Section 6: Procedures
Introduction and Definitions
The ability to skillfully perform invasive and non-invasive procedures is vital for Pulmonary and Critical Care Medicine fellows. During fellowship training, fellows must gain both technical and cognitive proficiency in a wide array of procedures. These procedures are categorized as follows:
Category “A” Procedures (Core)
Fellows must demonstrate independent, competent, and safe performance. Prior to graduation, fellows must show:
- Understanding of indications, contraindications, risks, and benefits
- Technical and cognitive skills to independently and safely perform the procedure
- Ability to recognize and manage complications appropriately or consult as needed
Category “B” Procedures (Non-Core, Supervised)
Fellows must be able to perform these procedures competently with supervision. Independent privileges may be granted on a case-by-case basis. Graduation requirements include:
- Knowledge of indications, contraindications, risks, and benefits
- Ability to perform the procedure safely with minimal supervision
- Understanding of complications, diagnostic steps to identify them, and recognition of when to consult for management
Category “C” Procedures (Familiarity Only)
Fellows must understand but are not required to perform these procedures independently. Generally, additional training beyond fellowship is required for independent privileges. Fellows must:
- Understand indications, contraindications, risks, and benefits
- Possess a basic knowledge of procedure techniques, expected outcomes, and potential complications
Procedural Categories
Category “A” Procedures
Diagnostic Flexible Bronchoscopy
- Inserting the bronchoscope via mouth, nose, or airway devices
- Using topical anesthetic appropriately
- Identifying standard vs. abnormal endoscopic findings
- Performing fluoroscopy-guided biopsy, endobronchial biopsy, brushing, bronchoalveolar lavage, trans-bronchial needle aspiration, and trans-bronchial lung biopsy
Basic Pleural Procedures
- Pleural ultrasound (performance and interpretation)
- Ultrasound-guided thoracentesis
- Tube thoracostomy
- Management of pneumothorax with needle/catheter drainage
Airway and Respiratory Procedures
- Establishing and maintaining an open airway in non-intubated, unconscious, or paralyzed patients
- Oral and nasotracheal intubation*
- Bronchoscopic intubation*
- Bag-mask ventilation
- Mechanical ventilation (pressure-, volume-, time-, and flow-cycled)
- Use of reservoir masks, CPAP masks, humidifiers, nebulizers, and incentive spirometry
- Liberation from mechanical ventilation and applying respiratory care techniques
- Placement of endobronchial blockers*
Circulatory Evaluation and Management
- Arterial puncture and blood sampling
- Insertion of arterial and central venous catheters
- Operation, calibration, and interpretation of hemodynamic monitoring (arterial lines, central venous catheters, pulmonary artery catheters, intracranial pressure monitors)
- Interpreting pulmonary artery (PA) catheter waveforms
- Basic and Advanced Cardiac Life Support
- Emergency cardioversion
- Point-of-care ultrasound (POCUS) assessment
- Titration of vasoactive agents
Pulmonary Function Tests
- Spirometry
- Bronchoprovocation studies (methacholine, exercise)
- Lung volume determination
- Diffusing capacity
- Arterial blood gas analysis
- Functional laryngoscopy
- Cardiopulmonary exercise testing
- Conscious Sedation Management during invasive procedures
Category “B” Procedures
Advanced Flexible Bronchoscopy
- Linear EBUS
- Radial EBUS
- Navigational bronchoscopy
- Bronchoscopic cryoextraction
- Emergent airway balloon dilatation
Advanced Pleural Procedures
- Tunneled indwelling pleural catheter placement and management
- Medical thoracoscopy (pleuroscopy)
- Ultrasound-guided transthoracic needle biopsy
Airway and Respiratory Procedures
- Percutaneous tracheostomy
Circulation Management
- Extracorporeal membrane oxygenation (ECMO) management
- Balloon pumps and other mechanical assist devices
- Interpretation of PA catheters
- Continuous renal replacement therapy (CRRT) management
Sleep Medicine
- Home sleep test (HST) interpretation
- Basic CPAP initiation and titration
Category “C” Procedures
Advanced Diagnostic Bronchoscopy
- Robotic bronchoscopy
- EUS-B (esophageal introduction and sampling with an EBUS bronchoscope)
Therapeutic Bronchoscopy
- Rigid bronchoscopy
- Central airway debulking
- Endobronchial ablative therapies (laser, APC, snare, etc.)
- Cryobiopsy
- Airway stent insertion and removal (including T-tubes)
- Endobronchial valve insertion
- Photodynamic therapy
- Mucosal injection of medications (steroids, chemotherapy)
- Non-emergent airway dilatation
Airway and Respiratory Procedures
- Surgical tracheostomy
Circulation Management
- ECMO cannulation
- Placement of mechanical assist devices
- Hemodialysis management
Sleep Medicine
- Polysomnogram interpretation
- MSLT/MWT interpretation
- Narcolepsy treatment
- Initiation and titration of advanced devices for sleep-disordered breathing (AVAPS, ASV, BiPAP AVAPS, etc.)
Other Procedures
- PEG tube insertion
- Pericardiocentesis
- Vasodilator studies for diagnosis of pulmonary hypertension
Procedural Supervision and Independence
As described in Section 5, our fellowship program is designed to encourage progressive responsibility, initiative, and independent decision-making while ensuring safe, high-quality patient care under appropriate supervision, consistent with the “NMCSD GRADUATE MEDICAL EDUCATION POLICY: Resident Supervision and Accountability”.
- Early in training, fellows perform all procedures with Direct Supervision from an attending physician.
