# Difference between Combi-tube and intubating



## Gen09 (Sep 20, 2009)

I'm just a basic student so I don't know the exact tools used to intubate or why it makes the procedure soo advanced, but I do know how and when to insert a combi-tube (which I think is amazing) and I do also love to learn. To me, (like I said I don't know as much as you experienced ALS people) they both seem the same. A tube that opens the airway and allows you to bag. So, I was hoping to learn some about the differences and more about each. Thanks!


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## MMiz (Sep 20, 2009)

There are several forms of intubation, the Combitube being one of the most simple.  ALS folks tend to drop an "ET" tube (EndoTracheal).  Here is a great thread with the differences.


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## ResTech (Sep 20, 2009)

A Combitube is blind insertion and 99% of the time it is going to end up in the esophagus. Intubation requires direct visualization of the vocal cords so you can pass the tube through them for the ultimate control of the airway. 

Intubation takes more skill since it requires the provider to visualize the cords. Some ppl's airway anatomy makes intubation difficult as does blood, fluids, and other junk in the airway, obstructing your view of seeing the vocal cords.


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## JPINFV (Sep 20, 2009)

ResTech said:


> Intubation requires direct visualization of the vocal cords so you can pass the tube through them for the ultimate control of the airway.



There are plenty of blind insertion techniques for ETTs. Gum bougie, digital, and light stylus to name a few.


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## WolfmanHarris (Sep 20, 2009)

JPINFV said:


> There are plenty of blind insertion techniques for ETTs. Gum bougie, digital, and light stylus to name a few.



that given failure rates need to be used far more often.


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## medic417 (Sep 20, 2009)

In simple uneducated terms if patient pukes and you have a combi in place good chance it will still get in the lungs. 

 A properly placed cuffed ET tube should keep vomit from the lungs.  

Plus as simple as a combi seems much damage can be done to the patients airway with it.  With your limited basic training you do not have the education to avoid doing this damage.


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## ResTech (Sep 20, 2009)

> There are plenty of blind insertion techniques for ETTs. Gum bougie, digital, and light stylus to name a few.



It was a 2am reply and I'm sure the OP was referring to oral intubation since that is the primary means of intubating. To the OP, there is also nasal intubation which is blind.... again more difficult than a Combitube because your aiming for the trachea and have to rely on knowledge of the airway anatomy and listen with a device called a BAM on the end of the tube that signals when your over the trachea.


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## ResTech (Sep 20, 2009)

> In simple uneducated terms if patient pukes and you have a combi in place good chance it will still get in the lungs.



While not as secure as an ETT, its my understanding that a Combitube and a KING airway can provide decent protection from aspiration. 



> With your limited basic training you do not have the education to avoid doing this damage.



And you as a Medic, how are you gonna 100% avoid this "damage" seeing how its a blind procedure??? It's like saying that because your a Paramedic, your not ever gonna cause any damage during a nasal intubation. 

Combitubes are inserted by many BLS services and were evaluated to be effective and safe. Where are you getting your information from that a BLS provider cannot safely place a suprglottic airway device?


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## VentMedic (Sep 20, 2009)

ResTech said:


> Combitubes are inserted by many BLS services and were evaluated to be effective and safe. Where are you getting your information from that a BLS provider cannot safely place a suprglottic airway device?


 
Pull up the incidence of damage with the CombiTube in the field on the medical search engines.  Thus, the reasons why they are falling out of favor and the King is coming into favor.


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## Shishkabob (Sep 20, 2009)

You also cannot push drugs down the CombiTube (though doing it down the ETT is going out as well)

And if there is a laryngospasm, or laryngeal edema, and you don't have an ETT in, you're in for a world of trouble.


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## medic417 (Sep 20, 2009)

ResTech said:


> And you as a Medic, how are you gonna 100% avoid this "damage" seeing how its a blind procedure??? It's like saying that because your a Paramedic, your not ever gonna cause any damage during a nasal intubation.
> ?




A Paramedic will still use visualization rather than just blindly shoving it in thus avoiding some of the common damage caused by the blind shove it in technique basics use.    Which ever opening it ends up going in it is guided in w/o near as much trauma to the sensitive tissues of the airway.

