# Combitube Vs. King Vs. ET



## bakertaylor28 (Oct 26, 2016)

As a student, having read a bit on the three devices, It still seems a bit confusing as to what the usefulness and indications of each really are, in the practical sense of things. (besides knowing that the combi is less complicated to deal with in general). But between the King and the ET, it would seem that one would want to Avoid a "bind" device, particularly where dealing with a difficult airway case. I'm interested in what practical pointers one might have in regards to the subject.


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## Aprz (Oct 26, 2016)

Well, endotracheal intubation used to be considered the gold standard while other devices like the King tube and Combitube used to be considered rescue airways. It seems like more and more people are going straight for these rescue airways instead (skipping endotracheal intubation) because of how infrequently they intubation and the complications from failed intubation attempts (interrupted chest compressions during a cardiac arrest or maybe tunnel vision on getting the airway, decreased SpO2, damaged airway, decreased venous return, increase intracranial pressure, etc).

The primary issue I've heard with these rescue airways right now is just decrease cerebral blood flow due to pressure against the carotids. People shouldn't inflate the balloon as much. Um, I hear that it doesn't work as well for protecting the airway, but has always confused me since they both have distal balloons in the esophagus that inflate. Meh. Maybe somebody can chime on that since I'm a fake paramedic. I know people say "it doesn't protect the airway", but I am not really sure why if that is something emperical or something I don't understand with the function of a King (maybe distal balloon doesn't put enough pressure against the wall of the esophagus?).

Difference between Combitube and King tube is simplicity. You don't have to worry about which tube you are ventilating or which balloon to inflate. King tube is really easy to use. The benefit of the Combitube is you can intubate with it, but it is very rare/unlikely.

At my service, our protocol wants us to attempt intubation first before using a rescue device in a cardiac arrest. :/



> *3.3.*Intubation Attempt will consist of the introduction of the laryngoscope with endotracheal tube and tube introducer (Bougie) or Bougie by itself, into the oral cavity with the intent of intubation.
> *3.4.*One intubation attempt with the endotracheal tube with Bougie will be completed on patients in cardiac arrest before a provider can attempt placement of a supraglottic airway (King Airway). If the first attempt fails, the provider may either elect to make a second attempt at intubation with the Bougie or elect to place the King Airway or return to the BLS airway.
> *3.5.*A combined total of two (2) attempts to successfully intubate will be allowed per patient. If after two (2) failed intubation attempts the provider(s) will place either a supraglottic airway (King Airway) or return to a BLS airway.


We do not carry Combitubes, but we do carry King tubes. It is an optional scope of practice for EMTS, but only EMTs in rural fire departments are trained for it and approved for it in my county.

I personally believe that if the patient is a suspected difficult airway (very obese or facial trauma for example), I will stick with a BLS airway or use a rescue device. I shouldn't waste my time attempting intubating.


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## SpecialK (Oct 26, 2016)

The role of intubation has decreased significantly over the past 5-10 years in the prehospital context but that is simply following an inhospital trend.  Gone are the days when everybody who is given a GA gets a tube; now largely all simple shortish procedures just use an LMA.  

The goal is oxygenation, how that is achieved is generally less important.  If an LMA (or any other supraglottic airway) does that for you, great, just use that.  There are some situations where an ETT is "better" such as somebody who has a grubby airway but the average officer at ICP level intubates about one person a month if that.  Look at how infrequently our American colleagues are tubing people by reading the studies which say ambulance personnel can't do it very well, I think I read one which said 2-3 people in a year!

Doesn't matter what you use really just as long as it oxygenates the patient.


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## Aprz (Oct 26, 2016)

Can confirm that I almost never intubate. I started working as a paramedic 11 months ago. I haven't intubated a single patient yet. Our new airway protocol just rolled out a couple of months ago literally a day or two after the last arrest I worked.


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## EpiEMS (Oct 26, 2016)

SpecialK said:


> Look at how infrequently our American colleagues are tubing people by reading the studies which say ambulance personnel can't do it very well, I think I read one which said 2-3 people in a year!



Do all paramedics in your service perform intubation? I think much of the problem in the U.S. is that (in the bulk of the services and protocols I'm aware of) all paramedics (and even some lesser trained practitioners) are expected to be able to intubate, so we see lots of skill dilution.


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## SpecialK (Oct 27, 2016)

EpiEMS said:


> Do all paramedics in your service perform intubation? I think much of the problem in the U.S. is that (in the bulk of the services and protocols I'm aware of) all paramedics (and even some lesser trained practitioners) are expected to be able to intubate, so we see lots of skill dilution.



We have approximately 350 Intensive Care Paramedics (the only clinical level able to intubate) out of approximately 2,500 ambulance personnel.  

To become an ICP now you are required to do an additional Postgraduate course at university; it's approximately one year.  The majority of new ICPs have completed a BHSc Paramedic but some may have come up from the old Dip Ambulance and had a briging course to Postgraduate level.  

Each ICP intubates approximately one person per month on average.  Some ICPs also have the RSI endorsement - approximately 50.


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## EpiEMS (Oct 27, 2016)

SpecialK said:


> Each ICP intubates approximately one person per month on average. Some ICPs also have the RSI endorsement - approximately 50.



