Flandes et al. Respir Res (2020) 21:320 https://doi.org/10.1186/s12931-020-01576-w RESEARCH Open Access Bronchoscopist’s perception of the quality aScope4™) in selected bronchoscopies: of the single‑use bronchoscope (Ambu a multicenter study in 21 Spanish pulmonology services Javier Flandes1, Luis Fernando Giraldo‑Cadavid2,25* , Javier Alfayate1, Iker Fernández‑Navamuel1, Carlos Agusti3, Carmen M. Lucena3, Antoni Rosell4, Felipe Andreo5, Carmen Centeno5, Carmen Montero6, Iria Vidal6, Lucía García‑Alfonso6, Antonio Bango7, Miguel Ariza7, Rocío Gallego8, Marta Orta8, Salvador Bello9, Elisa Mincholé9, Alfons Torrego10, Virginia Pajares10, Héctor González11, Aurelio Luis Wangüemert12, Julio Pérez‑Izquierdo13, Carlos Disdier14, Blanca de Vega Sanchez14, Rosa Cordovilla15, Juan Cascón15, Antonio Cruz15, J. Javier García‑López16, Luis Puente16, Paola Benedetti16, Cristina L. García‑Gallo17, Gema Díaz Nuevo17, Silvia Aguado17, Concepción Partida18, Prudencio Díaz‑Agero18, Estefanía Luque Crespo19, María Pavón19, Francisco Páez20, Enrique Cases21, Raquel Martínez21, Andrés Briones21, Cleofe Fernández22, Concepción Martín Serrano22, Ana Maria Uribe‑Hernández23 and Jose Robles24 Abstract Background: The disposable bronchoscope is an excellent alternative to face the problem of SARS-CoV-2 and other cross infections, but the bronchoscopist’s perception of its quality has not been evaluated. Methods: To evaluate the quality of the Ambu-aScope4 disposable bronchoscope, we carried out a cross-sectional study in 21 Spanish pulmonology services. We use a standardized questionnaire completed by the bronchoscopists at the end of each bronchoscopy. The variables were described with absolute and relative frequencies, measures of cen‑ tral tendency and dispersion depending on their nature. The existence of learning curves was evaluated by CUSUM analysis. Results: The most frequent indications in 300 included bronchoscopies was bronchial aspiration in 69.3% and the median duration of these was 9.1 min. The route of entry was nasal in 47.2% and oral in 34.1%. The average score for ease of use, image, and aspiration quality was 80/100. All the planned techniques were performed in 94.9% and the bronchoscopist was satisfied in 96.6% of the bronchoscopies. They highlighted the portability and immediacy of the aScope4TM to start the procedure in 99.3%, the possibility of taking and storing images in 99.3%. The CUSUM analysis *Correspondence: luisf.giraldo@unisabana.edu.co; lfgiraldo@neumologica.org 25 Department of Epidemiology and Biostatistics, School of Medicine, Universidad de La Sabana, Autonorte de Bogota Km 7, La Caro, Chía, Colombia Full list of author information is available at the end of the article © The Author(s) 2020. 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The Creative Commons Public Domain Dedication waiver (http://creat​iveco​ mmons​.org/publi​cdoma​in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Flandes et al. Respir Res (2020) 21:320 Page 2 of 9 showed average scores > 70/100 from the first procedure and from the 9th procedure more than 80% of the scores exceeded the 80/100 score. Conclusions: The aScope4™ scored well for ease of use, imaging, and aspiration. We found a learning curve with excellent scores from the 9th procedure. Bronchoscopists highlighted its portability, immediacy of use and the pos‑ sibility of taking and storing images. Keywords: Bronchoscopy, Quality, CUSUM analysis, aScope4™, Bronchoalveolar lavage Background low complexity in the usual practice in pulmonology ser- Fiberoptic bronchoscopy is a widely used procedure vices of university hospitals of third level of care. in most hospitals around the world, especially for the diagnosis of infectious, inflammatory and tumor lung Methods diseases. It is estimated that 92,000 bronchoscopies are Design performed annually in Spain, with a tendency to growth. A prospective, observational, multicenter, cross-sectional scope ­(Ambu® aScope4™) with European certification Unfortunately, bronchoscopy can spread infections by study was conducted of an approved disposable broncho- spreading an infection in the same patient, by cross- infection between patients, or by infecting the personnel (CEA) and used according to the product data sheet. involved in the procedure [1]. The study was carried out between February and The effects of cross infection can be severe for the August 2018, in tertiary care university hospitals with patient and the health system and include complications experience in performing bronchoscopies. The study of the infection and its consequences