The authors have no acknowledgments.

Following Danish law, an educational study without the participation of patients does not require ethical approval.
1. Handling of the scope
<ol>
	<li>Hold the bronchoscope in the left hand with the left thumb on the steering lever and the left forefinger on the suction button. Use the right hand to hold the distal part of the bronchoscope.</li>
	<li>Holding the scope with a straight arm and wrist, so the suction button is pointing directly forward and the steering lever is in the neutral position, is defined as the neutral position or 0&#176;. By twisting the wrist, turn the scope from the neutral position/0&#176;.</li>
	<li>Move the thumb up and down the lever to flex and extend the distal end of the endoscope. Move the wrist and hands, not the arm and body.</li>
</ol>
2. Structured progress: angle of the scope and the four landmarks
<ol>
	<li>Enter the airways either through the mouth or nostrils. Pass the vocal cords and enter the trachea.</li>
	<li>Find the four landmarks systematically from landmarks 1 to 4 and note the correct angle of the endoscope in each position (Table 1). 
	NOTE: The four landmarks approach is designed in a memorable way to decrease the cognitive load for novel bronchoscopists. It is based on a pairing between the angle of the bronchoscope and how to access the different lobes/landmarks. The approach, therefore, provides novice trainees with a basic training tool to navigate through the bronchial maze. As an example, by knowing if the bronchoscope is held at a 90&#176; angle to the right, the correct position to inspect the right upper lobe can be determined. When visualizing the lobe or landmark, one should defer from the designated angle to inspect the individual segments.</li>
	<li>Find the segments chronologically from 1-10, the right side first, then the left side according to the four landmarks.</li>
</ol>
3. Systematic bronchoscopy: the four landmarks approach
<ol>
	<li>Landmark 1: The carina with the right and the left main bronchus as seen from the trachea (Figure 2)
	<ol>
		<li>Locate the bronchoscope in the distal part of the trachea at a 0&#176; angle-the neutral position. If the orientation is lost, go back to landmark 1 to reorientate.</li>
	</ol>
	</li>
	<li>Landmark 2: Right segments 1, 2, and 3 (upper lobe) (Figure 3)
	<ol>
		<li>Turn the endoscope 90&#176; to the right while at the same time flexing the distal end of the bronchoscope upward by pushing the left thumb down to investigate the upper lobe. This landmark resembles the Mercedes star.</li>
		<li>When visualizing the Mercedes star, defer from the 90&#176; angle to inspect segments 1, 2, and 3.</li>
	</ol>
	</li>
	<li>Landmark 3: Right segments 4 and 5 (middle lobe) plus 6, 7, 8, 9, and 10 (lower lobe) (Figure 4)
	<ol>
		<li>Move on to the bronchus intermedius by placing the distal end of the endoscope at a 45&#176; angle to the right to see segments 4 and 5 (numbers from the lateral side at an oblique angle).</li>
		<li>Again, defer from the 45&#176; angle to inspect segments 4 and 5. Go back to the 45&#176; angle and extend the tip of the endoscope by pushing the stewing lewer upward with the left thumb to inspect segment 6 (just opposite the middle lobe).</li>
		<li>Turn the scope to a 0&#176; angle and progress to the lower lobe. Segment 7 is located medially, and segments 8, 9, and 10 (numbers from the lateral side at an oblique angle) at the bottom. Defer from the 0&#176; angle to inspect segments 7-10.</li>
	</ol>
	</li>
	<li>Landmark 4: Left segments 1+2, 3, 4, and 5 (upper lobe), plus segments 6, 8, 9, and 10 (lower lobe) (Figure 5)
	<ol>
		<li>Move the bronchoscope to the left main bronchus (90&#176; angle to the left), upward to see the upper lobe, and downward to see the lower lobe.</li>
		<li>Keep the scope at a 90&#176; angle to inspect the left upper lobe with the lingula. Defer from the 90&#176; angle to inspect segments 1+2 and 3 (left upper lobe) and segments 4 and 5 (lingula).</li>
		<li>Go back to the left main bronchus, turn the scope to a 45&#176; angle, and extend the end of the bronchoscope to inspect segment 6, which is opposite segments 4 and 5 (lingula).</li>
		<li>Turn the scope to a 0&#176; angle to visualize the lower lobe with segments 8, 9, and 10. Defer from the 0&#176; angle to inspect the segments. 
		NOTE: There is no segment 7 on the left side, as this area is filled out by the heart. Segments 4 and 5 plus 8, 9, and 10 follow the same numbering as for the right side, and are numbered from the lateral side at an oblique angle (Figure 6).</li>
	</ol>
	</li>
</ol>

