(See also Airway Establishment and Control Airway Establishment and Control Airway management consists of Clearing the upper airway Maintaining an open air passage with a mechanical device Sometimes assisting respirations (See also Overview of Respiratory Arrest.) read more and Airway and Respiratory Devices Airway and Respiratory Devices If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more .)
The esophageal-tracheal double lumen tube (Combitube®) and the King laryngeal tube are twin-lumen tubes that have fundamental similarities:
A large proximal balloon cuff seals the hypopharynx
A ventilating, proximal lumen terminates at side ports overlying the laryngeal inlet
A distal lumen and its smaller balloon cuff terminate in and seal the upper esophagus (in > 90% of insertions)
Supraglottic airways are useful for providing rescue ventilation to unconscious patients or patients without a gag reflex and are also used in some elective settings.
The esophageal-tracheal double lumen tube and King laryngeal tube have some advantages over other methods of ventilation:
Unlike endotracheal tubes, they can be successfully inserted blindly and by inexperienced operators.
Unlike bag-valve-mask (BVM) ventilation Bag-Valve-Mask Devices If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more , they avoid the difficulties of attaining and maintaining an adequate face-mask seal.
They cause less gastric insufflation or aspiration than BVM or laryngeal mask (LMA) ventilation Laryngeal Mask Airways (LMA) If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more because they better isolate the esophagus from the trachea and because the distal lumen permits gastric tube insertion
Like the other supraglottic airways, the Combitube® and King laryngeal tube are temporary airways that must be removed or replaced by a definitive airway, such as an endotracheal tube or surgical airway (cricothyrotomy Cricothyrotomy If the upper airway is obstructed because of a foreign body or massive facial trauma or if ventilation cannot be accomplished by other means, surgical entry into the trachea is required. Historically... read more or tracheostomy Tracheostomy If the upper airway is obstructed because of a foreign body or massive facial trauma or if ventilation cannot be accomplished by other means, surgical entry into the trachea is required. Historically... read more ).
Indications for Combitube® or King Laryngeal Tube
Apnea, severe respiratory failure Overview of Respiratory Failure Acute respiratory failure is a life-threatening impairment of oxygenation, carbon dioxide elimination, or both. Respiratory failure may occur because of impaired gas exchange, decreased ventilation... read more , or impending respiratory arrest Overview of Respiratory Arrest Respiratory arrest and cardiac arrest are distinct, but inevitably if untreated, one leads to the other. (See also Respiratory Failure, Dyspnea, and Hypoxia.) Interruption of pulmonary gas exchange... read more in which endotracheal intubation cannot be accomplished
Certain elective anesthesia cases
Situations where BVM ventilation is difficult or impossible (eg, in patients with severe facial deformity [traumatic or natural], thick beard, or other factors that interfere with the face mask seal, and in patients with upper airway blockage due to obstructing soft tissues
Contraindications to Combitube® or King Laryngeal Tube
There is no medical contraindication to providing ventilatory support to a patient; however, a legal contraindication (do-not-resuscitate order or specific advance directive) may be in force
Restricted mouth opening that blocks tube insertion (nasotracheal intubation or a surgical airway would be indicated in this case)
Impassable upper airway obstruction (surgical airway would be indicated in this case)
Consciousness or presence of a gag reflex
Hypopharyngeal or esophageal abnormalities or trauma (which increase the risk of further local damage by a supraglottic airway)
Combitube® is not recommended for patients < 4 feet tall
Complications of Combitube® or King Laryngeal Tube
Vomiting and aspiration during tube insertion or after placement in patients who regain a gag reflex
Dental or oropharyngeal soft tissue trauma during tube insertion
Tongue edema due to prolonged placement or balloon overinflation
Equipment for Combitube® or King Laryngeal Tube
Gloves, mask, gown, and eye protection (ie, universal precautions)
Syringes for balloon cuff inflation
Sterile water-soluble lubricant or anesthetic jelly
Combitube® or King laryngeal tube, appropriately sized to patient
Oxygen source (100 % oxygen, 15 L/minute)
Suctioning apparatus to clear the pharynx as needed
Pulse oximeter, capnometer (end-tidal carbon dioxide monitor), and appropriate sensors
Equipment for alternate methods of airway control should insertion fail (eg, laryngeal mask airway Laryngeal Mask Airways (LMA) If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more , bag-valve mask ventilation Equipment Bag-valve-mask (BVM) ventilation is the standard method for rapidly providing rescue ventilation to patients with apnea or severe ventilatory failure. (See also Airway Establishment and Control... read more , endotracheal intubation Endotracheal Tubes If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more , cricothyrotomy Cricothyrotomy If the upper airway is obstructed because of a foreign body or massive facial trauma or if ventilation cannot be accomplished by other means, surgical entry into the trachea is required. Historically... read more )
Additional Considerations for Combitube® or King Laryngeal Tube
The balloon cuffs of the Combitube® are inflated individually. The balloon cuffs of the King laryngeal tube share a single pilot tube and inflate simultaneously.
An estimated 1 to 5% of Combitube® insertions enter the trachea; in these cases, if the misplacement is recognized, the cuffed distal lumen can be used to function as an endotracheal tube. Probably at least 10% of insertions done with newer King laryngeal tubes enter the trachea; ventilation may be possible through the distal lumen in these cases. Older King tubes are contoured such that virtually all insertions enter the esophagus.
The ventilating lumen of the King tube is suitable for stylet insertion to facilitate conversion of the King tube to an endotracheal tube. However, visualization of the glottis through this lumen is often impossible.