- Once fellows have demonstrated the necessary skills for a Category A procedure, they may perform it under Indirect Supervision or Oversight, as deemed appropriate by the supervising attending and in line with institutional policy.
- When a fellow is deemed competent for a specific level of supervision for a procedure, the Program Director will issue a certificate of competency, which authorizes the fellow to perform those procedures under the specified level of supervision (Direct Supervision, Indirect Supervision, or Oversight).
- Ongoing supervision requirements for a specific procedure are determined on a case-by-case basis by the attending physician, taking into account the fellow’s competency, the complexity of the case, and institutional guidelines.
- Some “Category A” procedures may require ongoing Indirect Supervision in keeping with institutional and program policies (marked with a superscript ±).
- “Category B” and “Category C” procedures always require Direct Supervision.
- Certain high-risk “Category A” procedures—such as endotracheal intubation—require Direct Supervision at all times because of acuity and comorbidities. These are indicated with a superscript *.
Procedure Log
Every fellow must maintain an up-to-date procedure log that documents completion of all required procedures. The logs are reviewed semi-annually to ensure adequate case volume and the appropriate progression of skills. At a minimum, the following information must be recorded:
- Date of procedure
- Patient identification
- Attending physician
- Procedure name
- Any additional therapeutic maneuvers performed
- Any complications encountered
Fellows submit a summary Excel spreadsheet of completed procedures to the Residency Program Administrator (RPA). This summary and the procedure log are regularly reviewed by the Program Director.
Competency is not determined solely by the number of procedures performed. It is assessed based on procedural volume, faculty evaluations, and, where applicable, simulation-based assessments.
Target Procedural Volumes
Although there is no strict minimum number of procedures to establish competency, fellows are expected to achieve certain target volumes before graduation to ensure adequate exposure:
- Bronchoscopies: 100
- Thoracenteses: 20
- Chest tube insertions: 10
- Endotracheal intubations: 50
- Cardiopulmonary exercise tests: 10
- Percutaneous tracheostomies: 5
- EBUS procedures: 30
- Central venous catheter insertions: 15
- Arterial line insertions: 15
Scheduling Procedures: NMCSD Pulmonary Procedure Scheduling Guidelines
Quick Step Order:
- Arrange a pre-op screening, complete the “Adult Patient Evaluation Screening Worksheet (Anesthesia),” and obtain signed procedure consent.
- Scan and email signed forms to: [email protected]
- Receive email confirmation upon receipt.
- Enter a “Procedure Request Order” in PowerChart.
- Complete the information template (below) and email to Raquelle “Rocky” Taylor at [email protected]; CC the clinic RN (LT Clark), consulting staff for the procedural week, and Dr. Miller if he is performing the procedure.
- Receive an Outlook calendar invite once the procedure has been officially scheduled and a FIN Number has been generated.
- Using the assigned FIN Number, enter the relevant procedure set orders in Genesis.
- Proceed with the procedure as scheduled.
Pulmonary Clinic Bronchoscopy Suite Case:
- Confirm LT Clark’s availability for conscious sedation (via Outlook Calendar). Contact Rocky to request access if needed.
- Schedule a pre-op appointment and complete the procedure consent form.
- Complete and email the information template to Rocky, CC-ing LT Clark, the clinic RN, and the consult staff for the procedural week.
- Once a dedicated FIN is generated, enter procedure-related orders.
- Proceed with the procedure accordingly.
Frequently Asked Questions (FAQs) Regarding Procedural Scheduling
Which location should I select for the procedure?
- CEC: Routine bronchoscopy, EBUS, navigational bronchoscopy
- MOR: Higher-risk procedures (rigid bronchoscopy, cryo/APC biopsy) and/or higher ASA classification (III/IV)
- Clinic Bronch Suite: Routine inspection bronchoscopy for lower ASA classifications (I/II)
- Important: CEC does not accept bronchoscopy cases for TB rule-out; schedule these in the MOR or Clinic Bronch Suite.
How do I place the bronchoscopy procedure order?
- Type “bronchoscopy” in the orders search bar.
- Select the appropriate procedure.
- Complete the required fields and sign the order.
What should I do if I have a last-minute add-on case for the MOR?
Contact the OR CC at 619-384-6231 to discuss scheduling and logistics.
Do I need to order pre-op labs?
- Urine pregnancy test for premenopausal females if procedure is in Clinic Bronch Suite.
- Order other tests based on clinical necessity.
- No COVID test requirement currently.
How do I determine if a patient is suitable for the Clinic Bronch Suite?
- Appropriate for ASA I/II patients needing routine inspection bronchoscopy.
- For TB rule-out, schedule in MOR or Clinic Bronch Suite.
Follow these guidelines closely to ensure efficient scheduling and coordination of pulmonary procedures.
Moderate Sedation
Moderate sedation is frequently used in pulmonary procedures. It requires direct supervision by a nurse or another qualified healthcare provider skilled in patient monitoring. Before undergoing moderate sedation:
- The patient must have a physical exam, and an ASA risk classification documented.
- Outpatients undergoing conscious sedation must have a designated driver/guardian to take them home and assist with post-procedure care.
References and Appendices
- Section 6 Appendix 1: NMCSD GRADUATE MEDICAL EDUCATION POLICY: Resident Supervision and Accountability (22 January 2024)
- Section 6 Appendix 2: National Patient Safety Goals 2025 (Relevant excerpts, including Universal Protocol)
- Section 6 Appendix 3: NMCSD GME Trainees Prescribing Medications Policy (12 November 2024)