Waitin In The Wings

1
Waitin In The Wings
2
CombiTube-SA

• Jerry D. Andrews, NREMT-P
• EMS LIAISON
• EMS DISTRICT 6
• 802-371-4516 Work
• 802-371-4481 Fax
• Jerry.Andrews_at_hitchcock.org
• www.cvmc.hitchcock.org

3
CombiTube Kit
4
General Description

• The CombiTube is
• A double-lumen tube with one blind end which
  functions as an esophageal obturator airway and
  the other as a standard cuffed ET tube
• Inserted blindly and seals the oral and nasal
  pharyngeal cavities

5
1) Esophageal Lumen
C) Blind-end Tube
B) 12cc Cuff
A) 85cc Cuff
D) Open-end Tube
2) Tracheal Tube
6
Indications

• Ventilation in normal and abnormal airways
• Failed intubation
• Airway management in trapped patients

7
Contraindications

• Crush injury to oropharynx or throat
• Intact gag reflexes
• Known esophageal pathology
• Ingestion of caustic substances
• Under 4 feet tall
• Over 5½ feet with CombiTube-SA
• CONSIDER Latex Allergy

8
And The Survey Says
9
Advantages

• Requires minimal training
• May be more useful in non-fasted patients
• Successful passage and ventilation in many
  patients via esophageal route
• Portable, useful in remote setting
• Functions in either the trachea or esophagus

10
Disadvantages

• Only adult and small adult sizes
• Potential for esophageal trauma
• Problems maintaining seal in some patients

11
Special Features

• Techniques for Conventional ET intubation via
  CombiTube and CombiTube-SA have been described
• May be used electively to avoid intubation - not
  usually a choice in the prehospital setting!

12
Tips for Success

• Curve the distal tip (Lipp maneuver) just prior
  to insertion
• Withdraw gently from the airway if ventilation is
  inadequate suction must be at hand
• If included in the Scope of Practice use a
  laryngoscope to facilitate placement

13
Prepare Equipment

• Personal Protective Equipment
• Gloves
• Masks for all providers
• Eye protection for all providers
• CombiTube-SA
• Test BOTH balloons with recommended volumes

14

• Mask elbow (to deflect fluids)
• Suction Suction Catheter at patient side
• Water soluble lubricant
• Tube holder
• Tape
• Commercial tube holder
• BVM with oxygen supply connected

15
Insertion Technique
16

• Patients head in a neutral, semi-flexed position
• Sniffing position should be avoided!
• Neutral position is an advantage in patients with
  suspected or evident cervical spine injury
• The EMT may be
• behind the patient
• to one side of the patients head
• or face to face

17

• The patients tongue and lower jaw are grasped
  between the thumb and forefinger of the
  non-dominant hand, while a jaw lift is performed
• Use caution not to
• Cut your fingers on sharp or broken teeth
• Get bitten during seizure activity

18

• The lubricated CombiTube-SA
• Should not be inserted along the palate
• Should be inserted along the tongue
• Insert CombiTube-SA. following the natural curve,
  gently in a curved downward movement along the
  tongue

19

• Insert until printed ring marks lie between teeth
  or alveolar ridges
• Do not use brute force!

20

• Inflate oropharyngeal balloon first with the
  large syringe (blue dot) with 85 cc (40-85) of
  air
• Then with small syringe, inflate distal cuff with
  12 cc (5-12) of air

21
CAUTION!

• You may see slight outward movement during
  inflation, this is normal and should not
  interfere with ventilation!

22
Esophageal Intubation

• There is high probability of esophageal placement
  (90-97) of the CombiTube or CombiTube SA
• Therefore, test ventilation is started via the
  longer, blue tube 1
• Air cannot escape at the distal end of the
  blocked esophageal lumen and enters the pharynx
  via the perforations
• Since mouth, nose, and esophagus are sealed by
  the balloon and the cuff, air is forced into the
  trachea

23

• If auscultation over the lungs is positive (and
  epigastric insufflation is absent), ventilation
  may be continued
• The tracheal lumen serves to decompress the
  esophagus and the stomach

24
Tracheal Intubation

• On occasion (3-10), the CombiTube is placed
  blindly into the trachea
• If this is the case, ventilate the shorter, clear
  tube 2, leading to the tracheal lumen
• Air is blown directly into the trachea
• In a few cases, ventilation does not work, via
  the esophageal or tracheal lumen

25

• The oropharyngeal balloon may be inserted too
  deep, occluding the laryngeal aperture
• Pull the CombiTube-SA out about 2 to 3 cm, and
  start ventilation again via the blue tube

26
Paramedics, Physicians

• Use a laryngoscope whenever feasible!
• If adequate ventilation DO NOT remove
• Place an Orogastric suction tube

27
Placement Confirmation

• Absence of abdominal inflation
• Breath sounds in the chest
• Chest inflation
• Colormetric CO2 detection
• Mist in the tube
• Pulse oxymetery

28
Colormetric CO2 Detection
For patients gt15 kg
For patients 1 to 15 kg
29
Removal of CombiTube-SA

• Tube placement cannot be determined
• Patient no longer tolerates tube gags
• Patient vomits past either distal or proximal
  tube
• Palpable pulse and spontaneous breathing
• Staff to place ET tube are present and ready

30
Removal Technique
31

• Preoxygenate the patient
• Increase the depth, not the rate, of ventilation
• Have suction at hand and turned on!
• Turn the patient to LEFT side, if possible
• Deflate the large cuff of tube 1
• Deflate the small cuff on tube 2

32

• Withdraw the tube quickly and smoothly
• Be prepared for vomiting!!! !!! !!!
• Administer oxygen at 2-6 lpm via nasal cannula
• Avoid the use of masks due to potential of
  vomiting

33
Documentation

• Time of procedure
• Tube size
• Combitube
• Combitube-SA
• Tube air volume (CombiTube-SA)
• Tube 1 (40 to 85 ccs)
• Tube 2 (5 to 12 ccs)

34

• Placement check
• Manner of check mist, breath sounds, etc.
• Perform multiple checks
• Degree of difficulty, if any
• Complications encountered, if any
• EMT performing procedure
• EMT performing check generally should NOT be by
  EMT performing procedure

35
Summary

• Assessment must be appropriate to the patient
  presentation
• Remember noisy breathing is obstructed
  breathing, but quiet breathing maybe absent
• Find and correct any threats to life
• Assess, document, and report your findings,
  interventions and changes in patient status

36
Thank You!

• Care for the physical and emotional aspects of
  the patient
• Remember - the next patient could be you or your
  loved one
• Be safe, take care of each other as well
• Go home safe from all calls