Relevant Anatomy for Combitube® or King Laryngeal Tube
Aligning the ear with the sternal notch may help open the upper airway and establishes the best position to view the airway if endotracheal intubation becomes necessary.
The degree of head elevation that best aligns the ear and sternal notch varies depending on the patient's age and body habitus.
Positioning for Combitube® or King Laryngeal Tube
Optimal position for tube insertion is the sniffing position, but Combitube® or King tube insertion can be done with the patient’s neck in a neutral position.
The operator stands at the head of the stretcher.
An assistant may stand at the side.
The sniffing position is used only in the absence of cervical spine injury:
Position the patient supine on the stretcher.
Place folded towels or other materials under the head, neck, and shoulders, flexing the neck so as to elevate the head until the external auditory meatus lies in the same horizontal plane as the sternal notch. Then, tilt the head so that the face aligns on a parallel horizontal plane; this second plane will be above the first. In obese patients, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck (see figure head and neck positioning to open the airway Head and neck positioning to open the airway Endotracheal (ET) tubes are flexible tubes with a standard flange for attaching an oxygen source at the proximal end and a beveled tip and inflatable balloon cuff at the distal end. Under visualization... read more ).
Head and neck positioning to open the airway
A: The head is flat on the stretcher; the airway is constricted. B: Establishing the sniffing position, the ear and sternal notch are aligned, with the face parallel to the ceiling, opening the airway. Adapted from Levitan RM, Kinkle WC: The Airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007.
If cervical spine injury is a possibility:
Position the patient supine or at a slight incline on the stretcher. Avoid moving the neck and use only the jaw thrust maneuver How To Do Head Tilt–Chin Lift and Jaw-Thrust Maneuvers Part of pre-intubation and emergency rescue breathing procedures, the head tilt–chin lift maneuver and the jaw-thrust maneuver are 2 noninvasive, manual means to help restore upper airway patency... read more or chin lift How To Do Head Tilt–Chin Lift and Jaw-Thrust Maneuvers Part of pre-intubation and emergency rescue breathing procedures, the head tilt–chin lift maneuver and the jaw-thrust maneuver are 2 noninvasive, manual means to help restore upper airway patency... read more without head tilt to manually facilitate opening of the upper airway.
Step-by-Step Description of Procedure
Clear the oropharynx, as necessary, of obstructing secretions, vomitus, or foreign material.
Pre-oxygenate the patient with bag-valve-mask ventilation How To Do a Percutaneous Cricothyrotomy Cricothyrotomy, whether traditional surgical cricothyrotomy or percutaneous cricothyrotomy using a guidewire, uses an incision through the skin and cricothyroid membrane through which an artificial... read more , if possible.
Select the appropriately sized Combitube® or King laryngeal tube and note the appropriate cuff inflation volume for King tubes. This information is on the tube packaging and the cuff of the tube itself.
Inflate and deflate the cuffs to check that there are no leaks.
Apply a small amount of sterile, water-soluble lubricant to the deflated cuffs.
Lift the chin and tongue with your non-dominant hand. Grasp the tongue and chin between your thumb inside the mouth and your fingers on the underside of the chin, and lift up.
Insert the Combitube® or King tube into the mouth. Insert the Combitube® with a midline orientation. Insert the King tube initially at the corner of the mouth 45 to 90 degrees of rotation off-center, and then rotate it to midline position when the tip of the tube is past the tongue. Do not force either tube; you may cause soft tissue damage. If resistance is encountered, pull back somewhat and re-advance the tube, trying to follow the posterior pharyngeal wall. You may need to remove the tube, alter its curvature, and then reinsert it. At the proper distance of insertion (as confirmed by markings on the tube), the proximal (ventilating) lumen will open over the laryngeal opening, and the distal lumen will have entered the esophagus (in most cases).
Release your hand from the tube before inflating the cuffs.
Inflate the cuffs. When using a King laryngeal tube, use the manufacturer’s recommended volume. When using a Combitube®, inflate the distal balloon first using 10 to 15 mL, then inflate the proximal (pharyngeal, blue) balloon using 50 to 85 mL.
Connect a bag-valve apparatus to the ventilating lumen (on the Combitube®, the blue [pharyngeal] lumen).
Begin ventilation (8 to 10 breaths/minute, each about 500 mL and lasting about 1 second).
Assess lung ventilation by auscultation and chest rise. Check end-tidal carbon dioxide to confirm tube placement. Auscultation for Combitube® placement is often difficult and unreliable, so rely more on capnometry. However, during cardiac arrest, capnometry may not reliably indicate proper tube placement.
If assessment suggests inadvertent tracheal placement of a Combitube®, try ventilating through the distal cuff.
Aftercare for Combitube® or King Laryngeal Tube
Fix the tube in place with tape or ties, as appropriate.
The Combitube® or King laryngeal tube, after several hours at most, must be removed or be replaced by a definitive airway, such as an endotracheal tube or surgical airway (cricothyrotomy or tracheostomy).
Warnings and Common Errors
In about 5% of Combitube® insertions, the distal tube will enter the trachea; in this case, ventilation can be done through the distal tube. In up to 10% of insertions of newer King tubes, the distal tube will enter the trachea; adequate ventilation may be possible through the distal tube.
Generally, supraglottic airways should be inserted only in patients who are unresponsive; otherwise, aspiration is a risk. Do not allow a patient to awaken during insertion or ventilation with a supraglottic airway. If necessary, prevent the patient from waking up or gagging (using paralytics, adequate analgesia, and sedation), or remove the airway as clinically indicated.
Placing the dual lumen tubes too deeply may cause the balloon to obstruct the tracheal opening and inhibit ventilation. Obstruction can be remedied by pulling the airway back a few centimeters.