ORIGINAL CONTRIBUTION intubation, fiberoptic
Fiberoptic Intubation in the Emergency Department Fiberoptic-aided endotracheal intubation has been shown to be effective in difficult intubation secondary to anatomic abnormalities and traumatic conditions. A retrospective review of emergency airway management in an emergency department during a 30-month period found 35 patients who underwent fiberoptic-aided endotracheal intubation; 31 were treated for medical conditions, and four were trauma patients. Indications in the medical group included failed nasotracheal intubation (ten), anatomic abnormalities (six), and the initial airway maneuver attempted (15). Indications in the trauma group with suspected cervical-spine injury included failed nasotracheal intubation (one) and initial airway maneuver attempted (three). In the medical subgroup, 25 of 31 patients were intubated successfully fiberoptically. All four trauma patients were intubated successfully, and all attempts were done nasally. The limitations of the technique were varied. Twenty of the 25 successful intubations had times recorded for completion (mean time, 1.8 +- 1.4 minutes [SD]). Four of the six failed attempts had recorded times of 7.8 + 1.4 minutes. The mean time of the four trauma cases was 3 + 2.2 minutes. The presence of secretions, blood, or vomitus was the cause in five of the six failed intubations. The sixth patient kept swallowing the distal end of the scope. Fiscal restraints m a y also limit its use. A t our institution, the financial commitment has been approximately $17,000 during the past nine years. Repair or replacement of broken equipment appears to be necessary every two or three years. Immediate airway control is often difficult with fiberopticaided endotracheal intubation and should be used only in selected patients. This includes patients who are breathing but need intubation and have known anatomic abnormalities or confirmed or suspected cervicalspine injury and after failed nasotracheal intubation. The associated cost of the expensive, fragile equipment m a y require that specific indications exist for its use in the ED. [Mlinek EJ Jr, Clinton JE, Plummet D, Ruiz E: Fiberoptic intubation in the emergency department. Ann Emerg Med April 1990;19:359-362.]
Edward J Mlinek, Jr, MD Joseph E Clinton, MD David Plummer, MD Ernest Ruiz, MD Minneapolis, Minnesota From the Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota. Received for publication June 28, 1988. Revision received January 24, 1989. Accepted for publication November 20, 1989. Presented at the University Association for Emergency Medicine Annual Meeting in Cincinnati, Ohio, May 1988. Address for reprints: Edward J Mlinek, Jr, MD, Section of Emergency Medicine, University of Nebraska Medical Center, 42nd and Dewey Avenue, ©maha, Nebraska 68105-1065.
INTRODUCTION Airway management is the utmost priority in the care of the seriously ill or injured patient. Emergency physicians must have many options in airway management3 Fiberoptic-aided endotracheal intubation was shown to be an effective means of airway control by Murphy in 1967.2 Subsequently, its use has been described with difficult intubations involving various anatomic and traumatic conditions. 3-8 Despite these reports, emergency department use remains limited. Our ED experience with fiberoptic-aided endotracheal intubation is reviewed.
MATERIALS A N D METHODS For our retrospective review, a computerized critical care data base was used to identify all patients who had fiberoptic-aided endotracheal intubation performed in the ED stabilization room during a 30-month period from January 1, 1985, through July 1, 1987. The data base was compiled on each patient on completion of resuscitation. A detailed minute-by-minute
19:4 April 1990
Annals of Emergency Medicine
359/33
FIBEROPTIC INTUBATION Mlinek et al
FIGURE 1. Clinical settings requiring Jntubation.
Seizure 3%
FIGURE 2. Equipment repair and replacement cost.
