1. CAP Module 5 - Combitubes (GHEMS/DG_April2015) CAP – Module 5 COMBITUBES

2. COMBITUBES OBJECTIVES Review Anatomy of the Upper Airway Discuss Airway Management for the Utilizing the Combitube CAP Module 5 - Combitubes (GHEMS/DG_April2015)

3. UPPER AIRWAY ANATOMY CAP Module 5 - Combitubes (GHEMS/DG_April2015)

4. UPPER AIRWAY ANATOMY CAP Module 5 - Combitubes (GHEMS/DG_April2015)

5. UPPER AIRWAY ANATOMY CAP Module 5 - Combitubes (GHEMS/DG_April2015)

6. Airway Management for Utilizing the Combitube CAP Module 5 - Combitubes (GHEMS/DG_April2015)

7. Discussion Points What is a Combitube? Indications Contraindications Precautions Equipment Insertion Procedures – Esophageal Placement – Tracheal Placement CAP Module 5 - Combitubes (GHEMS/DG_April2015)

8. What is a Combitube? A double lumen airway device designed for emergency ventilation of a patient in respiratory arrest when visualization of the airway and endotracheal intubation are not possible CAP Module 5 - Combitubes (GHEMS/DG_April2015)

9. What is a Combitube? It is designed to be inserted blindly. The double lumen design allows effective ventilations to be provided regardless of whether esophageal or tracheal placement is accomplished Distal balloonPharyngeal balloon CAP Module 5 - Combitubes (GHEMS/DG_April2015)

10. What is a Combitube? The pharyngeal balloon fills the space between the tongue and soft palate, eliminating the need for a mask and the associated face mask seal problems. The patient can be successfully ventilated regardless if the tube is inserted into the trachea or the esophagus CAP Module 5 - Combitubes (GHEMS/DG_April2015)

11. Indications Primary method of airway management for EMTs (where allowed by local protocols) Respiratory failure in an unconscious patient without an intact gag reflex – Cardiopulmonary Arrest – Respiratory Arrest Secondary method of airway management for paramedics when orotracheal intubation is not possible CAP Module 5 - Combitubes (GHEMS/DG_April2015)

12. Contraindications The patient has in intact gag-reflex Conscious and unconscious breathing patients The patient is less than 5 feet tall The patient has known esophageal disease The patient has ingested a caustic substance Known or suspected FBAO of larynx or trachea The patient has an allergy or sensitivity to latex (the pharyngeal balloon contains latex) Presence of tracheostomy CAP Module 5 - Combitubes (GHEMS/DG_April2015)

13. Precautions Take appropriate Body Substance Isolation (BSI) precautions including facial protection, as expulsion of stomach contents can occur through the #2 tube if the initial placement is in the esophagus. DO NOT force the tube. If it does not advance easily, redirect it or withdraw and reinsert Attach the fluid deflector elbow to the esophageal tube to deflect stomach contents away from rescuers CAP Module 5 - Combitubes (GHEMS/DG_April2015)

14. Equipment Full Body Substance Isolation (BSI). Face mask, eye shield, protective eye-glasses, latex examination gloves and hepa-mask if patient is suspected of infectious disease CAP Module 5 - Combitubes (GHEMS/DG_April2015)

15. Equipment 140ml syringe 20ml syringe Combitube CAP Module 5 - Combitubes (GHEMS/DG_April2015)

16. Equipment Suction device with FR suction catheter BVM with oxygen supply CAP Module 5 - Combitubes (GHEMS/DG_April2015)

17. Insertion Procedures Place the patient in a supine position Provide artificial ventilation via BVM and hyperventilate the patient with 100% oxygen prior to device insertion CAP Module 5 - Combitubes (GHEMS/DG_April2015)

18. Insertion Procedures Inflate both balloons prior to insertion to test the integrity of the balloons Should either balloon fail after insertion, maintenance of the patient’s airway cannot be assured CAP Module 5 - Combitubes (GHEMS/DG_April2015)

19. Insertion Procedures Position the patient’s neck in a neutral position (the Combitube is designed to be blindly inserted into the esophagus) Lubricate the tube with sterile, water soluble lubricant Lift the tongue and lower jaw upward to open the oropharynx CAP Module 5 - Combitubes (GHEMS/DG_April2015)

20. Insertion Procedures Insert the Combitube so that it curves in the same direction as the natural curvature of the pharynx If resistance is met, withdraw tube and attempt to reinsert CAP Module 5 - Combitubes (GHEMS/DG_April2015)

21. Insertion Procedures Advance tube until the patient’s teeth are between the two black lines CAP Module 5 - Combitubes (GHEMS/DG_April2015)

22. Insertion Procedures Inflate the #1 blue pilot cuff with 100ml of air from the large syringe CAP Module 5 - Combitubes (GHEMS/DG_April2015)

23. Insertion Procedures Inflate the #2 white pilot cuff with 15ml of air from the small syringe CAP Module 5 - Combitubes (GHEMS/DG_April2015)

24. Insertion Procedures Begin ventilation through the longer blue tube labeled #1. If auscultation of breath sounds is good and gastric inflation is negative, continue CAP Module 5 - Combitubes (GHEMS/DG_April2015)

25. Insertion Procedures If auscultation of breath sounds is absent and gastric inflation is positive, then begin ventilation through the shorter clear tube labeled #2 CAP Module 5 - Combitubes (GHEMS/DG_April2015)

26. Esophageal Placement If the Combitube is placed in the esophagus, the distal balloon will occlude the esophagus. Ventilations are then provided through perforations in the side of the pharyngeal tube. Stomach contents can then be safely expelled via the hole in the end of the tube. CAP Module 5 - Combitubes (GHEMS/DG_April2015)

27. Tracheal Placement If placed in the trachea, it functions as an endotracheal tube, with the distal balloon preventing aspiration. Ventilations are then provided via the hole in the end of the tube as in an endotracheal tube. Stomach contents can then be safely expelled via perforations in the side of the pharyngeal tube. CAP Module 5 - Combitubes (GHEMS/DG_April2015)

28. Insertion Procedures During ventilation observe end-tidal CO 2 monitor and/or pulseoximetry to confirm oxygenation CAP Module 5 - Combitubes (GHEMS/DG_April2015)