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Lamb, Keith D. KLamb at Christianacare.org
Wed Apr 5 17:09:55 BST 2006

Sorry Charles.......I was replying to the post from Scott Hax to Jules as
follows.......but thanks for the info!!


A few other places that I'm aware of allow Combitube use by EMT-B's as a  
primary airway, which is well-supported by the evidence. 
Cautious anecdote: While I'm with you on the "never seems to wind up in the

trachea..." there are studies that describe up to 10% rate of tracheal  
placement, and further, I'm aware of a terrifying tale of a man who arrived
dead into the resus bay with a Combitube in his throat. The crew was  
ventilating through Port "#1" while the Combitube tube was actually seated
in  the 
trachea. This is analgous to an unrecognized esophageal intubation with a  
regular ETT. 
IMHO: ETCO2 and/or EDD use ought to be mandated for anyone using the  
Combitube as a rescue airway. Both will work. 
Scott Hax
Lebanon NH 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Charles Brault
Sent: Wednesday, April 05, 2006 11:11
To: Trauma &amp, Critical Care mailing list
Subject: Re: LMA

"Keith D. Lamb" <kdlamb at prodigy.net> wrote:  Scott,

Can you direct me to this "evidence"? Thanks.

  Yeah !
  But you are going to havbe to stop calling me Scott ! !)))
  Resuscitation. 2002 Jan;52(1):77-83.                                   
Use of the esophageal tracheal combitube by basic emergency medical

Lefrancois DP, Dufour DG.

Regie regionale de la sante et des services sociaux de la Monteregie,
Services prehospitaliers d'urgence, 1255, rue Beauregard, Longueuil Que.,
Canada J4K 2M3. m.laroche at rrsss16.gouv.qc.ca

The most appropriate airway device for use in EMS systems staffed by basic
skilled EMTs with (EMT-Ds) or without (EMT-Bs) defibrillation capabilities
is still a matter of debate. The purpose of this study was to assess the
feasibility, safety and effectiveness of the Esophageal Tracheal Combitube
(ETC) when used by EMT-Ds in cardiorespiratory arrest patients of all
etiologies. The EMTs had automatic external defibrillator (AED) training but
no prior advanced airway technique skills. The prehospital intervention was
reviewed using the EMTs cardiac arrest report, the AED tape recording of the
event and the assessment of the receiving emergency physician. The patients'
hospital records and autopsy report were reviewed in search of
complications. Eight hundred and thirty-one adult cardiac arrest patients
were studied. Placement was successful in 725 (95.4%) of the 760 patients
where it was attempted and ventilation was successful in 695 (91.4%).
Immediate complications
 encountered, but not necessarily related to the use of the ETC, were;
subcutaneous emphysema (18), tension pneumothorax (5), blood in the
oropharynx (15), and swelling of the pharynx (three). An autopsy was done in
133 patients; no esophageal lesions or significant injury to the airway
structures were observed. Our results suggest that EMT-Ds can use the ETC
for control of the airway and ventilation in cardiorespiratory arrest
patients safely and effectively.
  Anaesthesia 1999 Feb;54(2):181-3      
  A comparison of two airway aids for emergency use by unskilled personnel.
The Combitube and laryngeal mask.

Yardy N, Hancox D, Strang T.

Department of Anaesthesia, Manchester Royal Infirmary, Oxford Road,
Manchester M13 9WL, UK.

Many non-anaesthetists find airway control and intubation difficult. The
laryngeal mask has been advocated for use by non-anaesthetists at
cardiorespiratory arrests, whilst the Combitube is said to provide
protection from aspiration. We wished to determine which device was easiest
for unskilled staff to use. Staff not previously trained in airway support
were briefly taught insertion of each device. Twenty-six ASA 1 or 2 adults,
requiring muscle relaxation and tracheal intubation for surgery, were
recruited to this randomised crossover study. Both devices were inserted in
random order and the time to successful ventilation of the lungs recorded.
Both devices were successfully placed in 24/26 patients. The median times to
insertion were 40 s and 45 s for the laryngeal mask and Combitube,
respectively, with two failures, both with the Combitube (p > 0.05); these
were due to faulty operator technique. The Combitube may be a suitable
alternative to the laryngeal mask for use in
 resuscitation by unskilled staff.
  Prehosp Emerg Care 2000 Oct-Dec;4(4):333-7
Successful prehospital airway management by EMT-Ds using the combitube.

