Abstract
Objectives: To assess current adherence to international guidelines for practitioners of bronchoscopy in the Kingdom of Saudi Arabia.
Methods: A cross-sectional survey was conducted in Saudi Arabia between December 2016 and March 2017. Pulmonologists, thoracic surgeons, and intensivists were invited to answer an emailed self-administered questionnaire survey seeking information on how they performed flexible bronchoscopy in adults. The data collected were compared between the 3 specialties.
Results: Eighty-two (18%) of 456 invited practitioners completed the survey. Fifty-eight (72%) of the 82 respondents were pulmonologists. Forty (53%) of 76 respondents (93%) who had received bronchoscopy training received it abroad. Twenty-seven respondents (33%) had also received training in endobronchial ultrasound, electrocautery, brachytherapy, stent insertion, and laser procedures. Fifty-eight respondents (70%) preferred patients to undergo fasting for at least 4 hours before the procedure. Lidocaine was used for topical anesthesia, mainly by aerosol spray or nebulization. Midazolam was used by 62%, fentanyl by 50%, and propofol by 12% of respondents. Ninety percent of pulmonologists reported requesting a chest radiograph after transbronchial lung biopsy. Safety procedures for bronchoscopists, for example, wearing masks and eye protection, and for patients, for example, availability of anesthetic reversal agents, were not universally applied.
Conclusion: Bronchoscopy is not standardized in Saudi Arabia. National guidelines for the indications and practice of bronchoscopy are required.
Since its introduction in 1968, flexible bronchoscopy (FB) has evolved to become an essential tool in pulmonary medicine.1 Several international surveys on the practice of flexible bronchoscopy have been published.2-11 These surveys used different methodologies but consistently highlighted variations in practice between countries and over time. A practice guideline was published by the British Thoracic Society in 2013 and guidelines for bronchoscopy training were published subsequently by the American College of Chest Physicians, along with more specific guidelines on preparation of patients, use of anesthetic and sedative agents, and adjunctive therapies.12-14 Apart from one single-center study, there have been no reports on the practice of bronchoscopy in Saudi Arabia.15 The availability of a national training and practice standard for bronchoscopy procedures is essential to limit variability and improve the quality and consistency of health care. We aimed to assess current adherence to international standard training and practice guidelines for bronchoscopy procedures in Saudi Arabia, in comparison with other countries.
Methods
A cross-sectional survey was conducted in Saudi Arabia in December 2016. The study protocol was approved by our institutional biomedical research ethics committee and was performed in adherence to the tenets of the Helsinki Declaration of 1975, as revised in 2000. A standardized self-administered questionnaire and informed consent form for participation were emailed to pulmonologists, thoracic surgeons, and intensivists treating adult patients in different regions of the country. The contact details of the prospective study participants were identified from the Saudi Thoracic Society database. A second request to complete the survey was emailed 4 weeks after the initial attempt, to enhance the response rate. Survey results were collected over 12 weeks.
Our survey format was adapted from surveys that had been used previously to address this issue.4,5 The survey domains included demographics, procedural statistics, patient preparation and tests, sedation and anesthesia, patient monitoring, infection control measures, and bronchoscopy training and competency. The international standard for practice and training competence against which we assessed adherence was based on guidelines of the British Thoracic Society and the American College of Chest Physicians.12-14
Statistical analysis
Respondent characteristics are presented as proportions for dichotomous variables, and means for continuous variables. Comparisons between practitioners in the different specialties were performed using the chi-square test. All analyses were performed using StataCorp. 2011 software (Stata Statistical Software: Release 12. College Station, TX: StataCorp LP). Statistical significance was determined by the 95% confidence interval and p-values less than 0.05.
Results
Demographic characteristics
Eighty-two (18%) of the 456 practitioners invited to participate responded to the survey. Table 1 shows respondent demographic characteristics. The participants were from all regions of the country; 72 (88%) were male and the majority (n=58, 72%) were pulmonary specialists.
General participant characteristics.
