1. Advanced Airway Management
COMBITUBE

2. Adjunctive Airways Endotracheal Intubation – ET
Esophageal Obturator airway – EOA
Esophageal gastric tube airway – EGTA
Endotracheal intubation is the preferred method of airway maintenance in critically ill and injured patients. However, both patient and operator variables may reduce the probability of successful endotracheal intubation or make it outright impossible. Several alternative airway devices were created, the EOA and the EGTA.

3. Complications With EOA\EGTA
Esophageal rupture
Gastric rupture
Endotracheal intubation
Bag-valve-mask ventilation
Esophageal and gastric rupture is a serious complication of EOA/EGTA use. Moreover, unintentional endotracheal intubation results in an obstructed airway with the use of these devices. Even when the EOA/EGTA is correctly placed, it still required bag-valve-mask ventilation. Inadequate sealing of the face mask has been a common problem in use.

4. Combitube Ventilation in either esophageal or endotracheal position
Blind placement
No patient neck movement
The Combitube was designed specifically to overcome the problems with EOA/EGTA use even to take advantage of occasional endotracheal intubation. It is a double-lumen tube with two balloon cuffs. Ventilation is allowed in either the endotracheal or esophageal position. It is placed blindly, without direct laryngoscopy, therefore not requiring equipment, nor movement of the patients neck.

5. Combitube - Design Lumen #1 - esophageal obturator lumen
Lumen #2 - tracheal lumen
Pharyngeal balloon
Esophageal cuff – distal balloon
Lumen #1 (long and blue) is the esophageal obturator lumen, like the old EOA. The distal end is occluded and there are perforations throughout the pharyngeal section. Lumen #2 (short and clear) or tracheal Lumen is like an endotracheal tube. The distal end is open allowing the passage of air into the lungs. Pharyngeal balloon inflates to hold the Combitube firmly in place and helps prevent the escape of gas through the nose or mouth. Esophageal cuff inflates to seal the esophagus so that gas does not enter the stomach and gastric contents are not aspirated.

6. Combitube

7. Indications Endotracheal intubation cannot be done
Endotracheal intubation unsuccessful
Limited patient access
High risk for c-spine injury
There is no one certified to perform endotracheal intubation or no equipment to perform endotracheal intubation. Failure due to difficult anatomy, secretions, vomitus or blood. Entrapped patient or inability to access patients head for endotracheal intubation.

8. Contraindications Less than 16 years old Less than five (5) feet tall
Intact gag reflex
Known esophageal disease
Caustic ingestion

9. Procedure Start CPR, oxygen and defibrillation
Check Combitube balloons for leaks
Lift lower jaw and tongue
Insert Combitube following curve of the pharynx
Stop when black rings line up with upper teeth or alveolar ridge
You can use a water soluble lubricant to facilitate insertion. When inserting the Combitube be sure to maintain a mid-line position while following the natural curvature of the pharynx.

10. Procedure – Cont. Inflate blue pilot balloon with 100 cc of air
Inflate white pilot balloon with cc of air
Ventilate using longer blue tube – No. #1
Listen for breath sounds, if none …
Switch to the shorter clear tube – No. #2
Recheck breath sounds
When inflating the blue balloon slight movement will be noted as the balloon fills the area between the base of the tongue and the soft palate.
This longer blue lumen (also marked with a #1)is ventilated first, with breath sounds present over the lungs fields and absent breath sounds over the epigastrium, this is the usual esophageal placement and adequate ventilation across the perforations in the distal end of this lumen. If appropriate breath sounds are not heard (negative lung sounds and positive epigastric), then the Combitube was placed into the trachea. The shorter clear lumen (marked with a #2) should be used for ventilations. The Combitube is now functioning as a normal tracheal tube. In the esophageal placement (ventilating through the No. #1 (blue) lumen, the No. #2 (clear) lumen can be used for gastric suctioning.

11. Other Information Oxygen saturations similar Caution when giving drugs
Skills maintenance requirements
Studies comparing the Combitube with endotracheal intubation shows equivalent to improved oxygen saturation with ventilated patients in the operating room. When there is a need to administer medication into the lungs you should replace the Combitube with an endotracheal tube. The most common reason for failed use in the field was meeting resistance in insertion of the tube. This was felt to be more of a training issue as opposed to any design flaw. Other concerns demonstrated by prehospital research is in skill maintenance and retraining. It has been shown that more than annual retraining is required to maintain mostly the skills for determining location of the tube. This is true both of Paramedics and EMT”s.

12. Summary Rapid, effective airway management Ease of insertion
Airway is self-anchored
Posterior balloon protects from oral secretions
Posterior balloon can be deflated for visualization during endotracheal intubation

13. Summary –Cont. Posterior balloon protects from oral secretions
Posterior balloon can be deflated for visualization during endotracheal intubation
Gastric contents can be suctioned
The only disadvantage is that effective suctioning of the trachea is difficult with the Combitube in the esophageal position. However, this has not been shown to alter the outcome.

14. Combitube