Ochs M, Vilke GM, Chan TC, Moats T, Buchanan J.

San Diego County Department of Health Services, University of California,
San Diego Medical Center, 92103, USA.

OBJECTIVE: To evaluate the ability to train emergency medical
technicians-defibrillation (EMT-Ds) to effectively use the Combitube for
intubations in the prehospital environment. 
  METHODS: This was an 18-month prospective field study in which EMT-Ds were
trained how and in what situations to use the Combitube. Data were then
obtained for all patients in whom Combitube insertion was attempted.
Indications for use of the Combitube included: unconsciousness without a
purposeful response, absence of the gag reflex, apnea or respiratory rate
less than 6 breaths/min, age more than 16 years, and height at least 5 feet
tall. Contraindications were: obvious signs of death, intact gag reflex,
inability to advance the device due to resistance, or known esophageal
pathology. Data were entered prospectively from the San Diego County EMS
QANet database for prehospital providers. 
  RESULTS: Twenty-two EMT-D provider agencies, involving approximately 500
EMT-Ds, were included as study participants. Combitube insertions were
attempted in 195 prehospital patients in cardiorespiratory arrest, with
appropriate indication for Combitube use. An overall successful intubation
rate (defined as the ability to successfully ventilate) of 79% was observed.
Identical success rates for medical and trauma patients were noted. The
device was placed in the esophagus 91% of the time. Resistance during
insertion was the major reason for unsuccessful Combitube intubations. An
overall hospital admission rate of 19% was observed. No complications were
  CONCLUSION: EMT-Ds can be trained to use the Combitube as a means of
establishing an airway in the prehospital setting. Future studies will need
to further evaluate its effect on patient outcome.
  Prehosp Emerg Care 1997 Jan-Mar;1(1):1-10             
Comment in: 
  ·         Prehosp Emerg Care. 1997 Jan-Mar;1(1):58-9. 
The PTL, Combitube, laryngeal mask, and oral airway: a randomized
prehospital comparative study of ventilatory device effectiveness and
cost-effectiveness in 470 cases of cardiorespiratory arrest.

Rumball CJ, MacDonald D.

Paramedic Academy, Justice Institute of British Columbia Faculty of
Medicine, University of British Columbia, Canada.

PURPOSE: A prehospital study was conducted to assess and compare three
alternative airway devices and the oral airway for use by non-Advanced Life
Support emergency medical assistants (EMAs). METHOD: A modified randomized
crossover design was used. The Pharyngeal Tracheal Lumen Airway (PTL), the
laryngeal mask (LM), and the esophageal tracheal Combitube (Combi) were
compared objectively for success of insertion, ventilation, and arterial
blood gas and spirometry measurements performed upon hospital arrival.
Subjective assessment was carried out by EMAs and receiving physicians at
the time of device use, and an eight-question comparative evaluation of all
devices was completed by EMAs at study conclusion. A comparative cost
analysis was performed. Operating room training was compared with mannequin
training for the LM. Autopsy findings and survival to hospital discharge
were analyzed. The study took place in four non-ALS communities over four
and a half years, and involved
 470 patients in cardiac and/or respiratory arrest. EMAs had automatic
external defibrillator training but no endotracheal intubation skills.
RESULTS: Successful insertion and ventilation: Combi, 86%; PTL, 82%; LM, 73%
(p = 0.048). No significant difference was found for objective measurements
of ventilatory effectiveness (ABGs and spirometry). Significant comparative
differences in subjective evaluation were found. CONCLUSIONS: The PTL, LM,
and Combi appear to offer substantial advances over the OA/BVM system.
Although the most costly, the Combitube was associated with the least
problems with ventilation and was the most preferred by a majority of EMAs.
  Ann Emerg Med 1993 Oct;22(10):1573-5                
Emergency intubation with the Combitube: comparison with the endotracheal

Staudinger T, Brugger S, Watschinger B, Roggla M, Dielacher C, Lobl T, Fink
D, Klauser R, Frass M.