in terms of labora- was approved by the ethics committees of each institu- tory tests, medications, hospital stay, disability, and direct tion and all the participants signed the informed con- and indirect costs. For this reason, it is necessary to sent both for their participation in the study and for the take extreme care and precautions in the decontamina- bronchoscopy. tion and cleaning of equipment [2]. Despite complex and The inclusion criteria were patients over 18 years with advanced endoscope cleaning and disinfection systems, indication for the performance of a diagnostic bronchos- disinfection is often inadequate [3–5], with the conse- copy and that the procedure be approved by signing the quent risk of cross infection [5–7]. informed consent. Exclusion criteria were bronchos- A disposable bronchoscope could decrease the risk of copies that required flexible interventional bronchos- cross infection and increase accessibility to bronchoscopy copies or in which highly complex equipment was to in centers of less complexity or with limited resources be used. 300 subjects were recruited prospectively and and has been recommended by most respiratory societies consecutively in 21 Spanish pulmonology services. for bronchoscopies during the SARS-COv-2 pandemic Bronchoscopists had an experience of more than 500 [8–11]. Patients on mechanical ventilation [12], immu- bronchoscopies. nosuppressed or with infectious contagious diseases are There is few published experience with this broncho- those with the highest risk for cross infections and where scope for complex techniques, thus cases with risk of these devices may have a more relevant role. These bron- bleeding were excluded from the study. The bronchosco- choscopes are also desirable for procedures with a high pies were only diagnostic bronchoscopies with bronchial risk of damage the bronchoscope (e.g. bronchoscopy by aspiration and bronchoalveolar lavage (BAL) and thera- orotracheal tube), to reduce repair costs [13]. peutic bronchoscopies that involved the aspiration of The utility of single-use bronchoscopes has been exten- secretions or hematic remains. sively studied in anesthesiology, where they have been The procedures were performed following the same compared with reusable bronchoscopes in terms of ease sedation and analgesia protocol as in bronchoscopies of use [14]. In the field of pulmonology, there are not with the conventional videobronchoscope: local anesthe- publications listing the perception of pulmonologists sia on the airway with 1% lidocaine. On the other hand, when using these bronchoscopes for conventional diag- conscious sedation with propofol, fentanyl or midazolam nostic and therapeutic techniques. was used at the discretion of each research center who participates in the study. The bronchial aspirate (BAS) ­ mbu® aScope4™ This study seeks to evaluate the perception of the bron- choscopist about the quality of the A consisted of collecting the secretions found during the bronchoscope and the existence of a learning curve dur- examination by means of simple aspiration or by using ing the performance of conventional bronchoscopies of instillations of small volumes of physiological serum Flandes et al. Respir Res (2020) 21:320 Page 3 of 9 (5–10 cc) to favor the collection or try to carry away cel- score obtained on the item lularity or microbiota. of the airway. × 100. maximum possible score on the item BAL was performed by interlocking in a segmental or subsegmental bronchus (depending on the bron- In this way, the standardized score was left with a chial anatomy), three 50-cc aliquots of 0.9% saline were range from 0 (worst possible score) to 100 (best pos- instilled and successively aspirated and processed for sible score). study. It was assumed that the first aliquot would collect To assess the bronchoscopies quality related to the a sample from the bronchial area, while the last volume number of procedures performed with the aScope4 and instilled would carry distal airway and alveolar contents. the existence of learning curves, we used the binary The study aims to validate the bronchoscope by means CUSUM analysis method. We describe the details of this of a personal subjective questionnaire carried out by an method in the Additional file 1, which we summarize experienced bronchoscopist without considering quanti- below. We consider an acceptable failure rate (p0 ) 10% fiable parameters such as the quality of the samples or the (90% of the scores in the evaluated aspect ≥ 80/100) and volume of the BAL recovered. an unacceptable failure rate of 