Training and experience
Forty (51%) of the respondents had trained abroad; approximately half had more than 10 years’ experience in performing bronchoscopies. Among the advanced procedures, endobronchial ultrasound was the procedure for which training had been most commonly received, and transbronchial needle aspiration (TBNA) was seldom performed (Table 2).
Survey responses regarding training and experience of participants.
Table 3 compares the bronchoscopy training and experience of bronchoscopists in the different specialties. As expected, more thoracic surgeons were trained to perform rigid bronchoscopy (p<0.001) and laser procedures than were the bronchoscopists in other specialties (p=0.001). Intensivists performed significantly more bronchoscopies (p=0.012) than the other bronchoscopists. However, significantly more pulmonologists had performed at least 10 bronchial biopsies in the preceding year (p=0.031). Overall, relatively few participants reported performing therapeutic bronchoscopic interventions.
Bronchoscopic procedures trained and experienced by different specialties.
Bronchoscopy policy and practice
Table 4 highlights the policy and practice pertaining to bronchoscopic procedures. Pulmonologists preferred to perform the procedure in a bronchoscopy suite, and nasal insertion was the route preferred by pulmonologists and thoracic surgeons. Pulmonologists ordered significantly more chest radiographs after transbronchial lung biopsy (TBLB) than clinicians in the other specialties (p=0.001).
Survey responses regarding policy and preparation for bronchoscopic procedures by different specialties.
Preparation for bronchoscopy
The responses of the intensivists suggested that they ordered more tests before bronchoscopy than other specialties, but the difference was not statistically significant. All respondents reported that they secured venous access before the procedure. All pulmonologists and 90% of the thoracic surgeons reported that they explained the procedure to their patients. More thoracic surgeons than pulmonologists and intensivists explained the procedure to patients using illustrations (p=0.02; Table 4).
Infection control measures
All intensivists indicated that they always wear gloves, a gown, and a mask. All pulmonologists indicated that they always wear gloves. Significantly more intensivists than pulmonologists and thoracic surgeons reported wearing eye protection. Participants from all specialties reported implementing specific protective measures for high-risk patients (Table 5).
Survey responses regarding self-protection and patient monitoring during bronchoscopy.
Patient monitoring during bronchoscopy
Pulse oximetry was almost always used for monitoring during bronchoscopy across all specialties. Eighty-six percent of intensivists always used electrocardiographic (ECG) monitoring. All intensivists always used blood pressure monitoring during bronchoscopy (Table 5).
Sedation and anesthesia
The respondents’ preferences for sedation and anesthesia are shown in Table 6. Most respondents preferred to use an aerosol formulation of lidocaine for oropharyngeal anesthesia. Nebulized lidocaine was used by significantly more intensivists (86%) than clinicians in the other specialties (p=0.055). More than half the pulmonologists and intensivists and approximately one third of the thoracic surgeons used “spray as you go” lidocaine for tracheobronchial anesthesia.
Survey responses regarding medications used during bronchoscopy.
For sedation, most respondents used intravenous midazolam followed by intravenous fentanyl. Importantly, anesthetic reversal agents were available to all thoracic surgeons during the procedure but not to 14% of intensivists and 6% of pulmonologists.
