Re: Combi Tube Questions

[Guest guest]

A CO detector is going to be of little assistance on a combitube. The use of

the combitube is for a more secure airway, but; that does not mean you will

acheive an intubation even 30% of the time. A CO detector is good only for an

intubation as another tool to use to determine correct placement.

Combitube placement will not be in the trachea usually, although it is designed

for placement in either the esophagus or the trachea.

A commercial tube tamer would be the best although, here again; the combitube is

designed to stay in place without a securing device. As a student of old

techniques tape can be just as secure as a commercial device, if properly

applied.

Hope this helps.

Bernie Stafford wrote:

Greetings All,

I have a couple of questions about Combi Tubes and I need some input from

this learned group.

1. Do you use a CO detector with your Combi-tube. If so which brand do

you recommend

2. How do you secure your Combi-tube, commercial device or tape??

If you would like to reply to me direct, please email me at

bstafford@...

Thanks

Bernie Stafford EMTP

Director ERT

College of Chiropractic

[Guest guest]

The Combi-Tube is self securing, thanks to the huge oropharyngeal cuff (it holds

100 cc of air). I suppose you could tape it if you wanted to, but that is not

recommended by the manufacturer. I am not aware of any device that is marketed

as a " Combi-Tube holder " . Regardless of the placement (esophageal or tracheal,

and blind insertion will almost always wind up being esophageal) you can use any

capnography device intended for use with a ETT to assist with conformation of

placement and patient monitoring. The Combitube is a great " rescue " airway.

Combi Tube Questions

Greetings All,

I have a couple of questions about Combi Tubes and I need some input from

this learned group.

1. Do you use a CO detector with your Combi-tube. If so which brand do

you recommend

2. How do you secure your Combi-tube, commercial device or tape??

If you would like to reply to me direct, please email me at

bstafford@...

Thanks

Bernie Stafford EMTP

Director ERT

College of Chiropractic

[Guest guest]

Question- why would a CO2 detector beo f little assistance? If you end up

ventilating with port #2, you are in the trachea so there would be no difference

between that and an ETT basically. If you end up ventilating through port #1,

then you are in the esophagus with a cuff in the oropharynx and a cuff occluding

the esophagus. So exhaled air has to be drawn back up into that tube that you

are ventilating through, correct? Sooooo..... why wouldn't it work? Maybe I am

just being stupid because I am home sick today, but I am not sure why it

wouldn't be of some assistance.

Jane Hill

-------------- Original message from Danny :

--------------

A CO detector is going to be of little assistance on a combitube. The use of

the combitube is for a more secure airway, but; that does not mean you will

acheive an intubation even 30% of the time. A CO detector is good only for an

intubation as another tool to use to determine correct placement.

Combitube placement will not be in the trachea usually, although it is designed

for placement in either the esophagus or the trachea.

A commercial tube tamer would be the best although, here again; the combitube is

designed to stay in place without a securing device. As a student of old

techniques tape can be just as secure as a commercial device, if properly

applied.

Hope this helps.

Bernie Stafford wrote:

Greetings All,

I have a couple of questions about Combi Tubes and I need some input from

this learned group.

1. Do you use a CO detector with your Combi-tube. If so which brand do

you recommend

2. How do you secure your Combi-tube, commercial device or tape??

If you would like to reply to me direct, please email me at

bstafford@...

Thanks

Bernie Stafford EMTP

Director ERT

College of Chiropractic

[Guest guest]

I am not saying that it is of NO use I am saying it is of little use. The

combitube although it has two lumens only has one airway. The chance of

intubation is smaller than the chance for landing the tube in the esophogus.

That is why everyone is taught to use both lumens, on the chance you get an

intubation not on the chance you land in the esophogus. Landing in the

esophogus is expected on blind techniques. If you are talking about an actual

intubation attempt that is a horse of another color. Remember this is Texas.

EMT-Basics are not allowed to intubate. Different teaching than up north

perhaps.

I see what you are saying. This device is kind of like using the EGTA or the

EOA it just has two lumens. We use a CO Detector as another tool to confirm ET

placement. Unless something goes seriously wrong ( like you intubated the butt)

you probably will see the detector change no matter where the combitube goes.

That is why I made the comment. Sound logical?

je.hill@... wrote:

Question- why would a CO2 detector beo f little assistance? If you end up

ventilating with port #2, you are in the trachea so there would be no difference

between that and an ETT basically. If you end up ventilating through port #1,

then you are in the esophagus with a cuff in the oropharynx and a cuff occluding

the esophagus. So exhaled air has to be drawn back up into that tube that you

are ventilating through, correct? Sooooo..... why wouldn't it work? Maybe I am

just being stupid because I am home sick today, but I am not sure why it

wouldn't be of some assistance.

Jane Hill

-------------- Original message from Danny :

--------------

A CO detector is going to be of little assistance on a combitube. The use of

the combitube is for a more secure airway, but; that does not mean you will

acheive an intubation even 30% of the time. A CO detector is good only for an

intubation as another tool to use to determine correct placement.

Combitube placement will not be in the trachea usually, although it is designed

for placement in either the esophagus or the trachea.

A commercial tube tamer would be the best although, here again; the combitube is

designed to stay in place without a securing device. As a student of old

techniques tape can be just as secure as a commercial device, if properly

applied.

Hope this helps.

Bernie Stafford wrote:

Greetings All,

I have a couple of questions about Combi Tubes and I need some input from

this learned group.

1. Do you use a CO detector with your Combi-tube. If so which brand do

you recommend

2. How do you secure your Combi-tube, commercial device or tape??

If you would like to reply to me direct, please email me at

bstafford@...

Thanks

Bernie Stafford EMTP

Director ERT

College of Chiropractic

[Guest guest]

I agree. Does anyone out there have any experience with how well the CO2

detectors read with the Combitube when placed in the esophagus?

As for the intubation versus esophageal placement, while it finds its way into

the trachea sometimes, I teach my students that if that happens, rejoice. Yes,

it is technically an intubation and EMT's in Texas don't typically intubate;

however, if it happens I certainly wouldn't want them to pull it out and try

again for the esophagus.

As for the butt tube, wellllll, I don't think I should go there. LOL

Jane Hill

-------------- Original message from Danny :

--------------

I am not saying that it is of NO use I am saying it is of little use. The

combitube although it has two lumens only has one airway. The chance of

intubation is smaller than the chance for landing the tube in the esophogus.

That is why everyone is taught to use both lumens, on the chance you get an

intubation not on the chance you land in the esophogus. Landing in the

esophogus is expected on blind techniques. If you are talking about an actual

intubation attempt that is a horse of another color. Remember this is Texas.

EMT-Basics are not allowed to intubate. Different teaching than up north

perhaps.

I see what you are saying. This device is kind of like using the EGTA or the

EOA it just has two lumens. We use a CO Detector as another tool to confirm ET

placement. Unless something goes seriously wrong ( like you intubated the butt)

you probably will see the detector change no matter where the combitube goes.

That is why I made the comment. Sound logical?

je.hill@... wrote:

Question- why would a CO2 detector beo f little assistance? If you end up

ventilating with port #2, you are in the trachea so there would be no difference

between that and an ETT basically. If you end up ventilating through port #1,

then you are in the esophagus with a cuff in the oropharynx and a cuff occluding

the esophagus. So exhaled air has to be drawn back up into that tube that you

are ventilating through, correct? Sooooo..... why wouldn't it work? Maybe I am

just being stupid because I am home sick today, but I am not sure why it

wouldn't be of some assistance.

