of all occurrences of damage were preventable; the repairs in this study cost approximately 2,726.13 USD per damage incident.

In the study by Mehta et al. [1], 69.0% of all damage was preventable and the repairs cost approximately 2,139.60 USD per damage incident. The costs of unpreventable damage were 12,056.00 USD or 13.4% of the financial load, and the costs of preventable damage were 77,807.11 USD or 86.6% of all repair costs. The average price of a preventable occurrence of damage was 2,357.79 USD, and the average price of an unpreventable occurrence was 1,339.56 USD.

Lunn et al. [3 ] spent approximately 46 USD for bronchoscope repairs per procedure, 51 USD per procedure after implementing an interventional program, and only 8 USD per procedure after implementing additional training. The amount of preventable damage fell from 45.6 to 29.4%. These data show that the average price of an incident of preventable damage is significantly higher than that of damage caused by wear and tear. Each decline in the number of occurrences of preventable damage therefore significantly decreases the total costs of bronchoscope repairs.

The analysis of damage caused by training bronchoscopists did not show a greater number of occurrences of damage compared to the number of occurrences caused by skilled bronchoscopists who were also mentors in the training program. A low share of preventable damage is the result of the training program for new bronchoscopists, which begins with theoretical background and practical training on phantom devices. The participants of the training program are first introduced to a bronchoscope and additional bronchoscopic instruments, such as biopsy forceps and needles. They are also introduced to the cleaning process and shown how to handle the instruments correctly. They are allowed to perform procedures on a patient under direct supervision of their mentor only after they have passed an exam on the theoretical part of the program.

Learning bronchoscopy by using phantom devices and models has an unquestionably positive effect on the development of skills and accuracy during procedures. Consequently, it also results in an increase in the diagnostic value of the procedure and patient safety [6,7,8]. Familiarity with the equipment and proper working technique decreases both the occurrence of preventable damage and the costs in the bronchoscopy unit. This is well demonstrated in the article by Lunn et al. [3], where the effect of additional training was evaluated. As such, their results match our experience. The kind of training new bronchoscopists at our institution receive is thus not an additional financial load, because it does not increase the number of occurrences of bronchoscope damage.

 

goto top of outline Conclusions

Bronchoscopy units use relatively expensive equipment that gets occasionally damaged. By analyzing data on repairs of new bronchoscopes introduced into service between August 1, 2001, and December 31, 2006, we tried to define the frequency, type and cause of damage and price of repairs. All of these data were then compared to the data we found in the literature.

During this study, 47 occurrences of bronchoscope damage were reported. Six (12.8%) of these incidents could have been prevented and 41 (87.2%) could not. The financial burden of preventable damage reached 17,781.00 EUR which is 50.9% of the total costs of all damage repairs.

Our analysis has shown that preventable damage usually represents significantly higher costs than damage as a result of wear and tear. This is also the case in the existing literature. These types of damage can be prevented with additional training, which leads to substantial financial savings.

Bronchoscopy training methods that are used in our unit do not contribute to additional instrument damage. On the contrary, bronchoscopy training such as this results in a lower percentage of preventable damage, and when compared to the data from the existing literature, is very efficient.

 

goto top of outline Acknowledgments

The authors would like to thank Ms. Milijana Vegnuti for her contribution to the statistical data analysis and Ms. Anja Blazun for translating the article.


 goto top of outline References
  1. Mehta AC, Curtis PS, Scalzitti ML: The high price of bronchoscopy: maintenance and repair of the flexible fiberoptic bronchoscope. Chest 1990;98:448–454.
  2. Kirkpatrick MB, Smith JR, Hoffman PJ: Bronchoscope damage and repair costs: results of a regional postal survey. Respir Care 1992;37:1256–1259.
  3. Lunn W, Garland R, Gryniuk L, Smith L, Feller-Kopman D, Ernst A: Reducing maintenance and repair costs in an interventional pulmonology program. Chest 2005;127:1382–1387.
  4. Triller N: Smernice za bronhoskopijo z upogljivim bronhoskopom. Endosk Rev 2002;7:3–21.
  5. Mešič J, Zupanič S, Triller N: 50-letnica bronhoskopije na Golniku. ISIS – Glasilo Zdravniške Zbornice Slovenije 2002;11:64–65.
  6. Blum MG, Powers TW, Sundaresan S: Bronchoscopy simulator effectively prepares junior residents to competently perform basic clinical bronchoscopy. Ann Thorac Surg 2004;78:287–291.
  7. Ost D, DeRosiers A, Britt EJ, Fein AM, Lesser ML, Mehta AC: Assessment of a bronchoscopy simulator. Am J Respir Crit Care Med 2001;164:2248–2255.
  8. Davoudi M, Osann K, Colt HG: Validation of two instruments to assess technical bronchoscopic skill using virtual reality simulation. Respiration 2008;76:92–101.

