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MISADVENTURES OF A COMBITUBE
MM Defante, M.D. and DM Voltz, M.D.
Case Western Reserve University and the University Hospitals of Cleveland, Cleveland, Ohio
Introduction: In pre-hospital settings, the gold standard for securing the airway is placement of an endotracheal
tube (ETT) by direct laryngoscopy. However, the correct placement of the ETT requires a high level of skill,
experience, and in some cases, time. Adjuvant emergency airway devices such as the laryngeal mask airway
(LMA), the intubating LMA , and the Esophageal-Tracheal Combitube (ETC) have been developed to facilitate the
establishment of an airway rapidly if endotracheal intubation by laryngoscopy proves difficult. Although such
devices are easier to place and therefore are attractive in emergency situations, they are not without complications.
We present a case of a patient who had an unexpected complication subsequent to the placement of an ETC.
Description:
A morbidly obese 59y/o male presented to our institution after suffering a ventricular fibrillation
arrest at an area restaurant. The first responder team was the local fire department who were unable to successfully
place an ETT after multiple attempts. They blindly placed an ETC as the patient was being life-flighted directly to
the cardiac catheterization lab with a preliminary diagnosis of acute myocardial infarction. During transport, the
patient was being mechanically ventilated through the pharyngeal lumen while the tracheal-esophageal lumen was
positioned in the esophageal inlet. The patient became more difficult to ventilate and anesthesia was paged by
cardiology to “change the breathing tube”.
Upon arrival to the catheterization lab, it was noted that the patient was being mechanically ventilated via
the ETC with high airway pressures. Blood pressure was 100’s/60’s, pulse was in the low 100’s, and oxygen
saturation was 75% on 1.0 FiO2. A quick evaluation of this gentleman’s airway raised numerous concerns including
a short thyromental distance, massively distended abdomen, and obesity. With the progressive worsening of his
oxygenation and inability to continue ventilation via the ETC, it was removed. Adequate mask ventilation was
unsuccessful as well. Direct laryngoscopy with #4 MacIntosh blade revealed a small oral cavity, enlarged tongue,
and residual bloody secretions from previous laryngoscopic attempts. An attempt was made to blindly place the tube
under the epiglottis and into the trachea, but the tube entered the esophagus. An Eschman gum-elastic bougie was
attempted, but it also passed into the esophagus. A second direct laryngoscopy with a #2 Miller blade was also
unsuccessful. With further desaturation, notable cyanosis and a bradycardic trend developing, the decision was
made to proceed with an emergency surgical airway.
A vertical incision was made on the patient’s neck from the cricoid to the thyroid cartilage and blunt
dissection quickly revealed the cricothyroid membrane. A 7.0mm cuffed ETT was inserted through the emergent
tracheostomy which allowed for adequate oxygenation and ventilation.
The cardiac procedure was resumed resulting in the successful revascularization of an occluded obtuse
marginal artery. The following day, the patient’s emergent tracheotomy was revised by an otolaryngologist. With
the use of the Dido laryngoscope, the airway evaluation revealed a significantly swollen tongue and vocal cords.
Sedation was reduced to allow assessment of neurological function. The patient showed no gross neurologic
deficits.
Discussion:
Management of the airway in the controlled environment of the operating room can often be
challenging enough, but the options for difficult airway management drop precipitously when in an uncontrolled
setting, thus making airway management a seemingly impossible task. Successful combitube use in situations where
conventional ventilation has failed has been well documented. However, as this case illustrated, when an emergency
rescue airway device such as the combitube fails, one is often presented with a “cannot ventilate, cannot intubate”
situation. Then, it is up to the anesthesiologist to use his or her knowledge of airway management options together
with sound clinical judgement to secure the airway the best way possible. In our case, the patient required an
emergent surgical airway done by the anesthesiologist, which is a rare, but not unheard of phenomenon. The
successful outcome of this case implies the importance of having a premeditated difficult airway algorithm and the
ability to properly execute that algorithm (including emergent surgical airways).
References:
1. Retrograde Intubation Around an in situ Combitube: a difficult airway management strategy.
Anesthesiology. 2005 May;102(5):1061-2.
2. The Esophageal-Tracheal Combitube Resistance and Ventilatory Pressures. J Clin Anesth. 2005
Feb;17(1):26-9.
3.
Use of the Laryngeal Tube in two unexpected difficult airway situations:Lingual tonsillar hyperplasia and
morbid obesity. Can J Anaesth. 2004 Dec;51(10):1018-21.