Combitube Robert S. Cole Paramedic, CCEMT-P Esophageal

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Combitube

• Robert S. Cole
• Paramedic, CCEMT-P

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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.

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The Combitube

• Combitube Regular
• Combitube SA
• Should have both sizes on ambulance.

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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.

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The Combitube
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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.

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Disadvantages

• Cannot administer Medications like the ETT
• No infant/ped sizes like the LMA

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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.

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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

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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.

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Insertion Technique

• Place the patients 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.

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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.

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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.

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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.

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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.

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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.

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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!

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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.

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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.

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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!

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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.

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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.

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