The Combitube oesophageal-tracheal double lumen airway for difficult intubation

Maternal morbidity, mortality, and risk assessment

Maternal deaths in developed countries continue to decline and are rare. Maternal mortality statistics are essentially similar in the United States and United Kingdom. However, the situation is completely different in developing countries, where maternal mortality exceeds 0.5 million every year. This article not only assesses morbidity risks in some of the leading causes of maternal death but also highlights strategies to minimize the risks and to prevent maternal morbidity and mortality.

Difficult Airway Society guidelines for management of the unanticipated difficult intubation

Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flow-charts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS.

DISCLAIMER

It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.

The Esophageal-Tracheal Combitube

The ETC is an easily inserted, double-lumen/double-balloon supraglottic airway device. The major indication of the ETC is as a back-up device for airway management. It is an excellent option for rescue ventilation in both in- and out-of-the-hospital environments and in situations of difficult ventilation and intubation. It is useful especially in patients with massive airway bleeding or limited access to the airway and in patients in whom neck movement is contraindicated. Continued airway management with an ETC that has been placed is a reasonable option in many cases. Having thus secured the airway, it may not be necessary to abort the anesthetic or to continue with further airway management efforts. In order to avoid serious trauma to the esophagus or airway, redesigning the ETC using a softer material for the tube is advisable.

Use of the Combitube for airway maintenance during percutaneous dilatational tracheostomy

The Combitube airway allows short-term ventilation during cardiopulmonary resuscitation and can be useful in the management of the difficult airway. In a prospective observational study we assessed its use during percutaneous dilatational tracheostomy (PDT). Twenty-one intensive care patients scheduled for elective PDT had their tracheal tube replaced by a Combitube airway retaining the same ventilator settings. Arterial blood gases, airway pressures, SpO2 and end-tidal CO2 were measured as were the transmural pressures exerted by the Combitube cuffs. Combitube placement was successful in 20 of 21 patients although adequate ventilation was possible in only 17 (85%). There was no significant change in PaO2, SpO2, end-tidal CO2, Paco2 or mean airway pressure during Combitube ventilation. A high mean (SD) transmural pressure of 14.7 (5) kPa was exerted by the distal cuff. The Combitube provided a satisfactory alternative airway to the tracheal tube during performance of PDT in 85% of our patients. Potential problems associated with its use in intensive care patients are outlined.

Piriform sinus perforation during Esophageal-Tracheal Combitube placement

The Esophageal-Tracheal Combitube is a new alternative airway device. Few complications of its use have been reported. This article reports a case of a 71-year-old female with angioedema of the tongue and airway obstruction who suffered piriform sinus rupture during Combitube placement by prehospital personnel, resulting in massive subcutaneous emphysema. Caution is required when using this device in all but the most controlled situations.

Effectiveness of the self-inflating bulb for verification of proper placement of the Esophageal Tracheal Combitube

The esophageal tracheal Combitube (ETC; Sheridan Catheter Corporation, Argyle, NY) is a twin-lumen tube used to establish emergency ventilation. After blind placement, ventilation is performed via the proximal lumen if it is in the esophagus or via the distal lumen if it is in the trachea. This investigation was designed to test the reliability of the self-inflating bulb (SIB) in identifying the location of the ETC and facilitating its proper positioning in anesthetized patients. In Group 1 (n = 26), the ETC was introduced blindly. In Group 2 (n = 20), the tube was placed in the trachea (eight patients) or once in the trachea and once in the esophagus, randomly (12 patients) under direct vision rigid laryngoscopy by the anesthesiologist performing the intubation. In both groups, the efficacy of the SIB in identifying the location of the ETC was tested by a second blinded anesthesiologist. In Group 1, blind insertion of the ETC resulted in esophageal placement in all patients, and in each case was correctly identified. The second anesthesiologist reported no reinflation when the compressed SIB was connected to the distal lumen. When the compressed SIB was connected to the proximal lumen, instantaneous reinflation was observed in 23 patients, delayed reinflation (2-4 s) in two and no reinflation (> 4 s) in one patient. Instantaneous reinflation occurred in these three patients after repositioning of the ETC. In Group 2, the second anesthesiologist correctly identified the location of the ETC in all cases. The results confirm previous findings that blind introduction of the ETC leads to esophageal placement and yields adequate ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)