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

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

3. Head: Neutral position Open mouth, press away tongue

4. Flat insertion along tongue

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

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

7. Tracheal position Ventilation via shorter clear tube No. 2

9. Lipp maneuver Markus Lipp University Mainz

10. Frass Maneuver

11. Urtubia Maneuver

12. Combitube Produced by: TYCO - HEALTHCARE KENDALL Mansfield, MA

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

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

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

16. ALL - IN - ONE CONCEPT Combitube 37 SA:

17. 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) - 100 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...

18. 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: 534-537

19. 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

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

21. 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

22. 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 125-350 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

23. 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

24. 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

25. Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care American Heart Association JAMA 1992; 268:2203 2 / 2000: Class IIa DEVICE !!!

26. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice Guidelines for Management of the Difficult Airway. Anesthesiology 1993; 78:597-602

27. 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; 31:201-230

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

29. Combitube ® - Homepage: u http://www.combitube.org or or u http://www.combitube.net Webmaster: Roland Hofbauer