Department of Medicine I, Intensive Care Unit, Vienna, Austria.

STUDY OBJECTIVE: To evaluate the safety and effectiveness of the Combitude
as used by ICU nurses under medical supervision compared with endotracheal
airway established by ICU physicians during CPR. DESIGN: Prospective study
of ICU patients over a seven-month period. SETTING: Medical ICU.
PARTICIPANTS: Thirty-seven patients suffering from cardiac arrest.
INTERVENTIONS: Emergency intubation with either the Combitube by nurses or
the endotracheal airway by physicians and subsequent mechanical ventilation.
MEASUREMENTS AND MAIN RESULTS: Evaluation of blood gases after 20 minutes of
mechanical ventilation. Intubation time was shorter for the Combitube (P <
.001). Blood gases for each device showed comparable results; PaO2 was
slightly higher during ventilation with the Combitube (P < .001).
CONCLUSION: The Combitube as used by ICU nurses was as effective as
establishment of the endotracheal airway by intensivists during CPR. The
Combitube may be used whenever endotracheal
 intubation cannot be performed immediately.
  Ann Emerg Med 1993 Aug;22(8):1263-8                 
Ability of paramedics to use the Combitube in prehospital cardiac arrest.

Atherton GL, Johnson JC.

Emergency Medical Systems Education and Development, Porter Memorial
Hospital, Valparaiso, Indiana.

STUDY OBJECTIVE: To evaluate the ability of paramedics in a nonurban
emergency medical services system to use the Combitube, a combined
endotracheal and esophageal obturator airway adjunct, in prehospital cardiac
arrest patients. DESIGN: A prospective, controlled study to evaluate the
difficulty and complications of insertion, recognition of esophageal versus
tracheal placement, skill proficiency, and retention. The ability to use the
device in cases of failed endotracheal intubation also was scrutinized.
SETTING: Evaluation of the paramedic's ability to use the Combitube was
performed in a prehospital environment. A follow-up study to determine
retention of insertion skill was conducted in a controlled laboratory
setting. INTERVENTIONS: Fifty-two cases of paramedic prehospital Combitube
insertion were examined, and 11 paramedics were evaluated for skill
retention. MEASUREMENTS AND MAIN RESULTS: Combitube insertion was attempted
on 52 prehospital patients in cardiac arrest,
 and 69% were intubated successfully. Paramedics recognized esophageal
versus tracheal placement in 100% of the cases. The Combitube was inserted
successfully into 64% of the patients who could not be endotracheally
intubated by the conventional visualized method. The Combitube was inserted
successfully 71% of the time when used as a first-line airway adjunct. A
follow-up study on 11 randomly selected paramedics involved in the field
study was conducted 15 months later. Nine of 11 paramedics demonstrated
inadequate skill retention in the follow-up study. CONCLUSION: Although
visualized endotracheal intubation remains the preferred method of airway
control, the Combitube may be an effective prehospital airway device as both
a backup to the endotracheal tube and a primary airway. Although the
Combitube does not require visualization with a laryngoscope, comprehensive
training and continuing education are key factors affecting skill retention.


  Anesth Analg 2000 Nov;91(5):1274-8 
  Cervical spine motion during airway management: a cinefluoroscopic study
of the posteriorly destabilized third cervical vertebrae in human cadavers.

Brimacombe J, Keller C, Kunzel KH, Gaber O, Boehler M, Puhringer F.

