COMBITUBE

1. EMT Basic
Advanced Airway
Management
Pharyngeal Esophageal Airway Device
(PEAD)
A.K.A. Combitube©
PowerPoint developed by Jennifer Stanislaw, EMT-P, EMS Training Officer
West Valley Fire District, Willamina, OR

2. The Cat Fan (No Pun Intended)

3. Agenda
 Review Objectives
 Lesson 1
 Respiratory Anatomy & Physiology
 Lesson 2
 Respiratory Volume and Management
 Lesson 3
 Assessing Respiratory Problems

4. Agenda cont’d
 Lesson 4
 Respiratory/Cardiac Arrest
 Basic Airway Management
 Lesson 5
 Suctioning
 Lesson 6
 Dual-Lumen Airway Devices

5. Agenda cont’d
 Demonstration
 Practical Stations
 Basic Airway Management
 Manual Maneuvers and Simple Adjuncts
 Supplemental Oxygen
 Ventilation
 Suctioning
 Combitube Insertion

6. Practical
 Testing must be done with the Physician
Advisor (or another Physician of his / her
choosing)

7. Objectives
 Describe the anatomy and function of the upper
and lower airways
 Describe respiratory volumes and capacities in
relationship to the need for assisted ventilations
 Identify the specific observations and physical
findings commonly found in patients presenting
in respiratory and/or cardiac arrest.
 Identify the basic principles of airway
management

8. Objectives (cont’d)
 Describe the indications for suctioning.
 Identify rigid and flexible suction catheters
and the indications for use.
 Identify indications and contraindications
for use of the PEAD’s.
 Identify the advantages and disadvantages
of using PEAD’s.

9. Objectives (cont’d)
 Identify those situations in which PEAD’s
may be removed.
 Demonstrated placement of PEAD’s.
 Demonstrate methods of assuring and
maintaining correct placement of PEAD’s.
 Demonstrate re-ventilation for missed
placement of PEAD’s.

10. Objectives (cont’d)
 Demonstrate on a manikin the proper
technique for the use and maintenance of
the following airway adjuncts:
 Nasal cannula
 Non-rebreather mask
 Bag-Valve-Mask
 Demonstrate sterile suctioning techniques
on a manikin with a PEAD in place.

11. Lesson 1
Respiratory Anatomy & Physiology

12. Respiratory Anatomy & Physiology

13. Function of the Respiratory System
 Removes carbon
dioxide from the blood
 Transfers oxygen to
the blood

14. The Upper Airway
Epiglottis
Mandible
Frontal Sinus
Soft Palate
Trachea
Glottis
Esophagus
Vocal Cords
A
B
C
D
E
F
G
H

15. The Upper Airway
 Other Structures
 Nasopharynx
 Oropharynx
 Hypopharynx
 Larynx
 Functions

16. Functions of the Upper Airway
 Passageway for air
 Warm
 Filter
 Humidify
 Protection
 Gag Reflex
 Cough
 Speech

17. The Lower Airway
Primary Bronchi
Hyoid Bone
Right Lung
Secondary Bronchi
Tracheal Ligament
Trachea
Larynx
Esophagus
Left Lung
Trachea
A
B
C
D
E
F
G
H
I
J

18. Alveoli
 Gas Exchange

19. Lungs
 Structure
 Lobes
 Pleura

20. Physiology of Respiration
 Define Respiration
 The exchange of gases between a living
organism and the environment
 Define Ventilation
 Mechanical Process that moves air in and out of
the lungs

21. Muscles of Breathing
 Intercostal Muscles
 Diaphragm

22. Regulation of Respiration
Where is the Respiratory Center Controlled?
 Brainstem
 Medulla
 Apeustic Center (pons)
 Pneumotaxic center (pons)
 Stretch receptors
 Hering-Breuer reflex
 Chemoreceptors
 CSF
 Blood

23. Voluntary or Involuntary
 Both
 Humans can override body’s urge to breathe
 But only for so long

24. Respiratory Cycle
 Inspiration
 Active phase
 Lasts 1-2 seconds
 Expiration
 Passive phase
 Lasts 5 seconds

25. Lesson 2
Respiratory Volume and
Management

26. Drinking Straw Exercise
 Breathe through
straws for 1 minute

27. Carbon Dioxide & The Respiratory
System
 High CO2
 Increases respiratory rate
 Low CO2
 Decreases respiratory rate
 Hypoxic Drive
 Chronic COPD patients