Flexible Bronchoscopy for Novice Bronchoscopists

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	<li>Bray, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Global+cancer+statistics+2018:+GLOBOCAN+estimates+of+incidence+and+mortality+worldwide+for+36+cancers+in+185+countries.">Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.</a> CA: A Cancer Journal for Clinicians. 68 (6), 394-424 (2018).</li><li>Andolfi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+bronchoscopy+in+the+diagnosis+of+early+lung+cancer:+a+review.">The role of bronchoscopy in the diagnosis of early lung cancer: a review.</a> Journal of Thoracic Disease. 8 (11), 3329-3337 (2016).</li><li>Hsu, L. H., Liu, C. C., Ko, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Education+and+experience+improve+the+performance+of+transbronchial+needle+aspiration:+a+learning+curve+at+a+cancer+center.">Education and experience improve the performance of transbronchial needle aspiration: a learning curve at a cancer center.</a> Chest. 125 (2), 532-540 (2004).</li><li>Ouellette, D. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+safety+of+bronchoscopy+in+a+pulmonary+fellowship+program.">The safety of bronchoscopy in a pulmonary fellowship program.</a> Chest. 130 (4), 1185-1190 (2006).</li><li>Stather, D. R., MacEachern, P., Chee, A., Dumoulin, E., Tremblay, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trainee+impact+on+procedural+complications:+An+analysis+of+967+consecutive+flexible+bronchoscopy+procedures+in+an+interventional+pulmonology+practice.">Trainee impact on procedural complications: An analysis of 967 consecutive flexible bronchoscopy procedures in an interventional pulmonology practice.</a> Respiration. International Review of Thoracic Diseases. 85 (5), 422-428 (2013).</li><li>McGaghie, W. C., Issenberg, S. B., Cohen, E. R., Barsuk, J. H., Wayne, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Medical+education+featuring+mastery+learning+with+deliberate+practice+can+lead+to+better+health+for+individuals+and+populations.">Medical education featuring mastery learning with deliberate practice can lead to better health for individuals and populations.</a> Academic Medicine. 86 (11), e8-e9 (2011).</li><li>Konge, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Establishing+pass/fail+criteria+for+bronchoscopy+performance.">Establishing pass/fail criteria for bronchoscopy performance.</a> Respiration; International Review of Thoracic Diseases. 83 (2), 140-146 (2012).</li><li>Konge, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliable+and+valid+assessment+of+clinical+bronchoscopy+performance.">Reliable and valid assessment of clinical bronchoscopy performance.</a> Respiration; International Review of Thoracic Diseases. 83 (1), 53-60 (2012).</li><li>Colt, H. G., Crawford, S. W., Galbraith 3rd, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Virtual+reality+bronchoscopy+simulation:+A+revolution+in+procedural+training.">Virtual reality bronchoscopy simulation: A revolution in procedural training.</a> Chest. 120 (4), 1333-1339 (2001).</li><li>Cold, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+structured+progress+to+measure+competence+in+flexible+bronchoscopy.">Using structured progress to measure competence in flexible bronchoscopy.</a> Journal of Thoracic Disease. 12 (11), 6797-6805 (2020).</li><li>Cold, K. M., Konge, L., Clementsen, P. F., Nayahangan, L. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+mastery+learning+of+flexible+bronchoscopy:+Deciding+factors+for+completion.">Simulation-based mastery learning of flexible bronchoscopy: Deciding factors for completion.</a> Respiration; International Review of Thoracic Diseases. 97 (2), 160-167 (2019).</li><li>Nayahangan, L. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Identifying+technical+procedures+in+pulmonary+medicine+that+should+be+integrated+in+a+simulation-based+curriculum:+A+national+general+needs+assessment.">Identifying technical procedures in pulmonary medicine that should be integrated in a simulation-based curriculum: A national general needs assessment.