INTRODUCTION:

Refer to the Airway Management protocol for indications on use.

1. Physical Requirements / Limitations
   1. 16 y/o and between 48 and 84 inches in height.
   2. Absent gag reflex.

2. Insertion Procedure
   1. Ventilate the patient per AHA guidelines (1-2 seconds per ventilation) using a BVM with supplemental oxygen for at least two minutes prior to attempting to insert the CombiTube.
   2. With patient in supine position, head placed in neutral or "sniffing" position, grasp the mandible between thumb and forefingers. If C-Spine precautions are not a factor, the patient's head may be placed in the head-tilt position to facilitate placement.
   3. Lift the mandible anteriorly, keeping the C-Spine aligned as appropriate.
   4. Holding the CombuTube in the other hand, with its curve towards the pharynx, insert the tip into the mouth and advance it into the phaynx and esophagus.
   5. Advance the airway gently until the black printed lines on the proximal end of the airway, straddle the teeth or gums. If any resistance is met during insertion, withdraw, re-evaluate the patient and re-attempt placement.
   6. The insertion procedure should be accomplished in less than 20 seconds.
   7. Inflate the proximal cuff with approximately 100cc's of air. you should notice the airway moving slightly as the cuff inflates and seats in the posterior oropharynx. Inflate the distal cuff with approximately 15cc's of air.
   8. Using a BVM, ventilate through the port labeled #1 (blue tube). Auscultate lung sounds bilaterally. If lung sounds are present, epigastric sounds are absent and the chest rises, it is positioned in the esophagus and continued ventilation shoud be performed. If the chest does not rise and lung sounds are not heard, or epigastric sounds are heard, attempt ventilation through the port labeled #2 (clear tube). Auscultate breath sounds again. If breath sounds are heard, the tube has been placed into the trachea and ventilation should be continued. Insure that the proximal and distal cuffs are inflated and continue ventilations.

3. Removal Procedure
   1. The CombiTube should only be removed if the field if the patient regains spontaneous respirations and develops a resistance to the airway. If this occurs, turn the patient on his or her side, deflate the cuff, and withdraw the airway. VOMITING WILL MOST LIKELY OCCUR DURING THIS PROCEDURE, SO HAVE SUCTION READY. Contact Medical Control if unsure whether removal of the CombiTube is appropriate or not.

1. Do not use the CombiTube in patients with a history of:
   1. Caustic substance ingestion
   2. Esophageal disease (i.e., esophageal varices)
   3. Inhalation burns
2. Using a CombiTube in a patient with a puncture wound to the neck, may exacerbate airway complications as a result of 'compartmentalizing' hemorrhage in the airway itself.
3. Esophageal rupter, perforation, laceration, and vomiting with aspiration upon insertion or removal of the airway can occur. Do not remove the CombiTube unitl an ET tube has been passed around the airway unless appropriate criteria have been met.
4. Tracheal placement of the CombiTube occurs in approximately 20% of the cases. The most serious danger is not recognizing this immediately and therefore not ventilating through the appropriate port.