Is one intubation a month enough to demonstrate competency, you think?


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## VentMonkey (Oct 27, 2016)

SpecialK said:


> The goal is oxygenation, how that is achieved is generally less important...Doesn't matter what you use really just as long as it oxygenates the patient.


This. In the prehospital setting there are many variables that come into play when choosing the airway best suited for the patient in need of one (anatomy, ETA to the ED, SPO2, etc.), but as @SpecialK pointed out, as long as you are able to _adequately oxygenate and ventilate _your patient, the mode by which it is performed is irrelevant.

Use what ever tools, and/ or devices your county/ service mandates, be familiar with them, know all of your alternate airway devices and be familiar with those as well. There isn't much more to it than that in the prehospital realm.


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## EpiEMS (Oct 27, 2016)

VentMonkey said:


> as long as you are able to _adequately oxygenate and ventilate _your patient, the mode by which it is performed is irrelevant



I wish this were more widely acknowledged - but I think culture is a big problem. Too many systems have a culture of denigrating the so-called "rescue" devices and BLS airway measures.


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## TransportJockey (Oct 27, 2016)

Aprz said:


> Can confirm that I almost never intubate. I started working as a paramedic 11 months ago. I haven't intubated a single patient yet. Our new airway protocol just rolled out a couple of months ago literally a day or two after the last arrest I worked.


Really? I've had seven in the last nine months.  Granted, they've all been RSIs, and not every system has that

Sent from my SM-N920P using Tapatalk


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## VentMonkey (Oct 27, 2016)

EpiEMS said:


> I wish this were more widely acknowledged - but I think culture is a big problem. Too many systems have a culture of denigrating the so-called "rescue" devices and BLS airway measures.


Time, dear friend, give it time.

The culture as we know it will shift. In a "perfect EMS world" (I know, I know...) inside of the United States, advanced airway/ endotracheal intubation would only be performed by advanced care practioners who take the time to learn the ins and outs of airway management, and seek any, and all training needed to make them the most proficient at what they do.

This shouldn't be a skill for a run of the mill urban street paramedic; this is just my $0.02 as usual though.


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## Handsome Robb (Oct 27, 2016)

TransportJockey said:


> Really? I've had seven in the last nine months.  Granted, they've all been RSIs, and not every system has that
> 
> Sent from my SM-N920P using Tapatalk



I've don't more tubes since I moved here than in the last two years as a medic. The RSI/DSI definitely makes a huge difference in the amount of tubes we do. 


Sent from my iPhone using Tapatalk


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## chaz90 (Oct 27, 2016)

Cool discussion here! I've begun to learn over the last several years how much practice airway "proficiency" really takes. If you're in a system where you don't have the opportunity or need to intubate more than once a year or so, there's simply no need to have it in your protocols or scope. It doesn't make you less of a paramedic, but instead more of a clinician for recognizing the need for and potential pitfalls in a high risk/low frequency procedure. Any time we perform a procedure, we should be able to articulate why it is necessary over the alternatives. If we're only placing advanced airways in occasional cardiac arrests, why roll the dice on a successful outcome?


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## Carlos Danger (Oct 27, 2016)

Good discussion here.

I predict that the concern about LMA's reducing CPP by compressing the carotids will remain hypothetical and will never be shown to be a factor in humans. The reason I think this is because on the anesthesia side of things, the "LMA vs. ETT" controversy has been so heavily debated, discussed, and studied in both Europe and the US that if LMA's actually caused any clinically important reduction in CPP, it would have become apparent in the outcomes by now. 

Instead, the opposite is happening, and we find ourselves using LMA's more and more, in sicker and sicker patients. Yes, elective OR cases are different than emergency resuscitation cases, but still, we are using them in pretty sick patients who routinely experience MAPs under anesthesia much lower than what they are used to, and it doesn't seem to be harming anyone.


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## VinBin (Oct 29, 2016)

Remi said:


> Good discussion here.
> 
> I predict that the concern about LMA's reducing CPP by compressing the carotids will remain hypothetical and will never be shown to be a factor in humans. The reason I think this is because on the anesthesia side of things, the "LMA vs. ETT" controversy has been so heavily debated, discussed, and studied in both Europe and the US that if LMA's actually caused any clinically important reduction in CPP, it would have become apparent in the outcomes by now.
> 
> Instead, the opposite is happening, and we find ourselves using LMA's more and more, in sicker and sicker patients. Yes, elective OR cases are different than emergency resuscitation cases, but still, we are using them in pretty sick patients who routinely experience MAPs under anesthesia much lower than what they are used to, and it doesn't seem to be harming anyone.



Yeah, definitely spot on. There are advances in LMA's to a point where they are not only easier to insert but allow a "rescue" intubation through the tube if necessary, suction ports for gastric tubes, temperature probes, etc. We are trialing new LMA's that have a pilot balloon that has a built in pressure indicator (even lowering the "risk" of over inflation that Remi alluded to with the carotid compression), and yes its only a matter of time until we use LMA's for a wider scope of cases in the OR. In Europe they use LMA's for a lot of laparoscopic abdominal cases (with insuffilation), and have had great results but we have a cultural view here of avoiding LMA's in those cases (and even that is shifting slowly).


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