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Systematic Bronchoscopy: the Four Landmarks Approach

Published: June 23rd, 2023



1Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen, University of Copenhagen and the Capital Region of Denmark, 2Department of Pulmonary Medicine, Bispebjerg Hospital

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 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 "landmarks" 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 as a feedback and certification tool when training new bronchoscopists.

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's learning curve3,4,5. To ensure independent/unsupervised practice on patients, satisfactory educational levels must be ....

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Following Danish law, an educational study without the participation of patients does not require ethical approval.

1. Handling of the scope

  1. 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.
  2. Holding the scope with a straight arm and wrist, so the suction button is pointing directly forward and the steering lever is .......

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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.......

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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.......

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The authors have no acknowledgments.


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Name Company Catalog Number Comments
Evis Exera II Olympus Not provided Endoscopy Tower
BF-Q180 Bronchoscope Olympus Not provided Flexible Bronchoscope
CLA Broncho Boy CLA Not provided Bronchial Tree Phantom

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