combitube training mandatory training every 2 years for all bls providers verde valley emergency...

Combitube Combitube TrainingTraining

Mandatory training every 2 Mandatory training every 2 years for all BLS Providersyears for all BLS Providers

Verde Valley Emergency Medical ServicesVerde Valley Emergency Medical Services

Copyright 2004 Prentice Hall PublishingA division of Pearson Inc.

Prehospital Emergency Care 7eMistovich/Hafen/Karren

TopicsTopics

Airway and Respiratory Anatomy and Airway and Respiratory Anatomy and PhysiologyPhysiology

Basic Airway ManagementBasic Airway Management

Combi-Tube AirwayCombi-Tube Airway



IntroductionIntroduction

The importance of establishing and maintaining The importance of establishing and maintaining an airway in the patient can never be an airway in the patient can never be overstated.overstated.

Despite the majority of patients’ responding Despite the majority of patients’ responding favorably to manual and/or simple mechanical favorably to manual and/or simple mechanical adjuncts, some may need more advanced adjuncts, some may need more advanced airway procedures.airway procedures.

It is for this reason that advanced airway skills It is for this reason that advanced airway skills are now included as an elective in the EMT-B are now included as an elective in the EMT-B curriculum.curriculum.



Airway and Respiratory Airway and Respiratory Anatomy and PhysiologyAnatomy and Physiology

Airway AnatomyAirway Anatomy– Upper airwayUpper airway

Opening of the nose and mouth to the larynxOpening of the nose and mouth to the larynx Includes the nasopharynx, oropharynx, and hypopharynxIncludes the nasopharynx, oropharynx, and hypopharynx

– Lower airwayLower airway Lower portion of the larynxLower portion of the larynx TracheaTrachea BronchiBronchi




Airway AnatomyAirway Anatomy– NoseNose

Warms the air.Warms the air. Provides humidification.Provides humidification. Coarse hairs serve as an initial filter for inhaled air.Coarse hairs serve as an initial filter for inhaled air.

– MouthMouth Also a conduit for airflow.Also a conduit for airflow. Oropharynx contains special reflexes to guard the airway.Oropharynx contains special reflexes to guard the airway.

– PharynxPharynx Conducts airflow, and gives rise to the openings of the lower Conducts airflow, and gives rise to the openings of the lower

airway and the esophagus.airway and the esophagus.




Airway AnatomyAirway Anatomy– LarynxLarynx

Lies inferior to the pharynx and superior to the tracheaLies inferior to the pharynx and superior to the trachea Directs air from pharynx to tracheaDirects air from pharynx to trachea Houses the vocal cordsHouses the vocal cords Comprised of three cartilaginous structuresComprised of three cartilaginous structures

– Thyroid cartilage is the large shield shaped structure.Thyroid cartilage is the large shield shaped structure.

– Cricoid cartilage is the first compete cartilaginous ring that is Cricoid cartilage is the first compete cartilaginous ring that is attached to the trachea (inferior aspect of larynx).attached to the trachea (inferior aspect of larynx).

– Epiglottis is the leaf shaped structure that covers the larynx Epiglottis is the leaf shaped structure that covers the larynx during swallowing.during swallowing.





The vallecula is a depression located between the base of The vallecula is a depression located between the base of the tongue and the anterior surface of the epiglottis.the tongue and the anterior surface of the epiglottis.

The glossoepiglottic ligament which suspends and supports The glossoepiglottic ligament which suspends and supports the epiglottis is located at the center of the vallecula.the epiglottis is located at the center of the vallecula.

These structures are important as they are sometimes These structures are important as they are sometimes manipulated during advanced airway procedures to lift the manipulated during advanced airway procedures to lift the epiglottis (making it possible to visualize the glottic opening).epiglottis (making it possible to visualize the glottic opening).