Jane Hill

-------------- Original message from Danny :

--------------

A CO detector is going to be of little assistance on a combitube. The use of

the combitube is for a more secure airway, but; that does not mean you will

acheive an intubation even 30% of the time. A CO detector is good only for an

intubation as another tool to use to determine correct placement.

Combitube placement will not be in the trachea usually, although it is designed

for placement in either the esophagus or the trachea.

A commercial tube tamer would be the best although, here again; the combitube is

designed to stay in place without a securing device. As a student of old

techniques tape can be just as secure as a commercial device, if properly

applied.

Hope this helps.

Bernie Stafford wrote:

Greetings All,

I have a couple of questions about Combi Tubes and I need some input from

this learned group.

1. Do you use a CO detector with your Combi-tube. If so which brand do

you recommend

2. How do you secure your Combi-tube, commercial device or tape??

If you would like to reply to me direct, please email me at

bstafford@...

Thanks

Bernie Stafford EMTP

Director ERT

College of Chiropractic

[Guest guest]

I was in no way meaning it should be pulled if an intubation is accomplished no,

no, no, no, no.

Rejoice. Praise God, or whomever you choose. Drink a cold one for me. OOPS

wishful thinking.

je.hill@... wrote:

I agree. Does anyone out there have any experience with how well the CO2

detectors read with the Combitube when placed in the esophagus?

As for the intubation versus esophageal placement, while it finds its way into

the trachea sometimes, I teach my students that if that happens, rejoice. Yes,

it is technically an intubation and EMT's in Texas don't typically intubate;

however, if it happens I certainly wouldn't want them to pull it out and try

again for the esophagus.

As for the butt tube, wellllll, I don't think I should go there. LOL

Jane Hill

-------------- Original message from Danny :

--------------

I am not saying that it is of NO use I am saying it is of little use. The

combitube although it has two lumens only has one airway. The chance of

intubation is smaller than the chance for landing the tube in the esophogus.

That is why everyone is taught to use both lumens, on the chance you get an

intubation not on the chance you land in the esophogus. Landing in the

esophogus is expected on blind techniques. If you are talking about an actual

intubation attempt that is a horse of another color. Remember this is Texas.

EMT-Basics are not allowed to intubate. Different teaching than up north

perhaps.

I see what you are saying. This device is kind of like using the EGTA or the

EOA it just has two lumens. We use a CO Detector as another tool to confirm ET

placement. Unless something goes seriously wrong ( like you intubated the butt)

you probably will see the detector change no matter where the combitube goes.

That is why I made the comment. Sound logical?

je.hill@... wrote:

Question- why would a CO2 detector beo f little assistance? If you end up

ventilating with port #2, you are in the trachea so there would be no difference

between that and an ETT basically. If you end up ventilating through port #1,

then you are in the esophagus with a cuff in the oropharynx and a cuff occluding

the esophagus. So exhaled air has to be drawn back up into that tube that you

are ventilating through, correct? Sooooo..... why wouldn't it work? Maybe I am

just being stupid because I am home sick today, but I am not sure why it

wouldn't be of some assistance.

Jane Hill

-------------- Original message from Danny :

--------------

A CO detector is going to be of little assistance on a combitube. The use of

the combitube is for a more secure airway, but; that does not mean you will

acheive an intubation even 30% of the time. A CO detector is good only for an

intubation as another tool to use to determine correct placement.

Combitube placement will not be in the trachea usually, although it is designed

for placement in either the esophagus or the trachea.

A commercial tube tamer would be the best although, here again; the combitube is

designed to stay in place without a securing device. As a student of old

techniques tape can be just as secure as a commercial device, if properly

applied.

Hope this helps.

Bernie Stafford wrote:

Greetings All,

I have a couple of questions about Combi Tubes and I need some input from

this learned group.

1. Do you use a CO detector with your Combi-tube. If so which brand do

you recommend

2. How do you secure your Combi-tube, commercial device or tape??

If you would like to reply to me direct, please email me at

bstafford@...

Thanks

Bernie Stafford EMTP

Director ERT

College of Chiropractic

[Guest guest]

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides, there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward through the

mouth, and an esophageal cuff [small} which is preventing air from moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue " tube and

exits through the perforations of the " Blue " tube, and there is no place for

it to go but through the glottic opening. Conversely, on exhalation, gas

passes upward from the alveoli, into the trachea, and exits through the

perforations in the solid tube (the Blue Tube) of the Combitube, and out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square as if

there was an ET tube. There is no reason that is should not reflect the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

I have NO CLUE what you're saying.

The Combitube does nothing to change the amount of CO2 that's exhaled. So

if you put an end tidal CO2 sensor on the CBT, if there is CO2 in the exhaled

air it will be reflected in the ETCO2 monitor. There ain't no difference.

There's no significant resistance through the Combitube when compared with an

ET tube. Gas moves from an area of greater concentration to an area of

lesser concentration. Simple physics. Oh, there's a LITTLE difference, but

it

's so insignificant that it's ludicrous to even think about it.

GG

GG

> I am not saying that it is of NO use I am saying it is of little use.  The

> combitube although it has two lumens only has one airway.  The chance of

> intubation is smaller than the chance for landing the tube in the esophogus. 

> That is why everyone is taught to use both lumens, on the chance you get an

> intubation not on the chance you land in the esophogus.  Landing in the

esophogus

> is expected on blind techniques.  If you are talking about an actual

> intubation attempt that is a horse of another color.  Remember this is Texas. 

> EMT-Basics are not allowed to intubate.  Different teaching than up north

perhaps.

>

> I see what you are saying.  This device is kind of like using the EGTA or

> the EOA it just has two lumens.   We use a CO Detector as another tool to

> confirm ET placement.  Unless something goes seriously wrong ( like you

intubated

> the butt) you probably will see the detector change no matter where the

> combitube goes.  That is why I made the comment.  Sound logical?

>

> je.hill@... wrote:

> Question- why would a CO2 detector beo f little assistance?  If you end up

> ventilating with port #2, you are in the trachea so there would be no

> difference between that and an ETT basically.  If you end up ventilating

through port

> #1, then you are in the esophagus with a cuff in the oropharynx and a cuff

> occluding the esophagus. So exhaled air has to be drawn back up into that tube

> that you are ventilating through, correct?  Sooooo..... why wouldn't it

> work?  Maybe I am just being stupid because I am home sick today, but I am not

> sure why it wouldn't be of some assistance.

>

> Jane Hill

>

> -------------- Original message from Danny

> : --------------

>

> A CO detector is going to be of little assistance on a combitube.  The use

> of the combitube is for a more secure airway, but; that does not mean you will

> acheive an intubation even 30% of the time.  A CO detector is good only for

> an intubation as another tool to use to determine correct placement.  

>

> Combitube placement will not be in the trachea usually, although it is

> designed for placement in either the esophagus or the trachea.

>

> A commercial tube tamer would be the best although, here again; the

> combitube is designed to stay in place without a securing device.  As a

student of

> old techniques tape can be just as secure as a commercial device, if properly

> applied.

>

> Hope this helps.

>

> Bernie Stafford wrote:

> Greetings All,

>

>

>

> I have a couple of questions about Combi Tubes and I need some input from

> this learned group.

>

>

>

>

>

> 1.      Do you use a CO detector with your Combi-tube. If so which brand do

> you recommend

> 2.      How do you secure your Combi-tube, commercial device or tape??

>

>

>

> If you would like to reply to me direct, please email me at

> bstafford@...

>

>

>

> Thanks

>

> Bernie Stafford EMTP

>

> Director ERT

>

> College of Chiropractic

>

>

>

>

>

>

>

>

[Guest guest]

I have NO CLUE what you're saying.