20% (p1 ) (less than 80% of In the cases included in the study, the bronchoscopy the scores in the evaluated aspect ≥ 80/100); we defined a was performed by two observers, the main operator who type I error (probability of falsely qualifying the broncho- operated the bronchoscope and a collaborator who ana- scope as inadequate, designated as α) of 0.1 and a type II lyzed the exploration during its development. A video error (probability of falsely qualifying the bronchoscope as excellent, designated as β) of 0.1 [15–17]. We plotted memory of the ­Ambu® aView™ device for later visuali- of each bronchoscopy was recorded and saved in the the CUSUM graph by plotting the index number of each zations. The videos were labeled according to the order case (bronchoscopy) on the x-axis versus the cumulative number and date of the examination, without the patient sum score after that case on the y-axis. Consecutive fail- data being included. All procedures were anonymous in ures drive the CUSUM curve upward while consecutive storage and confidentiality and privacy regulations were successes drive the CUSUM curve downward. respected. The CUSUM chart includes horizontal lines called A search of the literature was carried out on ques- decision limits (­ h1 y h ­ 0), which are the limits of an accept- tionnaires that measured the quality of the fiberoptic able or unacceptable error rate. When the CUSUM curve bronchoscopes for the performance of diagnostic bron- crosses a decision boundary from above, it is inferred choscopies and none was found, so a new questionnaire that the failure rates were within the predetermined was constructed on the Bronchoscope Quality Question- acceptable rate of 10% (excellent performance); when naire (BQQ) by means of an expert consensus to estab- the CUSUM curve crosses a decision limit from below, lish the relevant items and domains to evaluate in the it is inferred that failure rates have reached the unac- quality of the bronchoscope. A pilot test was carried out ceptable failure rate of 20% (inadequate performance); If to adjust the questions and the psychometric measures of the CUSUM curve is stable between two decision limits, the final instrument were evaluated. stable performance is inferred within good levels. There- The BQQ was assessed independently and masked by fore, good performance is assumed when the CUSUM the two bronchoscopists after the bronchoscopy at two curve slopes downward or remains stable, but when the different times. Both questionnaires were archived and curve slopes upward it indicates a lower than acceptable after a period of 1–15 days from the bronchoscopy, one success rate. Decision limits (h1 and h0) were calculated of the two bronchoscopists viewed the video of the bron- based on the risk of type I errors (α) and II (β). In our choscopy, and completed the questionnaire again. case, as α = β = 0,1; p0 = 10% and p1 = 20%; therefore ­h0 = h1 = 2,71. For this reason, we mark the decision limits of our CUSUM charts as horizontal lines start- Statistic analysis ing from the axis and at intervals of 2.71. Software used The qualitative variables were described with absolute Microsoft Excel 2016 (Microsoft Corporation, Redmond, and relative frequencies, the quantitative ones by means WA, USA) and STATA vs 14.0 (StataCorp, Texas, USA). and standard deviations, or medians and interquartile Assuming a confidence of 95%, a margin of error of 6% range (25th percentile to 75th percentile) depending on and an average proportion of 50% their distribution. The internal consistency of the ques- for the qualitative variables (more demanding scenario tionnaire was measured with the Cronbach’s alpha coeffi- in terms of sample size), a sample size of 267 bronchos- cient. To unify the item scores and to be able to compare copies was deemed necessary for the study, to compen- them, the standardized scores were calculated using the sate possible losses it was decided to increase to 300 following equation: bronchoscopies. Flandes et al. Respir Res (2020) 21:320 Page 4 of 9 Results 36 bronchoscopist participated with a median of 4 bron- A total of 300 bronchoscopies were performed, 15 proce- choscopies (IQR 2.1—8.4). The most frequent indications dures were made by each Spanish pulmonology services, were BAS in 69.3% of all cases (208/300; 95% CI 63.9– 74.3%) and BAL in 125 of all bronchoscopies (41.7%; 95% CI: 36.2–47.3%) (Table 1 and Additional file 1: Fig. Table 1 General characteristics S1). The nasal route of entry was used in 47.2% (141/300; 95% CI 41.6–52.8%) and the oral one in 34.1% of cases N % 95% CI (95% CI 29.0–39.7%) (Table 1 and Additional file 1: Fig. Indication for bronchoscopy S2). The duration of the bronchoscopy had a median of Bronchial lavage or bronchial aspirate 208 69.3 63.9% 74.3% 9.1 min (IQR 6.0–13.0) (Table 1). The reliability of the Bronchoalveolar lavage 125 41.7 36.2% 47.3% questionnaire measured by Cronbach’s alpha was 0.88. Therapeutic aspiration of secretions 30 10.0 7.1% 13.9% The average in user-friendliness, image and aspiration Bronchial biopsy 17 5.7 3.6% 8.9% quality was 4 out of a maximum score of 5 (standardized Route of entry for bronchoscopy score: 80/100; for a maximum score of 100 and a mini- Nasal 141 47.2 41.6% 52.8% mum of 0). The average standardized score for ease of Oral 102 34.1 29.0% 39.7% use, image quality, and aspiration was 80/100 (Table 2 Orotracheal tube 27 9.0 6.3% 12.8% and Fig. 1). In 6% of the cases it was necessary to change Tracheostomy 26 8.7 5.1% 14.6% the aScope 4, the most frequent reasons were limita- VMNI mask 1 0.3 0.1% 1.9% tion to reach the goals of the procedure and damage to Other 2 0.7 0.2% 2.4% the bronchoscope. 54.4% considered that the aScope had Bronchoscopy duration lower image quality than reusable video endoscopes. In Time in minutes, median (IQR) 9.1 (6.0–13.0) more than 90% of the cases, all the pulmonary segments 95% CI 95% confidence interval, IQR interquartile range could be reached and all the planned techniques could be Table 2 Quality of the aScope 4 bronchoscope Median IQRa Score standardized (%)b Complexity to assemble the device 0: impossible → 5: extremely easy 4.0 4.0–5.0 80 Intubation facility 0: extremely difficult → 10: extremely easy 8.0 8.0–9.0 80 Ease of maneuvering in the tracheobronchial tree 0: extremely difficult → 10: extremely easy 8.0 7.0–9.0 80 Vasculature image quality 0: impossible to see vasculature → 5: maximum sharp‑ 4.0 3.0–4.0 80 ness of vasculature Mucous image quality 0: impossible to see mucosa folds → 5: maximum clarity 4.0 3.0–4.0 80 of mucosa folds Image quality of subsegmental bronchi from the seg‑ 0: impossible to see subsegmental bronchi → 5: maxi‑ 4.0 3.0–4.0 80 mental bronchus mum sharpness of subsegmental bronchi Image quality for pathological mucosal alterations 0: impossible visualization of pathological lesions → 5: 4.0 3.0–4.0 80 maximum sharpness of pathological lesions Image quality in case of bleeding 0: complete image loss in bleed → 4: highest image 3.0 2.0–3.0 75 quality in bleed Global image quality 0: no image → 10: optimal image quality 8.0 7.0–8.0 80 Quality to suction secretions 0: impossible to suction secretions → 5: excellent ability 4.0 4.0–4.0 80 to suction secretions Quality to suction blood clots and debris 0: impossible to suction blood clots and debris → 5: 4.0 4.0–4.0 80 excellent ability to suction clots and blood debris Capacity to suction blood in active bleeding 0: impossible to suction blood in active bleeding → 5: 4.0 3.0–4.0 80 excellent ability to suction blood in active bleeding Global suction quality 0: zero suction capacity → 10: optimal suction capacity 8.0 8.0–9.0 80 Average score for ease of use, image quality and aspiration quality 80 95% CI 95% confidence interval a IQR: interquartile range b Standardized score: calculated by dividing the score obtained by the maximum possible score and multiplying by 100, the best possible standardized score is 100% and the worst is 0% Flandes et al. Respir Res (2020) 21:320 Page 5 of 9 performed, for a general satisfaction with the device of 86.4% and a recommendation for its use in similar cases in 86.4% of the cases. times (Table 3). The analysis by the CUSUM Analysis graphical method ­Ambu® aScope4™ showed the following learning points to detect if there was a learning curve in the use of the (point in which the scores exceeded 80/100 in more 80% of bronchoscopies): ease of passing the fiberoptic bron- choscope to the trachea (intubation) in the 3rd proce- dure, ease of maneuvering during the bronchoscopy in the 4th procedure, and image quality during the bron- choscopy in the 9th procedure (Fig. 2). Before these learning points the average scores for these aspects were between 70/100 and 80/100. The assembly of the equip- Fig. 1 Image of the proximal third of the trachea obtained ment and the quality of aspiration of the bronchoscope with aScope 4 of a patient showing an osteochondroplastic obtained standardized scores higher than 80/100 from tracheobroncopathy the first procedure. Table 3 Capacity of the aScope 4TM bronchoscope to perform the planned techniques n % 95% CI Loss of functionality or deterioration during the