Introduction: Fiberscopy is widely used by anaesthetists. Virtual reality simulation is known to allow physicians to increase skills without harm for patients. Few high reality bronchoscopy simulators exist, their prices exceed US$ 25’000 and their sizes makes them difficult to transport. We developed an ultra-portable high reality iPad™-based bronchoscopy simulator and report of its first use by anaesthesiologists.
Methods: 
The CASS simulator (Computer Airway Simulation System) consists of a proxy bronchoscope and a basic robotic device, wirelessly connected to an iPad™. The robotic interface tracks proxy motions and provides haptic feedback while the iPad displays a specifically developed three-dimensional high quality graphic model of human airways. An optional roadmap indicates position of the proxy bronchoscope, recording automatically duration of the procedure, number and sequence of bronchial segments inspected and number of collisions with the tracheobronchial wall. 
Anaesthetists attending a Swiss difficult airway course were recruited to assess the CASS. Objective performances were assessed with participants performing a bronchoscopy from mouth to the right superior lobar bronchus(RSLB). We used an assessment tool of bronchoscopic performance1, combining number of wall collisions, ease of pass through vocal cords, image centering and “red-out time” (0 = bad to 8 = very good). Subjective criteria (bronchoscope proxy handling, graphic quality of the model, anatomy fidelity, reactivity of the system and usefulness for teaching) were assessed using a Likert scale (1 = bad to 5 = very good). 
Results: 22 physicians were enrolled (5 residents (22.7%), 2 fellows (9.1%) and 15 senior specialists (68.2%)). 17 (77.3%) had more than 10 years of clinical experience and 13 (59.1%) had performed more than 50 bronchoscopies.  Mean time to reach the RSLB was 92 ± 35 sec, mean number of wall collisions during procedure were 12 ± 15. Bronchoscopic performance was 4.7 ± 2.5. Subjective assessment of the simulator demonstrated bronchoscope proxy handling 4.0 ± 0.7, graphic quality of the model 4.7 ± 0.5, anatomy fidelity 4.5 ± 0.6, reactivity of the system 3.6 ± 1.1, usefulness for teaching 4.9 ± 0.3 and ease of use 4.3 ± 0.8.
Conclusion: Subjective assessment by participants of this new simulator was excellent, especially as a pedagogic tool for teaching and with regards to the graphic quality. Reactivity of the system should be improved in future. Bronchoscopic performance of participants was acceptable.

1 Graeser K et al. Eur J Anaesthesiol. 2014 Mar;31(3):125-30.

The CASS simulator: first results with a new ultra-portable iPad™ based flexible bronchoscopy simulator