The Combitube does nothing to change the amount of CO2 that's exhaled. So

if you put an end tidal CO2 sensor on the CBT, if there is CO2 in the exhaled

air it will be reflected in the ETCO2 monitor. There ain't no difference.

There's no significant resistance through the Combitube when compared with an

ET tube. Gas moves from an area of greater concentration to an area of

lesser concentration. Simple physics. Oh, there's a LITTLE difference, but

it

's so insignificant that it's ludicrous to even think about it.

GG

GG

> I am not saying that it is of NO use I am saying it is of little use.  The

> combitube although it has two lumens only has one airway.  The chance of

> intubation is smaller than the chance for landing the tube in the esophogus. 

> That is why everyone is taught to use both lumens, on the chance you get an

> intubation not on the chance you land in the esophogus.  Landing in the

esophogus

> is expected on blind techniques.  If you are talking about an actual

> intubation attempt that is a horse of another color.  Remember this is Texas. 

> EMT-Basics are not allowed to intubate.  Different teaching than up north

perhaps.

>

> I see what you are saying.  This device is kind of like using the EGTA or

> the EOA it just has two lumens.   We use a CO Detector as another tool to

> confirm ET placement.  Unless something goes seriously wrong ( like you

intubated

> the butt) you probably will see the detector change no matter where the

> combitube goes.  That is why I made the comment.  Sound logical?

>

> je.hill@... wrote:

> Question- why would a CO2 detector beo f little assistance?  If you end up

> ventilating with port #2, you are in the trachea so there would be no

> difference between that and an ETT basically.  If you end up ventilating

through port

> #1, then you are in the esophagus with a cuff in the oropharynx and a cuff

> occluding the esophagus. So exhaled air has to be drawn back up into that tube

> that you are ventilating through, correct?  Sooooo..... why wouldn't it

> work?  Maybe I am just being stupid because I am home sick today, but I am not

> sure why it wouldn't be of some assistance.

>

> Jane Hill

>

> -------------- Original message from Danny

> : --------------

>

> A CO detector is going to be of little assistance on a combitube.  The use

> of the combitube is for a more secure airway, but; that does not mean you will

> acheive an intubation even 30% of the time.  A CO detector is good only for

> an intubation as another tool to use to determine correct placement.  

>

> Combitube placement will not be in the trachea usually, although it is

> designed for placement in either the esophagus or the trachea.

>

> A commercial tube tamer would be the best although, here again; the

> combitube is designed to stay in place without a securing device.  As a

student of

> old techniques tape can be just as secure as a commercial device, if properly

> applied.

>

> Hope this helps.

>

> Bernie Stafford wrote:

> Greetings All,

>

>

>

> I have a couple of questions about Combi Tubes and I need some input from

> this learned group.

>

>

>

>

>

> 1.      Do you use a CO detector with your Combi-tube. If so which brand do

> you recommend

> 2.      How do you secure your Combi-tube, commercial device or tape??

>

>

>

> If you would like to reply to me direct, please email me at

> bstafford@...

>

>

>

> Thanks

>

> Bernie Stafford EMTP

>

> Director ERT

>

> College of Chiropractic

>

>

>

>

>

>

>

>

[Guest guest]

I have NO CLUE what you're saying.

The Combitube does nothing to change the amount of CO2 that's exhaled. So

if you put an end tidal CO2 sensor on the CBT, if there is CO2 in the exhaled

air it will be reflected in the ETCO2 monitor. There ain't no difference.

There's no significant resistance through the Combitube when compared with an

ET tube. Gas moves from an area of greater concentration to an area of

lesser concentration. Simple physics. Oh, there's a LITTLE difference, but

it

's so insignificant that it's ludicrous to even think about it.

GG

GG

> I am not saying that it is of NO use I am saying it is of little use.  The

> combitube although it has two lumens only has one airway.  The chance of

> intubation is smaller than the chance for landing the tube in the esophogus. 

> That is why everyone is taught to use both lumens, on the chance you get an

> intubation not on the chance you land in the esophogus.  Landing in the

esophogus

> is expected on blind techniques.  If you are talking about an actual

> intubation attempt that is a horse of another color.  Remember this is Texas. 

> EMT-Basics are not allowed to intubate.  Different teaching than up north

perhaps.

>

> I see what you are saying.  This device is kind of like using the EGTA or

> the EOA it just has two lumens.   We use a CO Detector as another tool to

> confirm ET placement.  Unless something goes seriously wrong ( like you

intubated

> the butt) you probably will see the detector change no matter where the

> combitube goes.  That is why I made the comment.  Sound logical?

>

> je.hill@... wrote:

> Question- why would a CO2 detector beo f little assistance?  If you end up

> ventilating with port #2, you are in the trachea so there would be no

> difference between that and an ETT basically.  If you end up ventilating

through port

> #1, then you are in the esophagus with a cuff in the oropharynx and a cuff

> occluding the esophagus. So exhaled air has to be drawn back up into that tube

> that you are ventilating through, correct?  Sooooo..... why wouldn't it

> work?  Maybe I am just being stupid because I am home sick today, but I am not

> sure why it wouldn't be of some assistance.

>

> Jane Hill

>

> -------------- Original message from Danny

> : --------------

>

> A CO detector is going to be of little assistance on a combitube.  The use

> of the combitube is for a more secure airway, but; that does not mean you will

> acheive an intubation even 30% of the time.  A CO detector is good only for

> an intubation as another tool to use to determine correct placement.  

>

> Combitube placement will not be in the trachea usually, although it is

> designed for placement in either the esophagus or the trachea.

>

> A commercial tube tamer would be the best although, here again; the

> combitube is designed to stay in place without a securing device.  As a

student of

> old techniques tape can be just as secure as a commercial device, if properly

> applied.

>

> Hope this helps.

>

> Bernie Stafford wrote:

> Greetings All,

>

>

>

> I have a couple of questions about Combi Tubes and I need some input from

> this learned group.

>

>

>

>

>

> 1.      Do you use a CO detector with your Combi-tube. If so which brand do

> you recommend

> 2.      How do you secure your Combi-tube, commercial device or tape??

>

>

>

> If you would like to reply to me direct, please email me at

> bstafford@...

>

>

>

> Thanks

>

> Bernie Stafford EMTP

>

> Director ERT

>

> College of Chiropractic

>

>

>

>

>

>

>

>

[Guest guest]

Dudley,

Thank you very much. You're correct. There's no appreciable difference in

readings.

Gene G.

> Thanks Gene...you beat me to the punch. As an agency that carries

> CBT's, we use wave form capnography on all difficulty breathing

> patients, patients with decreased LOC's, hyperglycemic patients and

> those that we perform advanced airway maneuvers on. We have seen no

> difference in ETCO2 readings or wave-forms with a combi-tube or ET

> tube....

>

> Dudley

>

> Re: Combi Tube Questions

>

> Not sure who I'm replying to, but the subject is whether or not an

> End-Tidal CO2 monitoring device would work on a Combitube.

>

> Well, let's think about this carefully.

>

>   When the Combitube is in the esophagus, where it usually resides,

> there is a

>   pharyngeal cuff [LARGE] which is preventing air from moving upward

> through the

>   mouth, and an esophageal cuff [small} which is preventing air from

> moving

> down the esophagus.

>

>   When the CBT is in place, air or oxygen is conducted down the " Blue "

> tube and

>   exits through the perforations of the " Blue " tube, and there is no

> place for

>   it to go but through the glottic opening. Conversely, on exhalation,

> gas

>   passes upward from the alveoli, into the trachea, and exits through

> the

>   perforations in the solid tube (the Blue Tube) of the Combitube, and

> out

> through

> the end. Therefore, if there is CO2 in that gas, an end tidal CO2

>   monitoring device placed on the Blue tube of the Combitube should come

> into

> contact

> with the exiting gas and the litmus paper should turn to a gold color,

> reflecting

> the presence of CO2.

