Combitube Pilot Program

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Combitube Pilot Program

• - Made Possible by -
• Kentucky Board of
• Emergency Medical Services
• - And -
• The Authors and Participants of the Kenton County
  Combitube Program

Kentucky Board Of Emergency Medical Services
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KBEMS Combitube Intubation Course Outline

• Lecture - Review of Basic Airway Anatomy
• Lecture - Review of Basic Airway Maintenance
  Techniques
• Skills / Testing Stations
• 1 - Basic Airway Maintenance techniques
• 2 - Combitube Familiarity

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KBEMS Combitube Intubation Course Outline

• Lecture - Advanced Airway Maintenance Using the
  Combitube
• Lecture - KBEMS Combitube Protocol
• Skills / Testing Stations
• 3 - Combitube Insertion SAED Integration
• 4 - Combitube Tracheal Problem Insertion

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KBEMS Combitube Intubation Course Outline

• Written Exam
• 35 Questions
• True / False
• Multiple Choice
• EMTs must pass
• All Skills Stations
• Exam gt 70

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BLS Prehospital Airway Management
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Outline

• Definitions
• Airway Anatomy
• Evaluating Respiration
• Opening the Airway
• Mechanical Adjuncts to Maintain an Open Airway
• Providing Mechanical Ventilations

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Definitions

• Respiration
• The exchange of CO2 for O2
• Respiratory Failure
• The exchange of CO2 for O2 is insufficient to
  support life
• Respiratory Arrest
• Cessation of breathing

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Definitions

• Normal Respiratory Rates (Breaths/Minute)
• Adult 12 - 20
• Child 15-30
• Infant 25-50

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Outline

• Definitions
• Airway Anatomy
• Evaluating Respiration
• Opening the Airway
• Mechanical Adjuncts to Maintain an Open Airway
• Providing Mechanical Ventilations

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Airway Anatomy

• Nose
• Nasal Air Passages
• Mouth
• Pharynx
• Glottis
• Trachea
• Bronchi
• Bronchioles, and Alveoli

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Airway Anatomy

• Nose Nasal Septum

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Airway Anatomy

• Nose with Nasal Septum Removed

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Airway Anatomy

• Nose and Sinuses

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Airway Anatomy

• Air Passageway from Nose to Pharynx

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Airway Anatomy

• Posterior Nasal Aperture

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Airway Anatomy

• Mouth, Pharynx, Tongue

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Airway Anatomy

• Air Passageway from Nose to Pharynx

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Airway Anatomy

• Trachea

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Airway Anatomy

• Bronchial Tree

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Airway Anatomy

• Bronchogram

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Outline

• Definitions
• Airway Anatomy
• Evaluating Respiration
• Opening the Airway
• Mechanical Adjuncts to Maintain an Open Airway
• Providing Mechanical Ventilations

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Evaluating Respiration

• LOOK
• Adequate, Equal Expansion of Chest
• Skin Color (cyanosis?)
• LISTEN
• Unusual sounds
• crowing, gasping, gurgling, wheezing
• breath sounds Present? Equal?
• FEEL
• Air movement at mouth / nose

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Signs of Respiratory Failure

• LOOK
• Anxious or comatose
• Absent, minimal or uneven Chest Rise
• Cyanosis
• Abdominal breathing
• Breathing rate is too rapid or too slow
• Retractions
• Nasal Flaring

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Signs of Respiratory Failure

• Listen
• Gurgling, Stridor, Crowing, Snoring
• Wheezing
• Speaks in short sentences
• May be Unable to Speak

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Signs of Respiratory Failure

• Feel
• Diaphoretic
• Diminished or absent air movement

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Outline

• Definitions
• Airway Anatomy
• Evaluating Respiration
• Opening the Airway
• Mechanical Adjuncts to Maintain an Open Airway
• Providing Mechanical Ventilations

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Opening the Airway

• Head Tilt / Chin Lift
• Jaw Thrust
• Modified Jaw Thrust

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Opening the Airway

• Head Tilt / Chin Lift
• DO NOT USE IF YOU
• SUSPECT NECK INJURY

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Opening the Airway

• Head Tilt / Chin Lift

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Opening the Airway

• Jaw Thrust

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Outline

• Definitions
• Airway Anatomy
• Evaluating Respiration
• Opening the Airway
• Mechanical Adjuncts to Maintain an Open Airway
• Providing Mechanical Ventilations

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Oropharyngeal Airway

• Insertion and Placement

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Oropharyngeal Airway

• Measure for proper size

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Oropharyngeal Airway

• Insertion

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Oropharyngeal Airway

• Insertion and Placement

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Airway Anatomy

• Air Passage from Nose to Pharynx

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Nasopharyngeal Airway

• Measure for size
• Similar Technique as for Oral - Pharyngeal Airway
• Corner of Nose to ear lobe

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Nasopharyngeal Airway

• Insertion

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Airway Anatomy

• Posterior Nasal Aperture

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Airway Anatomy

• Air Passage from Nose to Pharynx

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Outline

• Definitions
• Airway Anatomy
• Evaluating Respiration
• Opening the Airway
• Mechanical Adjuncts to Maintain an Open Airway
• Providing Mechanical Ventilations