 goto top of outline Author Contacts

Ales Rozman, MD
University Clinic for Pulmonary and Allergic Diseases Golnik
Golnik 36
SI–4204 Golnik (Slovenia)
Tel. +386 41 313 811, Fax +386 4 25 69 117, E-Mail ales.rozman@klinika-golnik.si


 goto top of outline Article Information

Received: March 25, 2008
Accepted after revision: August 28, 2008
Published online: December 20, 2008
Number of Print Pages : 6
Number of Figures : 0, Number of Tables : 2, Number of References : 8


 goto top of outline Publication Details

Respiration (International Journal of Thoracic Medicine)

Vol. 77, No. 3, Year 2009 (Cover Date: April 2009)

Journal Editor: Bolliger C.T. (Cape Town)
ISSN: 0025-7931 (Print), eISSN: 1423-0356 (Online)

For additional information: http://www.karger.com/RES


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Background: A significant part of the budget of our bronchoscopy unit represents repair costs for damaged bronchoscopes. Objectives: The purpose of this study was to determine the frequency, type and cause of damage to the bronchoscope as well as the repair costs. Methods: Frequency, type and cause of bronchoscope damage and repair costs of 13 new bronchoscopes that were used between August 1, 2001, and December 31, 2006, were retrospectively studied. Results: We recorded 47 instances of bronchoscope damage during the study, which is 1 instance of damage/141.6 procedures. Six instances of damage (12.7%) were potentially preventable. The most frequent wear and tear damage was to the rubber sheath on the distal bending portion of flexible bronchoscopes, and the most frequently preventable damage was that of the suction channel of the bronchoscope. The repair costs totaled 34,950.00 EUR or 5.25 EUR/procedure. 17,781.00 EUR (50.9%) can be attributed to preventable damage. The use of bronchoscopes for educational purposes was not associated with a higher rate of bronchoscope damage at our institution. Conclusions: Only a small number of occurrences of bronchoscope damage in our unit are potentially preventable, but they still represent an important expense. The relatively low occurrence of preventable damage is a result of the successful bronchoscopy training program.



 goto top of outline Author Contacts

Ales Rozman, MD
University Clinic for Pulmonary and Allergic Diseases Golnik
Golnik 36
SI–4204 Golnik (Slovenia)
Tel. +386 41 313 811, Fax +386 4 25 69 117, E-Mail ales.rozman@klinika-golnik.si


 goto top of outline Article Information

Received: March 25, 2008
Accepted after revision: August 28, 2008
Published online: December 20, 2008
Number of Print Pages : 6
Number of Figures : 0, Number of Tables : 2, Number of References : 8


 goto top of outline Publication Details

Respiration (International Journal of Thoracic Medicine)

Vol. 77, No. 3, Year 2009 (Cover Date: April 2009)

Journal Editor: Bolliger C.T. (Cape Town)
ISSN: 0025-7931 (Print), eISSN: 1423-0356 (Online)

For additional information: http://www.karger.com/RES


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Mehta AC, Curtis PS, Scalzitti ML: The high price of bronchoscopy: maintenance and repair of the flexible fiberoptic bronchoscope. Chest 1990;98:448–454.
  2. Kirkpatrick MB, Smith JR, Hoffman PJ: Bronchoscope damage and repair costs: results of a regional postal survey. Respir Care 1992;37:1256–1259.
  3. Lunn W, Garland R, Gryniuk L, Smith L, Feller-Kopman D, Ernst A: Reducing maintenance and repair costs in an interventional pulmonology program. Chest 2005;127:1382–1387.
  4. Triller N: Smernice za bronhoskopijo z upogljivim bronhoskopom. Endosk Rev 2002;7:3–21.
  5. Mešič J, Zupanič S, Triller N: 50-letnica bronhoskopije na Golniku. ISIS – Glasilo Zdravniške Zbornice Slovenije 2002;11:64–65.
  6. Blum MG, Powers TW, Sundaresan S: Bronchoscopy simulator effectively prepares junior residents to competently perform basic clinical bronchoscopy. Ann Thorac Surg 2004;78:287–291.
  7. Ost D, DeRosiers A, Britt EJ, Fein AM, Lesser ML, Mehta AC: Assessment of a bronchoscopy simulator. Am J Respir Crit Care Med 2001;164:2248–2255.
  8. Davoudi M, Osann K, Colt HG: Validation of two instruments to assess technical bronchoscopic skill using virtual reality simulation. Respiration 2008;76:92–101.