Endoscopic intubation is a technical challenge that requires initial training, and then skill maintenance activities to maintain speed and success. Manual dexterity in manipulating the endoscope is essential to performing endoscopic intubation in a timely fashion. This skill is best learned by attending endoscopic intubation workshops with expert instruction, and then practicing on intubation manikins or high-fidelity human patient simulators before one attempts to intubate a patient. This is particularly true in patients with difficult airways. The manufacturers of endoscopes can usually provide training videos, product support personnel, and manikins to support this endeavor.

The requisite psychomotor skills cannot be developed without dedicated practice, and lack of training, practice, and experience constitute the most common cause of failed endoscopic intubation. A reasonable level of dexterity in bronchoscopic manipulation can be achieved within 3 to 4 hours of independent practice using an intubation model. Recent studies have shown that the technique can also be learned in real-life situations by the performance of upper airway endoscopy when diagnostic opportunities, such as searching for foreign bodies and evaluating the causes of hoarseness, severe sore throat, and other upper airway conditions, present themselves. As is the case with many of the specialized airway techniques, the patient who requires semi-emergent, but controlled, intubation, such as an overdose victim without an anticipated difficult airway and patients who are easily ventilated with normal oxygen saturation, may be appropriate candidates for endoscopic intubation. Because success depends on familiarity and skill in using the device, gaining experience in routine cases is invaluable before one is required to perform a difficult endoscopic intubation in a crisis.

Although the emergency difficult or failed airway situation often does not permit lengthy preparation and a methodical approach, maximal success with this technique requires both psychological
and pharmacologic patient preparation. When the procedure is to be done “awake” (see Chapter 23), optimizing the chances for success includes the following:

Instrument selection for the emergency department (ED) is an important issue. Affordable and durable scopes are easily available from a variety of manufacturers. Selection of a manufacturer may be guided by existing service contracts in your specific institution. These instruments, although expensive, find several uses in the ED to justify such an expenditure:

Recently, at least one manufacturer has introduced a single-use flexible endoscope, using complementary metal-oxide semiconductor (CMOS) video, making flexible endoscopy much less expensive. (Fig. 15-1)

The scope should be of sufficient caliber and stiffness to guide the passage of an endotracheal tube (ETT) over itself through the angles of the airway without kinking and resist being flipped out of the trachea, while maintaining flexibility and ease of manipulation. Most endoscope manufacturers produce intubation-specific devices that have the added stiffness of the fiber bundle to allow ETTs to be guided into the trachea over the scope. This feature allows scopes that are small enough (3- to 4-mm tip diameter) to be painlessly and atraumatically passed through a topically anesthetized nose for diagnostic work also to be used for endoscopic intubation. Neonatal and pediatric endoscopes (2- to 3-mm tip diameter) are also available.

The endoscopic bundle should be long enough (600 mm) to allow bronchoscopy and airway toilet in the ED. Standard bronchoscopes are 600 mm in length. Some manufacturers produce 400-mm intubating endoscopes that are not long enough for pulmonary care if this is planned. A separate channel for the injection of local anesthetic or saline and suctioning is essential, although the smaller neonatal and pediatric endoscopes may not have them owing to their small size. A formerly recommended practice, the insufflation of oxygen through the suction working channel to maintain saturations and blow secretions out of the way, is now contraindicated following several cases of gastric insufflation, perforation, and death. Endoscopes with battery-powered, portable, self-contained light sources are compact and may be preferable for ED applications.

Some general precautions are necessary to prevent damage to the relatively delicate fiberoptic bundles in a fiberoptic scope and similar precautions are prudent even with the less damage-prone video endoscopes: