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Emergency intubation with the Combitube

1996; Lippincott Williams & Wilkins; Volume: 13; Issue: 1 Linguagem: Inglês

10.1097/00003643-199601000-00019

1365-2346

Georg Petroianu, Katharina Kötter, Wolfgang H. Maleck,

Respiratory Support and Mechanisms

Sir: Staudinger et al. presented two cases of emergency airway management by the Combitube [1]. Their contribution warrants several comments. The authors are right in their assessment that 'the physician ... in case one might have managed the situation better by taking [several] precautions for a difficult intubation': pre-oxygenation with 100% oxygen which should have been possible even with a leaking cuff; direct laryngoscopy prior to extubation and/or use of a tube exchanger; avoidance of a non-depolarizing muscle relaxant in a patient in whom both difficult intubation and difficult mask ventilation were predictable. However, they state that 'auscultation of breath sounds and the absence of gastric insufflation confirm adequate ventilation when the Combitube is in the oesophagus'. Reliance on auscultation is dangerous. It was shown with the tracheal tube and the oesophageal obturator that auscultation is not fail safe, and it is unlikely to be so with the Combitube [2-4]. Because emergency placement of the Combitube may result in tracheal placement in up to 17% [5], a fail safe device for assessment of the Combitube position is needed. The Oesophageal Detector Device (ODD), first described by Pollard in 1980 [6], reinvented by Wee in 1988 [7], and subsequently used in thousands of tracheal intubations [8], was tested successfully with the Combitube [9]. ODDs are commercially available (Ambu Inc., Linthicum, MD 21090, USA). Initial control of tube position with an ODD should always be followed by continuous monitoring of the end-tidal CO2 concentration [8]. The summary states the Combitube 'to be as good as an endotracheal tube in emergency situations'. This is in our opinion not supported by data. The Combitube allows neither tracheal application of drugs nor tracheal suction, does not protect against laryngeal oedema or laryngospasm, and is not available in paediatric size. It cannot replace the tracheal tube as the airway of choice in the hands of physicians or paramedics skilled in intubation. The American Heart Association gave the Combitube only a Ilb status, that is 'acceptable, possibly helpful' [10]. It is, however, an important backup device for patients impossible to intubate like the two cases reported by Staudinger et al. and other cases included in their references [1]. The American Society of Anesthesiologists suggests as contents of a Difficult Airway Management unit 'at least one device ... for emergency nonsurgical ... ventilation. Examples include ... transtracheal jet ventilator, ... jet ventilation stylet, ... laryngeal mask, and ... Combitube' [11]. The Combitube might also be useful for emergency care providers not skilled in intubation. This has not been widely studied and the results are equivocal. An earlier publication of Staudinger et al. reported a 94% success rate of Combitube insertion by ICU nurses, which was comparable to a 95% success rate of tracheal intubation by ICU physicians [12]. In a publication of Atherton and Johnson, however, the success rate of paramedics with the Combitube was only 69%, whereas the success rate of tracheal intubation was 84%. A follow-up 15 months later showed inadequate skill retention in 82% of the paramedics [5]. In summary, the Combitube is an important backup device for adult patients difficult or impossible to intubate. It is in our view not the emergency airway of choice for physicians skilled in tracheal intubation. Even in paramedics with suboptimal skills in tracheal intubation so far no superiority compared to tracheal intubation could be shown. It's insertion should always be followed by use of an Oesophageal Detector Device and capnometry. G. PETROIANU K. KOTTER W. MALECK Ludwigshafen, Germany