</a> Respiration; International Review of Thoracic Diseases. 91 (6), 517-522 (2016).</li><li>Konge, L., Arendrup, H., von Buchwald, C., Ringsted, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+performance+in+multiple+simulated+scenarios+to+assess+bronchoscopy+skills.">Using performance in multiple simulated scenarios to assess bronchoscopy skills.</a> Respiration; International Review of Thoracic Diseases. 81 (6), 483-490 (2011).</li><li>Kennedy, C. C., Maldonado, F., Cook, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+bronchoscopy+training:+systematic+review+and+meta-analysis.">Simulation-based bronchoscopy training: systematic review and meta-analysis.</a> Chest. 144 (1), 183-192 (2013).</li><li>Sealy, W. C., Connally, S. R., Dalton, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Naming+the+bronchopulmonary+segments+and+the+development+of+pulmonary+surgery.">Naming the bronchopulmonary segments and the development of pulmonary surgery.</a> The Annals of Thoracic Surgery. 55 (1), 184-188 (1993).</li><li>Naur, T. M. H., Nilsson, P. M., Pietersen, P. I., Clementsen, P. F., Konge, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+training+in+flexible+bronchoscopy+and+endobronchial+ultrasound-guided+transbronchial+needle+aspiration+(EBUS-TBNA):+A+systematic+review.">Simulation-based training in flexible bronchoscopy and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): A systematic review.</a> Respiration; International Review of Thoracic Diseases. 93 (5), 355-362 (2017).</li><li>Sanz-Santos, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+compared+with+targeted+staging+with+endobronchial+ultrasound+in+patients+with+lung+cancer.">Systematic compared with targeted staging with endobronchial ultrasound in patients with lung cancer.</a> The Annals of Thoracic Surgery. 106 (2), 398-403 (2018).</li><li>Colella, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+competence+in+simulated+flexible+bronchoscopy+using+motion+analysis.">Assessment of competence in simulated flexible bronchoscopy using motion analysis.</a> Respiration; International Review of Thoracic Diseases. 89 (2), 155-161 (2015).</li><li>Cold, K. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Automatic+and+objective+assessment+of+motor+skills+performance+in+flexible+bronchoscopy.">Automatic and objective assessment of motor skills performance in flexible bronchoscopy.</a> Respiration; International Review of Thoracic Diseases. 100 (4), 347-355 (2021).</li><li>Follmann, A., Pereira, C. B., Knauel, J., Rossaint, R., Czaplik, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+a+bronchoscopy+guidance+system+for+bronchoscopy+training,+a+randomized+controlled+trial.">Evaluation of a bronchoscopy guidance system for bronchoscopy training, a randomized controlled trial.</a> BMC Medical Education. 19 (1), 430 (2019).</li><li>Nilsson, P. M., Naur, T. M. H., Clementsen, P. F., Konge, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation+in+bronchoscopy:+current+and+future+perspectives.">Simulation in bronchoscopy: current and future perspectives.</a> Advances in Medical Education and Practice. 8, 755-760 (2017).</li><li>Strandbygaard, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+structured+four-step+curriculum+in+basic+laparoscopy:+development+and+validation.">A structured four-step curriculum in basic laparoscopy: development and validation.</a> Acta Obstetricia et Gynecologica Scandinavica. 93 (4), 359-366 (2014).</li><li>Konge, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+simulation+centre+at+Rigshospitalet,+Copenhagen,+Denmark.">The simulation centre at Rigshospitalet, Copenhagen, Denmark.</a> Journal of Surgical Education. 72 (2), 362-365 (2015).</li></ol>

The authors have nothing to disclose.