View of the laryngealView of the laryngeal

structures which showsstructures which shows

the vallecular spacethe vallecular space

and glossoepiglotticand glossoepiglottic

ligamentligament

insert fig 45-1





True vocal cordsTrue vocal cords False vocal cordsFalse vocal cords Arytenoid cartilagesArytenoid cartilages Corniculate cartilagesCorniculate cartilages Cuneiform cartilagesCuneiform cartilages All of the above canAll of the above can

be important visualbe important visuallandmarks during the landmarks during the intubation procedure.intubation procedure.

insert 45-2




Airway AnatomyAirway Anatomy– Trachea, Bronchi, and BronchiolesTrachea, Bronchi, and Bronchioles

Trachea is comprised of 16-20 “C” shaped cartilage rings.Trachea is comprised of 16-20 “C” shaped cartilage rings. Rings are posteriorly incomplete as they share a common Rings are posteriorly incomplete as they share a common

wall with the esophagus (trachealis muscle).wall with the esophagus (trachealis muscle). The trachea gives rise to two mainstem bronchi at about The trachea gives rise to two mainstem bronchi at about

the level of the 5the level of the 5thth thoracic vertebrae. thoracic vertebrae. The point of bifurcation is called the carina.The point of bifurcation is called the carina.




Airway AnatomyAirway Anatomy– Trachea, Bronchi, and BronchiolesTrachea, Bronchi, and Bronchioles

The right mainstem bronchi is of a larger diameter with a The right mainstem bronchi is of a larger diameter with a lesser angle than the left (that has a sharper angle due to lesser angle than the left (that has a sharper angle due to the position of the heart).the position of the heart).

– The lesser angle makes it easier to misdirect a tracheal tube The lesser angle makes it easier to misdirect a tracheal tube into the right mainstream bronchus than into the left.into the right mainstream bronchus than into the left.

– The lesser angle also accounts for the fact that aspiration of The lesser angle also accounts for the fact that aspiration of foods, liquids, or foreign bodies occurs more commonly in the foods, liquids, or foreign bodies occurs more commonly in the right than in the left.right than in the left.

Finally, the bronchi continue to subdivide into smaller and smaller Finally, the bronchi continue to subdivide into smaller and smaller bronchioles until the alveolar sacs are reached.bronchioles until the alveolar sacs are reached.

The alveolar sacs are the sites of gas exchange for the pulmonary The alveolar sacs are the sites of gas exchange for the pulmonary system.system.




Airway AnatomyAirway Anatomy




Airway AnatomyAirway Anatomy– LungsLungs

Right and left lungsRight and left lungs Separated by theSeparated by the

mediastinummediastinum Wrapped by theWrapped by the

pleural liningspleural linings




Airway Anatomy in Infants and ChildrenAirway Anatomy in Infants and Children– Differences that are important to rememberDifferences that are important to remember

Larger occipital region of the head.Larger occipital region of the head. Mouth, nose, and pharynx smaller, more pliable, and easier Mouth, nose, and pharynx smaller, more pliable, and easier

to obstruct.to obstruct. Tongue is proportionally larger.Tongue is proportionally larger. Larynx and trachea are funnel shaped, the cricoid ring the Larynx and trachea are funnel shaped, the cricoid ring the

narrowest portion.narrowest portion. Trachea, since it is more flexible, can kink from excessive Trachea, since it is more flexible, can kink from excessive

hyperextension of the head during airway procedures.hyperextension of the head during airway procedures. Chest wall more pliable, fails to adequately support ribs.Chest wall more pliable, fails to adequately support ribs. In concert, all these differences add up to a more difficult In concert, all these differences add up to a more difficult

airway to manage under even the best circumstances.airway to manage under even the best circumstances.




Often, the best situation to use advanced airway Often, the best situation to use advanced airway procedures is when you have a patient needing procedures is when you have a patient needing prolonged ventilation.prolonged ventilation.

Beyond this, you will only use these skills when Beyond this, you will only use these skills when basic airway maneuvers fail to provide you an basic airway maneuvers fail to provide you an airway.airway.

Remember, you should only use these skills Remember, you should only use these skills when when you need to;you need to; do not use them simply do not use them simply because you can.because you can.




