American Heart Association Guidelines

Section 3: Adjuncts for Oxygenation, Ventilation, and Airway Control

Alternative Airways
In some communities tracheal intubation is not permitted, or patients are so few that practitioners obtain little experience. Alternative airways that require blind passage of the device into the airway may be simpler to master than passage of a tracheal tube under direct vision. Alternative airways include the esophageal-tracheal Combitube (ETC), the laryngeal mask airway (LMA), and the pharyngotracheal lumen airway (PTL). When used by adequately trained healthcare providers, the ETC and the LMA provide superior ventilation compared with face masks in patients in cardiac arrest (Class IIa). To achieve good outcomes with these devices, healthcare providers must maintain a high level of knowledge and skills through frequent practice and field use.

Esophageal-Tracheal Combitube
The ETC is an invasive double-lumen airway with 2 inflatable balloon cuffs that is inserted without visualization of the vocal cords. Assessment of the location of the distal orifice is then made, and the patient is ventilated through the appropriate opening. One lumen contains ventilating side holes at the hypopharyngeal level and is closed at the distal end; the other lumen has a distal open end with a cuff similar to a tracheal tube. When inflated the large pharyngeal balloon fills the space between the base of the tongue and the soft palate, anchoring the ETC into position, and isolates the oropharynx from the hypopharynx. The tube most commonly finds its way into the esophagus because of the stiffness and curve of the tube and the shape and structure of the pharynx. The tube is advanced until the patient’s teeth lie between 2 marks printed on the tube. The pharyngeal and distal balloons are then inflated, thus isolating the oropharynx above the upper balloon and the esophagus (or trachea) below the lower balloon.

The advantages of the ETC over the face mask are similar to those of the tracheal tube over the face mask: isolation of the airway, reduction in the risk of aspiration, and more reliable ventilation. The advantages of the ETC over the tracheal tube relate chiefly to ease of training and maintenance of placement skills, because laryngoscopy and visualization of the vocal cords are not necessary for insertion of the ETC. Ventilation and oxygenation with the ETC compare favorably with those achieved with the tracheal tube. Successful insertion rates with the ETC range from 69% to 100%. Because successful insertion is not ensured, providers should have a strategy for airway management when they are unable to ventilate with their first-choice adjunct. Fatal complications with the ETC may occur if the position of the distal lumen of the ETC in the esophagus or the trachea is identified incorrectly. In one EMS system a retrospective review reported that the incorrect port was used for ventilation in 3.5% of cases. For this reason use the ETC in conjunction with an end-tidal CO₂ or esophageal detector device.

Another possible complication from the ETC is esophageal trauma. Eight cases of subcutaneous emphysema were retrieved from a retrospective review of 1139 patients resuscitated with the ETC by emergency medical technicians. Four patients underwent autopsy, and 2 were found to have esophageal lacerations. To optimize insertion rates and to minimize complications, providers should receive adequate initial training in use of the ETC and should practice with the device regularly. To ensure optimal outcomes, we also highly recommend that EMS and other healthcare providers monitor their success rates and the occurrence of complications.