procedure No 287 97.0 94.3–98.4% Yes 9 3.0 1.6–5.7% Need to change bronchoscope during the procedure It was not necessary to change 283 94.3 91.1–96.4% Changed due to rupture or damage to the bronchoscope 2 0.7 0.2–2.4% Changed for bad aspiration 1 0.3 0.1–1.9% Changed for limitation to reach procedure goals 3 1.0 0.3–2.9% It was changed for a bad image 1 0.3 0.1–1.9% It was changed for another reason 10 3.3 1.8–6.0% Compared to other video-endoscopic equipment how did Much better quality 9 3.1 1.6–5.7% you find the Ambú More quality 35 11.9 8.7–16.1% Equal quality 90 30.6 25.6–36.1% Less quality 152 51.7 46.0–57.4% Much less quality 8 2.7 1.4–5.3% Were you able to reach all lung segments? Yes 272 91.9 88.2–94.5% No 19 6.4 4.1–9.8% Does not apply 5 1.7 0.7–3.9% Ability to perform all the techniques provided Yes 280 94.9 91.8–96.9% No 12 4.1 2.3–7.0% Does not apply 3 1.0 0.3–2.9% General satisfaction with the bronchoscope Very satisfied 3. 4 11.6 8.4–15.7% Satisfied 102 34.7 29.5–40.3% Neutral 118 40.1 34.7–45.8% Somewhat unsatisfied 39 13.3 9.9–17.6% Dissatisfied one 0.3 0.1–1.9% I would recommend using this bronchoscope for similar I would recommend that it always be used 3. 4 11.6 8.4–15.7% procedures I would recommend that it be used in most cases 102 34.7 29.5–40.3% I would recommend that it be used in an acceptable number 118 40.1 34.7–45.8% of cases I would recommend that it be used only in very select cases 39 13.3 9.9–17.6% I would recommend that it never be used 1 0.3 0.1–1.9% 95% CI 95% confidence interval Flandes et al. Respir Res (2020) 21:320 Page 6 of 9 Fig. 2 Plots of cumulative checksums (CUSUM analysis). Intubation: passing the bronchoscope through the vocal folds into the trachea. When the CUSUM curve is directed upward it indicates inadequate performance (less than 80% of procedures were scored with a standardized score ≥ 80/100), when the curve stabilizes indicates that between 80 and 90% of the procedures were rated with a standardized score ≥ 80/100, when the curve is directed downwards indicates that more than 90% of the procedures were scored with a standardized score ≥ 80/100. The assembly of the equipment and the quality of aspiration obtained standardized scores ≥ 80/100 from the first procedure. Intubation ease obtained standardized scores ≥ 80/100 in more than 80% of cases since the 3rd procedure, the ease of maneuver obtained standardized scores ≥ 80/100 in more than 80% of cases since the 4th procedure, the image quality obtained standardized scores ≥ 80/100 in more than 80% of cases since the 9th procedure The most outstanding characteristics of the bron- Discussion choscope were its portability and immediacy to start Our study provides as novel aspects the evaluation of the procedure in 99.3% (296/300; 95% CI 97.6–99.8%), aScope4™ disposable bronchoscope through a standard- the bronchoscopist’s perception of the quality of the its sterility in 96.3% (287/300; 95% CI 93.5–97.9%), the possibility of taking and storing images and videos curve. The aScope4™ was very well evaluated in terms of ized questionnaire and the measurement of its learning of the procedure in 99.3% of cases (298/300; 95% CI 97.6–99.8%) and 88.6% (263/297; 95% CI 84.4–91.7%) ease of use, imaging and aspiration, obtaining an aver- considered that the images and videos were of suf- age score of 80/100 and a high degree of satisfaction in ficient quality. 93% of bronchoscopists considered it the bronchoscopist. After the 9th procedure, the scores useful that the bronchoscope be disposable and for exceeded 80/100 in more than 80% of the bronchosco- single use (277/300; 95% CI 89.5–95.3%). In one of the pies. They highlighted its portability, immediacy to start units of non-invasive mechanical ventilation where the procedure and the possibility of storing the images. this study was conducted, highlighted the usefulness of New bronchoscopes have recently been introduced the aScope 4 left at the bedside of a patient who pre- that offer advantages over existing ones. The quality sented dyspnea due to severe accumulation of secre- assessment of these bronchoscopes should be done in the tions, by allowing them to aspirate them under direct most objective way possible, to validate their function- vision more effectively than with the aspiration probe ality. The measurement of the bronchoscopist’s percep- at blind. tion using standardized questionnaires that include the Flandes et al. Respir Res (2020) 21:320 Page 7 of 9 most relevant domains is a key element for the valida- infection, had some difficulties in these aspects [20], the tion of