Establishing emergency bronchoscopy in Timor-Leste: a healthcare needs assessment-driven novel model of training

Extract

Bronchoscopy is an integral component of practice of respiratory medicine in many countries, though services are often limited in low-income countries (LICs) due to limitations in the human and equipment factors critical for success and sustainability. These challenges are similar to those that are well documented in establishing other endoscopic services in low-resource settings, including upper and lower gastrointestinal endoscopy and cystoscopy [1].

Shareable abstract

Standard models of bronchoscopy training are not suitable for low-income countries; a novel training programme comprising short intensive skills training and ongoing remote mentorship established bronchoscopy for management of airway emergencies https://bit.ly/46xDC8n

To the Editor:

Bronchoscopy is an integral component of practice of respiratory medicine in many countries, though services are often limited in low-income countries (LICs) due to limitations in the human and equipment factors critical for success and sustainability. These challenges are similar to those that are well documented in establishing other endoscopic services in low-resource settings, including upper and lower gastrointestinal endoscopy and cystoscopy [1].

Hospital Nacional Guido Valadares (HNGV) is the main hospital for Dili (population 222 000) and serves as the referral centre for all of Timor-Leste (population 1.38 million). The HNGV endoscopy service was developed in partnership with the Australian and New Zealand Gastroenterology International Training Association (ANZGITA). Since 2016, ANZGITA has guided development of a robust, sustainable, safe endoscopy unit in Dili in collaboration with the Ministry for Health of Timor-Leste.

In 2023, >1100 upper gastrointestinal endoscopic procedures and 200 colonoscopy procedures were performed, with no significant complications observed. In the same period, five patients presented to the HNGV emergency department with inhaled airway foreign bodies (FBA). With no bronchoscopy service available, patients were managed via air evacuation to neighbouring countries for surgical retrieval of the FBA via thoracotomy and bronchotomy. Unfortunately, two patients died prior to evacuation.

Medical leadership at HNGV contacted ANZGITA for support in establishment of a bronchoscopy service to complement their existing endoscopic service. ANZGITA facilitated an in-country focused healthcare needs assessment (HCNA) to assess the utility of bronchoscopy at HNGV, utilising established frameworks [2]. In-country review included attendance by an experienced endoscopy nurse (D. Jones) and an interventional pulmonologist (D.P. Steinfort) as well as consultation with lead clinicians at HNGV to inform needs assessment.

Key observations of HCNA included the following. Heightened setting-specific risks: 1) absence of negative-pressure ventilation in endoscopy suites; and 2) absence of anaesthetic support for conscious sedation procedures. Reduced diagnostic utility: 1) lower rates of lung cancer (per population); and 2) no treatment options available for patients with locally advanced/metastatic lung cancer or post-tuberculous stricture. Service needs assessment identified the following.

• 1) Existing factors/competencies present:

  • equipment factors (e.g. video processors and sterilisation equipment); and
  • facility factors (ergonomic space for theatre and recovery, including monitoring).
• 2) Workforce mapping:

  • experienced endoscopic nursing/technical staff;
  • highly motivated senior medical staff; and
  • established endoscopy/recovery workflow.

With uncertain utility of bronchoscopy and the potential for harm, establishment of a standard bronchoscopy service was considered not viable. In contrast, service needs assessment identified the presence of critical resources to support a bronchoscopy service and clinicians at HNGV remained highly motivated to establish a bronchoscopy service for management of future airway emergencies.

Recognising the challenge of developing and maintaining competency in bronchoscopy, we sought to establish the necessary skillset within HNGV clinicians via a novel model of bronchoscopic training using a programme developed specifically for HNGV, leveraging existing infrastructure and workforce capacity established at HNGV by the ANZGITA programme.

An internal medicine physician (H. Guterres) and experienced endoscopy nurse (A. da Silva Soares) from Timor-Leste were supported with a 4-day observership at tertiary bronchoscopy centres in Australia. H. Guterres was also provided with a low-fidelity three-dimensionally printed airway model [3] for unstructured simulation training, as previously described [3–5], and attended a 2-day bronchoscopy-focused skills workshop run at the Prince of Wales Hospital, Sydney [6]. This yearly course is endorsed by the Thoracic Society of Australia and New Zealand and the World Association for Bronchology and Interventional Pulmonology. On return to Dili, a remote support programme was established via WhatsApp to provide case/imaging review from an interventional pulmonologist for case formulation and, following confirmation of indication for bronchoscopy, “just-in-time” procedure planning [7].

