„Pharyngeal“ lumen No. 1 „Esophago- tracheal“ lumen No. 2 Esophageal - tracheal COMBITUBE Oropharyngeal balloon Distal cuff Perforations

Elbow deflector Suction catheter Small syringe: 10 ml distal cuff Large (blue) syringe: 85 ml large balloon Ringmarks Distal cuff Oropha- ryngeal ballon

Head: Neutral position Open mouth, press away tongue

Flat insertion along tongue

Emergency: No. 2: 10 ml Emergency: No. 1: 85 ml (or more) Ringmarks at level of upper teeth Elective cases:

Esophageal position Self- fixation behind hard palate Active decom- pression Ventilation via longer blue tube No. 1

Tracheal position Ventilation via shorter clear tube No. 2

Lipp maneuver Markus Lipp University Mainz

Frass Maneuver

Urtubia Maneuver

Combitube Produced by: TYCO - HEALTHCARE KENDALL Mansfield, MA

Size of COMBITUBE and height of patient GUIDELINES*STUDIES** *TYCO **Gaitini, Urtubia, Panning, Krafft

Specially useful: u Difficult intubation u Blind intubation u Difficult circumstances (space, illumination) (space, illumination) Combitube

u Emergency intubation u Bleeding and vomiting u Immediate decompression of esophagus and stomach of esophagus and stomach Indications Combitube

ALL - IN - ONE CONCEPT Combitube 37 SA:

Conclusions 4 the “standard“ Combitube 4 safe and efficient 4 insertion under direct vision recommended 4 slow inflation of oropharyngeal balloon 4 inflation volume: height (cm) or weight (kg) - 5 è suitable for all patients in whom tracheal intubation has to be avoided intubation has to be avoided the 37 Fr Combitube SA is...

FAILED RAPID SEQUENCE INTUBATION IN TRAUMA PTS. u Use of ETC in trauma pts. in whom orotracheal rapid sequence intubation failed u Flight nurses trained with ETC u 12 pts. had ETC, 10 included Blostein, Koestner, Hoak J Trauma 1998; 44:

FAILED RAPID SEQUENCE INTUBATION IN TRAUMA PTS. u Successful in all patients u Definitive airway control in ED: orotracheal (7), tracheostomy (2), cricothyroidotomy (1) u 7 mandible fractures, 4 TBI, 2 fa- cial fractures, 1 hemopneumoth

u Bridge between BVM and endotracheal tube Paramedic -Main indication-

COMPLICATIONS ASSOCIATED WITH THE USE OF THE COMBITUBE u 1139 pts. CPR with ETC + SAED u 2 pts. transparietal lacerations of anterior wall of esophagus u Distal cuff inflated with 20 to 40 ml !!! Maximum 12 ! CPR; CPPV Vézina, Lessard, Bussières, et al. Can J Anaesth 1998; 45:76-80

USE OF THE ESOPHAGEAL TRACHEAL COMBITUBE BY BASIC EMERGENCY MEDICAL TECHNICIANS u 420 Emergency medical technicians + automatic external defibrillator (EMT-Ds) u Firefighters with BLS-D u h course curriculum for EMTs u 18 h training with AED and Combitube u Assessment of location with EDD (syringe) + auscultation Lefrançois DP, Dufour DG Resuscitation 2002; 52:77-83

USE OF THE ESOPHAGEAL TRACHEAL COMBITUBE BY BASIC EMERGENCY MEDICAL TECHNICIANS u Montérégie / Quebec: 11,000 square km, population of 1.3 million u Successful placement in 725 out of 760 cardiac arrest patients (95.4 %) u Ventilation successful in 695 (91.4 %) pts. u Autopsy in 133 pts.: no esophageal lesions or injury to airway structures u EMT-Ds can use ETC safely + effectively

Merits of COMBITUBE u Low price, all-in-one device u Non invasive u No preparations necessary u Rapid and easy intubation u Immediate fixation u PREVENTION OF ASPIRATION u HIGH VENTILATORY PRESSURES u No power supply

Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care American Heart Association JAMA 1992; 268: / 2000: Class IIa DEVICE !!!

American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice Guidelines for Management of the Difficult Airway. Anesthesiology 1993; 78:

European Resus- citation Council Baskett PJF, Bossaert L, Carli P, Chamberlain D, Dick W, Nolan JP, Parr MJA, Scheidegger D, Zideman D: Guidelines for the advanced management of the airway and ventilation during resuscitation. Resuscitation 1996; 31:

Conclusion COMBITUBE u Whenever endotracheal intubation not immediately possible u Short training time u Adequate ventilation

Combitube ® - Homepage: u or or u Webmaster: Roland Hofbauer