Combitube

1. Combitube Robert S. Cole Paramedic, CCEMT-P

2. Esophageal Tracheal Combitube Defined: An advanced airway that incorporates a dual lumen incorporated within a single tube. The tube also incorporates dual cuffs. The distal cuff is used to seal the trachea or esophagus depending on placement. The proximal cuff is used to seal the pharynx.

3. The Combitube Combitube Regular Combitube SA Should have both sizes on ambulance.

4. A Comment On Size Selection While the manufactures guidelines differ, a large respected study on the Combitube in the OR found that: The Combitube SA was best suited (the best fit, less trauma) for most adult patients 4 ½ feet to 6 feet Standard Combitube provided the best fit for patients over 6 feet tall. This is why it is important to have both sizes. Either way there is quite a bit of size overlap with the two devices.

5. The Combitube

7. Advantages Excellent back up for paramedics (required for difficult airway protocols) Outstanding primary advanced airways for Basics and intermediates (as allowed by state scope of practice) Unlike the EOA/EGTA, OPA/NPA, and others it CONTROLS the airway (prevents aspiration). Aspiration increases mortality by 30-70% Minimal training (and retraining) time compared to the ETT. Gastric decompression is possible.

8. Disadvantages Cannot administer Medications like the ETT No infant/ped sizes like the LMA

9. Indications When endotracheal intubation is unsuccessful or not allowed. When Intubation may prove exceptionally difficult or movement or head may be undesired. (spinal trauma, facial trauma) Patients who do not exhibit an intact gag reflex. Patients in cardiac or respiratory arrest.

10. Contraindications The patient is less than 5 feet tall.( or 4 ½ feet for Combitube SA) Age is no longer considered a large factor in placement. Size is most important. The patient is responsive or has a gag reflex. The patient has swallowed a caustic substance. The patient has a known esophageal disease

11. Insertion Technique Hyperventilate the patient at a rate of 24 times per minute for at least 2 minutes before attempting insertion, an oropharyngeal airway should be utilized in this time. Assemble equipment, ensure that cuffs are not leaking, and lubricate the distal end of the tube with water-soluble lubricant.

12. Insertion Technique Place the patient’s head in a neutral in-line position. If spinal injury is suspected maintain the head in a neutral in line position. Perform a tongue-jaw lift maneuver and insert the device until the teeth are between the two black rings.

13. Insertion Technique Use the large syringe to inflate the #1 pharyngeal cuff with 100cc of air. The pharynx will be sealed once this cuff is inflated. Inflate the #2 distal cuff with 15cc of air. This will seal the esophagus or trachea depending on placement.

14. Insertion Technique Ventilate through the longer #1 ventilation tube. During ventilation, auscultate over the epigastrum and listen for gurgling sounds. If no sounds are heard, watch for chest rise and auscultate chest for breath sounds.

15. Insertion Technique If equal chest rise and breath sounds bilaterally are present, then continue to ventilate through the tube #1. If you hear gurgling sounds in the stomach then assume that you have inserted the device in the trachea and start to ventilate through the #2 tube.

16. Insertion Technique Auscultate over the epigastrum, if gurgling is STILL heard then remove the tube. If no gurgling is heard then auscultate breath sounds, if the breath sounds are equal bilaterally then continue to ventilate through the #2 tube.

17. Insertion Technique Hyperventilate the patient for two minutes, then resume normal ventilation. Reassess the tube placement after each patient move, and periodically check the pilot balloons to ensure that the two cuffs are adequately inflated.

18. Removal Removal should seldom be required. Studies have shown that good oxygenation and ventilation have been maintained even after many hours of use. Replacing the Combitube with out a very good reason is very risky, traumatic, and may constitute mal-practice in the pre-hospital setting if a more definitive airway cannot be secured. Removing the Combitube just so the Medic/Doc can get a tube for his stats is not a good reason!

19. Removal Two types of removal: Complete and patial (for intubation) Complete: The Combitube is totally removed from the oral-pharynx either for placement of another device or because the pt is now able to control his own airway. Partial: The proximal cuff only is deflated to make room for placement of an ETT tube, while still preventing aspiration.

20. Removal (Complete) Generally only if pt. Regains a gag reflex. If possible, sedation is preferred over removal in the pre-hospital setting. Have suction equipment ready for use. Deflate both cuffs and remove tube gently. Be alert for vomiting.

21. Removal (For Intubation) Have suction equipment ready for use. Deflate ONLY the proximal cuff, leaving the distal cuff in place. Use the laryngoscope to move combitube to left with the tongue Intubate as normal (only one hole left! ? ) After ETT is in place and secure, deflate distal cuff and CAREFULLY remove Combitube. Somewhat more difficult, but much safer!

22. End Tidal CO2 and Other Devices ETCO2 is a ver useful adjunct to monitor placement, pulmonary perfusion, etc. May be limited by physiological factors in severe shock/cardiac arrest. Other “tube check devices” are not appropriate for use with the Combitube. The stethoscope and sticking to the procedure are the golden rule for good placement.

23. Parting Comments The hardest part of using the Combitube is WHEN to use it, not the device itself. Be aggressive, thoughtful, and decisive. Have everything ready before you use the Combitube. When you decide to use the comb tube, be quick, competent, and sure. If it takes longer than 30 seconds , then it is more likely lack of operator preparation or operator error. Re-Training should be every 6 months to 1 year, with both rote skill and scenario practice.

24. Any questions, or do I have to sic Matilda and Leon on you?