The critical airway, rescue ventilation, and the combitube: Part 1

Emergency and unexpected difficult airway management can rapidly deteriorate into a critical airway event such as "cannot ventilate, cannot intubate" (CVCI). A critical airway event (i.e., inadequate mask ventilation, failed intubation, and CVCI) can be resolved by rescue ventilation, thus avoiding potential neurological disability or death. Recommended options include use of the larygeal mask airway, the esophageal-tracheal Combitube (ETC; Tyco-Healthcare-Nellcor, Pleasanton, Calif), transtracheal jet ventilation, or a surgical airway. This article reviews proper use of the ETC in combination with the self-inflating bulb (SIB) and/or portable carbon dioxide detector to resolve critical airway situations. The combined use of these 3 devices provides on ideal integrated system for airway control and ventilation. In addition, critical airway events and rescue ventilation options; ETC design, technical aspects, training, insertion, and ventilation; determining ETC location (i.e., esophagus vs trachea); and monitoring ETC lung ventilation are reviewed. The SIB primarily assesses ETC location within the esophagus or the trachea; the carbon dioxide detector also permits monitoring lung ventilation. Use of the ETC in prehospital, emergency medicine, and anesthesia settings, including ETC advantages, contraindications, and reported complications will be reviewed in Part 2. How to safely exchange the ETC for a definitive airway also will be reviewed.