Explore This IssueACEP Now: Vol 34 – No 04 – April 2015
In my airway education travels, I meet folks who claim no need for endoscopy skills. While it’s true you can be an emergency physician and not know how to do nasoendoscopy or long-scope intubation, the real question is, why would you? You can live without a dog, but why would you? You can be an emergency physician and not know ultrasound (coming up with ways to punt, work around, or make excuses), but let’s face it—the more you put in the “I don’t do that” column, the more uncomfortable you will be with the great challenge of being an emergency physician. Conversely, the less you fear, the easier it is to stand at the front door of your hospital, ready for anything, which is no easy task. It’s about making peace with the challenge you’ve accepted.
Until I felt really confident with an endoscope, I was particularly scared about trach changes, dislodged trachs, angioedema, Ludwig’s angina, and other airway challenges that I felt I needed otolaryngology/anesthesia to address. I still respect all of these things and appreciate the expertise our consultants can provide, if they’re available. Let’s not fool ourselves; patients are ours, and we are responsible for them. In some venues, like where I now work in rural New England, we are all they have.
I learned endoscopic skills through nasoendoscopy. Compared to a long scope (60 cm), nasoendoscopy (30 cm length) is far simpler. It can also be done frequently in the course of caring for ED patients. Long-scope intubation, especially now with the widespread use of video laryngoscopy, is usually done only when the mouth is the problem (angioedema/Ludwig’s).
Nasoendoscopy is great for those severe sore throats. It is far faster and better than plain films or CT to assess for epiglottitis. I like looking for foreign bodies, fish bones, etc., but I appreciate that objects can be embedded beneath the mucosa and not be visible by endoscopy. I had a patient who unknowingly ingested a folded small staple in her Chinese food a few days earlier and presented with sore throat. Her mucosal appearance was normal but tender, and she had a low-grade fever. CT identified the foreign body and abscess.
Another great use of nasoendoscopy is for diagnosing laryngeal asthma or spasmodic vocal cord dysfunction (ie, paroxysmal vocal cord motion). I, and most experienced emergency physicians, have mistakenly intubated patients who present with severe wheezing only to discover on induction that their airway abnormality corrects entirely when unconscious. If you make this diagnosis, you can prevent cycles of unnecessary intubation, steroids, etc. It requires observing vocal cord adduction during inspiration, which is opposite of what the larynx does normally. Treatment can be as simple as slow nasal inspiration and exhalation through the mouth via pursed lips. If the diagnosis is certain, benzodiazepines help tremendously. To nail the diagnosis, cord adduction with inspiration must be observed. Diagnostic clues include severe distress (requesting intubation) but normal pulse oximetry and loud stridor audible over the neck. Of course, this requires excluding other causes, like foreign body (above, at, or below the cords), severe allergy (causing edema), asthma, gastroesophageal reflux disease, cold exposure, etc.
I recently showed a patient his trachea through his trach tube. He he greatly appreciated viewing his own trachea for the first time in his life! It convinced him the trach was in position.
I think the most compelling reason emergency physicians should pick up nasoendoscopes is to do tracheoscopy. Gazing at the trachea is awesome for understanding airway anatomy. This is where our tracheal tubes interact with the rings. It is also so easy and so mission critical in trach patients with breathing problems. If a trach gets replaced, it should be verified by direct observation of tracheal rings, a chest X-ray, and documentation of exhaled CO2 and good pulse oximetry. It is not uncommon that a trach is placed subcutaneously in a patient who, while awake, can breathe around it but then is brought back dead to the ED with the trach in a subcutaneous location. Inspecting the trachea, you can exclude bleeding and mucous plugging. It’s only 11 centimeters from the cords to the carina. Inserting a short scope into the tracheostomy tube (cannula removed) gives you an easy and direct view. No drugs are required, and if you don’t exit the Shiley or other tube, you will not trigger coughing or gagging.