28. Normal Respiratory Rates
 Adult
 Children
 Infants
 Newborns
 12 – 20 / min
 18 – 24 / min
 22 – 36 / min
 40 – 60 / min

29. Factors Affecting Respiratory Rate
 Fever
 Depressant Drugs
 Anxiety
 Insufficient Oxygen
 Stimulant Drugs
 Sleep

30. Respiratory Volumes
 Lung Capacity
 Tidal Volume
 Dead Space
 Alveolar Air
 6000 mL of air
 500 mL at rest
 150 mL
 350 mL

31. Minute Volume
 Total air moved per minute
 Rate X Volume = Minute volume
 Important Assessment Item

32. Factors Affecting Minute Volume
 Head, neck, chest injury
 Shock
 Diabetes
 CO2 / O2 rapid changes

33. Maintaining the A in ABC
 Patient positioning
 Suctioning
 Supplemental Oxygen
 Mechanical Assistance

34. Pulse Oximetry
 Measures amount of oxygen in the blood.
 Gives percent of hemoglobin saturated
 Tool only, do not rely on totally
 Why?
 Normal Values
 95% - 100% Normal
 90% - 95% - Mild – Normal for COPD
 < 90 % Moderate – High Flow Oxygen

35. End-Tidal CO2 Detection
 Measured
 Colorimetric and Digital
 Tool to aid in determining correct placement

36. Lesson 3
Assessing Respiratory Problems

37. Patient Assessment

38. General Patient Assessment
 Primary Survey
 LOC
 ABC’s
 Speech Pattern
 Obvious Respiratory Noise
 Patient Position

39. General Assessment (cont’d)

40. Secondary Assessment
 SAMPLE history
 Chief Complaint
 Pertinent Negatives
 Chest Pain (pleuritic vs cardiac)
 Cough History
 Edema
 Vitals

41. Respiratory Assessment
 Confusion, Agitation, Orientation
 Cyanosis (late sign)
 Diaphoresis
 Retractions
 Accessory Muscle Use
 Jugular Venous Distention
 Nasal Flaring / Pursed Lip Breathing

42. Palpation
 Skin
 Turgor
 Color
 Temperature
 Diaphoresis
 Pulse
 Rate
 Rhythm
 Quality
 Chest Wall Pain
 Tracheal Deviation

43. Assessing Lung Sounds
 Methods
 Hand Out

44. Lung Sounds
 Normal
 Wheezes
 Rales (Crackles)
 Stridor
 Rhonchi
 Pleural Rub
 Listen on every patient
 End of Expiration
 End of Inspiration
 During both phases
 Expiration
 End of Inspiration

45. Respiratory Diseases
 COPD
 Asthma
 Pneumonia
 Pulmonary Edema
 Pulmonary Embolus
 Trauma

46. COPD

47. Chronic Obstructive Pulmonary
Disease
 Pink Puffers and Blue Bloaters
 Frequently on Home oxygen
 Assessment
 Typical Lung Sounds
 Common Medications
 May or May not be Hypoxic Drive

48. Asthma

49. Asthma
 Bronchiole Constriction & Mucous
Production
 Lung Sounds
 Wheezes
 Diminished
 None
 Usually Diagnosed

50. Pneumonia

51. Pneumonia
 Fever
 Productive Cough
 Colored Sputum
 General Illness
 Elderly & Pediatric most at risk
 Lung Sounds
 Rhonchi, Rales, Wheezes

52. Pulmonary Edema

53. Pulmonary Edema
 Congestive Heart Failure
 Acute – Flash Pulmonary Edema
 Chronic – Heart Failure
 Medications
 Orthopnea, PND
 Lung Sounds
 Keep them upright with legs dangling

54. Pulmonary Embolus

55. Pulmonary Embolus
 Lung Sounds
 History
 Surgery
 Bed Confined
 Long trip
 Rapid Transport & High Flow Oxygen

56. Trauma

57. Trauma
 Maintain spinal control
 Airway Management
 High Flow Oxygen
 Rapid Transport
 Seal Chest Wounds
 Stabilize Impaled Objects