medical student observer log was reviewed to determine the time required to perform the intubation. The sole responsibility of the medical student recorder in every stabilization room case is to document the timing of all critical interventions. The physician's dictated report and nursing records provided additional information including clinical diagnosis, indication for intubation, airway maneuvers attempted, and difficulties encountered. Initial introduction to fiberopticaided intubation was provided during the c h i e f r e s i d e n t r e s u s c i t a t i o n course by practicing on manikins until familiarity was obtained. Clinical proficiency was developed through frequent use in direct laryngoscopy; this provided knowledge of the anatomy of the nasopharynx and experience in the visualization of the vocal cords, which is required in fiberoptic intubation. Additional clinical instruction was given by the staff physician on duty while the intubation was ongoing. All fiberoptic intubations were performed nasally by either the chief resident or staff physician on duty in the ED. While formal policy or indications did not exist, fiberoptic intubation was performed if, in the judgment of the attending faculty and chief resident, it was an acceptable airway option. During the study period, a Fujinon fiberoptic scope was used. The technique used involved the initial placement of the lubricated endotracheal tube through the nose into the nasopharynx followed by the placement of a l u b r i c a t e d f i b e r o p t i c scope through the endotracheal tube. The vocal cords then were visualized. After the scope was advanced through the cords, the endotracheal tube was passed over the fiberoptic scope into the trachea. The bronchoscope was removed, and the patient was ventilated. Hypoxia was avoided by limiting the length of the intubation attempt. When blood or secretions were present, the suction port was used. Insufflation of oxygen through the suction port by attachment of the port to wall oxygen also helped to 34/360
ICB 9% Trauma 1 1% Cardiac Arrest 1 1% Overdose 1 7%
8 m
Annual Cumulative
m
2
m
m
0
m
m
8
H//
m
m
6 UJ HI, zzz, ,zH
N~A///j
1979
z/// /lie //// I/// /11/ //// KK/-z
198o 1981 1982 1983 1984
1985
1986 1987 1988
Year
clear secretions. If direct visualization of the glottis could not be obtained, ambient lighting was dimmed and the "lighted stylet" technique was used. 9 During the lighted stylet technique, the fiberoptic light is visualized transcutaneously over the larynx anteriorly to signify proper position. The endotracheal tube is advanced followed by evaluation of patient ventilation. Fiberoptic capabilities b e c a m e available in our ED in t979. ED costs from 1979 through 1987 were reviewed. Expenditures included the Annals of Emergency Medicine
repair and replacement cost of maintaining fiberoptic-aided endotracheal intubation capabilities.
RESULTS From January 1, 1985, through July 1, 1987, a total of 1,862 intubations were performed (nasotracheal intubations, 973; orotracheal intubations, 815; c r i c o t h y r o i d o t o m i e s , 39; and fiberoptic-aided intubations, 35). The f i b e r o p t i c i n t u b a t i o n s were performed in the clinical settings as outlined (Figure 1). The nine physicians who performed the procedures aver19:4 April 1990
Known anatomic abnormalities (kyphosis, trismus, clenched teeth) Suspected or confirmed cervicalspine injury Penetrating neck (vascular) injuries Failed nasotracheal intubation 4
F I G U R E 3. Example of fiberoptic casing buckling. FIGURE 4. Indications for fiberoptic
intubation.
TABLE 1. Fiberoptie intubation success rates No. of Attempts 25/31 22 3 9/10
Medical Successful With direct glottic visualization With stylet technique After failed nasotracheal intubation Unsuccessful Due to secretions, blood, or vomitus Persistent scope swallowing
6/31 5 1
Trauma Successful
4/4
TABLE 2. Time interval to completion of intubation
Successful attempts Failed attempts
Medical Patients (min) 1.8 ± 1.4 7.8 _+ 3.3
aged 4 ± 1.4 i n t u b a t i o n s e a c h . Thirty-one of 35 intubations (89%) involved medically related cases, and four (11%) involved traumatic conditions. In the medical group, the fiberoptic scope was used as the initial airway attempted in 21 of the 31 patients. 19:4 April 1990
Trauma Patients (min) 3.0 ± 2.2