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Artificial Ventilation Rates

• Adult
• 10-12 per minute One breath every 5-6 seconds
• Child / Infant
• 20 per minute One breath every 3 seconds

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Artificial Ventilation

• Mouth / Mask to Mouth
• Mouth / Mask to Nose
• Mouth / Mask to Stoma
• Bag - Valve - Mask
• Demand Valve
• Endotracheal Intubation

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Ventilation

• Bag - Valve - Mask
• 2 Persons

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Ventilation

• Bag - Valve - Mask
• 1 Person

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Ventilation

• BVM and Demand Valve

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Endotracheal Intubation

• Currently an ALS Skill
• The Combitube introduces this possibility to BLS
  level of care
• 5 of patients will be intubated in the trachea
  while using the Combitube

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Airway Anatomy

• Air Passage from Nose to Pharynx

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Flow of Patient Care
Scene Safety
Establish Unresponsiveness - Call For Help
Airway - Look, Listen, Feel
Reposition (Open) Airway
Airway - Look, Listen, Feel
2 Rescue Breaths
Reposition (Open) Airway
Remove Obstruction
Provide Ventilation
Check Pulse
SAED
CPR
Insert Airway
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Summary of Airway Management

• Scene Safety is Paramount
• Airway is Always First
• ABCs
• Recognize Respiratory Distress
• Confirm Respiratory Failure
• Look, Listen, Feel
• Rule out Obstruction
• Rescue Breathing

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Summary of Basic Airway Management

• Properly size Oral or Nasal Airway
• Insert with twisting Motion
• Use BVM or Demand valve Over Airway

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The Combitube

• An Esophageal Tracheal Double Lumen Aiwray

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Combitube / Combitube SA

• SA SMALL ADULT
• Small Adult Less than 5 ft 6 inches tall
• Small Adult Taller than 4 ft 0 inches
• Combitube SA can be used on small adults who are
  between 4 ft and 5 ft 6 inches tall.

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Combitube / Combitube SA

• Combitube is used for patients over 5 ft tall.

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COMBITUBE
COMBITUBE SA
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The Measuring Device
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Black Lines Used for Proper Tube Insertion Depth.
(Straddle upper teeth or gums)
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Inflation Point
Pilot Balloon for Large Pharyngeal Cuff
Large Proximal Pharyngeal Cuff (1)
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Large Syringe Attached to Pilot Balloon 1 Ready
to Inflate with 100ccs of Air
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Pilot Balloon (1) Remains Inflated.
Large Pharyngeal Cuff Inflated
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Small Distal Esophageal Cuff (2)
Inflation Point
Pilot Balloon for Esophageal Cuff (2)
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Small Syringe Attached to Pilot Balloon 2 Ready
to Inflate with 15ccs of Air
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Pilot Balloon 2 for Small Distal Esophageal Cuff
2 Remains Inflated
Small Distal Esophageal Cuff 2 Inflated
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2 Lumens allow for ventilation if the tube is
inserted into the Esophagus (most common) or into
the Trachea
Tracheal Lumen (2)
Esophageal Lumen (1)
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Esophageal Lumen (1)
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2 Lumens allow for ventilation if the tube is
inserted into the Esophagus (most common) or into
the Trachea
Tracheal Lumen (2)
Esophageal Lumen (1)
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Tracheal Lumen (2)
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2 Lumens allow for ventilation if the tube is
inserted into the Esophagus (most common) or into
the Trachea
Tracheal Lumen (2)
Esophageal Lumen (1)
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Quick Combitube Summary
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Combitube / Combitube SA

• SA SMALL ADULT
• Small Adult Less than 5 ft 6 inches tall
• Small Adult Taller than 4 ft 0 inches
• Combitube SA can be used on small adults who are
  between 4 ft and 5 ft 6 inches tall.

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COMBITUBE
COMBITUBE SA
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Black Lines Used for Proper Tube Insertion Depth.
(Straddle upper teeth or gums)
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Large Syringe Attached to Pilot Balloon 1 Ready
to Inflate with 100ccs of Air
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Pilot Balloon (1) Remains Inflated.
Large Pharyngeal Cuff Inflated
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Small Syringe Attached to Pilot Balloon 2 Ready
to Inflate with 15ccs of Air
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Pilot Balloon 2 for Small Distal Esophageal Cuff
2 Remains Inflated
Small Distal Esophageal Cuff 2 Inflated
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Esophageal Lumen (1)
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2 Lumens allow for ventilation if the tube is
inserted into the Esophagus (most common) or into
the Trachea
Tracheal Lumen (2)
Esophageal Lumen (1)
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Tracheal Lumen (2)
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Skills / Testing Stations

• Basic airway maintenance techniques.
• Equipment, techniques, oxygen, suction.
• Combitube familiarity.
• Combitube insertion SAED incorporation.
• Combitube tracheal and problem insertion.
• Written exam.