Combitube placement

[chbare]

Agreed. Another question if I may? Are you using multiple objective methods to confirm ETC placement. ETCO2, Esophageal bulbs, and Capnometry? I see allot of people not using objective methods following rescue airway placement, but use them with ETT placement. Somewhat of a mystery to me. :-k

Take care,

chbare.

[brentoli]

No.

If our ALS service has that capabilty, I have never seen it used in 2 years. Any of those methods.

[chbare]

I wonder why these modalities are not used with rescue airways? I have done a few intercepts where ETC's have been place prior to arrival. In all cases, I utilized waveform capnography and a esophageal bulb with success. I have yet to use a rescue device in my current role; however, when that day arrives, I will use objective methods in addition to subjective methods to assist with identification of proper placement. Unfortunately, my many in-hospital experiences with the ETC in particular did not have the benefit of such modalities.

Take care,

chbare.

[brentoli]

I don't know if this is the reason, but the ALS trucks, come from a large nationwide company that focus on interfacilty transport, and 911 intercept is a afterthought.

No it's not AMR.

I know they also use the protocols of the next county over, so I am not sure if it is included in there or not.

[CBEMT]

The one time I've encountered a Combi-Tube during a call was a pediatric critical care transport of a post-cardiac arrest patient. Combi-Tube was placed by ALS after failed intubation due to the patient's size (140 pounds at an age where such a number is almost unheard of).

I believe that one was a mainstem intubation, and the doc on the team asked the RT if she wanted to pull the tube and attempt ETI. "No way. It works, she's satting well, good waveform, it fits to my vent, why screw with it? Let's get the hell out of here." (Justification being that none of them had ever encountered a Combi before, since they aren't used in the state we came from, and as such they did not want to attempt a re-position of a device they didn't know how to use.)

[VentMedic]

The one time I've encountered a Combi-Tube during a call was a pediatric critical care transport of a post-cardiac arrest patient. Combi-Tube was placed by ALS after failed intubation due to the patient's size (140 pounds at an age where such a number is almost unheard of)

IBW or fat? If it's fat, the glottic region may still be the size of the age.

I believe that one was a mainstem intubation, and the doc on the team asked the RT if she wanted to pull the tube and attempt ETI. "No way. It works, she's satting well, good waveform, it fits to my vent, why screw with it? Let's get the hell out of here." (Justification being that none of them had ever encountered a Combi before, since they aren't used in the state we came from, and as such they did not want to attempt a re-position of a device they didn't know how to use.)

Combitubes are not used in hospitals. Our difficult airway cart has a large variety of devices, but no Combitube.

We have gotten a few cases to our hospital as referrals for repair of damage from Combitubes. Some of which were caused by the insertion and some at the hospital by people who didn't know how much air is in those cuffs. It would help if the EMTs would bring the syringe in with the patient. That might provide a clue. The length of time alone it takes someone to deflate the cuff allows for all the apirated matter to drain into the lungs. It's a bad week to save a patient from a cardiac event and then have them die from complications from a tube.

We reintubate even if the Combitube is in the trachea as soon as we get a stable opportunity or before the patient goes to ICU. If it is an esophagus placement, then we tube immediately upon arrival to the ER. My Medical Director would bust me down to O2 tank tech if I put a patient with a Combitube on a ventilator in our ICU.

[brentoli]

What types of damage do they cause? How can it be avoided?

[VentMedic]

For a recent article:

http://www.medscape.com/medline/abstract/17272251

Esophageal tears

vocal cord damage

fracture of the larynx

damage to soft tissues

One case that sticks in my mind, probably because I had to give a deposition on it, was a 20 y/o guy who had a little too much to drink. Because he had "snoring respirations" he got a combitube which somehow did go through the vocal cords. But, the cords were severely damaged to where he would not be using them again. And, then there was the vomit issue which bought him several days on the ventilator for PNA after the tracheostomy was done while his cords were being evaluated. The Combitube was removed in the OR when the trach was placed that night. Too bad, as long as he was moving air with his snoring, he could have just gotten a cot in the ER and maybe a banana bag instead of a stoma and an electronic talkie.

If you must use the Combitube, have a thorough knowledge of the anatomy in the throat. Have a good instructor. Don't force the device if resistance is met. Retrain often. If you take a patient to the hospital with a Combitube in place, take the syringe with you if possible and give a brief explanation of the tube to the RT and Doctor. Even if they act like they know what it is, refresh them again on its unique characteristics.

[CBEMT]

IBW or fat? If it's fat, the glottic region may still be the size of the age.

Oh no, he was fat. Everything about him seemed bigger than it should have been, but he had no medical history that would cause him to be that size other than a long history of over-eating and under-exercising.

Combitubes are not used in hospitals. Our difficult airway cart has a large variety of devices, but no Combitube.

I know. Nor does EMS in the state the children's hospital we were transporting to. Hence why they had never seen it before. The ER staff where we were taking the kid from weren't real familiar with it either.

It would help if the EMTs would bring the syringe in with the patient. That might provide a clue.

One thing I remember is the ER telling us how much air was in each bulb, so I guess we had somewhat of an idea.

We reintubate even if the Combitube is in the trachea as soon as we get a stable opportunity or before the patient goes to ICU. If it is an esophagus placement, then we tube immediately upon arrival to the ER. My Medical Director would bust me down to O2 tank tech if I put a patient with a Combitube on a ventilator in our ICU.

The kid was hanging on by a thread; it wasn't the time or place to be screwing with a valid airway. I don't know what happened after we completed the transport, other than that he died later that day.