As mentioned previously, the EMT-B will be able As mentioned previously, the EMT-B will be able to establish a patent airway in the majority of the to establish a patent airway in the majority of the patients by just using the following skills:patients by just using the following skills:– Nasopharyngeal or oropharyngeal suctioningNasopharyngeal or oropharyngeal suctioning– Manual airway techniques (head-tilt chin-lift, and jaw-Manual airway techniques (head-tilt chin-lift, and jaw-

thrust)thrust)– Simple mechanical adjuncts (OPA/NPA)Simple mechanical adjuncts (OPA/NPA)– Patient positioning and use of cricoid pressure Patient positioning and use of cricoid pressure

(Sellick’s)(Sellick’s)

If, however, the above fails to work – or becomes If, however, the above fails to work – or becomes ineffective ineffective –– then the implementation of advanced then the implementation of advanced airway skills becomes the only other option.airway skills becomes the only other option.



Combi-TubeCombi-Tube

Esophageal Tracheal Double Lumen Airway Esophageal Tracheal Double Lumen Airway Device (ETDLAD)Device (ETDLAD)– Dual Lumen Airway DevicesDual Lumen Airway Devices

These airway devices are designed with dual lumens side-by-These airway devices are designed with dual lumens side-by-side, but of varying length.side, but of varying length.

The premise is that upon insertion and inflation of the The premise is that upon insertion and inflation of the appropriate cuffs, one of the tubes will result in lung inflation appropriate cuffs, one of the tubes will result in lung inflation while the other winds up directing air into the esophagus.while the other winds up directing air into the esophagus.

The goal naturally is to use the lumen that ventilates the The goal naturally is to use the lumen that ventilates the lungs, but the beauty of the device is that regardless of where lungs, but the beauty of the device is that regardless of where the longer tube is positioned (either in the esophagus or in the the longer tube is positioned (either in the esophagus or in the trachea), successful ventilation can be achieved. trachea), successful ventilation can be achieved.

The CombitubeThe Combitube

An Esophageal Tracheal Double Lumen An Esophageal Tracheal Double Lumen AirwayAirway

Combitube / Combitube SACombitube / Combitube SA

SA = SMALL ADULTSA = SMALL ADULT Small Adult = Less than 5 ft 6 inches tallSmall Adult = Less than 5 ft 6 inches tall Small Adult = Taller than 4 ft 0 inchesSmall Adult = Taller than 4 ft 0 inches Combitube SACombitube SA can be used on small adults can be used on small adults

who are between 4 ft and 5 ft 6 inches tall.who are between 4 ft and 5 ft 6 inches tall.

Combitube / Combitube SACombitube / Combitube SA

CombitubeCombitube is used for patients is used for patients overover 5 ft tall. 5 ft tall.

Black Lines Used for Proper Tube Insertion Depth. (Straddle upper teeth or gums)

Large Proximal Pharyngeal Cuff (#1)

Inflation Point

Pilot Balloon for Large Pharyngeal Cuff

Large Syringe Attached to Pilot Balloon #1 Ready to Inflate with 100cc’s of Air

Large Pharyngeal Cuff Inflated

Pilot Balloon (#1) Remains 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

Small Distal Esophageal Cuff #2 Inflated

Pilot Balloon #2 for Small Distal Esophageal Cuff #2 Remains Inflated

Tracheal Lumen (#2)

Esophageal Lumen (#1)

2 Lumens allow for ventilation if the tube is inserted into the Esophagus (most common) or into the Trachea

Esophageal Lumen (#1)

Tracheal Lumen (#2)

Skills / Testing StationsSkills / Testing Stations

Basic airway maintenance techniques.Basic airway maintenance techniques.– Equipment, techniques, oxygen, suction.Equipment, techniques, oxygen, suction.

Combitube familiarity.Combitube familiarity. Combitube insertion & AED incorporation.Combitube insertion & AED incorporation. Combitube tracheal and problem insertion.Combitube tracheal and problem insertion. Written exam.Written exam.

combitube training mandatory training every 2 years for all bls providers verde valley emergency...

Documents

prehospital emergency

division of pearson

prentice hall

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advanced airway skills

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