Combitube!

20 years ago when I was an EMT-Intermediate, we used a device called an EOA (esophageal obdurator airway). The airway was designed to occlude the esophagus, thus enabling supraglottic ventilation. The main problem with the EOA was sometimes instead of going in the esophagus, it ended up in the trachea and was not recognized. I was only an Intermediate for about a year before I became a medic and never got the opportunity to use one.

Eventually, the EOA was replaced by the Combitube. The Combitube had an answer for the EOA going in the trachea. It has two lumens. In most cases the tube ends up in the esophagus, but if it ends up in the trachea, it can be used like an ET tube and ventilated through the second of two ports. The problem with the Combitube is it has two ports, and you need to figure out which one to ventilate. Simple if you are playing with a mannequin, but the thought of figuring it out in the heat of the moment in a live patient is not quite as easy to dismiss if you have never used it before on a live patient.

In my first years as a medic we didn’t carry Combitubes. The service had a few intermediates and when they went out with basic partners they took the cardboard box holding the Combitube with them, but it was never left in the ambulance. A backup airway wasn’t in the paramedic parlance then. If you didn’t get the tube, you bagged the patient. If you were a self-respecting paramedic, you usually always got the tube. When you came in with the patient, the question was always “Did you get the tube?” not “How long did it take you to get the tube?” or “How many tries?” I went seven years in a row and always got the tube. But like I said, we didn’t count the number of times we tried or how long it took to get the tube.

Then we started carrying the Combitube regularly, but it was strictly a backup. It wasn’t in the in-house kit, it was it is that bulky cardboard box shoved deep in some cabinet.

Once a year at skills sessions, we could play with one if we wanted. I’d pick it up and look at the two ports and try to figure out which one was which. I’d figure it out enough to drop one in the airway head, but I didn’t think I would ever use one. Hey, after all, I’m a medic and the medic gets the tube. Ask me then which port you ventilated first, the blue one or the white one and I couldn’t have told you without more than a fifty-fifty chance of being right. Same with how much air you put in each balloon. One was 15, one was around 85.

In recent years we made the Combitube and the LMA alternative airways, not just backup airways. Still, I kept getting the tubes. Then we went to limiting ET attempts to 2, I started carrying the LMA in my in house back and last year used it a couple times with some success. I wrote about one such call in The Battle. I used an LMA again earlier this year as a first line airway in a cardiac arrest. It worked well. Meanwhile the Combitube was sitting on the shelf in its cardboard box.

So now I am back in the city. In the city, many of the inhouse bags have the Combitube in a flexible package rolled up in the in-house bag. The LMAs are in the cabinet. When I noticed this, I thought to myself, maybe if I get the chance, I’ll give this Combitube a try (if only I can remember which port is which.)

First cardiac arrest back in the city. Obese man on the second floor of a hoarder’s house, laying in bed in the corner of the room with a wall against the side and head of the bed and newspapers on the other sides, first responders standing on the bed, doing CPR. I looked at the round head, and no neck and crooked front teeth and I looked at the walls and the piles of hoard, and the picture in the bubble over my head was clear. “Combitube!”

I spread the teeth, pulled the tongue a little and shoved that tube on down to the teeth markings. Went in easy. I attached the capnography without hesitation to the blue tube and ventilated. On the monitor it read ETCO2 60 with a wave form. How easy was that! I did have to wonder aloud how much air I had to put in the balloon, but the other medic on scene who held the syringes stepped up and inflated them for me. (We talked about combitubes afterwards and he said he has had such success with them, he often uses them as his frontline airway).

No interruption to CPR, No having to reposition the unpositionable patient, no laying down on my belly to intubate, no staring down the throat hoping to see the chords. Just slide it down, attach the bag and ventilate. I did attach a tube holder, which was the most difficult part of the operation, but even that didn’t take more than ten seconds and didn’t interrupt CPR.

The tube was solid too. It held perfectly all during the getting the patient on a board and carried out of the cramped hoard-filled room and down the stairs and out to the front yard where the stretcher sat. Another medic told me once, you could drag someone out of a house by their Combitube it was that solid. I can see that. ETCO2 of 30 with perfect wave form all the way to the hospital.

My first Combitube use ever! Woo-hoo! I was impressed.

***

Here’s a Combitube video on a live patient where they use a larengyscope (interesting!):

And here’s some more information on the device:

Combitube

8 Comments

  • C s says:

    All the services I know of in southrast pa have switched from the combi-tube to the king lt…one tube, and just as easy. I’ve only used it once on a patient but reconize that after three missed attempts at eti I’ll use it.

  • Robert B says:

    Great backup airway…I’ll try once with an ET and then generally go with the combitube. Before being a medic I was an intermediate and these were in our scope too, so they’re pretty familiar. Downside is no pedi sizes, so the King LTD has that advantage. Nice thing is being able to get an OG tube down the combitube.

  • Justin Miller says:

    In WV we get to use the combitube on pulseless and apenic patients as a basic so usually i would try to secure airway and get AED and compressions started before a medic could intercept with my basic squad. I feel it worked quite well and most medics were pretty happy to not have to deal with securing an airway upon arriving.

  • Mark S. says:

    We’ve switched to the King LT. The Combitube has latex in the cuff and has been relagated to a back-up in our rig. The King LT takes the ease of placement of the Combitube and removes the guesswork of which port to ventilate!

  • JCW says:

    Combitubes were put on a back burner in several areas due to the king airway, however I must say I have been a part of 4 intubation attempts with a king, three off which didn’t work. I have yet to have a combitube fail to work and have been a part of placing 3 of them. Bottom line in the field work I have done the combitube has been far more trustworthy, to the point that our service has removed king airways from the protocols, we only use combitubes

  • medicscribe says:

    Thanks for all the great comments. The service I oversee as an EMS coordinator has King Lts and has had great luck with them. I am hoping to get the service I work for to get them as well, although I have heard some reports of people having trouble. I guess no airway works all the time. To me the important thing is to have an easily available backup if Plan A doesn’t work. And key to having that available is having a package that fits in the inhouse bag.

    Peter C

  • jeff boulier says:

    The first place winner gets a blue ribbon, so blow up the blue balloon first. The numbers on how much air to use are also printed on the little balloons in case you forget.

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