When/why do you guys intubate?

RedAirplane

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I'm curious, and was hoping that some of you ALS providers could fill me in on this.

When/why do you intubate patients?

My understanding is that concerns is the airway (duh) and of getting air into the lungs, not the stomach. Also to prevent the chance of vomit interfering with the airway.

But... something like the Combitube has balloons that will seal off the esophagus. It has two tubes so no matter whether you hit the trachea or the esophagus, you can still deliver ventilations correctly. Under what situation would you need to use an ETT instead of something like a Combitube?

Maybe I just haven't had enough experience with bad airways and/or forgot something fundamental from class, but any insight is appreciated. Thank you.
 

Carlos Danger

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I'm curious, and was hoping that some of you ALS providers could fill me in on this.

When/why do you intubate patients?
An endotracheal tube is placed in two situations:

- Inadequate breathing, and the ET tube's primary job is to provide a secure route for positive pressure to be delivered
- Airway protection: The patient is breathing fine, but for some reason (drugs, coma) the ability to protect the airway from aspiration and secretions is unreliable.

Often but not always, these two indications exist simultaneously.

But... something like the Combitube has balloons that will seal off the esophagus. It has two tubes so no matter whether you hit the trachea or the esophagus, you can still deliver ventilations correctly. Under what situation would you need to use an ETT instead of something like a Combitube?

Combitubes, LMA's, King airways, etc all serve the primary purpose of keeping the airway open, making it easier to ventilate the patient. They also offer some measure of airway protection - depending on the device - but none secure the trachea nearly as well as an ET tube does.
 
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TXmed

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An ET tube provides you with airway protection that far surpasses the backup airway (although king tubes do an excellent job). Also if you work a vent you should do it through an ET tube as a backup device is not ideal.
 

EMT11KDL

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You nailed the first part, using an Advanced Air way device is to "Secure" an airway so you can probably oxygenate and ventilate the patient. Now determining to use a King/Combi/LMA Vs ETT varies by provider and situation. Most of my code arrest I will use a King because it is a blind insertion and quick, if we get ROSC than I change it to ETT because my agency does pre-hospital hypothermia protocols and the patient will be placed on a vent.

In deciding which to use, what is my goal and why am I providing an advanced air way. is it to prevent aspiration or is it to secure an airway to ventilate and why am I having to provide this. I also look at the patient and determine how hard of an intubation is this patient going to be. If I have failed to place an ETT than I must use a back up device. Anytime I RSI or do any intubation I always have a King in arms reach just in case I am unable to place the tube successfully. That is just me though and should be everyone's practice to have a backup device ready.

Just like everyone else has said the King/Combi/LMS provides some protection but it does not secure the trachea. A patient is able to vomit around the balloon of esophageal airway devices.
 
OP
RedAirplane

RedAirplane

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Out of curiosity, it seems like King is the preferred airway on this forum.

In what little my instructors have told me about these airway devices, it would seem that the Combitube is the best as a backup airway because it is blind insertion, but unlike the King, if you manage to hit the trachea out of sheer chance, you have a second tube through which you can ventilate.

Any reason the King is preferred?
 

systemet

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This is the key piece of information I was missing.

An ETT also allows greater airway pressures without bypassing the device. The blind insertion devices typically fail around 25-35 cmH20. So it will allow higher airway pressures in patient who need it, e.g. those with high airway resistance, or need for higher levels of PEEP for oxygenation.

Both the blind airway devices and the ETT may be problematic to place due to some patient's anatomy. Typically with the ETT, as long as you can visualise the cords, you can place the device. Not everyone's anatomy is conducive to a good seal with a blind insertion device.
 

Brandon O

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An ETT also allows greater airway pressures without bypassing the device. The blind insertion devices typically fail around 25-35 cmH20. So it will allow higher airway pressures in patient who need it, e.g. those with high airway resistance, or need for higher levels of PEEP for oxygenation.

Higher than 35? Fun times.

To the OP: there's also some question about the balloon on SGAs blocking flow of the internal carotids during cardiac arrest.

Nevertheless, just bear in mind that part of the answer to this is always going to be somewhat intangible. An endotracheal tube is considered the most secure you're going to get an airway -- it's a tube going directly into the lungs with a balloon to help seal it. Other devices are... not that. So in the long run, it's always going to be perceived as the eventual goal, which is probably right to some extent and wrong to some extent. (For instance, the ETT balloon doesn't completely protect the lungs from aspiration either. Does it do it better than a King or Combi or whatever? I don't know, maybe, but I haven't seen that demonstrated.)
 