University of Queensland, Department of Anesthesia and Intensive Care,
Cairns Base Hospital, Australia. jbrimacombe at north.net.au

We conducted a randomized, controlled, crossover study to determine cervical
spine motion for six airway management techniques in human cadavers with a
posteriorly destabilized third cervical (C-3) vertebra. A destabilized C-3
segment was created in 10 cadavers (6-24 h postmortem). Cervical motion was
recorded by continuous lateral fluoroscopy. The following airway management
techniques were performed in random order on each cadaver with manual
in-line stabilization applied: face mask ventilation (FM),
laryngoscope-guided orotracheal intubation (OETT), fiberscope-guided nasal
intubation (FOS-NETT), esophageal tracheal Combitube((R)) (Kendall-Sheridan,
Neustadt, Germany) insertion (ETC), intubating laryngeal mask insertion with
fiberscope-guided tracheal intubation (ILM-OETT), and laryngeal mask airway
insertion (LMA). Afterward, maximum head-neck flexion (FLEX-MAX) and maximum
head-neck extension (EXT-MAX) without manual in-line stabilization was
performed to determine
 maximum motion. The maximum posterior displacement of C-3 and the maximum
segmental sagittal motion of C2-3 were determined. There was a significant
increase in posterior displacement for the FM (1.9 +/- 1.2 mm, P: < 0.01),
OETT (2.6 +/- 1.6 mm, P: < 0.0001), ETC (3.2 +/- 1.6 mm, P: < 0.0001),
ILM-OETT (1.7 +/- 1.3 mm, P: < 0. 01), LMA (1.7 +/- 1.3 mm, P: < 0.01),
FLEX-MAX (3.7 +/- 1.9 mm, P: < 0.0001), EXT-MAX (1.8 +/- 1.7, P: < 0.01),
however, not for FOS-NETT (0.1 +/- 0.7 mm). Posterior displacement was less
for the ILM-OETT and LMA than for the ETC (both P: < 0.04). There were no
significant increases in segmental sagittal motion with any airway
manipulation other than with FLEX-MAX (-4.5 +/- 4.0 degrees, P: < 0.01).
Posterior displacement was similar to FLEX-MAX for the OETT and ETC;
however, it was less for the FM, FOS-NETT, ILM-OETT, and LMA (all P: <
0.01). Posterior displacement was similar to EXT-MAX for all airway
manipulations other than for FOS-NETT (P: <
 0.001). For cervical motion and the techniques tested, the safest method of
airway management in a patient with a posteriorly destabilized C-3 segment
is FOS-NETT. LMA devices may be preferable to the ETC. Implications: In the
cadaver model of a destabilized third cervical vertebrae, significant
displacement of the injured segment occurs during airway management with the
face mask, laryngoscope-guided oral intubation, the esophageal tracheal
Combitube (Kendall-Sheridan, Neustadt, Germany), the intubating and standard
laryngeal mask airway; but not with fiberscope-guided nasal intubation. For
cervical motion and the techniques tested, the safest airway technique with
this injury is fiberscope-guided nasotracheal intubation. Laryngeal mask
devices are preferable to the esophageal tracheal Combitube.

  Can J Anaesth 1999 Apr;46(4):393-7                   
Erratum in: 
  ·         Can J Anaesth 1999 Jul;46(7):706 
Esophageal and tracheal distortion by the Esophageal-Tracheal Combitube: a
cadaver study.

Vezina D, Trepanier CA, Lessard MR, Bussieres J.

Departement d'anesthesie, Centre hospitalier affilie universitaire de
Quebec, P. Quebec, Canada. vezd at quebectel.com