Six of these 21 medical patients had an identified anatomic condition inf l u e n c i n g the d e c i s i o n (kyphosis, three; clenched teeth, two; and trismus, one). The remaining ten medical patients had fiberoptic-aided nasal intubation attempted after blind nasotracheal intubation failed. Direct Annals of Emergency Medicine
visualization of the glottis with the fiberoptic scope was obtained in 22 successful medical intubations. When the glottis could not be visualized in three patients, the lighted styler technique with the fiberoptic e l e m e n t s was used. In the t r a u m a group, it was the first m e t h o d attempted in three of the four patients. Two of these three patients had gunshot wounds to the neck with vascular a n d / o r c e r v i c a l - s p i n e i n v o l v e m e n t . The third p a t i e n t presented with clenched teeth and a globe injury. Blind n a s o t r a c h e a l i n t u b a t i o n had failed before the fiberoptic attempt in the fourth trauma patient, w h o had a flail chest. T h e overall success rate was 83% (81% in medical a n d 100% in t r a u m a patients) (Table 1). The fiberoptic technique failed in six instances, all medical conditions. The airway was secured by the orotracheal route in four of these patients. Blind nasotracheal intubation and c r i c o t h y r o i d o t o m y w e r e performed in one patient each. T i m e elapsed f r o m i n i t i a t i o n to completion of intubation was available for 20 of the 25 successfully intubated medical patients. It was also available for four of the six failed m e d i c a l cases. T i m e intervals were retrieved on all the trauma patients (Table 2). ED financial records revealed expenditures as diagrammed (Figure 2). In 1979, a fiberoptic b r o n c h o s c o p c was p u r c h a s e d ; its f i b e r o p t i c elements required replacement two years later. T h e r e p l a c e m e n t elements were also broken within two years. Therefore, a flexible and a malleable laryngoscope were purchased in 1984. This was followed in 1985 by 361/35
FIBEROPTIC INTUBATION Mlinek et al
a pediatric 3 - m m scope, w h i c h was the fiberoptic scope used during the study period. Due to b u c k l i n g of the c a s i n g a r o u n d t h e f i b e r o p t i c elem e n t s , a n o t h e r pediatric scope was purchased at the end of 1987 as a replacement. The total cost during this n i n e - y e a r period was a p p r o x i m a t e l y $17,000. Replacement or repair of the fiberoptic scopes was needed every two to three years. Breakage of the fiberoptic e l e m e n t s or b u c k l i n g of the surrounding casing were the main causes. T h i s o c c u r r e d d e s p i t e attempts to lubricate the endotracheal tube and fiberoptic scope (Figure 3). The same conditions were seen even w h e n a 3 - m m d i a m e t e r scope was used with an endotracheal tube size of 7.5 m m or more. In addition to e q u i p m e n t cost, time of a physician, n u r s e , or b o t h is r e q u i r e d to clean the equipment, thereby reducing direct patient care time. DISCUSSION Our experience with fiberopticaided scope i n t u b a t i o n in the ED has c o n v i n c e d us that the t e c h n i q u e is v a l u a b l e i n selected patients. While formal indications did not exist during the study period, our experience led to the indications s h o w n (Figure 4}. The patients who need fiberoptic intubation represent only a small m i n o r i t y of patients requiring emergency tracheal intubation. Alternatively, the use of paralytic agents c o u l d be c o n s i d e r e d . D e p o l a r i z i n g agents provide rapid i n d u c t i o n of a flaccid paralysis with proven efficacy i n obtaining airway control. ~o In several of our patients, the use of paralytic agents was relatively contraindicated due to their alert m e n t a l status and potential for an unstable cervical spine. O t h e r c o m p l i c a t i o n s of succinylcholine administration may pose unnecessary risks to the patient if they could have been fiberoptically intubated. If the technique is to be successful, a skilled user should expect intubation to be achieved quickly. The int u b a t i o n times listed support this belief (Table 2). Successful intubations were
36/362
