Combitube^® Insertion

Indications:

The Esophageal-Tracheal Combitube^® can now be considered a primary airway device and is a suitable alternative to endotracheal tubes for some patients. The patient must be unresponsive, as in cardiac and/or respiratory arrest.

Contraindications:

• Patient with intact gag reflex
• Patient with esophageal trauma or caustic substance ingestion
• Known or suspected foreign body airway obstruction
• Known esophageal disease (e.g. reflux, cancer, varices, scleroderma)
• Patient less than 5 feet tall (unless the smaller Combitube^® SA is used; it is suitable for patients 4 feet tall or taller)
• Children under 16 years of age, unless at least 5 feet tall (or 4 feet tall if Combitube^® SA)

Procedure:

• Observe body substance isolation precautions.
• Provide 100% oxygen via BVM, monitor Lead II ECG, pulse oximetry, capnography.
• Test the cuffs on the Combitube^® prior to insertion.
• Lubricate the distal tip of the device with water-soluble jelly.
• Position the patient’’s head in a neutral or sniffing position.
• Open the airway with a tongue-jaw lift maneuver. A laryngoscope may be used to help lift the jaw.
• Gently insert the device blindly in the midline and to a depth where the printed ring is aligned with the incisors.
• Inflate line 1 (blue pilot balloon) leading to the pharyngeal cuff with 85-100* cc. of air from the 140 cc. syringe, then remove the syringe. Do not over-inflate past the point of “no leak”.
• Inflate line 2 (white pilot balloon) leading to the distal cuff with approximately 12-15* cc. of air from the 20 cc. syringe, then remove the syringe. Do not over-inflate.
• Attach the BVM & capnography sensor to the blue lumen (lumen 1, esophageal placement) and attempt to ventilate.
• Confirm placement & ventilation through the correct lumen by observing for chest rise, auscultation over the epigastrium, and bilateral auscultation over the lung fields:
• If the chest rises, there are no epigastric sounds and ETCO2 readings are detected, continue ventilation through blue lumen.
• If the chest does not rise, epigastric sounds are present with ventilation, there is no detectable ETCO2 and poor breath sounds are heard, remove the BVM from the blue lumen and attach it to the white lumen (lumen 2, tracheal placement).

• Properly secure the device, and reassess every 5 minutes or after every patient movement or manipulation.

Complications:

Sore throat; dysphagia; upper airway hematoma; esophageal rupture; hemodynamic instability (hypotension and/or bradycardia), which can be minimized by avoiding over-inflation of the cuffs*.

*The volumes on the package insert are 100 cc. and 15 cc., respectively, for the regular size, and 85 cc. and 12 cc. for the SA. However, to minimize the risk of upper airway trauma, esophageal rupture and hemodynamic instability, use the minimal volume necessary to achieve an effective seal.