Thoughts about Combitubes.

How much tracheal trauma can Combitubes potentially cause? I ask this because if you stick it in the trachea, doesn't it equal about a size 12 ET tube??

They're useful as an airway when you can't really get anything else. Although I've put them in mannequins, I've never seen one used or needed to be used in clinical practice.

They remind me of the old esophageal obturator airways (EOA). They were eventually abandoned because of a fairly high incidence of esophageal rupture.

Can only comment on one experience. Paramedics unable to intubate in the field so placed a combitube. Very thick necked male. Asked to come to ER to change out for ETT. Multiple attempts at ETT had been made in the field so airway very edematous and bloody when I did DL. Also, patient with + vomit with combitube placement. Intubation successful but did not see anything for landmarks. Just went midline and bent ETT about 60 degrees with stylet.

Tracheal placement is rare...in almost eight years in EMS, I have never seen a tracheal placement and no one in my paramedic class ever admitted to seeing one. I don't remember for sure, but I believe the distal end of the Combitube is more like an 8 or maybe a 9...there are guidelines about what size of people they can be used with (there are pediatric Combitubes, but I've never seen one). According to the anesthesiologist that taught our airway classes, most adults can safely tolerate a 9 for a short period. Also, the anesthesiologist said that even though you are usually using a Combitube because you can't get an ET, and you're not going to be able to hit the trachea blind if you can't hit it visualized, best practice would be to use the larygoscope and visualize to ensure an esophageal placement.

I think I confused myself...hope this makes sense!

Tracheal placement is rare...in almost eight years in EMS, I have never seen a tracheal placement and no one in my paramedic class ever admitted to seeing one. I don't remember for sure, but I believe the distal end of the Combitube is more like an 8 or maybe a 9...there are guidelines about what size of people they can be used with (there are pediatric Combitubes, but I've never seen one). According to the anesthesiologist that taught our airway classes, most adults can safely tolerate a 9 for a short period. Also, the anesthesiologist said that even though you are usually using a Combitube because you can't get an ET, and you're not going to be able to hit the trachea blind if you can't hit it visualized, best practice would be to use the larygoscope and visualize to ensure an esophageal placement.

I think I confused myself...hope this makes sense!

Although you won't see many tracheal placements, it can happen (that's why the tube is designed the way it is). And the idea that you won't hit it blindly if you can't see it is BS.

Also - the whole idea for this tube is blind placement, with a device DESIGNED to be used whether it's placed in the esophagus or trachea. Placing under direct vision makes little sense to me.

Remember - this is NOT a first-line A/W device - it's designed to be used when you can't get an ETT in or for those who aren't allowed to place ETT's. Unless you have no alternatives, it is NOT a device that should be used with any frequency at all, and if your paramedics are using them a lot after unsuccessful intubations, they need to work on their intubation skills, not continue to resort to an inferior airway device

We recently had a discussion about keeping Combitubes in our 'difficult airway' cart in the ED, the only justification we could come to was some studies that used them to tamponade bleeding in severe facial trauma. One of our local EMT crews will use them occasionally but we usually replace with ETT on arrival.

My thoughts are that the combitube should be pulled from service and replaced with the LMA. This is from 13 years of experience in the field as a paramedic. Intubation is first line and like someone else said, if the combitube is being used more than rarely maybe some practice needs to be done to become more proficient in the skill. I also believe that if there is a need for a secondary device (at least in the prehospital setting) it should be the LMA not the Combitube