EMT11KDL

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Being able to vomit around the tube and being able to aspirate is always a big concern. This is the reason why you seen Oral Gastric or nasal gastric tubes being placed, this can help decrease the chance of vomiting because you are suctioning out the stomach and decreasing the pressure in the stomach from when you were pre-oxygenating your patient. And I believe and most likely others will agree is that the placement of an OG/NG tube after intubation is a good idea and provides better level of care. I have yet to see a patient that is coming from the hospital that is on a vent not have one placed.
 

tklingbeil

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One of the main reasons services perfer the King over the combi is going to be because of the ease of inflating one lumen instead of two for the combi. Also with the combi you have to place the BVM on one of two tubes. While bagging you have to listen for epigastric sounds, lung sounds and look for rise and fall, IF you choose the wrong tube with the combi you have to repeat the process on the other tube. It can be lenghty. With the King you have one lumen and one tube so when you get placement you do not have to worry about picking the wrong tube. They are both "blind" insertion devices because you do not have to visualize the vocal cords to place them.
 

EMSComeLately

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You have to also realize that supraglottic airways (king, combi) have contraindications for their use as well. Esophageal cancer, varices, doesn't resolve severe tracheal trauma, etc. Also, combitubes are not sized for pediatrics.

Now, King vs. Combi (can't speak to LMA). King is just simpler and the chance of a tracheal intubation with a Combi is fairly small (can't quote the stats, but that is what we were told) to take that much advantage of it. King has one lumen and one syringe whereas the Combi has two with two different sized syringes. It's really inconvenient to have all that jazz flopping around while you're trying to establish an airway. If you have to reposition Combi, you should deflate the cuffs (from what we were taught) whereas the King was designed to pull back without deflating. King has pediatric sizes. Also, with the KIng LTS-D, you can place a NG tube through an available port.
 

NTXFF

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Out of curiosity, it seems like King is the preferred airway on this forum.

In what little my instructors have told me about these airway devices, it would seem that the Combitube is the best as a backup airway because it is blind insertion, but unlike the King, if you manage to hit the trachea out of sheer chance, you have a second tube through which you can ventilate.

Any reason the King is preferred?
Our Kings got taken away in our system as with many systems in our area. We have the good ole ET or an I-gel...... My advice is don't miss because the I-gel is garbage. We've got a pretty agressive RSI protocol and track record here just because of transport times and the nature of calls we tend to get. If an airway needs to be secured they're going to get intubated.
 

Tigger

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Out of curiosity, it seems like King is the preferred airway on this forum.

In what little my instructors have told me about these airway devices, it would seem that the Combitube is the best as a backup airway because it is blind insertion, but unlike the King, if you manage to hit the trachea out of sheer chance, you have a second tube through which you can ventilate.

Any reason the King is preferred?
The regular sized combitube can only be used with patients over 5' tall, though a small adult model exists that goes down to 4.5.' The kings on the other hand come in a greater range of sizes, are easier to use with there only being one balloon, and allegedly do less damage to the airway.
 

WildlandEMT89

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As a BLS provider I had a question.
When dropping a et tube into a pt and you miss on your first attempt, why pull out the tube instead of just dropping another one in then removing the missed tube?(or leaving it in place)

It seems like if you missed your first shot but have now sealed off the route you don't want to take, the second tube would only have one place to go, this easily secure the airway.
 

Smash

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Broadly speaking the reasons to intubate are:

Airway compromise.
Failure of oxygenation.
Failure of ventilation.
Predicted clinical course.
Humane reasons.

Or a combination of these factors.

WildlandEMT89, that may be an option in some patients, however it is not always as simple as that. Why did the tube not pass in the first place? How much room do you have to get a view and is the other tube going to obscure your view or making passing another tube difficult? Is the oesophageal tube acting as a conduit for stomach contents? Is this a good thing (draining contents) or a bad thing (firing them into your face)? What size tube was used: is there still room to slot another one in the oesophagus?

Airways are like ****s: the more you fiddle, the harder they get. Your first shot is likely to be your best (assuming you optimised everything first, which you should have) and every attempt thereafter is going to have less chance of succeeding.
 

NTXFF

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As a BLS provider I had a question.
When dropping a et tube into a pt and you miss on your first attempt, why pull out the tube instead of just dropping another one in then removing the missed tube?(or leaving it in place)

It seems like if you missed your first shot but have now sealed off the route you don't want to take, the second tube would only have one place to go, this easily secure the airway.
Who said you take it out? I know guys that will and guys that wont. The ones that wont usually tie it to the side and then drop in another.
 

TXmed

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I wouldn't recommend leaving missed tubes in, as I found out the hard way that the esophagus can hold more than one inflated ET tube, and it could also push upwards on the trachea

Your best bet would be to pull it out and try a different blade or technique.

Personally I always use a bougie because the bougie will stop when it hits the Carina and if your in the gut it'll keep going all the way down. That way you don't have to find out the rough way that you missed.
 

Brandon O

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There's plenty of patients out there with peak inspiratory pressures exceeding 35 cmH20, even with minimal PEEP.

Oh, fair enough, thought you meant 35+ of PEEP...

Plateaus like that make RTs shed the single Indian tear.
 

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