EsophagealTracheal Double Lumen Airway Combitube

1
Esophageal/Tracheal Double Lumen Airway
(Combitube)

• Indications and Usefor thePrehospital Provider

2
Overview

• Introduction The combitube, what is it?
• Indications
• Contraindication
• Precautions
• Equipment
• Insertion procedures

3
History

• Developed in the early eighties.
• Intended to bridge the gap between a respiratory
  arrest situation and the institution of a
  definite airway when conventional endotracheal
  intubation is not immediately possible.
• The idea kept in mind was to allow for a quick
  and easy method securing the patients airway and
  adequately ventilating the lungs.

4
What is it?

• 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

5
Definition

• It is blind insertion device with dual lumens to
  allow for effective ventilations to be provided
  regardless of whether esophageal or tracheal
  placement is accomplished.

Dual lumens
Distal Balloon
Pharyngeal Balloon
6
Definition

• 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

7
Indications

• Respiratory failure in an unconscious patient
  without an intact gag reflex
• Secondary method of airway management for
  paramedics when orotracheal intubation is not
  possible
• Primary method of airway management for EMT-Bs
  (where allowed by local protocols)

8
Contraindications

• The patient has in intact gag-reflex
• The patient is less than 5 feet tall or under 16
  years old
• The patient has known esophageal disease
• The patient has ingested a caustic substance
• Burns involving the airway
• The patient has an allergy or sensitivity to
  latex (the pharyngeal balloon contains latex)

9
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

10
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

11
Equipment

• Esophageal Tracheal Airway (Combitube), 140ml
  syringe, 20ml syringe, fluid deflector attachment

12
Equipment

• Suction device with FR suction catheter, BVM with
  oxygen supply

13
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

14
Insertion Procedures

• Inflate both balloons prior to insertion to test
  the integrity of the balloons
• Should either balloon fail after insertion,
  maintenance of the patients airway cannot be
  assured

15
Insertion Procedures

• Position the patients neck in a neutral
  position.
• Lubricate the tube with sterile, water soluble
  lubricant
• Lift the tongue and lower jaw upward to open the
  oropharynx

16
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

17
Insertion Procedures

• Advance tube until the patients teeth are
  between the two black lines

18
Insertion Procedures

• Inflate the 1 blue pilot cuff with 100ml of air
  from the large syringe

19
Insertion Procedures

• Inflate the 2 white pilot cuff with 15ml of air
  from the small syringe

20
Insertion Procedures

• Begin ventilation through the longer blue tube
  labeled 1. If auscultation of breath sounds is
  good and gastric inflation is negative, continue.

21
Insertion Procedures

• If auscultation of breath sounds is absent and
  gastric inflation is positive, then begin
  ventilation through the shorter clear tube
  labeled 2

22
Esophageal Placement

• If the Combitube is placed in the esophagus, the
  distal balloon will occlude the esophagus.
• Ventilations are provided through perforations in
  the side of the pharyngeal tube.
• Stomach contents can be safely expelled via the
  hole in the end of the tube.

23
Tracheal Placement

• If placed in the trachea, it functions as an
  endotracheal tube, with the distal balloon
  preventing aspiration.
• Ventilations are provided via the hole in the end
  of the tube.
• Stomach contents can be safely expelled via
  perforations in the side of the pharyngeal tube.

24
Verify

• During ventilation observe end-tidal CO2 monitor
  or pulseoximetry to confirm oxygenation

25
QUESTIONS?
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References

• Frass M, Frenzer R, Rauscha F, et al.
  "Ventilation with the Esophageal Tracheal
  Combitube in Cardiopulmonary Resuscitation."
  Critical Care Medicine 15609, 1987.
• American Society of Anesthesiologists Task Force
  on Management of the Difficult Airway. "Practice
  Guidelines for Management of the Difficult
  Airway." Anesthesiology 78597, 1993.
• Gaitini LA, Vaida SJ, Somri M, Fradis M.
  "Fiberoptic-guided Airway Exchange of the
  Esophageal-tracheal Combitube in Spontaneously
  Breathing versus Mechanically Ventilated
  Patients." Anesth Analg. 1999 Jan88(1)193-6.
• Gaitini LA, Vaida SJ, Mostafa S, Yanovski B,
  Croitoru M, Capdevila MD, Sabo E, Ben-David B,
  Benumof J. "The Combitube in Elective Surgery A
  Report of 200 Cases." Anesthesiology. 2001 Jan
  94(1)79-82.