Training and proficiency in endobronchial ultrasound-guided transbronchial needle aspiration: A systematic review

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is currently the modality of choice for evaluation of mediastinal lymphadenopathy. However, there is still uncertainty regarding the training methodology and the number of procedures required to attain proficiency in EBUS. Herein, we performed a systematic review of studies selected from PubMed, EmBase and Scopus databases describing the training and assessment of proficiency during EBUS, specifically studies investigating various methods for training, its outcome and the number of procedures required to overcome the learning curve for EBUS. Twenty-seven (simulator-based learning (n = 8), tools for assessing competence in EBUS-TBNA (n = 5) and threshold numbers needed to attain proficiency in EBUS-TBNA (n = 16)) studies were identified. An EBUS simulator accurately stratified individuals based on the level of experience in performing EBUS. Training received on a simulator was comparable with traditional apprentice-based training. Importantly, skills acquired on a simulator could be transferred to real-world patients. The number needed to overcome the initial learning curve of EBUS varied from 10 to 100 in individual studies with a mean of 37-44 procedures. Tools such as EBUS-STAT (EBUS skill and task assessment tool) and EBUSAT (EBUS skill and assessment tool) were effective in evaluating the EBUS trainees. We conclude that an EBUS simulator or EBUS assessment tools can objectively assess the training of an EBUS trainee. Simulator-based training is a useful modality in EBUS training. The number of procedures needed to overcome the initial learning curve is about 40. Centres involved in EBUS training could incorporate simulator-based training in their curriculum before allowing operators to perform EBUS on patients.