We propose a systematic and complete inspection of the bronchial segments, splitting the bronchoscopy into four landmarks to help guide novice bronchoscopists through the bronchial maze. As more specific guidelines that govern bronchoscopy training are needed14, we propose that our systematic and stepwise approach should be evaluated using three basic outcome measures: DC, SP, and PT. 
DC and PT are established outcome measures and the first used when evaluating broncho...

Lung cancer is the leading cause of cancer mortality1. Flexible bronchoscopy is essential to navigate through the bronchial tree and identify the correct segments for the diagnosis and staging of lung cancer and allocation to the correct treatment for the patient2. Lower yields of diagnostic biopsy material, higher complication rates, and increased patient discomfort are seen in the early part of a trainee&#39;s learning curve3,4,5. To ensure independent/unsupervised practice on patients, satisfactory educational levels must be met. A training modality to ensure basic competence is simulation-based mastery learning, where the trainee practices until proficiency criteria are met6. Several tools have been developed to assess bronchoscopy performance7,8, and the following performance measures have been established: (1) diagnostic completeness (DC)-proportion of visualized segments9; (2) structured progress (SP)-number of segments visited in the correct progression order10; and (3) procedure time (PT)-time from passing through the vocal cords to the end of the procedure9.
Novice bronchoscopists can be confused by the maze, looking like similar bronchi, and several fail to complete a course in simulation-based bronchoscopy11, even though it has been identified as the most important technical procedure to learn in pulmonary medicine12. Therefore, through this protocol, we propose a stepwise, structured progression through the bronchial tree (Figure 1), relying on four landmarks as a guide. We suggest that novice operators should be taught according to this approach to ensure visualization of all the bronchial segments in a structured way, in the shortest amount of time, with correct handling of the scope.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Evis Exera II</td>
			<td>Olympus</td>
			<td>Not provided</td>
			<td>Endoscopy Tower</td>
		</tr>
		<tr>
			<td>BF-Q180 Bronchoscope</td>
			<td>Olympus</td>
			<td>Not provided</td>
			<td>Flexible Bronchoscope</td>
		</tr>
		<tr>
			<td>CLA Broncho Boy</td>
			<td>CLA</td>
			<td>Not provided</td>
			<td>Bronchial Tree Phantom</td>
		</tr>
	</tbody>
</table>

systematic bronchoscopy: the four landmarks approach

Flexible bronchoscopy is a technically difficult procedure and has been identified as the most important procedure that should be integrated into a simulation-based training program for pulmonologists. However, more specific guidelines that govern bronchoscopy training are needed to meet this demand. To ensure patients a competent examination, we propose a systematic, stepwise approach, splitting the procedure into four &#34;landmarks&#34; to support novice endoscopists navigating the bronchial maze. The procedure can be evaluated based on three established outcome measures to ensure a thorough and effective inspection of the bronchial tree: diagnostic completeness, structured progress, and procedure time.
The stepwise approach relying on the four landmarks is used at all simulation centers in Denmark and is being implemented in the Netherlands. To provide instant feedback to novice bronchoscopists when training and to relieve time constraints from consultants, we suggest that future studies should implement artificial intelligence&#160;as a feedback and certification tool when training new bronchoscopists.

