Impact of Pulmonary and Critical Care Fellow Participation during Advanced Diagnostic Bronchoscopy

Background: Pulmonary and critical care medicine (PCCM) fellows frequently participate in advanced diagnostic bronchoscopy (ADB) procedures. Objective: To investigate the impact of PCCM fellow involvement during ADB on various procedural outcomes in a real-world setting. Methods: This was a retrospective observational cohort study analyzing prospectively collected registry data of consecutive ADB procedures performed between February 2018 and December 2021. Procedure duration, safety, breadth, and diagnostic performance of ADBs performed by PCCM fellows supervised by interventional pulmonologists (IPs) were compared with those completed solely by IP faculty. Results: Among 628 ADBs, fellows participated in 379 (60.3%). With unadjusted analysis, fellow-involved cases were a median 11.5 minutes longer for convex-probe endobronchial ultrasound bronchoscopy (95% confidence interval [CI], 6.0-14.0; P < 0.001) and 10.5 minutes longer for peripheral bronchoscopy (95% CI, 2.0-18.0; P = 0.016). Compared with ADBs performed by IP faculty alone, procedures with second-year (post-graduate year 5) fellows had the largest duration differences. These included convex-probe endobronchial ultrasound bronchoscopy (+14.5 min; 95% CI, 7.0-18.0 min; P < 0.001), cases not using rapid on-site evaluation (+14.0 min; 95% CI, 8.0-21.0 min; P < 0.001) and those performed with moderate sedation (+12.0 min; 95% CI, 7.0-18.0 min; P < 0.001). After multivariate adjustment, fellow-involved procedures overall were 7.2 minutes longer in duration (95% CI, 3.8-10.5; P < 0.001), and 8.8 minutes longer when performed by post-graduate year 5 fellows-an approximate 16% decrease in efficiency. Bronchoscopies performed with fellows were also more likely to experience complications (38.7% compared with 25.8% with faculty procedures; adjusted odds ratio [OR], 2.0; 95% CI, 1.3-3.0; P < 0.001) and be prematurely terminated (adjusted OR, 4.95; 95% CI, 1.44-17.02; P = 0.011). Diagnostic performance and occurrence of major complications were similar between fellow and no-fellow bronchoscopies. Conclusion: Participation of PCCM fellows during ADB increases procedure duration and the risk for minor complications compared with cases completed solely by IPs. Procedures performed with fellows on the steepest portion of the ADB learning curve are the least efficient. Fellowship directors and faculty bronchoscopists should acknowledge these potential impacts on ABD practice while optimizing the approach to bronchoscopy training.