Transcript Combitube Training - Verde Valley Emergency Medical Services

Combitube
Training
Mandatory training every 2 years
for all BLS Providers
Verde Valley Emergency Medical Services
TOPICS
 Airway and Respiratory Anatomy and
Physiology
 Basic Airway Management
 Combi-Tube Airway
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
INTRODUCTION
 The importance of establishing and maintaining
an airway in the patient can never be
overstated.
 Despite the majority of patients’ responding
favorably to manual and/or simple mechanical
adjuncts, some may need more advanced
airway procedures.
 It is for this reason that advanced airway skills
are now included as an elective in the EMT-B /
I-99 curriculum.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Upper airway
 Opening of the nose and mouth to the larynx
 Includes the nasopharynx, oropharynx, and hypopharynx
– Lower airway
 Lower portion of the larynx
 Trachea
 Bronchi
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Nose
 Warms the air.
 Provides humidification.
 Coarse hairs serve as an initial filter for inhaled air.
– Mouth
 Also a conduit for airflow.
 Oropharynx contains special reflexes to guard the airway.
– Pharynx
 Conducts airflow, and gives rise to the openings of the lower
airway and the esophagus.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Larynx

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Lies inferior to the pharynx and superior to the trachea
Directs air from pharynx to trachea
Houses the vocal cords
Comprised of three cartilaginous structures
– Thyroid cartilage is the large shield shaped structure.
– Cricoid cartilage is the first compete cartilaginous ring that is
attached to the trachea (inferior aspect of larynx).
– Epiglottis is the leaf shaped structure that covers the larynx
during swallowing.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Larynx
 The vallecula is a depression located between the base of
the tongue and the anterior surface of the epiglottis.
 The glossoepiglottic ligament which suspends and supports
the epiglottis is located at the center of the vallecula.
 These structures are important as they are sometimes
manipulated during advanced airway procedures to lift the
epiglottis (making it possible to visualize the glottic opening).
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Larynx
 View of the laryngeal
structures which shows
the vallecular space
and glossoepiglottic
ligament
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
insert fig 45-1
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Larynx






Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
True vocal cords
False vocal cords
Arytenoid cartilages
Corniculate cartilages
Cuneiform cartilages
All of the above can
be important visual
landmarks during the
intubation procedure.
insert 45-2
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Larynx
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Trachea, Bronchi, and Bronchioles
 Trachea is comprised of 16-20 “C” shaped cartilage rings.
 Rings are posteriorly incomplete as they share a common
wall with the esophagus (trachealis muscle).
 The trachea gives rise to two mainstem bronchi at about
the level of the 5th thoracic vertebrae.
 The point of bifurcation is called the carina.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Trachea, Bronchi, and Bronchioles
 The right mainstem bronchi is of a larger diameter with a
lesser angle than the left (that has a sharper angle due to
the position of the heart).
– The lesser angle makes it easier to misdirect a tracheal tube
into the right mainstream bronchus than into the left.
– The lesser angle also accounts for the fact that aspiration of
foods, liquids, or foreign bodies occurs more commonly in the
right than in the left.
 Finally, the bronchi continue to subdivide into smaller and smaller
bronchioles until the alveolar sacs are reached.
 The alveolar sacs are the sites of gas exchange for the pulmonary
system.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy
– Lungs
 Right and left lungs
 Separated by the
mediastinum
 Wrapped by the
pleural linings
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Airway and Respiratory
Anatomy and Physiology
 Airway Anatomy in Infants and Children
– Differences that are important to remember
 Larger occipital region of the head.
 Mouth, nose, and pharynx smaller, more pliable, and easier
to obstruct.
 Tongue is proportionally larger.
 Larynx and trachea are funnel shaped, the cricoid ring the
narrowest portion.
 Trachea, since it is more flexible, can kink from excessive
hyperextension of the head during airway procedures.
 Chest wall more pliable, fails to adequately support ribs.
 In concert, all these differences add up to a more difficult
airway to manage under even the best circumstances.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Basic Airway Management
 Often, the best situation to use advanced airway
procedures is when you have a patient needing
prolonged ventilation.
 Beyond this, you will only use these skills when
basic airway maneuvers fail to provide you an
airway.
 Remember, you should only use these skills
when you need to; do not use them simply
because you can.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Basic Airway Management
 As mentioned previously, the EMT-B will be able
to establish a patent airway in the majority of the
patients by just using the following skills:
– Nasopharyngeal or oropharyngeal suctioning
– Manual airway techniques (head-tilt chin-lift, and jawthrust)
– Simple mechanical adjuncts (OPA/NPA)
– Patient positioning and use of cricoid pressure
(Sellick’s)
 If, however, the above fails to work – or becomes
ineffective – then the implementation of advanced
airway skills becomes the only other option.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
Combi-Tube
 Esophageal Tracheal Double Lumen Airway
Device (ETDLAD)
– Dual Lumen Airway Devices
 These airway devices are designed with dual lumens sideby-side, but of varying length.
 The premise is that upon insertion and inflation of the
appropriate cuffs, one of the tubes will result in lung inflation
while the other winds up directing air into the esophagus.
 The goal naturally is to use the lumen that ventilates the
lungs, but the beauty of the device is that regardless of
where the longer tube is positioned (either in the esophagus
or in the trachea), successful ventilation can be achieved.
Copyright 2004
Prentice Hall Publishing
A division of Pearson Inc.
Prehospital Emergency Care 7e
Mistovich/Hafen/Karren
The Combitube
 An Esophageal Tracheal Double Lumen
Airway
Combitube Sizes
Two sizes:
–Combitube SA
–Combitube
Combitube SA
 SA = SMALL ADULT
 Small Adult = Less than 5 ft 6 inches tall
 Small Adult = Minimum 4 ft 0 inches
 Combitube SA can be used on small adults
who are between 4 ft and 5 ft 6 inches tall.
Combitube
 Combitube is used for patients over 5
ft tall.
Black Lines Used for
Proper Tube Insertion
Depth. (Straddle upper
teeth or gums)
Inflation Point
Pilot Balloon for
Large Pharyngeal Cuff
Large Proximal Pharyngeal Cuff
(#1)
Large Syringe Attached to Pilot Balloon #1
Ready to Inflate with 100cc’s of Air
Pilot Balloon (#1) Remains
Inflated.
Large Pharyngeal Cuff Inflated
Small Distal Esophageal Cuff (#2)
Inflation Point
Pilot Balloon for
Esophageal Cuff (#2)
Small Syringe Attached to Pilot Balloon #2
Ready to Inflate with 15cc’s of Air
Pilot Balloon #2 for Small Distal
Esophageal Cuff #2 Remains
Inflated
Small Distal
Esophageal Cuff
#2 Inflated
2 Lumens allow
for ventilation if
the tube is inserted
into the
Esophagus (most
common) or into
the Trachea
Tracheal Lumen (#2)
Esophageal Lumen (#1)
Esophageal
Lumen (#1)
Tracheal
Lumen (#2)
APPROVED USE OF SUPRAGLOTTIC DEVICES
POLICY:
 VVEMS Medical Direction supports the use of approved Supraglottic
devices as an optional rescue airway device by properly trained BLS/I99 and Paramedic providers in accordance with Arizona Revised
Statutes.
PURPOSE:
This airway adjunct is to be used by BLS/I-99 providers only after:
attempts to ventilate with a BVM are unsuccessful and/or inadequate,
when no ALS providers are available for advanced airway
management or after unsuccessful attempts for other advanced airway
management.
APPROVED USE OF SUPRAGLOTTIC DEVICES
PROCEDURE:
 1. Initial and ongoing training shall be performed at the agency level in
accordance with R9-25-511.
 2. Records on training shall be maintained at the agency level and
made available to Pre-Hospital Coordinator as requested.
 3. BLS providers will complete a training session on approved
supraglottic devices at the agency level by an ALS trained provider
utilizing the recommended curriculum.
 4. Initial training shall include no less than 5 successful manikin airway
placements.
 5. An EMT and I-99 who has completed initial training is required to
complete a refresher training that complies with R9-25-511 at least
every 24 months.
Skills / Testing Stations
 Basic airway maintenance techniques.
– Equipment, techniques, oxygen, suction.
 Combitube familiarity.
 Combitube insertion & AED incorporation.
 Combitube tracheal and problem insertion.