achieved within two minutes in medical and three m i n u t e s in t r a u m a cases. Vision occluded by blood or v o m i t u s in the p h a r y n x was o f t e n blamed for delay, especially i n injury cases. Failed a t t e m p t s persisted for an average of almost eight m i n u t e s . This experience suggests that lack of quick success with the technique should be followed by the next airway a l t e r n a t i v e w i t h o u t persistence beyond a three-minute interval in m o s t cases. Such practice will prevent u n d u e delay i n achieving airway c o n t r o l a n d also w i l l l i m i t scope damage i n c u r r e d d u r i n g p e r s i s t e n t , futile attempts to pass the tube o w r the scope. Although not done at our institution, it would seem that practicing on p a t i e n t s i n the operating room could be helpful i n developing and m a i n t a i n i n g proficiency of the technique. Neither oximetry nor art e r i a l b l o o d gases were r o u t i n e l y used to m o n i t o r for hypoxia during the attempt. Hypoxia was avoided by l i m i t i n g the length of the i n t u b a t i o n a t t e m p t . Various a n e s t h e s i a m a s k s s p e c i f i c a l l y m o d i f i e d to f a c i l i t a t e b r o n c h o s c o p i c i n t u b a t i o n could be used to allow c o n t i n u e d v e n t i l a t i o n during the procedure. 11,12 The fiberoptic e q u i p m e n t is expensive and fragile. During an eight-year period, $17,000 was spent to m a i n t a i n a n d replace w o r n e q u i p m e n t . Our experience was w i t h 35 patients during 2.5 years. Using these figures, $2,125 per year was spent for use i n 14 p a t i e n t s per year. Therefore, the per-patient cost was a p p r o x i m a t e l y $152.00. The calculation ignores the m u c h m o r e f r e q u e n t u s e of t h e scopes for direct l a r y n g o s c o p y a n d h y p o p h a r y n x v i s u a l i z a t i o n i n patients n o t requiring airway managem e n t . T h e f a i r e s t cost a l l o c a t i o n would consider these patients and u n d o u b t e d l y l o w e r the p e r - p a t i e n t cost significantly. Accurate data on the n o n i n t u b a t i o n uses of the scopes are not available to perform further calculation. The wear and tear on the scopes is clearly greatest w h e n they are used for i n t u b a t i o n . Sliding e n d o t r a c h e a l t u b e s over t h e f i b e r o p t i c e l e m e n t s cannot be done gently. Although gen-
Annals of Emergency Medicine
erous lubrication of the scope is important, it only limits, n o t prevents, scope damage w i t h repeated i n t u b a tion use. Unless more durable fiberoptic elements and casing can be developed, m a i n t e n a n c e costs of t h e e q u i p m e n t will probably r e m a i n at the described level. CONCLUSION Fibcroptic-aided nasotracheal i n t u bation is a valuable airway managem e n t technique in selected patients. Indications include various a n a t o m i c abnormalities, traumatic conditions of the head and neck, and use after failed n a s o t r a c h e a l i n t u b a t i o n s . A more durable scope should be developed to keep costs at an acceptable level for most EDs. REFERENCES 1. Clinton JE, Ruiz E: Emergencyairway management, in Roberts JR (ed): Clinical Procedures in Emergency Medicine. Philadelphia,WB Saunders, 1985, p 2-29. 2. Murphy P: A fiber-optic endoscope used for nasal intubation. Anaesthesia 1967;22:489. 3. Mulder DS, Wallace DH, Woolhouse FM, et ah The use of the fiberoptic bronchoscopeto facilitate endotracheal intubation followinghead and neck trauma. J Trauma 1975;15:638-640. 4. Conyers AB, Wallace DH, Mulder DS, et ah Use of the fiberoptic bronchoscope for nasotracheal intubation: Case report. Can Anesth Soc I 1972;19:654-655. 5. Guyuron B, Dinner MI: Bronchoscopic intubation of patients with trismus. Ann Plast Surg 1983;10:386-390. 6. Venus B: Acromegalicpatient -- Indication for fiberoptic bronchoscopy but not tracheostomy. Anesthesiology 1980;52:100. 7. Rucker RW, Silva WJ, Worcester CC, et al: Fiberoptic bronchoscopicnasotracheal intubation in children. Chest 1979;76:56-58. 8. Schafermeyer RW: Fiberoptic laryngoscopy in the emergencydepartment. A m J Emerg Med 1984;2:160-163. 9. Verdile VP, Chang J-L, Bedger R, et ah Nasotracheal intubation using a flexible lighted stylet (abstract). Ann Emerg Med 1988;17:410. 10. Thompson J, Fish S, Ruiz E: Succinylcholine for endotracheal intubation. Ann Emerg Med 1982;11:526. 11. Mallios C: A modificationof the laerdal anaesthesia mask for nasotracheal intubation with the fiberoptic laryngoscope. Anesthesiology 1980;35:599-600. 12. Imai M, KemmotsuO: A new adapter for fiberoptic bronchoscopy-aidedtracheal intubation under controlledventilation (abstract).A n n Emerg Med 1987;16:517.
