Double lumen tube with pharyngeal lumen (1) and tracheo-esophageal lumen (2). Pharyngeal lumen with blocked distal end and perforations at pharyngeal level. Tracheo-esophageal lumen with open upper and lower end. Large oropharyngeal balloon serves to seal mouth and nose, distal cuff seals either esophagus or trachea.

2. Insertion:

Patient's head should be in neutral position (not in sniffing position). Insert Combitube gently in a curved downward movement by grasping the back of the tongue and jaw between thumb and forefinger and lifting the jaw. Insert until printed ringmarks lie between teeth or alveolar ridges. Do not use force ! (Lipp maneuver: Holding the distal end of the Combitube bent for a few seconds alleviates insertion) Alternative Urtubia insertion technique: Pull away the upper jaw and press the chin forward. This technique augments the space for intubation.

 

3. Inflation of balloon and cuff:

Inflate oropharyngeal balloon first by help of the bypacked large syringe (blue dot) with 85 cc of air with the Combitube 37 F SA or with 100 cc of air with the Combitube 41 F (use valve with blue pilot balloon). In many cases you may observe a slight outward movement during inflation (during elective cases, you may use the minimal leakage technique: inflate the balloon with 40 to 85 or 40 to 100 cc of air).Then, inflate distal cuff with 5 to 12 cc of air (Combitube 37 F) or 5 to 15 cc of air (Combitube 41 F).

 

4. Esophageal placement and ventilation:

With blind insertion, there is a high probability of esophageal placement of the Combitube. Therefore, test ventilation is started via the longer, blue tube No. 1. Air cannot escape at the distal end of the blocked pharyngeal lumen and enters the pharynx via the perforations. Since mouth, nose, and esophagus are sealed by the balloon and the cuff, air is forced into the trachea. If auscultation over the lungs is positive (and epigastric insufflation negative), ventilation may be continued. The tracheo-esophageal lumen serves to decompress the esophagus and the stomach. Therefore, an elbow deflector is provided for avoiding soiling of the rescuer by attaching it to the tube No. 2.

 

5. Tracheal placement and ventilation:

On a few occasions, the Combitube has been placed blindly into the trachea. In this case, ventilation is changed to the shorter, clear tube No. 2, leading to the tracheo-esophageal lumen. Air is blown directly into the trachea. In a few cases, ventilation does not work neither via the esophageal nor tracheal lumen. The reason may be, that the oropharyngeal balloon is inserted to deep, thereby occluding the laryngeal aperture. The Combitube has to be pulled out for about 2 to 3 cm, and ventilation started again via the longer tube.

 

6. Laryngoscope:

Use laryngoscope whenever feasible !   Minimal Volume technique to avoid injury to the pharyngeal mucosa when the Combitube is used for up to eight hours: In elective cases: start with 40 ml for the orophangeal balloon. If you obtain a tight seal, stay with 40 ml. If not, inflate additional increments of 10 ml each up to a volume of 85 ml resp. 100 ml (in few patients 150 ml may be necessary).