>

>   If you have waveform Capnometric, your wave should be just as square

> as if

>   there was an ET tube. There is no reason that is should not reflect

> the same

> level of CO2.

>

>   I see no reason why an end tidal CO2 monitoring device would not work

> with a

> Combitube.

>

> If anyone has any evidence-based disagreement, please post.

>

> Gene Gandy.

>

>

>

> E.(Gene) Gandy

> POB 1651

> Albany, TX 76430

> wegandy1938@...

>

>

>

>

[Guest guest]

Dudley,

Thank you very much. You're correct. There's no appreciable difference in

readings.

Gene G.

> Thanks Gene...you beat me to the punch. As an agency that carries

> CBT's, we use wave form capnography on all difficulty breathing

> patients, patients with decreased LOC's, hyperglycemic patients and

> those that we perform advanced airway maneuvers on. We have seen no

> difference in ETCO2 readings or wave-forms with a combi-tube or ET

> tube....

>

> Dudley

>

> Re: Combi Tube Questions

>

> Not sure who I'm replying to, but the subject is whether or not an

> End-Tidal CO2 monitoring device would work on a Combitube.

>

> Well, let's think about this carefully.

>

>   When the Combitube is in the esophagus, where it usually resides,

> there is a

>   pharyngeal cuff [LARGE] which is preventing air from moving upward

> through the

>   mouth, and an esophageal cuff [small} which is preventing air from

> moving

> down the esophagus.

>

>   When the CBT is in place, air or oxygen is conducted down the " Blue "

> tube and

>   exits through the perforations of the " Blue " tube, and there is no

> place for

>   it to go but through the glottic opening. Conversely, on exhalation,

> gas

>   passes upward from the alveoli, into the trachea, and exits through

> the

>   perforations in the solid tube (the Blue Tube) of the Combitube, and

> out

> through

> the end. Therefore, if there is CO2 in that gas, an end tidal CO2

>   monitoring device placed on the Blue tube of the Combitube should come

> into

> contact

> with the exiting gas and the litmus paper should turn to a gold color,

> reflecting

> the presence of CO2.

>

>   If you have waveform Capnometric, your wave should be just as square

> as if

>   there was an ET tube. There is no reason that is should not reflect

> the same

> level of CO2.

>

>   I see no reason why an end tidal CO2 monitoring device would not work

> with a

> Combitube.

>

> If anyone has any evidence-based disagreement, please post.

>

> Gene Gandy.

>

>

>

> E.(Gene) Gandy

> POB 1651

> Albany, TX 76430

> wegandy1938@...

>

>

>

>

[Guest guest]

Dudley,

Thank you very much. You're correct. There's no appreciable difference in

readings.

Gene G.

> Thanks Gene...you beat me to the punch. As an agency that carries

> CBT's, we use wave form capnography on all difficulty breathing

> patients, patients with decreased LOC's, hyperglycemic patients and

> those that we perform advanced airway maneuvers on. We have seen no

> difference in ETCO2 readings or wave-forms with a combi-tube or ET

> tube....

>

> Dudley

>

> Re: Combi Tube Questions

>

> Not sure who I'm replying to, but the subject is whether or not an

> End-Tidal CO2 monitoring device would work on a Combitube.

>

> Well, let's think about this carefully.

>

>   When the Combitube is in the esophagus, where it usually resides,

> there is a

>   pharyngeal cuff [LARGE] which is preventing air from moving upward

> through the

>   mouth, and an esophageal cuff [small} which is preventing air from

> moving

> down the esophagus.

>

>   When the CBT is in place, air or oxygen is conducted down the " Blue "

> tube and

>   exits through the perforations of the " Blue " tube, and there is no

> place for

>   it to go but through the glottic opening. Conversely, on exhalation,

> gas

>   passes upward from the alveoli, into the trachea, and exits through

> the

>   perforations in the solid tube (the Blue Tube) of the Combitube, and

> out

> through

> the end. Therefore, if there is CO2 in that gas, an end tidal CO2

>   monitoring device placed on the Blue tube of the Combitube should come

> into

> contact

> with the exiting gas and the litmus paper should turn to a gold color,

> reflecting

> the presence of CO2.

>

>   If you have waveform Capnometric, your wave should be just as square

> as if

>   there was an ET tube. There is no reason that is should not reflect

> the same

> level of CO2.

>

>   I see no reason why an end tidal CO2 monitoring device would not work

> with a

> Combitube.

>

> If anyone has any evidence-based disagreement, please post.

>

> Gene Gandy.

>

>

>

> E.(Gene) Gandy

> POB 1651

> Albany, TX 76430

> wegandy1938@...

>

>

>

>

[Guest guest]

Thanks Gene...you beat me to the punch. As an agency that carries

CBT's, we use wave form capnography on all difficulty breathing

patients, patients with decreased LOC's, hyperglycemic patients and

those that we perform advanced airway maneuvers on. We have seen no

difference in ETCO2 readings or wave-forms with a combi-tube or ET

tube....

Dudley

Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

Thanks Gene...you beat me to the punch. As an agency that carries

CBT's, we use wave form capnography on all difficulty breathing

patients, patients with decreased LOC's, hyperglycemic patients and

those that we perform advanced airway maneuvers on. We have seen no

difference in ETCO2 readings or wave-forms with a combi-tube or ET

tube....

Dudley

Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

Thanks Gene...you beat me to the punch. As an agency that carries

CBT's, we use wave form capnography on all difficulty breathing

patients, patients with decreased LOC's, hyperglycemic patients and

those that we perform advanced airway maneuvers on. We have seen no

difference in ETCO2 readings or wave-forms with a combi-tube or ET

tube....

Dudley

Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

To all;

The original question posted was in relation to which CO monitors were used

with combitubes and of those which was the best. The question was also posed as

to which type of securing device was used for the combitube.

My reply was that a CO detector was of little or no use. A reply was made

asking why. The resulting dialogue was an explanation as to the use of a CO

detector on the combitube. That reply had to do with the fact that a combitube

is a dual lumen airway. No matter where the combitube is placed the detector

will read.

The explanation was intended to explain that a CO detector was a, to put it

bluntly; waste of money and time to use. A CO detector is a valuable tool when

used in conjunction with an ET but how can one honestly say it is of use on a

combitube? The detector will change color no matter where it is located, a

needless use of a tool in my opinion.

THEDUDMAN@... wrote:

Thanks Gene...you beat me to the punch. As an agency that carries

CBT's, we use wave form capnography on all difficulty breathing

patients, patients with decreased LOC's, hyperglycemic patients and

those that we perform advanced airway maneuvers on. We have seen no

difference in ETCO2 readings or wave-forms with a combi-tube or ET

tube....

Dudley

Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

To all;

The original question posted was in relation to which CO monitors were used

with combitubes and of those which was the best. The question was also posed as

to which type of securing device was used for the combitube.

My reply was that a CO detector was of little or no use. A reply was made

asking why. The resulting dialogue was an explanation as to the use of a CO

detector on the combitube. That reply had to do with the fact that a combitube

is a dual lumen airway. No matter where the combitube is placed the detector

will read.

The explanation was intended to explain that a CO detector was a, to put it

bluntly; waste of money and time to use. A CO detector is a valuable tool when

used in conjunction with an ET but how can one honestly say it is of use on a

combitube? The detector will change color no matter where it is located, a

needless use of a tool in my opinion.