19:4 April 1990
Fiberoptic Intubation in the Emergency Department Fiberoptic-aided endotracheal intubation has been shown to be effective in difficult intubation secondary to anatomic abnormalities and traumatic conditions. A retrospective review of emergency airway management in an emergency department during a 30-month period found 35 patients who underwent fiberoptic-aided endotracheal intubation; 31 were treated for medical conditions, and four were trauma patients. Indications in the medical group included failed nasotracheal intubation (ten), anatomic abnormalities (six), and the initial airway maneuver attempted (15). Indications in the trauma group with suspected cervical-spine injury included failed nasotracheal intubation (one) and initial airway maneuver attempted (three). In the medical subgroup, 25 of 31 patients were intubated successfully fiberoptically. All four trauma patients were intubated successfully, and all attempts were done nasally. The limitations of the technique were varied. Twenty of the 25 successful intubations had times recorded for completion (mean time, 1.8 +- 1.4 minutes [SD]). Four of the six failed attempts had recorded times of 7.8 + 1.4 minutes. The mean time of the four trauma cases was 3 + 2.2 minutes. The presence of secretions, blood, or vomitus was the cause in five of the six failed intubations. The sixth patient kept swallowing the distal end of the scope. Fiscal restraints m a y also limit its use. A t our institution, the financial commitment has been approximately $17,000 during the past nine years. Repair or replacement of broken equipment appears to be necessary every two or three years. Immediate airway control is often difficult with fiberopticaided endotracheal intubation and should be used only in selected patients. This includes patients who are breathing but need intubation and have known anatomic abnormalities or confirmed or suspected cervicalspine injury and after failed nasotracheal intubation. The associated cost of the expensive, fragile equipment m a y require that specific indications exist for its use in the ED. [Mlinek EJ Jr, Clinton JE, Plummet D, Ruiz E: Fiberoptic intubation in the emergency department. Ann Emerg Med April 1990;19:359-362.]
Edward J Mlinek, Jr, MD Joseph E Clinton, MD David Plummer, MD Ernest Ruiz, MD Minneapolis, Minnesota From the Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota. Received for publication June 28, 1988. Revision received January 24, 1989. Accepted for publication November 20, 1989. Presented at the University Association for Emergency Medicine Annual Meeting in Cincinnati, Ohio, May 1988. Address for reprints: Edward J Mlinek, Jr, MD, Section of Emergency Medicine, University of Nebraska Medical Center, 42nd and Dewey Avenue, ©maha, Nebraska 68105-1065.
INTRODUCTION Airway management is the utmost priority in the care of the seriously ill or injured patient. Emergency physicians must have many options in airway management3 Fiberoptic-aided endotracheal intubation was shown to be an effective means of airway control by Murphy in 1967.2 Subsequently, its use has been described with difficult intubations involving various anatomic and traumatic conditions. 3-8 Despite these reports, emergency department use remains limited. Our ED experience with fiberoptic-aided endotracheal intubation is reviewed.
MATERIALS A N D METHODS For our retrospective review, a computerized critical care data base was used to identify all patients who had fiberoptic-aided endotracheal intubation performed in the ED stabilization room during a 30-month period from January 1, 1985, through July 1, 1987. The data base was compiled on each patient on completion of resuscitation. A detailed minute-by-minute
19:4 April 1990
Annals of Emergency Medicine
359/33
FIBEROPTIC INTUBATION Mlinek et al
FIGURE 1. Clinical settings requiring Jntubation.
Seizure 3%
FIGURE 2. Equipment repair and replacement cost.