Discussion
We attempted to analyze the practice and training of responders before, during and after bronchoscopy. Our respondents were from all parts of Saudi Arabia and from specialties such as pulmonology, intensive care and thoracic surgery. Almost all respondents in our survey had received formal training in bronchoscopy, and at least half of them had received their training abroad. However, surveys in other countries, including Egypt, Singapore, Australia, and New Zealand, have indicated that most bronchoscopists receive their training locally.4,5,10,11 This variation is likely explained by the extensive postgraduate scholarship programs offered to Saudi doctors, and the high percentage of non-Saudi national doctors practicing in Saudi Arabia who had been trained in their home countries. Only 22% of the bronchoscopists in our study had performed more than 50 bronchoscopies in the previous year; this is less than the figure reported in the UK survey, in which the majority of respiratory physicians performed more than 100 bronchoscopies per year with a median bronchoscopy rate of 175 procedures per physician per year.6 The number of bronchoscopies performed annually may serve as a surrogate marker for establishing and maintaining competency, but evidence to support this suggestion is lacking. Nevertheless, the guidelines published by the various relevant societies recommend a minimum number of bronchoscopies to achieve competency, although there is no consensus on a mandatory requirement.16,17 Replacing volume-based certification with acquisition of knowledge and skills-based competencies has recently been recommended.13 Competence could also be assessed by the diagnostic yield of bronchoscopic biopsies and monitoring of complication rates taking into account the total number of procedures performed. In contrast to the study in India where 74% of bronchoscopists performed conventional TBNA in the preceding year, more than half the respondents in our survey had not performed a TBNA in the previous year.11 Low rates of TBNA have also been reported in surveys performed in North America and UK.2,6 This finding may reflect a lack of adequate training in TBNA during pulmonary fellowships or concern about potential complications. Furthermore, the advent of endobronchial ultrasound may have rendered conventional TBNA a less favorable option. However, one study suggested that conventional TBNA can still be routinely performed even at centers where endobronchial ultrasound (EBUS) is available.18 More participants in our survey had received training in EBUS than those in the Singapore survey (26% versus 7%).5 However, training in therapeutic bronchoscopy procedures seems to be less common in our survey population than in Singapore (18% versus 32% for rigid bronchoscopy, 13% versus 25% for brachytherapy, 15% versus 29% for laser procedures, and 19.5% versus 21% for stent insertion).5 Among pulmonologists in our survey, although 10% reported being trained in laser procedures and stent insertion, none performed laser procedures and only 8% performed stent insertion. This is similar to the findings of older surveys in the USA and UK; 4.5% of the respondents in the USA and 4.7% in UK had performed laser procedures or stent insertion.2,6 The low performance rates of therapeutic procedures may be explained by the lack of training and competency among pulmonologists, unavailability of equipment, case scarcities, and the fact that thoracic surgeons historically manage these cases. At least 50% of the bronchoscopists in our study routinely ordered a complete blood count, coagulation profile, and chest imaging (radiography and/or computed tomography) before bronchoscopy. Other investigations, such as basic laboratory tests (electrolytes and renal function), arterial blood gases, spirometry, and ECG, were less frequently requested before the procedure. The frequency of pre-procedure investigations is not consistent in the published studies; routine requests for a complete blood count and coagulation profile were reported to be common in Egypt and Italy, but less so in North America, UK, and India.2,4,6,7,11 Almost all bronchoscopists in our study, except for a minority (10%) of thoracic surgeons, counseled their patients at least verbally before the procedure, and most across all specialties recommended more than 4 hours of fasting before bronchoscopy. This fasting duration is similar to what has been reported by members of the Canadian Thoracic Society and the surveys in UK and India.3,6,11 Intravenous access was established prior to bronchoscopy by almost all respondents in our study but by only 71.5% of respondents in the Italian survey. Some Italian bronchoscopists prefer the intramuscular route for administration of sedatives and 60% reported sedating patients only occasionally.7 In accordance with the recent recommendations of the American College of Chest Physicians and the British Thoracic Society, the majority of our respondents did not use anticholinergic agents.12,14 However, 10% of pulmonologists and 12.5% of thoracic surgeons reported routine use of atropine. Randomized control studies have shown that the use of 1% lidocaine in “spray as you go” technique is effective and safe with significantly less total dose of lidocaine administered when compared to 2% lidocaine.19,20 In our survey, use of topical anesthetics deviated from the evidence to some extent. Although aerosol and “spray as you go” methods were frequently used, the use of nebulized lidocaine was surprisingly high, especially by intensivists (85.7%), despite the lack of evidence to support this practice.14 Some respondents, especially thoracic surgeons and intensivists, used transcricoid injections. This route of administration is discouraged because it requires special training and is invasive. Our findings in this regard are very similar to those of the Canadian survey, in which nebulized formulations were used by 65% of respondents and transcricoid injections by 40%.3 In our study, benzocaine was used as a topical anesthetic by 28.6% of intensivists and 4% of pulmonologists despite the recommendation against its use because of its narrow therapeutic window and potential to cause methemoglobinemia.14