THEDUDMAN@... wrote:

Thanks Gene...you beat me to the punch. As an agency that carries

CBT's, we use wave form capnography on all difficulty breathing

patients, patients with decreased LOC's, hyperglycemic patients and

those that we perform advanced airway maneuvers on. We have seen no

difference in ETCO2 readings or wave-forms with a combi-tube or ET

tube....

Dudley

Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

To all;

The original question posted was in relation to which CO monitors were used

with combitubes and of those which was the best. The question was also posed as

to which type of securing device was used for the combitube.

My reply was that a CO detector was of little or no use. A reply was made

asking why. The resulting dialogue was an explanation as to the use of a CO

detector on the combitube. That reply had to do with the fact that a combitube

is a dual lumen airway. No matter where the combitube is placed the detector

will read.

The explanation was intended to explain that a CO detector was a, to put it

bluntly; waste of money and time to use. A CO detector is a valuable tool when

used in conjunction with an ET but how can one honestly say it is of use on a

combitube? The detector will change color no matter where it is located, a

needless use of a tool in my opinion.

THEDUDMAN@... wrote:

Thanks Gene...you beat me to the punch. As an agency that carries

CBT's, we use wave form capnography on all difficulty breathing

patients, patients with decreased LOC's, hyperglycemic patients and

those that we perform advanced airway maneuvers on. We have seen no

difference in ETCO2 readings or wave-forms with a combi-tube or ET

tube....

Dudley

Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

Danny,

You need to look at the Combi-tube a little closer. Your statement of

" no matter where the CBT is placed the detector will read " is

absolutely correct...BUT only if it is on the CORRECT lumen. If it

would get CO2 out of both lumens no matter what...then why can't we

ventilate into both lumens no matter what? Why does the choice of lumen

depend upon where the CBT comes to rest?

CO2 only comes out of one place in the body (don't even bother going

down the " he drank 2 liters of coke " stuff). It comes out of the lungs

after gas exchange has occurred. If the CBT comes to rest in the

esophagus (which is most likely) and the cuffs are properly inflated,

then ventilating into tube 1 will send O2 into the lungs and once

forced inspiration has stopped, CO2 will exhale. A ETCO2 detector

placed on Tube 1 will show color change (or the presence of CO2). If

you place the ETCO2 detector on Tube 2...it should not change color nor

detect any CO2 when you ventilate into it and if you continue, you will

need the 90 degree elbow that comes in the CBT kit very quickly.

If you are lucky enough to get the CBT into the trachea...put the

ETCO2 on Lumen 1 and you will see no CO2...BUT put it onto Lumen 2, you

will get ETCO2 detected...

Having a device to help confirm which lumen to ventilate through on

the CBT after placing it into the patient does not sound like a waste

of time or money...at least not as much a waste of money as the check

written to the plaintiff if you don't use it and are wrong...ETCO2 is

the standard of care...so much so that some state(s) are requiring its

presence and use on all ambulances in the next couple of years.

Hope this helps clarify my point. ETCO2 is never a waste of money or

time...it is a cheap tool to help prevent some very costly mistakes.

Dudley

Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

Danny,

Jane and Dudley have covered the subject comprehensively. I only have one

thing to add, from the lawyer's standpoint. Standard of Care.

Standard of Care requires a secondary method of tube placement verification.

The best is wave-form capnography, which WILL BE the standard in ALL

settings very soon if it is not now, and second is end-tidal CO2 monitoring +

esophageal tube detection device.

You either use those or you're not giving Standard of Care. Period.

Plus, they give a means of measurable documentation other than one's

observations of chest rise or breath sounds.

It is naive in the extreme to believe that if board certified

anesthesiologists miss a significant number of esophageal intubations in the OR,

paramedics

in the field would be able to do better. Since caphography became standard

in ORs, the incidence of undetected esophageal intubations and claims arising

therefrom has dwindled to almost nothing.

If you're interested, I can refer you to the closed case studies done by the

American Society of Anesthesia and the American Association of Nurse

Anesthestists which were the basis for these findings. Further, it is now

REQUIRED by

ASA and AANA that these devices be used.

Best,

Gene Gandy

> I too echo Jane on this one. Danny, I agree...there should be no excuse

> for not ventilating correctly in a CBT or having a misplaced ET tube.

> None at all. Now, however, we have a piece of technology that is

> relatively cheap (ETCO2 caps and the ETCO2 detector built into the

> BVM's) and the cost of wave form capnography is dropping to.

>

>   I believe as you do that unrecognized ET tube (or CBT) placement

> should never happen. But after having intubated patients with ETCO2

> (detector and capnography both) I can tell you that I would never

> consider ever doing it again without at least one of these pieces of

> equipment.

>

>   Plus, with wave form capnography it allows us to properly ventilate

> our patients at the right rate without super-hyperventilation (60+

> times per minute) and maintaining an ETCO2 at 34-36 which is what is

> recommended by our local head injury docs. Enough hypervent...but not

> too much.

>

>   I always teach people that " It is an airway thing...not an ego

> thing... " when we are putting any tube into a patient. Can't imagine

> having to live with myself if I didn't detect a bad tube (ET or CBT)

> and, as Jane mentioned, I have gone back in to look more than once when

> a tube couldn't be confirmed by auscultation...now, slap the ETCO2

> detector on...no mystery....listen to the chest, the belly and look at

> my reading...all of them are good...I know I am in.

>

> Good discussion though.

>

> Dudley

>

> Re: Combi Tube Questions

>

>   Danny, there is research out to indicate that belly sounds may be

> heard even

>   with correctly placed tracheal tubes and that there are also times

> where breath

>   sounds are not very audible even in correctly placed tubes. There are

> many

>   cases where breath sounds AND belly sounds are heard with correct and

> incorrect

>   placement of advanced airways making it difficult to be sure which

> " hole " you

>   are in. I think it is safe to say this would not be limited to

> endotracheal

>   type airways but to anyway airway device placed in the trachea or

> laryngopharynx

> area.

>

>   I went to a very good capnography training class in Fort Worth by a

> doctor who

>   has a terrific course on this subject, and he pointed out that

> research showed

>   that endotracheal tubes were misplaced in a very high number of

> patients in OR

>   and were not caught initially by the standard methods of watching for

> chest rise

>   and fall, fogging of the tube, and listening to breath and belly

> sounds. Based

>   on those standard " primary " assessments, experienced anethesiologists

> and CRNA's

> mistakenly still thought the tube was in the right place. In fact, the

>   percentage was about the same for Paramedics bringing in intubated

> patients in a

> study in Florida. However, when capnography was added to both of these

>   sitiuations on more recent research studies, the percentage of

> misplaced tubes

>   went to 0%. It seems that the standard of care issue about CO2

> readings will be

>   changing again soon based on these types of studies to using capno

> checks as a

> PRIMARY verification of correct tube placement instead of a SECONDARY

> verification.

>

>   I realize we were talking about Combitubes but based on the design and

> function

> of the device, there is really no difference when we are talking about

>   verifications of tube placement. For ET tubes and Combitubes we are

> taught to

>   assess for breath sounds in at least 4 places and listen to the

> epigastric

>   region for sounds as a primary method of assessing tube placement. We

> know now

>   through research that this is not sufficient and the percentage of

> misplaced

>   tubes with this as the only method of verification is extremely high.

> Many of

>   these misplaced tubes are not found by providers who are not using

> capno until

>   the belly starts to blow up or other signs of a misplaced tube occur,

> which is

>   too late for brain cells in many cases. Providers using capno devices

> as a

>   primary method of placement verification should be able to identify a

> misplaced

>   tube in most cases immediately allowing them to quickly correct the

> problem

> without any adverse outcome for the patient. Due to the design of the

>   Combitube, we should easily be able to do the same thing because CO2

> exchange

>   should only come from one of the two tubes. Then we can back that up

> by

> listening to breath sounds, belly sounds, pulse oximetry readings, etc.

