EBUS-STAT Subscore Analysis to Predict the Efficacy and Assess the Validity of Virtual Reality Simulation for EBUS-TBNA Training Among Experienced Bronchoscopists

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Linear endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) represents a pivotal innovation in interventional pulmonology; determining the best approach to guarantee systematic and efficient training is expected to become a main issue in the forthcoming years. Virtual reality simulators have been proposed as potential EBUS-TBNA training instruments, to avoid unskilled beginners practicing directly in real-life settings. A validated and perfected simulation program could be used before allowing beginners to practice on patients. Our goal was to test the reliability of the EBUS-Skills and Task Assessment Tool (STAT) and its subscores for measuring the competence of experienced bronchoscopists approaching EBUS-guided TBNA, using only the virtual reality simulator as both a training and an assessment tool.


Fifteen experienced bronchoscopists, with poor or no experience in EBUS-TBNA, participated in this study. They were all administered the Italian version of the EBUS-STAT evaluation tool, during a high-fidelity virtual reality simulation. This was followed by a single 7-hour theoretical and practical (on simulators) session on EBUS-TBNA, at the end of which their skills were reassessed by EBUS-STAT.


An overall, significant improvement in EBUS-TBNA skills was observed, thereby confirming that (a) virtual reality simulation can facilitate practical learning among practitioners, and (b) EBUS-STAT is capable of detecting these improvements. The test’s overall ability to detect differences was negatively influenced by the minimal variation of the scores relating to items 1 and 2, was not influenced by the training, and improved significantly when the 2 items were not considered. Apart from these 2 items, all the remaining subscores were equally capable of revealing improvements in the learner. Lastly, we found that trainees with presimulation EBUS-STAT scores above 79 did not show any significant improvement after virtual reality training, suggesting that this score represents a cutoff value capable of predicting the likelihood that simulation can be beneficial.


Virtual reality simulation is capable of providing a practical learning tool for practitioners with previous experience in flexible bronchoscopy, and the EBUS-STAT questionnaire is capable of detecting these changes. A pretraining EBUS-STAT score below 79 is a good indicator of those candidates who will benefit from the simulation training. Further studies are needed to verify whether a modified version of the questionnaire would be capable of improving its performance among experienced bronchoscopists.

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