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Interbronchoscopist Variability in Endobronchial Path Selection^*

A Simulation Study

^* From the Department of Medicine (Drs. Dolina and Bascom), Division of Pulmonary, Allergy, and Critical Care Medicine, and the Department of Radiology (Dr. Mahraj), College of Medicine, Penn State University, Hershey, PA; and the Department of Electrical Engineering (Mr. Cornish, Dr. Merritt, Mr. Rai, and Dr. Higgins), College of Engineering, Penn State University, University Park, PA.

Correspondence to: Rebecca Bascom, MD, MPH, MC HO41, 500 University Dr, Hershey, PA 17033; e-mail: rbascom{at}psu.edu

Abstract

Background: Endobronchial path selection is important for the bronchoscopic diagnosis of focal lung lesions. Path selection typically involves mentally reconstructing a three-dimensional path by interpreting a stack of two-dimensional (2D) axial plane CT scan sections. The hypotheses of our study about path selection were as follows: (1) bronchoscopists are inaccurate and overly confident when making endobronchial path selections based on 2D CT scan analysis; and (2) path selection accuracy and confidence improve and become better aligned when bronchoscopists employ path-planning methods based on virtual bronchoscopy (VB).

Methods: Studies of endobronchial path selection comparing three path-planning methods (ie, the standard 2D CT scan analysis and two new VB-based techniques) were performed. The task was to navigate to discrete lesions located between the third-order and fifth-order bronchi of the right upper and middle lobes. Outcome measures were the cumulative accuracy of making four sequential path selection decisions and self-reported confidence (1, least confident; 5, most confident). Both experienced and inexperienced bronchoscopists participated in the studies.

Results: In the first study involving a static paper-based tool, the mean (± SD) cumulative accuracy was 14 ± 3% using 2D CT scan analysis (confidence, 3.4 ± 1.3) and 49 ± 15% using a VB-based technique (confidence, 4.2 ± 1.1; p = 0.0001 across all comparisons). For a second study using an interactive computer-based tool, the mean accuracy was 40 ± 28% using 2D CT scan analysis (confidence, 3.0 ± 0.3) and 96 ± 3% using a dynamic VB-based technique (confidence, 4.6 ± 0.2). Regardless of the experience level of the bronchoscopist, use of the standard 2D CT scan analysis resulted in poor path selection accuracy and misaligned confidence. Use of the VB-based techniques resulted in considerably higher accuracy and better aligned decision confidence.

Conclusions: Endobronchial path selection is a source of error in the bronchoscopy workflow. The use of VB-based path-planning techniques significantly improves path selection accuracy over use of the standard 2D CT scan section analysis in this simulation format.

Key Words: airway roadmap • bronchoscopy • lung cancer • navigation • virtual bronchoscopy