From 23 February 2024 to 23 June 2025, four patients presented to HNGV with FBA (age range 14 months–12 years). Flexible bronchoscopy was performed via laryngeal mask airway under general anaesthesia via laryngeal mask airway using a 5.5-mm diameter bronchoscope (Olympus BF-Q180; Olympus, Tokyo, Japan). Bronchoscopic retrieval of FBA was unsuccessful in one 14-month-old 6.5-kg boy, due to bronchoscope size precluding introduction into the airways. The child was evacuated for thoracotomy retrieval of FBA. Bronchoscopic FBA retrieval was successful in three cases: a 2 year-old boy with an aspirated stone in the distal trachea (figure 1a and b), a 12-year-old boy with an aspirated needle (figure 1c and d) and a 5-year-old boy with an aspirated coffee bean occluding the proximal right main bronchus. All patients were discharged 1 day following bronchoscopy without any complication.

FIGURE 1.

Following presentation of a 2-year-old to emergency room with a history of choking and cyanosis, a) chest radiography demonstrated a radio-opaque foreign body in the distal trachea (arrow). b) Bronchoscopy demonstrated impaction of a stone in the distal trachea, with near complete luminal occlusion. A 12-year-old boy presented with a clear history of aspirating a needle. c) Computed tomography of the chest demonstrated an aspirated pin at the main carina, extending into the proximal left main bronchus. d) Bronchoscopy confirmed that the pin was resting on the posterior wall of the proximal left main bronchus.

FBA is an airway emergency and remains one of the commonest causes of death in young children [8]. Surgical thoracotomy and bronchotomy are required where the foreign body cannot be retrieved bronchoscopically [9], although is associated with significant morbidity and mortality, as well as high resource utilisation. As the HNGV experience in 2023 demonstrates, there remains a critical role for bronchoscopy in LICs.

Our novel model of intensive skills training combined with remote mentoring, leveraging the existing endoscopic competencies (equipment/facility factors and nursing expertise) established by ANZGITA, proved highly effective in establishing an emergency bronchoscopy service, as evidenced by prevention of death or major morbidity in three patients with FBA. This lifesaving intervention aligns with the Lancet Commission on Global Surgery's [10] goal of timely essential surgical care and ensuring universal access to safe and affordable procedural care.

Concerns regarding establishment of bronchoscopy in LICs include funding for equipment, acquisition and maintenance of bronchoscopic competency, as well as service and maintenance costs and availability of equipment [11, 12]. Lack of training is another major barrier [12]. Bronchoscopy training programmes in high-resource settings frequently combine procedural simulation, with supervised stepwise escalation in procedural complexity and risk, and while competence assessment is increasingly valued, most professional societies remain focused on procedural volume (over multiple years) as a precondition of competence. Due to low caseloads, absence of existing expertise and competing workloads, it is difficult for LIC clinicians to attend a traditional 6–12-month fellowship in a high-volume centre to develop competency. An alternative model of training is required for LICs.

Our model of physician-performed bronchoscopy with a short intensive fellowship including ongoing remote mentoring support effectively addresses barriers to competence and may prove a model to similar resource-limited settings to be able to establish the key competency of bronchoscopy for FBA retrieval. Use of three-dimensional (3D) airway models for simulation addresses the inevitable decay in dexterity skills resulting from low procedural volume [5]. Our model leverages the successful endoscopic service established by ANZGITA, including equipment factors (e.g. video processors and sterilisation equipment), facility factors (ergonomic space for theatre and recovery, including monitoring), and procedural clinician and nursing competencies (including case planning and recovery).

Remote mentorship is an effective tool in gastroscopy and colonoscopy training, and has been proven to overcome isolation faced by clinicians in low-resource environments. Remote mentoring by video (e.g. Zoom, Teams or WhatsApp) may be a way forward for real-time (or just-in-time [7, 13]) support during emergency cases in bronchoscopy, as demonstrated previously in gastrointestinal endoscopy [14, 15].

To support ongoing provision of this service, remote mentoring, including just-in-time case review via WhatsApp, is continuing. Similarly, decay in bronchoscopic dexterity has been observed in as little as 8 weeks [5]. Consequently, skill retention will be supported by ad hoc unstructured simulation using the 3D model mentioned above (as previously described [5]), with refresher attendance of a bronchoscopy skills training course planned for every 2–3 years.

In conclusion, current models of bronchoscopic training and competence assessment are not suitable models for LICs. We describe a novel model – developed in partnership with clinicians at HNGV – for successful establishment of bronchoscopy in LICs, where indications for bronchoscopy are rare, comprising short intensive skills training and supported with simulation, remote mentoring and just-in-time case review, leveraging existing institutional endoscopy skills and resources. The value of bronchoscopy for management of airway emergencies is high, as demonstrated by successful potentially life-saving bronchoscopic retrieval of FBA. This model of targeted service improvement with ongoing mentorship may provide a model for other LICs to develop necessary services for their patient populations.