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Interact CardioVasc Thorac Surg 2007;6:567-569. doi:10.1510/icvts.2007.153601 © 2007 European Association of Cardio-Thoracic Surgery
Inexpensive anatomical trainer for bronchoscopy
a Department of Transplantation, San Martino University Hospital, University of Genoa, Largo Rosanna Benzi n10, 16132 Genoa, Italy Received 6 February 2007; received in revised form 17 April 2007; accepted 23 April 2007
*Corresponding author. Tel.: +39 338 2749604/+39 010 555 3108; fax: +39 010 503965.
Flexible fiberoptic bronchoscopy is an indispensable tool for optimal management of intensive care unit patients. However, the acquisition of sufficient training in bronchoscopy is not straightforward during residency, because of technical and ethical problems. Moreover, the use of commercial simulators is limited by their high cost. In order to overcome these limitations, we realized a low-cost anatomical simulator to acquire and maintain the basic skill to perform bronchoscopy in ventilated patients. We used 1.5 mm diameter iron wire to construct the bronchial tree scaffold; glazier-putty was applied to create the anatomical model. The model was covered by several layers of newspaper strips previously immersed in water and vinilic glue. When the model completely dried up, it was detached from the scaffold by cutting it into six pieces, it was reassembled, painted and fitted with an endotracheal tube. We used very cheap material and the final cost was  16. The trainer resulted in real-scale and anatomically accurate, with appropriate correspondence on endoscopic view between model and patients. All bronchial segments can be explored and easily identified by endoscopic and external vision. This cheap simulator is a valuable tool for practicing, particularly in a hospital with limited resources for medical training.
Key Words: Inexpensive; Homemade; Simulator; Training; Bronchoscopy
Flexible fiberoptic bronchoscopy (FFB) is an indispensable tool for the optimal management of intensive care unit (ICU) patients with both diagnostic and therapeutic goals [1]. However, FFB should be performed by experienced operators who are skilled in the use of this versatile instrument [2]. Acquiring sufficient training in FFB on patients during residency in anesthesiology and general surgery is not straightforward, mainly because of technical and ethical problems. Experienced operators can teach the basic skills on intubated patients in operative room and in ICU, but in this setting the time spent in examination must be limited and the number of FFBs performed could be insufficient for a satisfactory training. Furthermore, patients have a right to be protected from the total novice [3, 4]. As a consequence, it is reasonable to prepare trainees as well as possible with alternative methods before they are allowed to attempt FFB on patients. Simple models and manikins were traditionally used to teach residents how to manipulate the fiberoptic bronchoscope [5, 6], and the advantages of a virtual simulator have been recently evaluated by several authors [7, 8]. However, these simulators are expensive, limiting a wide utilization. In order to overcome these limitations, we realized a low-cost anatomical simulator to acquire and maintain the basic skill to perform FFB in ventilated patients.
We used 1.5 mm diameter iron wire to construct the bronchial tree scaffold based on anatomical pictures from textbooks of human anatomy and thoracic surgery [9, 10]. The iron wire scaffold was fixed to a wooden stick on a wood base (Fig. 1a).
In order to increase the thickness of the scaffold, the iron wire was wrapped using newspaper sheets; glazier-putty was then applied to create the anatomical model in real scale (Fig. 1b). At this point a layer of common food transparent film wrapped the entire model. Strips of newspaper sheet were immersed in a solution of water and vinilic-glue (2:1 ratio) for 1 h, and then they were used to cover the model in several layers (6–7 layers). The model completely dried up in ambient temperature in approximately 48 h (Fig. 1c). The model was then easily detached from the scaffold by cutting it into six pieces, and the inner surface was painted with water-based enamel (Fig. 1d). The model was reassembled using further layers of newspaper strips soaked by water and vinilic glue. Once the model dried, it was painted and segmental bronchi were labeled according to the international classification. The model basement was built using a board of 30x40x2 cm of dimension, where three supports for the bronchial tree and one for the endotracheal tube were fixed; nails were driven into supports in an oblique direction in order to hook rubber bands. We used common rubber bands to secure the bronchial tree to the supports on the basement, and an 8-mm inner-diameter endotracheal tube was fitted in the groove on its support (Fig. 1e).
The model resulted in real-scale and anatomically accurate, with an appropriate correspondence on endoscopic view between model and patients (Fig. 2).
All bronchial segments can be explored and easily identified by endoscopic and external vision. The simulator can be disassembled easily and quickly for cleaning, repairing and for trouble-free transport.
The complete model required approximately 8 h of work, excluding the drying time. We used very cheap material and the final cost was
Anatomy recognition and dexterity are essential for endoscopic examination. Bronchoscopy requires considerable hand–eye coordination and this psychomotor skill can be learned and maintained only by practicing. Simulators offer the opportunity of unlimited training, minimizing the use of patients for practicing their skills. Residents can acquire some degree of skill and knowledge before their first patient contact and can maintain their ability especially in a clinical setting with a low number of FFB examinations required. We designed the anatomical simulator in order to train anaesthesiologists and general surgeon residents in FFB in intubated patients. In our model, the simultaneous endoscopic view and the external anatomy of the bronchial tree resulted in being very useful during the training: checking the position of the bronchoscope by internal and external vision is a valuable tool for the acquisition of topographic anatomy and dexterity. In conclusion, our airway simulator is an effective tool for training basic FFB skills, it is useful in preparing residents for their first patient examination and to maintain the acquired endoscopic ability. It is also very cheap in contrast to commercial training systems, allowing a potential wide application in every hospital with limited resources for medical training.
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Abstract
1. Introduction