PURPOSE: To understand the anatomical relationships of the
Esophageal-Tracheal Combitube (ETC) with the larynx, pharynx, esophagus and
trachea. METHODS: An extensive dissection of the neck and thorax of a
70-yr-old caucasian male cadaver was done to expose the larynx, pharynx,
trachea and esophagus. The ETC was inserted following the manufacturer's
recommendations. Effects of the ETC on the surrounding structures were
observed with the ETC first inserted in the esophagus and then, in the
trachea. RESULTS: When inserted in the esophagus, the ETC produced marked
bulging of the anterior wall of the esophagus and anterior displacement (4.5
cm) of the trachea. Inflation of the distal cuff of the ETC produced
distension of the esophagus. When inserted in the trachea, the ETC also
caused anterior protrusion. CONCLUSION: Protrusion of the anterior wall of
the esophagus and distension resulting from inflation of the distal cuff
could lead to esophageal injuries. These observations
 may explain the previously reported complications associated with the use
of the ETC.
  Resuscitation 2000 Mar;44(1):71-4      
  A case report of difficult ventilation with the Combitube - valve-like
upper airway obstruction confirmed by fibreoptic visualisation.

Jaehnichen G, Golecki N, Lipp MD.

Clinic of Anaesthesiology, University Hospital Mainz, Langenbeckstrasse 1,
55131, Mainz, Germany.

This case report describes difficulty with ventilation because of valve-like
upper airway obstruction by aryepiglottic folds after uncomplicated
insertion of a Combitube in a 30-year-old female patient. After correct
(oesophageal) placement increased ventilation pressures occurred and a
fibreoptic device was used to investigate the cause. Valve-like obstruction
was discovered and subsequently observed during controlled ventilation.
After removal of the Combitube and mask ventilation no valve mechanism was
seen. This effect appeared to be due to an increased air stream caused by
the obstruction of seven out of eight Combitube perforations.

  Anaesthesia 1999 Dec;54(12):1161-5                   
Comment in: 
  ·         Anaesthesia. 2000 Apr;55(4):394-5. 
  ·         Anaesthesia. 2000 Jun;55(6):597-9. 
  Complications following the use of the Combitube, tracheal tube and
laryngeal mask airway.

Oczenski W, Krenn H, Dahaba AA, Binder M, El-Schahawi-Kienzl I, Kohout S,
Schwarz S, Fitzgerald RD.

Department of Anaesthesia, City of Vienna Hospital Lainz, Vienna, Austria.

In a prospective, randomised trial, 75 patients scheduled for routine
surgery were randomly allocated to one of three groups to evaluate trauma
and postoperative complications after insertion of the Combitube, tracheal
tube or laryngeal mask airway. Insertion of the Combitube was associated
with a higher incidence of sore throat (48% vs. 16% vs. 12% [p < 0.01]) and
dysphagia (68% vs. 12% vs. 8% [p < 0.01]) compared with tracheal intubation
or insertion of the laryngeal mask airway, respectively. Hoarseness was
significantly less common in both the Combitube and the laryngeal mask
groups (both 12%) than in the tracheal tube group (44%; p < 0.01). Haematoma
occurred in 36% of the Combitube group compared with 4% in both the
laryngeal mask and the tracheal tube groups (p < 0.01). The higher incidence
of complications should be considered when using the Combitube.
  Anaesthesia 1998 Oct;53(10):971-4                    
Comment in: 
  ·         Anaesthesia. 1999 Mar;54(3):304-5. 
Insertion of the Combitube airway with the cervical spine immobilised in a
rigid cervical collar.

Mercer MH, Gabbott DA.

Department of Anaesthesia, Southmead Hospital, Westbury-on-Trym, Bristol,

The Combitube is a twin lumen device designed to establish the airway after
blind insertion. Under general anaesthesia a rigid cervical collar was used
to immobilise the neck in 15 ASA 1 and 2 patients. Insertion of the
Combitude airway was then attempted. In 10/15 (66%) patients, blind
insertion was not possible. In 5/15 (33%) successful blind insertions the
Combitube entered the oesophagus on each occasion. In 8/10 of the failures,
re-insertion of the Combitude was attempted with the aid of a Macintosh
laryngoscope. In 6/8 cases (75%) satisfactory placement was then possible
with the Combitube again entering the oesophagus on each occasion.
Ventilation was satisfactory in all patients when insertion was successful.
Blood staining of the Combitube was present in 7/15 (47%) patients. The
Combitude cannot be recommended for use in patients whose necks are
immobilised in rigid cervical collars.