medical student observer log was reviewed to determine the time required to perform the intubation. The sole responsibility of the medical student recorder in every stabilization room case is to document the timing of all critical interventions. The physician's dictated report and nursing records provided additional information including clinical diagnosis, indication for intubation, airway maneuvers attempted, and difficulties encountered. Initial introduction to fiberopticaided intubation was provided during the c h i e f r e s i d e n t r e s u s c i t a t i o n course by practicing on manikins until familiarity was obtained. Clinical proficiency was developed through frequent use in direct laryngoscopy; this provided knowledge of the anatomy of the nasopharynx and experience in the visualization of the vocal cords, which is required in fiberoptic intubation. Additional clinical instruction was given by the staff physician on duty while the intubation was ongoing. All fiberoptic intubations were performed nasally by either the chief resident or staff physician on duty in the ED. While formal policy or indications did not exist, fiberoptic intubation was performed if, in the judgment of the attending faculty and chief resident, it was an acceptable airway option. During the study period, a Fujinon fiberoptic scope was used. The technique used involved the initial placement of the lubricated endotracheal tube through the nose into the nasopharynx followed by the placement of a l u b r i c a t e d f i b e r o p t i c scope through the endotracheal tube. The vocal cords then were visualized. After the scope was advanced through the cords, the endotracheal tube was passed over the fiberoptic scope into the trachea. The bronchoscope was removed, and the patient was ventilated. Hypoxia was avoided by limiting the length of the intubation attempt. When blood or secretions were present, the suction port was used. Insufflation of oxygen through the suction port by attachment of the port to wall oxygen also helped to 34/360
ICB 9% Trauma 1 1% Cardiac Arrest 1 1% Overdose 1 7%
8 m
Annual Cumulative
m
2
m
m
0
m
m
8
H//
m
m
6 UJ HI, zzz, ,zH
N~A///j
1979
z/// /lie //// I/// /11/ //// KK/-z
198o 1981 1982 1983 1984
1985
1986 1987 1988
Year
clear secretions. If direct visualization of the glottis could not be obtained, ambient lighting was dimmed and the "lighted stylet" technique was used. 9 During the lighted stylet technique, the fiberoptic light is visualized transcutaneously over the larynx anteriorly to signify proper position. The endotracheal tube is advanced followed by evaluation of patient ventilation. Fiberoptic capabilities b e c a m e available in our ED in t979. ED costs from 1979 through 1987 were reviewed. Expenditures included the Annals of Emergency Medicine
repair and replacement cost of maintaining fiberoptic-aided endotracheal intubation capabilities.
RESULTS From January 1, 1985, through July 1, 1987, a total of 1,862 intubations were performed (nasotracheal intubations, 973; orotracheal intubations, 815; c r i c o t h y r o i d o t o m i e s , 39; and fiberoptic-aided intubations, 35). The f i b e r o p t i c i n t u b a t i o n s were performed in the clinical settings as outlined (Figure 1). The nine physicians who performed the procedures aver19:4 April 1990
Known anatomic abnormalities (kyphosis, trismus, clenched teeth) Suspected or confirmed cervicalspine injury Penetrating neck (vascular) injuries Failed nasotracheal intubation 4
F I G U R E 3. Example of fiberoptic casing buckling. FIGURE 4. Indications for fiberoptic
intubation.
TABLE 1. Fiberoptie intubation success rates No. of Attempts 25/31 22 3 9/10
Medical Successful With direct glottic visualization With stylet technique After failed nasotracheal intubation Unsuccessful Due to secretions, blood, or vomitus Persistent scope swallowing
6/31 5 1
Trauma Successful
4/4
TABLE 2. Time interval to completion of intubation
Successful attempts Failed attempts
Medical Patients (min) 1.8 ± 1.4 7.8 _+ 3.3
aged 4 ± 1.4 i n t u b a t i o n s e a c h . Thirty-one of 35 intubations (89%) involved medically related cases, and four (11%) involved traumatic conditions. In the medical group, the fiberoptic scope was used as the initial airway attempted in 21 of the 31 patients. 19:4 April 1990
Trauma Patients (min) 3.0 ± 2.2
