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.

I recently showed a patient his trachea through his trach tube. He flipped the scope over and looked in the eyepiece; he greatly appreciated viewing his own trachea for the first time in his life! It convinced him the trach was in position, the reason he came to the ED in the first place. He followed up as an outpatient with his otolaryngologist.

Finally, there are the cases where a tube cannot be inserted through the mouth, and it must go through either the nose or the neck. In the “surgically inevitable airway,” for those patients who will get a surgical airway because of significant pathology (not quickly reversible) of the oropharynx, it makes sense to go through the neck first if you’re forced to intervene. However, in patients with angioedema or Ludwig’s who may be much improved within a day or two, the nasal route with endoscopic guidance is worth trying. Understand, however, when attempting to intubate these patients, the backup, immediate default plan is to cut the neck. Have them marked, have a tray open and ready, and discuss the possibility with patients and staff so if cutting is required, it’s no surprise, and you are cognitively and physically ready. These types of patients will likely be impossible to rescue by passive oxygenation, mask, or supraglottic ventilation.

There are two other factors changing the rules and enabling, or requiring, emergency physicians to pick up endoscopes. First, there’s no logistical or financial excuse not to have scopes in the ED. There are now single-use disposable endoscopes (AMBU aScope) and sterile endoscopic sheaths (Medtronic EndoSheath) to put over short and long scopes. These eliminate the need to have scopes sent out of the department for cleaning or repair. Some endoscopes also attach directly to our video laryngoscope monitors (Storz).

The second new reason to embrace endoscopy of the airway is that otolaryngology coverage is declining. More and more, we are at risk of having to manage these cases ourselves. We are becoming one of only a few specialties remaining that is made of “proceduralists,” like acute care surgeons in trauma or critical care physicians in some venues.

We cannot run from our fears in this job. It is better to run at them, expanding our skills set, to the do the best for our patients and make better decisions. In the long run, as you gain confidence and eliminate fear, you will last longer in the challenging environment of emergency medicine. The need for endoscopic skills may be infrequent; the benefit of knowing how to do it, priceless.

Editor’s note: Dr. Levitan actually learned nasoendoscopy on himself to better teach airway anatomy—it’s a party trick he has done on stage in numerous conference venues. He now shares this learning experience in some of his airway courses, where operators practice on one another and themselves using sterile sheaths.

Dr. Levitan is an adjunct professor of emergency medicine at Dartmouth College’s Geisel School of Medicine in Hanover, N.H., and a visiting professor of emergency medicine at the University of Maryland in Baltimore. He works clinically at critical care access hospitals in rural New Hampshire and teaches cadaveric and fiber-optic airway courses.