>

>   I think it is obvious that humans make many mistakes in regards to

> assessing

>   whether a tube is in the right place or that we are ventilating

> through the

>   right lumen. Why then would we want to risk a patient's life by not

> using the

>   tools that drop the percentage of our human mistakes to 0 no matter

> which airway

>   we use? A wise man once said, " Insanity is doing the same thing over

> and over

> again and expecting a different outcome. "

>

>   Not flaming at all, Danny, just trying to add to the discussion. Thank

> you for

>   bringing the discussion to the forum because it has given a good

> opportunity for

>   us all to work on this issue and hopefully gain insight for us all on

> things we

> may not have even thought about yet.

>

> Jane Hill

>   --------- Re: Combi Tube Questions

>

> Not sure who I'm replying to, but the subject is whether or not an

> End-Tidal CO2 monitoring device would work on a Combitube.

>

> Well, let's think about this carefully.

>

> When the Combitube is in the esophagus, where it usually resides,

> there is a

> pharyngeal cuff [LARGE] which is preventing air from moving upward

> through the

> mouth, and an esophageal cuff [small} which is preventing air from

> moving

> down the esophagus.

>

> When the CBT is in place, air or oxygen is conducted down the " Blue "

> tube and

> exits through the perforations of the " Blue " tube, and there is no

> place for

> it to go but through the glottic opening. Conversely, on exhalation,

> gas

> passes upward from the alveoli, into the trachea, and exits through

> the

> perforations in the solid tube (the Blue Tube) of the Combitube, and

> out

> through

> the end. Therefore, if there is CO2 in that gas, an end tidal CO2

> monitoring device placed on the Blue tube of the Combitube should come

> into

> contact

> with the exiting gas and the litmus paper should turn to a gold color,

> reflecting

> the presence of CO2.

>

> If you have waveform Capnometric, your wave should be just as square

> as if

> there was an ET tube. There is no reason that is should not reflect

> the same

> level of CO2.

>

> I see no reason why an end tidal CO2 monitoring device would not work

> with a

> Combitube.

>

> If anyone has any evidence-based disagreement, please post.

>

> Gene Gandy.

>

>

>

> E.(Gene) Gandy

> POB 1651

> Albany, TX 76430

> wegandy1938@...

>

>

>

>

[Guest guest]

Dudley;

I see your points. Perhaps I just don't grasp the concept that someone would be

ventiliating the wrong lumen. I can see possibly missing an intubation and the

need for the CO2 Detector in that cirmcumstance.

I should have realized there is the possibility that someone may not be as

adept at determining ventilation of lungs vs ventilation of stomach. Come to

think of it NO I CAN'T. There is a distinct difference when ventilation of

the lungs occur and when ventilation of the stomach ocurrs. With the combitube

in place a quick determination of which lumen to use should be as easy as

putting a key in the ignition to start your unit. Proper training is necessary

for this to occur. Why do we continue to believe that certain fools in EMS need

to be kept when they can not do the job. Laziness that's why. Laziness in not

wanting to conduct a proper interview to find proper personnel and laziness in

not wanting to take the time to do proper re-training to assure that those in

the field know what they are doing when needed. Most EMS are there because they

want to be. A simple explanation and re-training does not offend, or it

shouldn't. If there is a problem in determining where the

combitube is placed someone needs to stop, readjust, then continue. We have

lives in our hands; to rush through blindly is not an option.

Ok now that I have done that. Again I will have to admit that using a CO

Detector could be of some use if your problem is going to be in having to

explain to a jury why the person was ventilated incorrectly. Being an employer

and supervisor of EMS personnel this only happens once, if at all. (It has not

happened by the way) Do it more than once you need to look for employment at

Mc's or Walmart. My point being something less stressful without lives in

your hands is probably your best bet. Perhaps I am being too simple in my

belief of using this tool. Perhaps I need medicaton to relieve me of this anger

problem. I am not exactly sure. Flame on. Nomex Sounds like a sexy thing to

wear.

THEDUDMAN@... wrote:

Danny,

You need to look at the Combi-tube a little closer. Your statement of

" no matter where the CBT is placed the detector will read " is

absolutely correct...BUT only if it is on the CORRECT lumen. If it

would get CO2 out of both lumens no matter what...then why can't we

ventilate into both lumens no matter what? Why does the choice of lumen

depend upon where the CBT comes to rest?

CO2 only comes out of one place in the body (don't even bother going

down the " he drank 2 liters of coke " stuff). It comes out of the lungs

after gas exchange has occurred. If the CBT comes to rest in the

esophagus (which is most likely) and the cuffs are properly inflated,

then ventilating into tube 1 will send O2 into the lungs and once

forced inspiration has stopped, CO2 will exhale. A ETCO2 detector

placed on Tube 1 will show color change (or the presence of CO2). If

you place the ETCO2 detector on Tube 2...it should not change color nor

detect any CO2 when you ventilate into it and if you continue, you will

need the 90 degree elbow that comes in the CBT kit very quickly.

If you are lucky enough to get the CBT into the trachea...put the

ETCO2 on Lumen 1 and you will see no CO2...BUT put it onto Lumen 2, you

will get ETCO2 detected...

Having a device to help confirm which lumen to ventilate through on

the CBT after placing it into the patient does not sound like a waste

of time or money...at least not as much a waste of money as the check

written to the plaintiff if you don't use it and are wrong...ETCO2 is

the standard of care...so much so that some state(s) are requiring its

presence and use on all ambulances in the next couple of years.

Hope this helps clarify my point. ETCO2 is never a waste of money or

time...it is a cheap tool to help prevent some very costly mistakes.

Dudley

Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

Danny, there is research out to indicate that belly sounds may be heard even

with correctly placed tracheal tubes and that there are also times where breath

sounds are not very audible even in correctly placed tubes. There are many

cases where breath sounds AND belly sounds are heard with correct and incorrect

placement of advanced airways making it difficult to be sure which " hole " you

are in. I think it is safe to say this would not be limited to endotracheal

type airways but to anyway airway device placed in the trachea or laryngopharynx

area.

I went to a very good capnography training class in Fort Worth by a doctor who

has a terrific course on this subject, and he pointed out that research showed

that endotracheal tubes were misplaced in a very high number of patients in OR

and were not caught initially by the standard methods of watching for chest rise

and fall, fogging of the tube, and listening to breath and belly sounds. Based

on those standard " primary " assessments, experienced anethesiologists and CRNA's

mistakenly still thought the tube was in the right place. In fact, the

percentage was about the same for Paramedics bringing in intubated patients in a

study in Florida. However, when capnography was added to both of these

sitiuations on more recent research studies, the percentage of misplaced tubes

went to 0%. It seems that the standard of care issue about CO2 readings will be

changing again soon based on these types of studies to using capno checks as a

PRIMARY verification of correct tube placement instead of a SECONDARY

verification.

I realize we were talking about Combitubes but based on the design and function

of the device, there is really no difference when we are talking about

verifications of tube placement. For ET tubes and Combitubes we are taught to

assess for breath sounds in at least 4 places and listen to the epigastric

region for sounds as a primary method of assessing tube placement. We know now

through research that this is not sufficient and the percentage of misplaced

tubes with this as the only method of verification is extremely high. Many of

these misplaced tubes are not found by providers who are not using capno until

the belly starts to blow up or other signs of a misplaced tube occur, which is

too late for brain cells in many cases. Providers using capno devices as a

primary method of placement verification should be able to identify a misplaced

tube in most cases immediately allowing them to quickly correct the problem

without any adverse outcome for the patient. Due to the design of the

Combitube, we should easily be able to do the same thing because CO2 exchange

should only come from one of the two tubes. Then we can back that up by

listening to breath sounds, belly sounds, pulse oximetry readings, etc.

I think it is obvious that humans make many mistakes in regards to assessing

whether a tube is in the right place or that we are ventilating through the

right lumen. Why then would we want to risk a patient's life by not using the

tools that drop the percentage of our human mistakes to 0 no matter which airway

we use? A wise man once said, " Insanity is doing the same thing over and over

again and expecting a different outcome. "

Not flaming at all, Danny, just trying to add to the discussion. Thank you for

bringing the discussion to the forum because it has given a good opportunity for

us all to work on this issue and hopefully gain insight for us all on things we

may not have even thought about yet.

Jane Hill

--------- Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

I too echo Jane on this one. Danny, I agree...there should be no excuse

for not ventilating correctly in a CBT or having a misplaced ET tube.

None at all. Now, however, we have a piece of technology that is

relatively cheap (ETCO2 caps and the ETCO2 detector built into the

BVM's) and the cost of wave form capnography is dropping to.

I believe as you do that unrecognized ET tube (or CBT) placement

should never happen. But after having intubated patients with ETCO2

(detector and capnography both) I can tell you that I would never

consider ever doing it again without at least one of these pieces of

equipment.

Plus, with wave form capnography it allows us to properly ventilate

our patients at the right rate without super-hyperventilation (60+

times per minute) and maintaining an ETCO2 at 34-36 which is what is

recommended by our local head injury docs. Enough hypervent...but not

too much.

I always teach people that " It is an airway thing...not an ego

thing... " when we are putting any tube into a patient. Can't imagine

having to live with myself if I didn't detect a bad tube (ET or CBT)

and, as Jane mentioned, I have gone back in to look more than once when

a tube couldn't be confirmed by auscultation...now, slap the ETCO2

detector on...no mystery....listen to the chest, the belly and look at

my reading...all of them are good...I know I am in.

Good discussion though.

Dudley

Re: Combi Tube Questions

Danny, there is research out to indicate that belly sounds may be

heard even

with correctly placed tracheal tubes and that there are also times

where breath

sounds are not very audible even in correctly placed tubes. There are

many

cases where breath sounds AND belly sounds are heard with correct and

incorrect

placement of advanced airways making it difficult to be sure which

" hole " you

are in. I think it is safe to say this would not be limited to

endotracheal

type airways but to anyway airway device placed in the trachea or

laryngopharynx

area.

I went to a very good capnography training class in Fort Worth by a

doctor who

has a terrific course on this subject, and he pointed out that

research showed

that endotracheal tubes were misplaced in a very high number of

patients in OR

and were not caught initially by the standard methods of watching for

chest rise

and fall, fogging of the tube, and listening to breath and belly

sounds. Based

on those standard " primary " assessments, experienced anethesiologists

and CRNA's

mistakenly still thought the tube was in the right place. In fact, the

percentage was about the same for Paramedics bringing in intubated

patients in a

study in Florida. However, when capnography was added to both of these

sitiuations on more recent research studies, the percentage of

misplaced tubes

went to 0%. It seems that the standard of care issue about CO2

readings will be

changing again soon based on these types of studies to using capno

checks as a

PRIMARY verification of correct tube placement instead of a SECONDARY

verification.

I realize we were talking about Combitubes but based on the design and

function

of the device, there is really no difference when we are talking about

verifications of tube placement. For ET tubes and Combitubes we are

taught to

assess for breath sounds in at least 4 places and listen to the

epigastric

region for sounds as a primary method of assessing tube placement. We

know now

through research that this is not sufficient and the percentage of

misplaced

tubes with this as the only method of verification is extremely high.

Many of

these misplaced tubes are not found by providers who are not using

capno until

the belly starts to blow up or other signs of a misplaced tube occur,

which is

too late for brain cells in many cases. Providers using capno devices

as a

primary method of placement verification should be able to identify a

misplaced

tube in most cases immediately allowing them to quickly correct the

problem

without any adverse outcome for the patient. Due to the design of the

Combitube, we should easily be able to do the same thing because CO2

exchange

should only come from one of the two tubes. Then we can back that up

by

listening to breath sounds, belly sounds, pulse oximetry readings, etc.

I think it is obvious that humans make many mistakes in regards to

assessing

whether a tube is in the right place or that we are ventilating

through the

right lumen. Why then would we want to risk a patient's life by not

using the

tools that drop the percentage of our human mistakes to 0 no matter

which airway

we use? A wise man once said, " Insanity is doing the same thing over

and over

again and expecting a different outcome. "

Not flaming at all, Danny, just trying to add to the discussion. Thank

you for

bringing the discussion to the forum because it has given a good

opportunity for

us all to work on this issue and hopefully gain insight for us all on

things we

may not have even thought about yet.

Jane Hill

--------- Re: Combi Tube Questions

Not sure who I'm replying to, but the subject is whether or not an

End-Tidal CO2 monitoring device would work on a Combitube.

Well, let's think about this carefully.

When the Combitube is in the esophagus, where it usually resides,

there is a

pharyngeal cuff [LARGE] which is preventing air from moving upward

through the

mouth, and an esophageal cuff [small} which is preventing air from

moving

down the esophagus.

When the CBT is in place, air or oxygen is conducted down the " Blue "

tube and

exits through the perforations of the " Blue " tube, and there is no

place for

it to go but through the glottic opening. Conversely, on exhalation,

gas

passes upward from the alveoli, into the trachea, and exits through

the

perforations in the solid tube (the Blue Tube) of the Combitube, and

out

through

the end. Therefore, if there is CO2 in that gas, an end tidal CO2

monitoring device placed on the Blue tube of the Combitube should come

into

contact

with the exiting gas and the litmus paper should turn to a gold color,

reflecting

the presence of CO2.

If you have waveform Capnometric, your wave should be just as square

as if

there was an ET tube. There is no reason that is should not reflect

the same

level of CO2.

I see no reason why an end tidal CO2 monitoring device would not work

with a

Combitube.

If anyone has any evidence-based disagreement, please post.

Gene Gandy.

E.(Gene) Gandy

POB 1651

Albany, TX 76430

wegandy1938@...

[Guest guest]

Gene et al;

Are we talking intubations or are we talking combitube placement? I understand

the findings on ET placement and agree that use of the end tidal co2 detection

is essential.

Combitube placement should be a separate animal all together. This device was

designed to augment the facilitation of a secure airway. I would like to see

the studies on this and find out which anesthesiologist had a problem with

combitube.

Standard of Care with respect to using capnography for intubations is well

known to me. What I am seeing in print is someone making the claim that it

should be considered acceptable for medical personnel to shirk their duty to be

fully trained because they do not possess a technical piece of equipment, being

used on another piece of equipment designed to acheive an airway regardless of

where it is placed; to avoid making the mistake of ventilating the patient

incorrectly.

UNACCEPTABLE!

Being an EMS Instructor as well as working in the field I see that the more

technical we are becoming the less able we are to use the basic skills. I shall

elaborate.

Use of automatic blood pressure machines, inability to properly ausciltate a

blood pressure or palpate a blood pressure. Use of IV pumps, inability to

correctly calculate intraveinous drips or calculate just a simple intraveinous

flow. Use of end tidal co2 monitors, inability to properly ausciltate lung

sounds and/or intubate.

