Re: Combi Tube Questions

September 12, 2005

I did not actually make the original post. I was responding to a post. I tend

to get very passionate about patient care.

As per the original post. Does anyone have a preference on CO2 Detectors or

tube securing devices????

THEDUDMAN@... wrote:

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@...

September 12, 2005

Jane - I can't claim any real experience with ETC02 detectors and PTC's but I'd

like to survey our staff for their results. We are like most others - not a lot

of PTC's getting dropped but enough to get a feel for their use with

capnography. The interesting thing, I think, would be a study that could reflect

any differences in exhaled C02 levels in comparison to endotracheal intubation

(with a tube meant to go there). Do we know of any? This would speak to the

effectiveness of the device.

Oropharyngeal cuff/esophageal cuff or not - a PTC can shift up or down (argument

for the tube-holder) which can affect the position of the slots in relation to

the glottis. I cannot see any real valid study happening to help us with that

question but just wondering how it could affect ventilation.

It seems to be a very good simple tool that works well and maybe too much time

has already been spent talking about it (?). Are we trying to over-complicate

this?

BTW - there are butt-breathers. You know.... " he's asleep butt breathing " .

You're actually wise by not going there.

Don

>>> je.hill@... 9/9/2005 5:06:36 PM >>>

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

September 12, 2005