Fiberoptic intubation

[Aesculapius]

Doing an anesthesia rotation and got to play a little bit with the flexible fiberoptic bronchoscope. Seems like it could be pretty slick in some circumstances. How often, if ever, do you all use it for your airways?

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[pseudoknot]

Never since my anesthesia rotation. I wouldn't mind using it every now and then for less urgent intubations just to maintain the skill, but remember that this is not recommended as a backup plan when other strategies have already failed. It's for anticipated difficult airways in elective situations, and the ED isn't necessarily the best place to mess around with those (or it may be, but this is really going to depend on your hospital and resources).

 

[Groove]

I've used it for an emergent awake angioedema intubation, nasotracheal... and another similar awake intubation, just under different circumstances. It's a nice skill to have, but I'm not entirely sure how practical it is in the long term. I seem to only have it available at my tertiary care institution and virtually nowhere else I moonlight or have interviewed, so the skill begs the question of utility. I honestly don't know how commonly available a bronchoscope is going to be after residency and I don't feel that I need it in 99% of my intubations. I have frequent availability of a nasopharyngoscope that I use all the time if possible, just to keep my skills up since it translates so well to using a bronchoscope.

Any of the attendings in a non-academic place that have availability? I'd be genuinely curious.

 

[RustedFox]

Never used one. Don't have access to one. Won't use one.

MAC-4 and a good strong arm FTW.


...


I kid with the last part, but never used one.

 

[Aesculapius]

Speak of the devil... Ron Walls on September EMRAP talking about flexible scopes!

 

[EMPD]

I'm going to respectfully disagree with the master of airways, Dr. Walls. I've read his book, and I have practiced with faculty who were staff at his courses. I have also personally attended Rich Levitan's course and I just think his philosophy and techniques are the best. Not to take anything away from Dr. Walls. He is obviously an expert on this subject. I just believe that fiberoptics are not readily enough available nor cheap enough to be the standard of care, and I also feel that you can never rely solely on technology to work correctly. I would equate it to doing an all laparoscopic surgery residency without doing any open cases. Now trust me, I am a huge fan of the video scopes. I have a King Vision, an Airtraq, a Glidescope, a McGrath (being borrowed currently), and I love to play with them and show them to the residents. But I am nowhere near taking the cold hard metal out of our resident's hands.

 

[Tiger26]

I'll chime in pro-fiberoptic. I just did an elective in the bronch suite where I did 35-40 fiberoptic intubations + bronchs and now feel extremely comfortable with the procedure.

With that said, before doing the elective, I did two successfully in the ED because I knew the anatomy and workings of the scope after making an effort to use an NP scope frequently on clinical shifts (i.e. frequently for sore throat . . . )

Both situations were high risk, high stress scenarios with a little bit of time for set-up: 1) guy with tongue half the size of his face and needing an urgent airway and 2) tiring asthmatic with crooked looking vertical scar on her neck from a previous crash cric.

Even for places for which fiberoptic isn't immediately available in the form a bronchoscope, I think it will become increasingly more available with the following disposable scope with a non-disposable monitor at a good cost ($2000 for 10 scopes), which makes it cost-effective for places that don't use it as frequently.

http://www.ambu.com/ascope2-new/key_benefits.aspx

 

[dotcb]

The time to use this is for the patient who needs to be intubated, anticipated to be difficult, and you have at least 20-30 min. Example is angioedema. However, much of the time this may as well be done in the OR and not in the ED. Video larygoscopy is a much more applicable skill for the ED. I use an NP scope with some frequency for foreign body visualization. And while I am familiar with the basics of the fiber scope, it is so rarely used in the ED that I feel I'd be better with RSI VL or DL, or awake VL.

 

[joeDO2]

I'll chime in pro-fiberoptic. I just did an elective in the bronch suite where I did 35-40 fiberoptic intubations + bronchs and now feel extremely comfortable with the procedure.

With that said, before doing the elective, I did two successfully in the ED because I knew the anatomy and workings of the scope after making an effort to use an NP scope frequently on clinical shifts (i.e. frequently for sore throat . . . )

Both situations were high risk, high stress scenarios with a little bit of time for set-up: 1) guy with tongue half the size of his face and needing an urgent airway and 2) tiring asthmatic with crooked looking vertical scar on her neck from a previous crash cric.

Even for places for which fiberoptic isn't immediately available in the form a bronchoscope, I think it will become increasingly more available with the following disposable scope with a non-disposable monitor at a good cost ($2000 for 10 scopes), which makes it cost-effective for places that don't use it as frequently.

http://www.ambu.com/ascope2-new/key_benefits.aspx

I think the ascope would be the best bet for ED use. its easy and single use so theres no cleaning / maintenance issues. I played around with it a bit and it seems pretty quick to master.