Perhaps I am getting off track. This is an issue that bites at the very inner

soul. Let's not assure that skills have been properly taught. Let's not assure

that re-training, when necessary; has been done. Let's give another piece of

technical equipment to those individuals who are less than proficient, no,

usually totally inept at their position; the ability to skate by. Who loses in

this? The patient is who loses in this.

I would venture a guess that those medical professionals who care about their

position understand what I am trying to convey.

Are we trying to prevent a regular and serious problem? Or are we again

allowing those individuals who do not actually possess the skills, knowledge, or

heart; to practice medicine?

That is what we do we practice medicine, albeit with oversight; that is what

we do.

wegandy1938@... wrote:

Danny,

Jane and Dudley have covered the subject comprehensively. I only have one

thing to add, from the lawyer's standpoint. Standard of Care.

Standard of Care requires a secondary method of tube placement verification.

The best is wave-form capnography, which WILL BE the standard in ALL

settings very soon if it is not now, and second is end-tidal CO2 monitoring +

esophageal tube detection device.

You either use those or you're not giving Standard of Care. Period.

Plus, they give a means of measurable documentation other than one's

observations of chest rise or breath sounds.

It is naive in the extreme to believe that if board certified

anesthesiologists miss a significant number of esophageal intubations in the OR,

paramedics

in the field would be able to do better. Since caphography became standard

in ORs, the incidence of undetected esophageal intubations and claims arising

therefrom has dwindled to almost nothing.

If you're interested, I can refer you to the closed case studies done by the

American Society of Anesthesia and the American Association of Nurse

Anesthestists which were the basis for these findings. Further, it is now

REQUIRED by

ASA and AANA that these devices be used.

Best,

Gene Gandy

> I too echo Jane on this one. Danny, I agree...there should be no excuse

> for not ventilating correctly in a CBT or having a misplaced ET tube.

> None at all. Now, however, we have a piece of technology that is

> relatively cheap (ETCO2 caps and the ETCO2 detector built into the

> BVM's) and the cost of wave form capnography is dropping to.

>

> I believe as you do that unrecognized ET tube (or CBT) placement

> should never happen. But after having intubated patients with ETCO2

> (detector and capnography both) I can tell you that I would never

> consider ever doing it again without at least one of these pieces of

> equipment.

>

> Plus, with wave form capnography it allows us to properly ventilate

> our patients at the right rate without super-hyperventilation (60+

> times per minute) and maintaining an ETCO2 at 34-36 which is what is

> recommended by our local head injury docs. Enough hypervent...but not

> too much.

>

> I always teach people that " It is an airway thing...not an ego

> thing... " when we are putting any tube into a patient. Can't imagine

> having to live with myself if I didn't detect a bad tube (ET or CBT)

> and, as Jane mentioned, I have gone back in to look more than once when

> a tube couldn't be confirmed by auscultation...now, slap the ETCO2

> detector on...no mystery....listen to the chest, the belly and look at

> my reading...all of them are good...I know I am in.

>

> Good discussion though.

>

> Dudley

>

> Re: Combi Tube Questions

>

> Danny, there is research out to indicate that belly sounds may be

> heard even

> with correctly placed tracheal tubes and that there are also times

> where breath

> sounds are not very audible even in correctly placed tubes. There are

> many

> cases where breath sounds AND belly sounds are heard with correct and

> incorrect

> placement of advanced airways making it difficult to be sure which

> " hole " you

> are in. I think it is safe to say this would not be limited to

> endotracheal

> type airways but to anyway airway device placed in the trachea or

> laryngopharynx

> area.

>

> I went to a very good capnography training class in Fort Worth by a

> doctor who

> has a terrific course on this subject, and he pointed out that

> research showed

> that endotracheal tubes were misplaced in a very high number of

> patients in OR

> and were not caught initially by the standard methods of watching for

> chest rise

> and fall, fogging of the tube, and listening to breath and belly

> sounds. Based

> on those standard " primary " assessments, experienced anethesiologists

> and CRNA's

> mistakenly still thought the tube was in the right place. In fact, the

> percentage was about the same for Paramedics bringing in intubated

> patients in a

> study in Florida. However, when capnography was added to both of these

> sitiuations on more recent research studies, the percentage of

> misplaced tubes

> went to 0%. It seems that the standard of care issue about CO2

> readings will be

> changing again soon based on these types of studies to using capno

> checks as a

> PRIMARY verification of correct tube placement instead of a SECONDARY

> verification.

>

> I realize we were talking about Combitubes but based on the design and

> function

> of the device, there is really no difference when we are talking about

> verifications of tube placement. For ET tubes and Combitubes we are

> taught to

> assess for breath sounds in at least 4 places and listen to the

> epigastric

> region for sounds as a primary method of assessing tube placement. We

> know now

> through research that this is not sufficient and the percentage of

> misplaced

> tubes with this as the only method of verification is extremely high.

> Many of

> these misplaced tubes are not found by providers who are not using

> capno until

> the belly starts to blow up or other signs of a misplaced tube occur,

> which is

> too late for brain cells in many cases. Providers using capno devices

> as a

> primary method of placement verification should be able to identify a

> misplaced

> tube in most cases immediately allowing them to quickly correct the

> problem

> without any adverse outcome for the patient. Due to the design of the

> Combitube, we should easily be able to do the same thing because CO2

> exchange

> should only come from one of the two tubes. Then we can back that up

> by

> listening to breath sounds, belly sounds, pulse oximetry readings, etc.

>

> I think it is obvious that humans make many mistakes in regards to

> assessing

> whether a tube is in the right place or that we are ventilating

> through the

> right lumen. Why then would we want to risk a patient's life by not

> using the

> tools that drop the percentage of our human mistakes to 0 no matter

> which airway

> we use? A wise man once said, " Insanity is doing the same thing over

> and over

> again and expecting a different outcome. "

>

> Not flaming at all, Danny, just trying to add to the discussion. Thank

> you for

> bringing the discussion to the forum because it has given a good

> opportunity for

> us all to work on this issue and hopefully gain insight for us all on

> things we

> may not have even thought about yet.

>

> Jane Hill

> --------- Re: Combi Tube Questions

>

> Not sure who I'm replying to, but the subject is whether or not an

> End-Tidal CO2 monitoring device would work on a Combitube.

>

> Well, let's think about this carefully.

>

> When the Combitube is in the esophagus, where it usually resides,

> there is a

> pharyngeal cuff [LARGE] which is preventing air from moving upward

> through the

> mouth, and an esophageal cuff [small} which is preventing air from

> moving

> down the esophagus.

>

> When the CBT is in place, air or oxygen is conducted down the " Blue "

> tube and

> exits through the perforations of the " Blue " tube, and there is no

> place for

> it to go but through the glottic opening. Conversely, on exhalation,

> gas

> passes upward from the alveoli, into the trachea, and exits through

> the

> perforations in the solid tube (the Blue Tube) of the Combitube, and

> out

> through

> the end. Therefore, if there is CO2 in that gas, an end tidal CO2

> monitoring device placed on the Blue tube of the Combitube should come

> into

> contact

> with the exiting gas and the litmus paper should turn to a gold color,

> reflecting

> the presence of CO2.

>

> If you have waveform Capnometric, your wave should be just as square

> as if

> there was an ET tube. There is no reason that is should not reflect

> the same

> level of CO2.

>

> I see no reason why an end tidal CO2 monitoring device would not work

> with a

> Combitube.

>

> If anyone has any evidence-based disagreement, please post.

>

> Gene Gandy.

>

>

>

> E.(Gene) Gandy

> POB 1651

> Albany, TX 76430

> wegandy1938@...

>

>

>

>