these devices. In the absence of a questionnaire advantage of the single-use bronchoscope may be due to with these characteristics, we designed one by a panel of not needing to couple an external sheath with a second expert bronchoscopists, which included questions related working channel. Image quality, ease of tracheal intuba- to the route of entry, ease of assembly of the equipment, tion and maneuvering had standardized scores ≥ 80/100 ease of operation, image quality and aspiration, robust- from the 9th procedure, with previous scores between ness of the equipment to maintain full functionality and 70/100 and 80/100, these results show a good perfor- to allow the planned sampling, in addition to the degree mance of the aScope4 from the first procedure and excel- of general satisfaction. lent performance from the 9th procedure. However, like The evaluation of the psychometric properties of the previous studies on the quality of single-use broncho- BQQ showed a very good internal consistency as meas- scopes [14, 21, 22] or disposable sheaths [20]. They did ured by Cronbach’s alpha, with a value of 0.88 [18]. It is not evaluate the existence of learning curves by methods noteworthy that the Cronbach’s alpha coefficient can validated for this purpose, nor did they use standardized have values between 0 and 1, 0 indicates absence of con- questionnaires. Their comparison with our results has sistency and 1 total consistency. Values between 0.8 and these limitations. In this study 54.4% of physicians found 0.9 are considered very good, values less than 0.7 are con- the quality of images worse than those from reusable sidered low and values greater than 0.94 are considered videobronchoscopes. Thus, reusable videobronchoscopes indicative of redundancy in the questions. The participa- remain the cornerstone in interventional pulmonology tion of a panel of experts in the construction of the ques- units. tionnaire and the values obtained in Cronbach’s alpha In a study done with a previous version of aScope4, gave us the necessary support in aspects related to the aScope2 [21], authors observed lower image quality and validity of appearance, content and construct to apply the greater difficulty in maneuverability. In our study, the questionnaire in our study. scores in the domains related to image quality, maneu- A single-use disposable bronchoscope has significant verability, aspiration, ease of assembly and general satis- advantages related to reducing the risk of cross infection, faction were good, which is probably due to the technical ease of compliance with cleaning and disinfection regu- improvements made in this new version of the device. lations during non-working hours, and reducing costs Our study has as limitations not having included more related to trauma repairs during use or reprocessing of complex procedures such as taking biopsies or punc- the equipment. Studies on the effectiveness of repro- tures and not having included a control group, so that it cessing techniques have shown failures that can occur does not allow us to establish the usefulness of aScope 4 even when current regulations are followed [4, 5]. This for such procedures or the superiority or inferiority of makes single-use bronchoscopes preferable for patients aScope 4 versus other video bronchoscopes. at increased risk of infection, such as immunocompro- Among the advantages of the aScope 4 they highlighted mised patients, or those at risk of spreading infections by the fact that it is sterile, that it is for single use, the port- resistant or virulent germs (e.g., hepatitis B and C, HIV, ability and immediacy to start the procedure, the pos- multi-resistant bacteria and tuberculosis, among other). sibility of taking and storing videos and photos of the Particularly, during the current COVID-19 pandemic procedure. Taking and storing images can be particu- most respiratory societies have recommended disposable larly useful when the equipment is used in intensive care bronchoscopes to decrease transmission of the SARS- units, where fiberoptic bronchoscopes having such func- CoV-2 to other patients and to the health care provid- tionality are often not used, and therefore the exploration ers [8–11]. However, these advantages would be of little is only visualized by the bronchoscopist who performs it. value if the bronchoscope did not fulfill its functions with The aScope 4 indications are very varied, such as emer- quality. gency situations, COVID infections, mycobacteria or Given their high sensitivity to detect changes in posi- multi-resistant germs, immunosuppressed