Six of these 21 medical patients had an identified anatomic condition inf l u e n c i n g the d e c i s i o n (kyphosis, three; clenched teeth, two; and trismus, one). The remaining ten medical patients had fiberoptic-aided nasal intubation attempted after blind nasotracheal intubation failed. Direct Annals of Emergency Medicine
visualization of the glottis with the fiberoptic scope was obtained in 22 successful medical intubations. When the glottis could not be visualized in three patients, the lighted styler technique with the fiberoptic e l e m e n t s was used. In the t r a u m a group, it was the first m e t h o d attempted in three of the four patients. Two of these three patients had gunshot wounds to the neck with vascular a n d / o r c e r v i c a l - s p i n e i n v o l v e m e n t . The third p a t i e n t presented with clenched teeth and a globe injury. Blind n a s o t r a c h e a l i n t u b a t i o n had failed before the fiberoptic attempt in the fourth trauma patient, w h o had a flail chest. T h e overall success rate was 83% (81% in medical a n d 100% in t r a u m a patients) (Table 1). The fiberoptic technique failed in six instances, all medical conditions. The airway was secured by the orotracheal route in four of these patients. Blind nasotracheal intubation and c r i c o t h y r o i d o t o m y w e r e performed in one patient each. T i m e elapsed f r o m i n i t i a t i o n to completion of intubation was available for 20 of the 25 successfully intubated medical patients. It was also available for four of the six failed m e d i c a l cases. T i m e intervals were retrieved on all the trauma patients (Table 2). ED financial records revealed expenditures as diagrammed (Figure 2). In 1979, a fiberoptic b r o n c h o s c o p c was p u r c h a s e d ; its f i b e r o p t i c elements required replacement two years later. T h e r e p l a c e m e n t elements were also broken within two years. Therefore, a flexible and a malleable laryngoscope were purchased in 1984. This was followed in 1985 by 361/35
FIBEROPTIC INTUBATION Mlinek et al
a pediatric 3 - m m scope, w h i c h was the fiberoptic scope used during the study period. Due to b u c k l i n g of the c a s i n g a r o u n d t h e f i b e r o p t i c elem e n t s , a n o t h e r pediatric scope was purchased at the end of 1987 as a replacement. The total cost during this n i n e - y e a r period was a p p r o x i m a t e l y $17,000. Replacement or repair of the fiberoptic scopes was needed every two to three years. Breakage of the fiberoptic e l e m e n t s or b u c k l i n g of the surrounding casing were the main causes. T h i s o c c u r r e d d e s p i t e attempts to lubricate the endotracheal tube and fiberoptic scope (Figure 3). The same conditions were seen even w h e n a 3 - m m d i a m e t e r scope was used with an endotracheal tube size of 7.5 m m or more. In addition to e q u i p m e n t cost, time of a physician, n u r s e , or b o t h is r e q u i r e d to clean the equipment, thereby reducing direct patient care time. DISCUSSION Our experience with fiberopticaided scope i n t u b a t i o n in the ED has c o n v i n c e d us that the t e c h n i q u e is v a l u a b l e i n selected patients. While formal indications did not exist during the study period, our experience led to the indications s h o w n (Figure 4}. The patients who need fiberoptic intubation represent only a small m i n o r i t y of patients requiring emergency tracheal intubation. Alternatively, the use of paralytic agents c o u l d be c o n s i d e r e d . D e p o l a r i z i n g agents provide rapid i n d u c t i o n of a flaccid paralysis with proven efficacy i n obtaining airway control. ~o In several of our patients, the use of paralytic agents was relatively contraindicated due to their alert m e n t a l status and potential for an unstable cervical spine. O t h e r c o m p l i c a t i o n s of succinylcholine administration may pose unnecessary risks to the patient if they could have been fiberoptically intubated. If the technique is to be successful, a skilled user should expect intubation to be achieved quickly. The int u b a t i o n times listed support this belief (Table 2). Successful intubations were
36/362