Resuscitation 2001 Nov;51(2):135-8      


An assessment of protection of the airway from aspiration of

oropharyngeal contents using the Combitube airway.


Mercer MH.


Department of Anaesthesia, Frenchay Hospital, North Bristol NHS

Trust, Bristol BS16 1LE, UK.


A Combitube airway was inserted blindly into 27 American Society of

Anaesthesiologist (ASA) grade 1 and 2 patients undergoing general

anaesthesia. All had Cormack and Lehane grade 1 direct views of the

larynx. Ten ml of 0.1% methylene blue dye was instilled into each

patients mouth for the duration of surgery. The oropharynx was then

aspirated and dried at completion of surgery and the Combitube

removed. The laryngeal inlet and trachea were examined for dye

staining. In 25/27 patients (93%) no tracheal soiling was seen. In

2/27 patients (7%) tracheal soiling was seen (95% confidence interval

0.9-24.3%). The Combitube protects the airway in the majority of

patients from aspiration of dye within the oral cavity, but the

failure rate means it cannot be relied upon absolutely to do so. This

has implications for management of the trauma patient

    Epinephrine application via an endotracheal airway and via the Combitube
in esophageal position

  Julia Kofler, MD; Fritz Sterz, MD; Roland Hofbauer, MS; Suzanne Rödler,
MD; Ernst Schuster, PhD; Marianne Winkler, MD; Ilse Schwendenwein, DVM; Udo
Losert, DVM; Christian Bieglmayer, PhD; Jonathan L. Benumof, MD; Michael
Frass, MD
  From the Department of Emergency Medicine (Drs. Kofler and Sterz), the
Department of Anesthesiology B (Mr. Hofbauer), the Department of Internal
Medicine II (Dr. Rödler), the Department of Medical Computer Sciences (Dr.
Schuster), the Department of Anesthesiology and General Intensive Care
Medicine (Dr. Winkler), the Center for Biomedical Research (Drs.
Schwendenwein and Losert), the Institute for Medical and Chemical Laboratory
Diagnostics (Dr. Bieglmayer), and the Department of Internal Medicine I,
Intensive Care Unit (Dr. Frass), University of Vienna, School of Medicine,
Vienna, Austria; and the Department of Anesthesiology (Dr. Benumof),
University of California, San Diego, CA.
  CRITICAL CARE MEDICINE 2000;28:1445-1449

  Objective: To compare plasma concentrations and cardiovascular effects of
epinephrine after application via a conventional endotracheal airway and via
the esophageal lumen of a new emergency airway, the esophageal tracheal
  Design: Prospective, randomized study.
  Setting: Center for Biomedical Research, University of Vienna.
  Subjects: Fourteen juvenile swine received either an endotracheal tube
(Group A) or a Combitube in esophageal position (Group B).
  Interventions: In Part I of the study, epinephrine was administered during
spontaneous beating of the heart; in Part II, epinephrine was administered
during cardiopulmonary resuscitation, using a ten-fold higher dosage in
Group B, respectively.
  Measurements: Plasma epinephrine levels were measured 1, 2, 3, 5, 7, 10,
15, and 30 mins after application. Systolic arterial blood pressure and
cardiac output in Part I, and end-tidal CO2 and coronary perfusion pressure
in Part II were recorded.
  Main Results: In Part I, increased levels of plasma epinephrine and
systolic arterial pressure were maintained significantly longer in Group B
when compared with Group A. In Part II, no significant differences between
the groups were found with regard to plasma epinephrine levels and
hemodynamic variables.
  Conclusion: Epinephrine applied via the esophageal lumen of the Combitube
in a ten-fold higher dosage has similar effects on plasma epinephrine levels
and hemodynamic variables compared to endotracheal administration.
  Key Words: cardiopulmonary resuscitation; drug administration routes;
endotracheal tube; epinephrine administration; epinephrine plasma levels;
esophageal tracheal Combitube; pharyngeal mucosa.

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