patients, ICU tive or negative trends, the cumulative checksum graphs admissions, etc. This device also constitutes an advantage (CUSUM) are probably the most appropriate method in the training of specialists because it allows them to vis- to evaluate the introduction of new technologies, study ualize the examination or teach the bronchoscopic find- learning curves and assess the quality of the results ings to the members of the medical team and could also [15–17, 19]. This analysis showed that the aScope4 did reduce the costs related to the damage of such equipment not require a learning curve in aspects related to equip- due to the trauma they receive when entering through ment assembly and aspiration quality, probably because orotracheal tubes or non-invasive ventilation masks. In it works similarly to reusable bronchoscopes. The dis- addition, the characteristics of the aScope 4 allow it to posable sheaths, also designed to reduce the risk of cross be kept permanently at the patient’s bedside when there Flandes et al. Respir Res (2020) 21:320 Page 8 of 9 are serious problems with airway obstruction due to Author details 1 Pneumology Service, Bronchoscopy and Interventional Pulmonology Unit, abundant secretions, so that they can be aspirated under University Hospital “Fundación Jiménez Díaz”, ISS-FJD CIBERES, Madrid, Spain. direct vision in a way that is probably more effective than 2 Interventional Pulmonology, Fundación Neumológica Colombiana, Profesor blindly. Finally, one of the factors to take into account in Titular Universidad de La Sabana, Bogotá, DC, Colombia. 3 Pneumology Ser‑ vice, Hospital Clínic Universitari, Barcelona, Spain. 4 Pneumology Service, Hos‑ the future is the possible ecological impact of this device pital Universitari deBellvitge, Barcelona, Spain. 5 Pneumology Service, Hospital since it is necessary to dispose of it after use and because Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain. 6 Pulmonology it is made of plastic materials. Service, Complexo Hospitalario Universitario, A Coruña, Spain. 7 Pneumology Service, Central University Hospital of Asturias, Oviedo Asturias, Spain. 8 Pneu‑ mology Service, Hospital San Pedro de Alcántara, Cáceres, Spain. 9 Pneumol‑ ogy Service, Miguel Servet University Hospital, Zaragoza, Spain. 10 Pneumology Conclusions Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. 11 Pneumology Service, University Hospital of the Canary Islands, Santa Cruz de Tenerife, Spain. The aScope 4 scored very well in terms of ease of use, 12 Pneumology Service, Hospital San Juan de Dios, Santa Cruz de Tenerife, image quality, and aspiration. We observed a learning Spain. 13 Pneumology Service, Galdakao University Hospital, Bilbao Vizcaya, curve with excellent scores from the 9th procedure. They Spain. 14 Pneumology Service, Hospital Clínico Universitario, Valladolid, Spain. 15 Pneumology Service, University Assistance Complex, Salamanca, Spain. highlighted its portability, immediacy of use and the pos- 16 Pneumology Service, Hospital Universitario Gregorio Marañón, Madrid, sibility of taking and storing images. Spain. 17 Pneumology Service, Puerta de Hierro University Hospital, Madrid, Spain. 18 Thoracic Surgery Service, Hospital Universitario La Paz, Madrid, Spain. 19 Pneumology Service, Virgen de Macarena University Hospital, Seville, Spain. Supplementary information 20 Pneumology Service, Carlos Hay Regional University Hospital, Malaga, Spain. Supplementary information accompanies this paper at https​://doi. 21 Respiratory Endoscopy Unit, Hospital Universitari i Politècnic La Fe, Valencia, org/10.1186/s1293​1-020-01576​-w. Spain. 22 Pneumology Service, General University Hospital, Alicante, Spain. 23 Fundación Neumológica Colombiana, Bogotá, DC, Colombia. 24 Industrial Electronic Engineering, GHS SL, Madrid, Spain. 25 Department of Epidemiology Additional file 1: CUSUM analysis. and Biostatistics, School of Medicine, Universidad de La Sabana, Autonorte de Bogota Km 7, La Caro, Chía, Colombia. Abbreviations Received: 5 August 2020 Accepted: 18 November 2020 CUSUM: Cumulative checksum graphs; CEA: European certification; BAL: Bronchoalveolar lavage; BAS: Bronchial aspirate; BQQ: Bronchoscope quality questionnaire; IQR: Interquartile range. Acknowledgements Not applicable. References 1. Prakash UBS. Does the bronchoscope propagate infection? Chest. Authors’ contributions 1993;104(2):552–9. https​://doi.org/10.1378/chest​.104.2.552. JF, JA, IF-N, JR contributed to the study design, patient recruitment, collection 2. 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