In keeping with the international guidelines, midazolam and fentanyl were the intravenous agents most commonly used for sedation.12,14 Combination of a benzodiazepine and an opiate is recommended because of these agents have synergistic effects in terms of the patient’s tolerance of the procedure and the additional antitussive properties of opioids.14 Propofol is being used increasingly for sedation during short interventions worldwide. However, only 4% of pulmonologists, 13% of thoracic surgeons, and 15% of intensivists in our survey reported using propofol for sedation. In Switzerland, 77% of pulmonologists, and 70% in Germany, reported using propofol either as a single agent or in combination.8,21 In Canada, only 8% of bronchoscopists used propofol for bronchoscopy.3 These differences reflect country-specific differences in practice, training, and availability of propofol. Despite the basic requirement for sedation reversal agents to ensure safety, 6% of pulmonologists and 14% of intensivists reported that these medications were not readily available during procedures. Compliance with this important standard varies between countries; only 42% of bronchoscopists in the Egyptian survey reported availability of sedation reversal agents, but all physicians in the UK survey reported availability.4,6 Most bronchoscopists in our study monitored oxygen saturation, ECG, and blood pressure during a bronchoscopy procedure. They also universally reported wearing gloves and a gown for self-protection. However, masks appear to be worn less often, particularly by surgeons, and eye protection is infrequent. The incidence of pneumothorax following TBLB without fluoroscopy is 5%.22 Therefore, the British guidelines recommend ordering a chest radiograph post-TBLB if a patient is symptomatic or there is a high clinical suspicion of pneumothorax.12 Nevertheless, the majority of bronchoscopists in this study would routinely order a chest radiograph post-TBLB to rule out pneumothorax.
Study limitations
First, it was designed as an email survey to assess the perceptions and attitudes of respondents. Such surveys are self-reported, relying on the respondent’s memory and the responses are not verifiable by case records. Second, the response options for several questions, for example, “always” or “sometimes,” do not provide an objective assessment. Third, some of the respondents might not have provided complete information; however, this is an inherent limitation of self-administered surveys. The fourth limitation was the low response rate of 18%, but this is expected in email surveys. Moreover, it is possible that not all of the 456 individuals who were invited to participate are still practicing in Saudi Arabia, and that not all of those who are practicing here are performing bronchoscopies. Nevertheless, we had respondents from all regions in the country.
In conclusion, this survey provides information that emphasizes the importance of establishing local standards for bronchoscopy practice and training. Advanced bronchoscopic procedures are becoming the standard of care for many diagnostic and therapeutic indications. The low level of training and experience in performing such procedures among our bronchoscopists highlights the importance of considering this field for planning our future international training sessions. In addition, our bronchoscopists are performing relatively low numbers of bronchoscopies in comparison with other countries, which raises questions about our standards for the indications to perform this procedure. Safety procedures for self-protection of bronchoscopists, such as wearing masks and eye protection, and for protecting patients, such as the availability of anesthetic antagonists, were not universally applied in practice in our population. Furthermore, the significant variation in practice and techniques performed before, during, and after bronchoscopy in our survey indicates a lack of a uniform standard of practice, which is important to ensure and maintain quality of care at a national level. Considering our study limitations, especially the low response rate, further prospective multicenter studies with larger sample sizes are required to address bronchoscopy practice and training requirements in Saudi Arabia. Establishment of national standard guidelines for the indications and practice of bronchoscopy is recommended.
Acknowledgment
We thank the Saudi Thoracic Society administration and secretaries for their help in disseminating the survey. We also thank Editage for the English language editing.
Footnotes
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
- Received August 14, 2018.
- Accepted January 28, 2019.
- Copyright: © Saudi Medical Journal
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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