And there is no one that does 100% damage free intubation's every time, even Vent will have to admit the most experienced and educated at time cause damage and that is why she gets so frustrated hearing the uneducated complain when an increase in education is needed.


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## JPINFV (Sep 20, 2009)

ResTech said:


> It was a 2am reply and I'm sure the OP was referring to oral intubation since that is the primary means of intubating. To the OP, there is also nasal intubation which is blind.... again more difficult than a Combitube because your aiming for the trachea and have to rely on knowledge of the airway anatomy and listen with a device called a BAM on the end of the tube that signals when your over the trachea.



All of those techniques are oral intubation techniques using an ETT.


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## ResTech (Sep 20, 2009)

> All of those techniques are oral intubation techniques using an ETT



I think you knew what I meant.... but to be clear... the oral intubation technique that is most often utilized using a laryngoscope.


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## Gen09 (Sep 20, 2009)

Thanks for giving me a better idea. I guess I'm still wondering, when the ER staff takes over, do they leave the Combi tube in, or take it out then intubate using a more advanced method? As far as the damage to the pts airway goes, I would imagine that if the pt is in bad enough condition to need one put in, that the damage that comes along with it wouldn't matter as much as getting oxygen circulating. If the Combi tube were that bad and had such bad effects, I don't think it would be used. I think its a good method and one that I can't wait to master. Thanks.


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## medic417 (Sep 20, 2009)

Gen09 said:


> Thanks for giving me a better idea. I guess I'm still wondering, when the ER staff takes over, do they leave the Combi tube in, or take it out then intubate using a more advanced method? As far as the damage to the pts airway goes, I would imagine that if the pt is in bad enough condition to need one put in, that the damage that comes along with it wouldn't matter as much as getting oxygen circulating. *If the Combi tube were that bad and had such bad effects, I don't think it would be used.* I think its a good method and one that I can't wait to master. Thanks.



Sadly you are wrong.  Much of what we do in EMS has no proven benefit.  And even worse many skills have been proven to cause harm yet they are still what EMS does in many places.  It all goes back to the we do it this way because of tradition.  

Often the hospital staff does remove and properly intubates and ventilates the patients.


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## Akulahawk (Sep 20, 2009)

One of the issues with the Combitube is that it's essentially an 8.0 ETT inside another larger tube (hence the term "dual lumen"). About 20% of the time, the Combitube will end up intubating the trachea, instead of the esophagus. If the tracheal lumen is not quite big enough, you'll see a LOT of damage to the trachea, vocal cords, and so on. Another issue is that the Combitube isn't anywhere near as flexible as the ETT is. IF there's any movement of the patient's head, the tube can move around. If the trachea is intubated, that means that the distal cuff will do a lot of rubbing on the tracheal wall. With the Combitube, when you inflate the proximal cuff, you fix the tube in place, but that can pull the tube towards midline... and the tube wall right into the tracheal wall and vocal cords...

There's a reason why the Combitube is a rescue airway... At least if the Combitube intubates the esophagus, it's a little easier to decompress the stomach. 

I look at the King Tube as a Combitube that's been redesigned to eliminate the possibility of tracheal intubation (and all of those problems) while still serving as a rescue airway. 

There are some blind techniques with ETT's... but I prefer direct visualization....


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## el Murpharino (Sep 21, 2009)

Akulahawk said:


> There are some blind techniques with ETT's



As in the intubating LMA...



Akulahawk said:


> ...but I prefer direct visualization



The gold standard!


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## Gen09 (Sep 21, 2009)

Using the Combi tube in a rescue situation is better than nothing is what I'm trying to say then. The "proven benefit" is that the patient is recieving oxygen and is alive, in most good cases. Saying that it has "no proven benefit" seems obsured. Just like with most EMS procedures it's not going to be 100% perfect and cause no harm, but at least it's something that can be done to help the present emergency. My question was what are the differences, so thank you to those who answered my question without putting me down and acting like you're better than everyone else. I also don't think that it is right to label different peoples ability based on what level of training they have. I could very well practice visualization outside of class and perform this technique just as well as a Paramedic, as can anyone willing to learn. 

Thanks Akulahawk, I'm anxious to learn more about this King Tube.


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## medic417 (Sep 21, 2009)

Gen09 said:


> Saying that it has "no proven benefit" seems obsured. .



Did not say combi had no benefit.


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