Endotracheal Tube or Combitube??

[vcfd35s]

Hey guys,

I was reading in my EMT textbook and come up with a question. When reading about endotracheal tubes, I understand that the purpose of these is too protect the airway and to guide the tube into the trachea and not the esophogus, thus allowing for adequate ventilations. However, i then started reading about the combitube and read that you still push for ventilations into the trachea. Yes, you do have two bulbs but when you inflate one of them, it closes off the esophogus and you can ventilate through the trachea. So my question is this, why dont we just use the combitube instead of trying to "hit and miss" the trachea with the endotracheal tube? I am a student filled with questions....please bear with me. Thanks guys and I look forward to the wealth of knowledge.

Jonathan

[nsmedic393]

We don't use combitubes but from what I understand, if you place a conbitube into the trachea it can act like a ETT tube, but if you place it into the esophagus than you can only ventilate through holes on the sides of the tube. This takes away your med route, deep suctioning and correct me if i'm wrong but you couldn't use PEEP on it either.

Also Direct laryngoscopy is kind of an art as opposed to blindly ramming a tube down someones gullet.

[BoiledEgg]

I believe combi's arn't used as much because if I remember correctly from an ACLS instructor, when NYC used those, idiots thought you could just shove them in "randomly." Started damaging tracheas and esophoguses... all sorts of stuff and so now we're stuck w/ ETT...

someone please correct me if i'm wrong

[paramedicmike]

Placing an endotracheal (ET) tube is not a matter of "hit or miss". It is a process of directly visualizing the epiglottic opening and watching as you actually place the ET tube through the vocal cords and into the trachea itself. Once in place with the cuff inflated and the tube secured you have direct access through the tube into the trachea and lungs.

Placing a combitube is a matter of opening the patients mouth and sliding it in (blind insertion). Once in place and secured, there is still the risk of losing the airway due to some form of tracheal or epiglottic injury as air from ventilations still has to pass these anatomic structures. It is not as direct a route to the trachea and the lungs as is the ET tube. Since it's not as direct a route, the airway is not as secure as it might possibly be with an ET tube in place.

Further, a properly placed and secured ET tube offers access to certain medications in certain situations. While this isn't strongly recommended, it is still an option. You just can't push medications down a combitube.

Lastly, please do a search on the subject. There have been many discussions here regarding this very topic. Some of these discussions have gone into quite a bit of depth regarding many aspects of the use of either airway management device. The search function is your friend. Please use it accordingly.

-be safe.

[Ridryder 911]

Ditto.. to Paramedic Mike reply. Copmbitube is an alternative airway, not the best airway.

Be safe,

R/R 911

[safetyparamedic]

I like the Combitube as a great backup. The advantage of the ETT is that it can be placed in patients that have a gag reflex, works great for giving "definitive" protection, and can be inserted a variety of ways (oral, nasal, retrograde, etc.) The downside is there's no backup if it doesn't it. Also, there is a definite skill to doing it and it takes quite a bit of practice to do it right.

Also, using the ETT to administer medication is quickly losing favor. It takes way too long for the medication to hit the circulation. Instead, IOs are gaining more favor if an IV can't be established.

[Dustdevil]

Combitube does not offer a direct pathway to the pulmonary system.

Combitube is available in limited sizes.

Combitubes do not seal the trachea at all, so they do not protect the airway as an ET does.

Combitube utilizes high pressure cuffs which cause damage to the pharynx, esophagus, and trachea.

High pressure cuffs offer inferiour seal.

Inferiour seal creates air leaks and inadequate ventilation, as well as aspiration danger.

Blind insertion creates high risk of trauma on insertion and inflation.

Blind insertion increases risk of inappropriate placement.

In appropriate placement causes death.

Combitubes have no place in the hands of anyone under the education level of a paramedic.

[safetyparamedic]

What I think people need to realize is that the Combitube is not designed to replace the ETT. The Combitube is designed for non-ALS levels of EMS. In Wisconsin, which is the only state that I can really comment on) Combitubes are allowed all the way to the First REsponder level. Very simply, it provides a better airway and less chance of inflation of the stomache than an Oral Airway when using a BVM. The only time it is being used is during cardiac arrest.

I disagree with the statement that improper placement causes death. Ok, that part is true, but the chance of an improper placement is pretty low. The Dual-Lumen system allows for placement in the esophogus (primary), but also allows for placement in the trachea. I believe that Kendal says that it will work in 95% of all patients.

I agree that the Combitube does have some severe disadvantages, but I don't think that they override the advantage of providing some sort of advanced airway for the cardiac arrest patient in the BLS setting. Not to mention, there is no where near the risk of inexperienced or untrained personnel performing intubation. Not to mention, trauma to the oropharynx is the least of my concern during a cardiac arrest.

[Dustdevil]

Safety, I am mostly in agreement with your points. The only comments I have would be:

• 1. Improper placement causes death because inadequately educated, inadequately experienced, and inadequately intelligent providers are commonly incapable of determining the proper route for inflation. Look at how many full paramedics still intubate and inflate the esophagus. So you know that the chances of improper use of the combitube by lesser providers increases exponentially.

2. While I agree that you can make an excellent case for just about anything in a CPR, I have seen and heard too many stories of inadequately educated responders doing things simply because they can. You give them that tube, and by God, they are going to find an excuse to use it. Consequently, I would hope that any system that has basic level providers using them makes it positively clear that a full-arrest CPR is the only situation they should be deployed in.

• Of course, the true answer lies in the system providing adequate paramedic coverage for their community so that a bandaid approach to care isn't needed in the first place.

[safetyparamedic]

I've heard of a couple of situations where the Combitube was used in respiratory arrest after trauma, but they've been few and far between. Paramedic coverage is the gold standard, but many places cannot provide paramedic coverage due to cost or the inability to recruit paramedics. In Wisconsin, only 75% of the state is covered by ALS, and I think that just means they can start an IV. In places that cannot provide paramedic level coverage, the Combitube is better than the alternative of a simple airway. And I've never heard of a case where the Combitube was incorrectly placed, but that doesn't mean it doesn't happen. Again, education is the key. We have to re-cert every 6 months on Combitube.