58. Lesson 4
Respiratory/Cardiac Arrest
Basic Airway Management

59. Respiratory & Cardiac Arrest

60. Assessing the Patient
 First Steps of CPR
 Annie, Annie You Okay?
 Other Signs and Symptoms
 Unconsciousness
 Cardiac Seizure
 Agonal respirations or apnea
 Cyanosis, Ashen, Mottled
 No signs of spontaneous respiration or circulation
 No Pulse

61. Combitube

62. When to Use the Combitube
 CPR
 Remember to do CPR!
 Attach AED!
 Respiratory Arrest
 Agonal Respirations without intact gag reflex
 Respiratory Arrest leads to Cardiac Arrest

63. Airway Management – The Basics
Manual Maneuvers
 Chin Lift
 Jaw Lift
 Jaw Thrust
 Head Tilt – Chin Lift
 Modified Jaw thrust

64. Airway Management – The Basics
Mechanical Airways
 NPA’s
 OPA’s
 Description
 Advantages
 Disadvantages
 Indications
 Contraindications
 Methods of Insertion

65. Airway Management – The Basics
Ventilation
 Mouth to Mask
 BVM
 Description
 Advantages
 Disadvantages
 Indications
 Contraindications
 Methods of Use

66. Evaluation of Effectiveness
 How do I know I am ventilating?
 Chest movement
 Lung Sounds
 Epigastric sounds/Abdominal distention
 Patient Response

67. Lesson 5
Suctioning

68. Reviewing Suctioning
 BSI – Scene Safety
 Equipment
 Suction device
 Rigid or Soft Tip
 Insert with Suction Off
 Withdraw while
Suctioning
 No more than 15
seconds before
ventilating!

69. Oh, That Sucks!
 Vomitus
 Food
 Protein dissolving
enzymes
 Hydrochloric Acid
 Aspiration damage
 Alveolar Damage
 Increased fluid
 Obstruction
 Aspiration Pneumonia

70. Oh, Go Spit on It
 Saliva
 Digestive enzymes
 Bacteria
 Aspiration Damage
 Fills alveoli
 Pneumonia

71. Food
 Clogs airways
 Interferes with
ventilation
 Pneumonia

72. Blood
 Contents
 Protein
 Fibrin
 Water
 Electrolytes
 Aspiration Damage
 Clog small airways
 Creates chemical
reaction

73. Suction Catheters
Rigid
 Advantages
 Disadvantages
 Indications
 Contraindications
 Methods of Use
Flexible
 Advantages
 Disadvantages
 Indications
 Contraindications
 Methods of Use

74. Lesson 6
Dual-Lumen Airway Devices

75. Combitube©

76. Description
 Other Similar Devices
 Pharyngeal tracheal lumen airway (PTLA)
 EGTA
 EOA
 What we use
 Combitube©

77. Indications for Combitube©
 Respiratory Arrest
 Cardiac Arrest
 Unconscious, without a gag reflex

78. Contraindications for Combitube©
 Gag Reflex
 Conscious
 Breathing Adequately
 Caustic Ingestion
 Known esophageal disease or varices
 Under 16 y/o
 Under 5 feet or over 6 feet 8inches

79. Advantages for Combitube©
 Rapid Insertion
 Limits regurgitation, aspiration & distention
 Blind insertion
 High oxygen delivery
 Less training required
 Inserted in neutral position

80. Disadvantages for Combitube©
 Patient must be unresponsive without gag
reflex
 Some are difficult to obtain adequate seal
 Some do not totally protect against
aspiration
 Most responsive patients will vomit when
removed
 May damage esophagus

81. Demonstration

82. When Can I Remove the Combitube?
 Patient returns to full consciousness
 Patient able to maintain own airway
 Orders from OLMC

83. Procedure for Removing
 SUCTION READY!
 Deflate Tube #2
 Deflate Tube #1
 Tell patient to exhale
 Pull out quickly and in-line
 SUCTION

84. Demonstration

85. Skills Labs
 Basic Airway Management
 Manual Maneuvers and Simple Adjuncts
 Supplemental Oxygen
 Ventilation
 Suctioning
 Advanced Airway Management
 Combitube

86. Questions?