achieved within two minutes in medical and three m i n u t e s in t r a u m a cases. Vision occluded by blood or v o m i t u s in the p h a r y n x was o f t e n blamed for delay, especially i n injury cases. Failed a t t e m p t s persisted for an average of almost eight m i n u t e s . This experience suggests that lack of quick success with the technique should be followed by the next airway a l t e r n a t i v e w i t h o u t persistence beyond a three-minute interval in m o s t cases. Such practice will prevent u n d u e delay i n achieving airway c o n t r o l a n d also w i l l l i m i t scope damage i n c u r r e d d u r i n g p e r s i s t e n t , futile attempts to pass the tube o w r the scope. Although not done at our institution, it would seem that practicing on p a t i e n t s i n the operating room could be helpful i n developing and m a i n t a i n i n g proficiency of the technique. Neither oximetry nor art e r i a l b l o o d gases were r o u t i n e l y used to m o n i t o r for hypoxia during the attempt. Hypoxia was avoided by l i m i t i n g the length of the i n t u b a t i o n a t t e m p t . Various a n e s t h e s i a m a s k s s p e c i f i c a l l y m o d i f i e d to f a c i l i t a t e b r o n c h o s c o p i c i n t u b a t i o n could be used to allow c o n t i n u e d v e n t i l a t i o n during the procedure. 11,12 The fiberoptic e q u i p m e n t is expensive and fragile. During an eight-year period, $17,000 was spent to m a i n t a i n a n d replace w o r n e q u i p m e n t . Our experience was w i t h 35 patients during 2.5 years. Using these figures, $2,125 per year was spent for use i n 14 p a t i e n t s per year. Therefore, the per-patient cost was a p p r o x i m a t e l y $152.00. The calculation ignores the m u c h m o r e f r e q u e n t u s e of t h e scopes for direct l a r y n g o s c o p y a n d h y p o p h a r y n x v i s u a l i z a t i o n i n patients n o t requiring airway managem e n t . T h e f a i r e s t cost a l l o c a t i o n would consider these patients and u n d o u b t e d l y l o w e r the p e r - p a t i e n t cost significantly. Accurate data on the n o n i n t u b a t i o n uses of the scopes are not available to perform further calculation. The wear and tear on the scopes is clearly greatest w h e n they are used for i n t u b a t i o n . Sliding e n d o t r a c h e a l t u b e s over t h e f i b e r o p t i c e l e m e n t s cannot be done gently. Although gen-
Annals of Emergency Medicine
erous lubrication of the scope is important, it only limits, n o t prevents, scope damage w i t h repeated i n t u b a tion use. Unless more durable fiberoptic elements and casing can be developed, m a i n t e n a n c e costs of t h e e q u i p m e n t will probably r e m a i n at the described level. CONCLUSION Fibcroptic-aided nasotracheal i n t u bation is a valuable airway managem e n t technique in selected patients. Indications include various a n a t o m i c abnormalities, traumatic conditions of the head and neck, and use after failed n a s o t r a c h e a l i n t u b a t i o n s . A more durable scope should be developed to keep costs at an acceptable level for most EDs. REFERENCES 1. Clinton JE, Ruiz E: Emergencyairway management, in Roberts JR (ed): Clinical Procedures in Emergency Medicine. Philadelphia,WB Saunders, 1985, p 2-29. 2. Murphy P: A fiber-optic endoscope used for nasal intubation. Anaesthesia 1967;22:489. 3. Mulder DS, Wallace DH, Woolhouse FM, et ah The use of the fiberoptic bronchoscopeto facilitate endotracheal intubation followinghead and neck trauma. J Trauma 1975;15:638-640. 4. Conyers AB, Wallace DH, Mulder DS, et ah Use of the fiberoptic bronchoscope for nasotracheal intubation: Case report. Can Anesth Soc I 1972;19:654-655. 5. Guyuron B, Dinner MI: Bronchoscopic intubation of patients with trismus. Ann Plast Surg 1983;10:386-390. 6. Venus B: Acromegalicpatient -- Indication for fiberoptic bronchoscopy but not tracheostomy. Anesthesiology 1980;52:100. 7. Rucker RW, Silva WJ, Worcester CC, et al: Fiberoptic bronchoscopicnasotracheal intubation in children. Chest 1979;76:56-58. 8. Schafermeyer RW: Fiberoptic laryngoscopy in the emergencydepartment. A m J Emerg Med 1984;2:160-163. 9. Verdile VP, Chang J-L, Bedger R, et ah Nasotracheal intubation using a flexible lighted stylet (abstract). Ann Emerg Med 1988;17:410. 10. Thompson J, Fish S, Ruiz E: Succinylcholine for endotracheal intubation. Ann Emerg Med 1982;11:526. 11. Mallios C: A modificationof the laerdal anaesthesia mask for nasotracheal intubation with the fiberoptic laryngoscope. Anesthesiology 1980;35:599-600. 12. Imai M, KemmotsuO: A new adapter for fiberoptic bronchoscopy-aidedtracheal intubation under controlledventilation (abstract).A n n Emerg Med 1987;16:517.
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