It’s also important to assess your patients’ anxiety and comfort levels. “I always try to judge a patient’s comfort level with the procedure while they’re still awake,” Dr. Zandifar said. “Sometimes an endoscopic procedure can cause a vasovagal response that causes the patient to pass out. I can almost judge which patients this will happen to, based on their level of anxiety about the procedure. So, before I schedule a patient for an office procedure, I first make sure that they can tolerate it and are not excessively worried about it.”
Explore this issue:June 2013
If the patient seems particularly nervous or worried about pain control, it may be better to schedule OR time, even if the procedure is one you normally perform in office.
Airway emergencies, while rare in office settings, obviously merit tremendous concern. “When it comes to emergencies, the one thing that makes our specialty unique is that the area we service includes the airway, so airway emergencies are always something that we worry about,” Dr. Zandifar said. Possible causes of an in-office airway emergency include bleeding into the airway, swelling or inflammation related to an infectious process or allergic reaction and laryngospasm.
An airway obstruction can also occur during routine tracheostomy changes. “Occasionally, especially in children, you lose the airway when you remove the tracheostomy tube. The tract closes and doesn’t have the same path you’d expect it to,” said Dr. Zandifar. “The first thing you have to do is to stay calm. Remember that you have the skill set to solve the problem.”
If the tracheostomy tract seems to have closed up, try inserting a smaller trach tube. “I’ve used smaller tubes than the one that the patient had previously to get through,” Dr. Zandifar said. “I let that sit there for a few minutes, let the patient breathe, then take out the small tube and put in one that’s a little bigger—essentially serially dilating the tract.”
Every otolaryngology office should have basic airway resuscitation equipment on hand: oxygen, an Ambu bag, oral airway, nasal airways and intubation equipment of various sizes. “Intubation equipment is particularly important if you’re doing facial plastics or biopsies of the tongue or nose,” Dr. Fung said.
Keep in mind that bigger is not always better when it comes to intubation. “The idea still floats around that someone who is obese may need a bigger tube,” said H. Steven Sims, MD, director of the Chicago Institute for Voice Care. “The reality is that a woman who is 5’2” and 250 pounds probably still has a small airway.” And, while securing the airway is always the number one concern, using a tube that’s too big can cause trauma to the vocal cords, which may result in unwanted sequelae.