Combitube Protocol

The Combitube Airway is approved for use by the Monroe County Medical Control Board.

First Responder Agency participation requires the following:

Medical Director Approval

Michigan Department of Consumer and Industrial Services - EMS Division Licensure

Completion of Combitube training

Completion of annual on-going education

Use of the Combitube is restricted to personnel licensed as EMT, EMT-S or EMT-P, and who have completed training. Monroe County First Response agencies shall be responsible for meeting and documenting the annual combitube continuing education of their personnel. It is the responsibility of each agency to ensure the competency of their personnel in the use of the combitube. This is to include annual assessment of cognitive and psychomotor skills. Agencies that elect to participate in the Combitube program shall assure that Combitubes are available on responding vehicles.

Indications for Combitube Use

Patient is unconscious and unable to protect own airway; no apparent gag reflex.

Contraindications

1. Patients under 70 lbs. and under 5 feet tall.

2. Responsive patients with an intact gag reflex.

3. Patients with known esophageal disease.

4. Patients who have ingested caustic substances.

5. Known or suspected foreign body obstruction of the larynx or trachea.

6. Presence of tracheostomy

Procedure - Prehospital

Cardiorespiratory/Respiratory (Pulse Present) Arrest

a. The first priority is to defibrillate the patient in cases of ventricular fibrillation. The AED

should be applied first, using conventional airway management, following the AED protocol.

b. The Combitube should be placed during the one minute of CPR between sets of AED

analyses. (This may somewhat delay subsequent AED analysis).

c. Hyperventilate the patient prior to Combitube insertion for 10-15 seconds using either a BVM or Mouth-to-Mask device with supplemental oxygen.

d. Insertion -- done quickly between ventilation

i. Except in cases of suspected cervical spine injury, hyper-extend the head and neck.

ii. In cases of suspected cervical spine injury, c-spine precautions will be taken at all times.

iii. Patent airway and ventilation should already have been established by other basic methods.

iv. In the supine patient, insert the thumb of a gloved hand into the patient's mouth, grasping the tongue and lower jaw between the thumb and index finger, and lift upward.

Caution: When facial trauma has resulted in sharp, broken teeth or dentures, remove denture and exercise extreme caution when passing the Combitube into the mouth to prevent the cuff from tearing.

v. With the other hand, hold the Combitube with the curve in the same directions as the curve of the pharynx. Insert the tip into the mouth and advance carefully until the printed ring is aligned with the teeth. Caution: DO NOT FORCE THE COMBITUBE. If the tube does not advance easily, redirect it or withdraw and reinsert. Have suction available and ready whenever withdrawing tube.

vi. If the Combitube is not successfully placed within 30 seconds, remove the device and hyperventilate the patient for 30 seconds using basic methods, as described in C above, before re-attempting insertion.

e. Inflation of Combitube

i. Inflate line 1, blue pilot balloon leading the pharyngeal cuff, with 100ml of air using the

140ml (cc) syringe. (This may cause the Combitube to move slightly from the patient's mouth).

ii. Inflate line 2, white pilot balloon leading the distal cuff, with approximately 15ml of air using the 20ml (cc) syringe.

f. Ventilation

i. Begin ventilation through the longer blue (distal) tube. Watch for chest rise. If auscultation of breath sounds is positive and auscultation of gastric air sounds is negative, continue ventilation.

ii. If no chest rise, negative lung sounds, and/or positive gastric air sounds with ventilation through the distal tube, begin ventilation through the shorter clear (proximal) tube. Confirm ventilation with chest rise, presence of auscultated lung sounds, and absence of gastric air sounds.

iii. If there is no chest rise or positive lung sounds through either tube, remove the device, hyperventilate the patient 20-30 seconds as described in C above, and repeat the insertion/inflation/ventilation procedures.

iv. Continue to ventilate the patient through the tube which resulted in lung sounds using a BVM or a manually triggered oxygen delivery value.

v. REASSESS TUBE PLACEMENT FOLLOWING EVERY PATIENT MOVEMENT.

g. If two consecutive attempts at intermediate airway placement fail to result in a proper placement and ventilation, do not attempt placement again. Ventilate the patient using basic methods and equipment.

h. Removal of Combitube - at direction of Medical Control or when attempting reinsertion, or if the patient awakens. Remove combitube as follows:

i. Have suction ready

ii. Deflate blue tube

iii. Deflate white tube

iv. Remove combitube

v. Be prepared for vomiting

NOTE ON SUCTIONING THROUGH THE COMBITUBE: When suctioning the patient through the Combitube, always introduce the suction catheter through Tube #2 (white). Because the Combitube will usually be in the esophagus, most through the tube suctioning will be gastric suctioning and will result in decreased gastric distension. In the event that the Combitube is in the trachea, suctioning of the patient's airway will result.

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