Combitube Airways

Placing Combitube and replacing with endotracheal tube

Placing the Combitube
1.  Ensure both cuffs of the Combitube are completely deflated.
2.  Lubricate the tube with a water-soluble lubricant.
3.  Place the patient in a supine position; lift the tongue and jaw upward with one hand.
4.  With the other hand, hold the Combitube airway with the curve in the same direction as the anatomic curve of the pharynx.
5.  Insert the tip into the patient's mouth and guide it gently behind the tongue until the two black (alveolar) rings on the tube are between the teeth.
6.  Inflate the upper oropharyngeal (blue) cuff with 100 ml of air (85 ml for the Combitube SA).
7.  Inflate the distal (white) cuff with 15 ml of air (12 ml for the Combitube SA).
8.  Immediately ventilate through the longer blue tube with a bag-valve-mask while observing the rise and fall of the chest.
9.  If the chest does not rise with ventilation through the longer blue tube, the distal portion may have entered the trachea. In this case, attempt ventilation through the shorter, clear tube. Assess the breath sounds and the chest rise to confirm the placement of the distal portion in the trachea.
10. If the distal portion of the Combitube is confirmed to be in the esophagus, decompress the stomach by placing a suction catheter or a nasogastric tube through the shorter, clear tube.

Replacing the Combitube with an Endotracheal Tube

1.  To replace the Combitube when ventilating through the longer, blue tube:
  a.  Decompress the stomach.
  b.  Hyperventilate the patient.
  c.  Withdraw all the air from the pharyngeal cuff (blue) by using the 140-ml syringe.
  d.  Position the Combitube to the left side of the mouth.
  e.  Insert the laryngoscope and intubate the trachea quickly, with the Combitube still in place.
  f.  Deflate the distal cuff by withdrawing 15 ml of air (12 ml for the Combitube SA) by syringe. Withdraw the Combitube.
  g.  An alternative is to deflate both cuffs, remove the Combitube airway, and intubate the patient.
2.  To replace the Combitube airway when ventilating through the shorter, clear tube:
  a.  Hyperventilate the patient.
  b.  Pass a tube-changing stylet through the shorter, clear tube.
  c.  Deflate both cuffs by using the appropriate syringes and remove the Combitube airway.
  d.  Insert the properly sized endotracheal tube over the stylet to reintubate the patient.
3.  To remove the Combitube airway if the patient regains consciousness or the gag reflex returns:
  a.  Turn the patient to the side (if possible) and remove all the air from the pharyngeal and distal cuffs by syringe.
  b.  Pull out the Combitube airway.
  c.  Be prepared to suction the patient as indicated.

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