Combitube In-service

Joe Lewis, M.D.,FACEP

Schofield Barracks Ambulance Service

Combitube Intubation Protocol

INDICATIONS

• - Cardiac Arrest

• - Respiratory Arrest/Apnea

CONTRAINDICATIONS

• A patient under age of 18 or less then 4 ft. tall.• A patient who has swallowed a corrosive

substance.• A patient with a known Esophageal Disease.• EMT not trained and authorized to use the

Combitube.®• Suspected cervical spine injury requiring cervical

spine immobilization.

Initial Procedure

• Assure scene safety and use universal blood / body fluid precautions.

• ABC’s.

• Clear airway and ventilate with 2 rescue breaths.

• Check Pulse – if absent, follow the AED Protocol.

Initial Procedure

• After the 2nd analysis cycle (if no shock is indicated) or after the 2nd series of 3 shocks is administered – insert the Combitube ® as per the insertion procedure.

• Continue the Protocol.

Initial Procedure

• If the patient initially has a pulse but is apneic – follow the insertion procedure and perform rescue breathing through the Combitube ®.

• Continually re-assess for spontaneous respirations.

Insertion Procedure

• Continually re-assess for spontaneous respirations and pulse.

• Note that ALS may continue Combitube® use, orally intubate around the Combitube®, or remove the Combitube® at the discretion of the responding Paramedic.

• The Combitube can NOT be used with the demand valve regulator.

Using The Combitube

• ABC’s• Measure (Combitube or Combitube SA?)• Check Cuffs• Insert• Inflate Cuffs• Ventilate through tube #1• Check for Breath Sounds• Switch & Ventilate through tube #2 if needed• Check for Breath Sounds• Continue Ventilation

Check ABC’s

• Establish Unresponsiveness.– Verbal / tactile stimuli.

• Look Listen and Feel for air movement.• Deliver 2 rescue breaths.

– reposition and try again if needed,– clear airway if obstructed.

• Check Pulse.– SAED & CPR if needed.

Measure the patient

• Put loop of measuring device over the patient’s foot.

• Determine which Combitube to use.– Combitube or Combitube SA.

• IF LESS THAN 4 FEET - use basic airway maintenance techniques.

• Select tube if the patient is over 4 feet.

COMBITUBE

COMBITUBE SA

Check the Cuffs

• Inflate Pilot Balloon #1 with 100cc’s of air.– Check for proper inflation of cuff.

• Deflate Cuff.

• Inflate Pilot Balloon #2 with 15cc’s of air.– Check for proper inflation of cuff.

• Deflate Cuff.

Large Syringe Attached to Pilot Balloon #1 Ready to Inflate with 100cc’s of Air

Large Pharyngeal Cuff Inflated

Pilot Balloon (#1) Remains Inflated.

Small Syringe Attached to Pilot Balloon #2 Ready to Inflate with 15cc’s of Air

Small Distal Esophageal Cuff #2 Inflated

Pilot Balloon #2 for Small Distal Esophageal Cuff #2 Remains Inflated

Lubricate the Combitube

• Use water soluble gel. (Surgilube)

• Spread over tube.– Use package or gloved hand.

Insert the Combitube

• Hold tube like a pencil with dominant hand.

• Lift jaw and tong between thumb and index finger of non-dominant hand.

• Insert Combitube into mouth with curve facing upward.

• Stop inserting when the upper teeth or gums are between the Black Rings.

Insert the Combitube

• If any resistance is met during insertion:– Remove the Combitube,– Reposition,– Re-insert one time.

• If resistance is met on the second attempt:– Remove the Combitube,– Maintain airway using basic airway techniques.

Inflate the Cuffs

• Attach Large Syringe to Pilot Balloon #1.

• Inflate cuff #1 with 100cc’s of air.

• Remove syringe.

• Confirm that Pilot Balloon is inflated.– If not - attempt to re-inflate.– If still no inflation - remove Combitube and

maintain airway with basic airway techniques.

Large Syringe Attached to Pilot Balloon #1 Ready to Inflate with 100cc’s of Air

Large Pharyngeal Cuff Inflated

Pilot Balloon (#1) Remains Inflated.

Inflate the Cuffs

• Attach Small Syringe to Pilot Balloon #2.• Inflate cuff #2 with 15cc’s of air.• Remove syringe.• Confirm that Pilot Balloon is inflated.

– If not - attempt to re-inflate.– If still no inflation - Deflate Cuff #1, remove

Combitube and maintain airway with basic airway techniques.

Small Syringe Attached to Pilot Balloon #2 Ready to Inflate with 15cc’s of Air

Small Distal Esophageal Cuff #2 Inflated

Pilot Balloon #2 for Small Distal Esophageal Cuff #2 Remains Inflated

Ventilate

• Attach Bag / Valve and CO2 detector to Tube #1. (Esophageal)

• Ventilate.

• Listen over Chest for breath sounds.– If present - continue ventilation at a rate of 12-

20 breaths per minute.

Removing the Combitube

• If the Combitube needs to be removed at any time -– Get suction ready,– Turn patient on left side,– Deflate both balloons,– Remove tube,– Suction as necessary.

CONTRAINDICATIONS

• A patient under age of 18 and less then 4 ft tall.• A patient who has swallowed a corrosive

substance.• A patient with a known Esophageal Disease.• EMT not trained and authorized to use the

Combitube. ®• Suspected cervical spine injury requiring cervical

spine immobilization.

Possible Complications of Combitube Insertion

• Tear or rupture of esophagus.

• Bleeding.

• Puncture of carotid artery.

• Tear of pharynx.

• Pneumothorax.

• Death from asphyxiation.

• Vocal cord injury.