Author Spotlight: Learning Systematic Bronchoscopy in a Simulation-Base Setting 

Systematic Bronchoscopy: the Four Landmarks Approach

This protocol provides novice bronchoscopist with a memorable way to learn how to navigate the bronchial tree using the four landmarks approach. For the unexperienced operator is quite difficult to find the way in the bronchial three when performing a bronchoscopy. We have developed a four-landmark approach, meaning that you should find four landmarks and you can always go back to the four landmarks when you lose your way, and then you can proceed.And we use the four landmarks in connection with the angles. This is the distal end of the endoscope, this is a handle, so when I turn my wrist, I can turn the distal end of the endoscope in different angles. And these angles, we connect with the four landmarks.With the development of artificial intelligence, we hope to develop an automatic bronchial identification system that can help novice bronchoscopist to identify the individual segments and ensure a full inspection of the bronchial tree. Bronchoscopy has historically been taught with a see one, do one, teach one"approach. But with this protocol, we present a standardized way of teaching bronchoscopy.

The four landmarks approach has been taught at CAMES since 2011, where the simulation-based bronchoscopy course is concluded by passing a finalizing test13. From 2015-2017, 77 participants entered the course, of which only 33 (43%) completed it11. The low completion rate was due to several factors: time constraints, the course not being mandatory, maternity leave, and no protected time to train. Of those who completed the course, 14 (42%) found the most important factor for...

Watch this Scientific Journal Video about Learning Systematic Bronchoscopy in a Simulation-Base Setting at JoVE.com

Here, we present a protocol to navigate the bronchial maze in a structured manner, splitting the bronchoscopy into a stepwise approach-the four landmarks approach.

Flexible bronchoscopy is a technically difficult procedure and has been identified as the most important procedure that should be integrated into a ...

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Structured Progress for Systematic Bronchoscopy: The Four Landmarks Approach

To begin, enter the airways through the mouth or nostrils, then pass the vocal cords and enter the trachea. Locate the four landmarks systematically from landmarks one to four, and note the correct angle of the endoscope in each position. Next, according to the four landmarks, find the segments chronologically from one to 10 from the right side first, and then from the left side.At landmark one, locate the bronchoscope in the distal part of the trachea at a zero degree angle, maintaining a neutral position. Then at landmark two, turn the endoscope 90 degrees to the right while simultaneously flexing the distal end of the bronchoscope upward by pushing the left thumb down to investigate the upper lobe. While visualizing the Mercedes star, defer from the 90 degree angle to inspect segments one, two, and three.Next at landmark three, move on to the bronchus intermedius by placing the distal end of the endoscope at a 45 degree angle to the right to view segments four and five. Temporarily defer from the 45 degree angle to examine segments four and five. Then return to the 45 degree angle and extend the tip of the endoscope by pushing the stewing lever up with the left thumb to inspect segment six.Turn the scope to a zero degree angle and proceed to the lower lobe to locate segments seven, eight, nine, and 10. Then defer from the zero degree angle to inspect segments seven to 10. At landmark four, move the bronchoscope to the left main bronchus at a 90 degree angle upward to view the upper lobe and downward to view the lower lobe.Retain the scope at a 90 degree angle and inspect the left upper lobe with the lingular. Then defer from the 90 degree angle to examine segments one plus two and three from the left upper lobe, and segments four and five from the lingular. Then return to the left main bronchus.Turn the scope to a 45 degree angle and extend the end of the bronchoscope to inspect segment six, which is opposite segments four and five. Finally turn the scope to a zero degree angle to visualize the lower lobe. Then defer from the zero degree angle to inspect segments eight, nine, and 10.The most important factors for the completion of a simulation-based course in flexible bronchoscopy are shown here. The total of responses is greater than 100%as some participants mentioned more than one factor. Of those who completed the course, 57%found it clinically relevant and 47%found the course valuable.

1.7K Views.  University of Copenhagen and the Capital Region of Denmark.  Here, we present a protocol to navigate the bronchial maze in a structured manner, splitting the bronchoscopy into a stepwise approach-the four landmarks approach. 

Flexible Bronchoscopy for Novice Bronchoscopists

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