Rigid Bronchoscopy Training in India – Time for a Redressal

Sir, Interventional pulmonology (IP) is gaining momentum in our country, like never before. Many centers in the country are doing advanced IP work including central airways stenting, coring of mass lesions, airway laser, and cryotherapy procedures.1 Most in-training pulmonologists are well versed with flexible bronchoscopy and associated procedures, including bronchial washings and biopsies. Endobronchial ultrasound and pleuroscopy training are also commonplace at most institutes now. The same, however, cannot be said about rigid bronchoscopy training in our country. As the oncology services grow in our country, many of us encounter patients with central airway masses and complications such as tracheo-esophageal fistulas. Many patients with benign airway stenosis and bronchopleural fistulas also require rigid bronchoscopic interventions. Rigid bronchoscopy is also employed routinely in difficult airway foreign body removal and in the management of massive hemoptysis. Unfortunately, rigid bronchoscopy training is not a part of many post graduate pulmonology teaching programs including post-doctoral (DM) courses. To learn these procedures, many young pulmonologists go for training abroad for observerships and fellowships. Many of these programs are expensive, do not provide hands on experience, and are being conducted in non-native English-speaking countries, where language barrier is a major concern. Unlike, American and European training programs, where pulmonology fellows need to perform certain fixed number of procedures, including rigid bronchoscopies, no such competency certifications exist in our country. In United States of America, a fellow needs to perform at least 50 rigid bronchoscopies, and in Europe, at least 20 rigid bronchoscopies ought to be performed, to qualify for the fellowship exit examinations.2 Learning a procedure such as rigid bronchoscopy, in a controlled, well-equipped environment is always better than just randomly learning the procedure via a hit-and-trial method. A lot of patients who require rigid bronchoscopy are moribund, and have a precarious general condition. In such patients, if the procedure is not performed well and by experts, the chances of complications are going to be high. A general perception among pulmonologists is that rigid bronchoscopy is a very difficult procedure and is only done at institutional level and may not be possible at general hospitals. With proper and structured training, this fear can be mitigated, and many patients who continue to suffer for the lack of these procedures can offered a ray of hope. A useful primer would be the introduction of mannequin-based initial training of rigid bronchoscopy, where intubation and scope maneuvering can be initially learnt before moving on to a real patient. While, Indian consensus guidelines on flexible bronchoscopy, pleuroscopy, and even on rarely performed cryo-trans bronchial lung biopsies exist,3 no such guidelines have been formulated for rigid bronchoscopy. The need of the hour is to streamline rigid bronchoscopy training in our country and to organize more hands-on training and simulation programs, so that the unnecessary fear of this procedure is allayed. Competency-based IP training, especially in rigid bronchoscopy is an absolute must, and rigid bronchoscopy training must be a necessary part of post graduate pulmonology training in the country.