Emergency intubation with the Combitube in a grossly obese patient with bull neck

Airway management in the obese patient

Airway management is a major factor underlying morbidity and mortality in the obese population. The validity of anthropomorphic prediction model in assessing a difficult airway is less accurate compared with lean subjects. Preoperative evaluation and anticipation of potential complications are critical for safe and successful intubation. Application of noninvasive positive airway pressure can prevent atelectasis and improve oxygenation during the anesthetic induction as well during the postoperative period and after liberation from mechanical ventilation. When performed by trained operators, bedside percutaneous dilatation tracheostomy in obese patients has a safety profile comparable to surgical tracheostomy but provides advantages including ease of performance and lesser cost, and obviates transporting a critically ill patient outside the intensive care unit.

Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients

The ventilatory management of patients with acute respiratory failure is supported by good evidence, aiming to reduce lung injury by pressure limitation and reducing the duration of ventilatory support by regular assessment for discontinuation. Certain patient groups, however, due to their altered physiology or disease-specific complications, may require some variation in usual ventilatory management. The present manuscript reviews the ventilatory management in three special populations, namely the patient with brain injury, the pregnant patient and the morbidly obese patient.

Alternative airway devices for use in children requiring prehospital airway management: update and case discussion

This manuscript reviews the latest literature on alternative airways for use in children requiring prehospital airway management. Case discussions serve as a springboard for discussion of alternatives to bag-mask ventilation and endotracheal intubation for management of ventilation in infants and children in the prehospital setting. Few airway procedures have been studied with any rigor in this setting, and most of the data that are available are extrapolated from adults. Laryngeal mask airway may be the best alternative airway with the most promise to add to the armamentarium of the prehospital provider, but no controlled trial to date has been conducted.

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.

Resuscitation of the morbidly obese patient

Obesity is a major health care problem in the United States. The body mass index (BMI) is the standard measure of obesity. A BMI >25 kg/m2 is defined as overweight and obesity as a BMI > 30 kg/m2. Recent surveys indicate that 54% of adults, or roughly 97 million people, are overweight. Given the incidence of obesity in the general population, it is likely that EM physicians will be involved in the emergency care of critically ill or injured obese patients. The objective of this article is to present the clinical problems associated with the resuscitation of the critically ill or injured obese patient and their potential solutions.

Tracheal esophageal combitube: a useful airway for morbidly obese patients who cannot intubate or ventilate

The tracheal esophageal combitube has been successfully used in many difficult airway circumstances. We report the dramatic case of a morbidly obese patient with a well-known difficult airway who was successfully rescued from a cannot ventilate-cannot intubate situation in our critical care unit by using the tracheal esophageal combitube. Surgical tracheostomy was performed while she was mechanically ventilated through the tracheal esophageal combitube. The tracheal esophageal combitube is a very important device that should be kept available in all cases of morbidly obese airway management.

Use of the esophageal tracheal combitube by basic emergency medical technicians

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.

Respiratory failure after tracheal extubation in a patient with halo frame cervical spine immobilization--rescue therapy using the Combitube airway

A 78-yr-old man, with halo frame cervical spine immobilization, suffered rapid respiratory deterioration after tracheal extubation in the intensive care unit. Control of the airway was difficult as bag-valve-mask ventilation was ineffective, tracheal intubation was known to be difficult from management of a previous episode of respiratory failure on the ward, and laryngeal mask insertion proved impossible. Rescue therapy using a Combitube airway is described and discussed.

Microbiological, microstructure, and material science examinations of reprocessed Combitubes after multiple reuse

Reprocessing (repeated cleaning, disinfection, and sterilization) and reuse of single-use medical devices has been performed safely with some devices. The aim of our study was to analyze whether reprocessing of the Combitubes (Kendall-Sheridan, Argyll, NY) airway device, used for emergency endotracheal intubation and difficult airway management, is possible and can be performed appropriately and safely. Microbiological, microstructure, and material science examinations were performed with unused, as well as multiple reused and reprocessed Combitubes. The reprocessing procedure consisted of a cleaning, a disinfection, a final inspection, and a sterilization. Microbiological examinations of multiple reused and reprocessed Combitubes found no test organisms in quantitative cultures. A microbial reduction between four and five log levels compared with nonreprocessed tubes was found. Microstructure analysis for the examination of topographical alterations and changes in the chemical composition of the surface demonstrated nonsignificant alterations between new and reprocessed medical devices. In material science examinations, cuff burst pressures were not different between unused and multiple reprocessed Combitubes. The results of all examinations proved that the decontamination process is adequately effective, and that no significant superficial alterations are generated by the multiple reuse and reprocessing of the Combitubes. To assure uniformly good results, a quality management system must be established and only validated methods should be used.

IMPLICATIONS

Reprocessing of single-use medical devices offers the opportunity of significant savings and is already performed with some devices. Microbiological, microstructure, and material science examinations proved that reprocessing of multiple reused Combitubes (Kendall-Sheridan, Argyll, NY), mainly used for emergency airway management, is possible and safe.

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.

Lost airway during anesthesia induction: alternatives for management

Pediatric and adult patients with upper airway obstruction pose several challenges to the anesthesiologist and otolaryngologist--head and neck surgeon. The initiation of general anesthesia and endotracheal intubation may progress to complete life-threatening respiratory decompensation with failure to achieve endotracheal intubation or mask ventilation. Hurried invasive maneuvers such as large-bore needle tracheal entry and cricothyrotomy are recognized salvage techniques, but other modes of extratracheal ventilation are now possible before surgical airway procedures are required. The laryngeal mask airway and esophagotracheal Combitube (Kendall Sheridan Health Care Products Co., Argyle, NY) are described, with examples of their clinical application. The combined technique of anterior commissure laryngoscopy and intubation with the gum elastic bougie is the preferred alternative for achieving tracheal entry when extratracheal ventilation cannot be accomplished. An algorithm for joint management of the problem airway by anesthesiologist and otolaryngologist--head and neck surgeon is illustrated.

Successful intubation with the Combitube in acute asthmatic respiratory distress by a Parkmedic

The Combitube is a relatively new device used for blind insertion emergency intubation. We report a case of successful Combitube treatment of an acute respiratory arrest secondary to an acute asthma exacerbation. An advanced EMT-II (National Park Service Parkmedic) utilized this device. Our review of the literature revealed no reported cases of an advanced EMT-II, nor any other cases, using the Combitube in asthma-related respiratory failure.