Alternative management techniques for the difficult airway: esophageal-tracheal Combitube

To summarize knowledge about the esophageal-tracheal Combitube in emergency medicine and anesthesia, with special emphasis on uncommon indications. Papers published between August 2003 and July 2004 are reviewed.

Tracheal intubation in the field is difficult and success rates are dependent upon training level (90-98%). Therefore, the esophageal-tracheal Combitube has been recommended for emergency ventilation after failed tracheal intubation with success rates of about 90%, even when performed by emergency medical technicians. Combitube insertion is easy to learn, but practice is necessary to retain skills. Use of this device has also been recommended for ventilatory support during routine anesthesia. Combitube ventilation is successful in over 96% of patients, with minimal trauma. Since only a small percentage of American anesthesiologists are familiar with the Combitube (<50%), using the device in anesthesia care may improve the skills required during emergency airway management. Blood gases are in the range of those obtained during endotracheal tube ventilation and aspiration prophylaxis is at least as good as that of the laryngeal mask airway. Successful uncommon uses of the device have also been recommended, for example, Combitube ventilation in craniomaxillomandibular surgery via the submental route and insertion of the device in a burns patient with minimal mouth opening and significant tracheal stenosis after long-term ventilation.

The esophageal-tracheal Combitube is a useful and efficient alternative airway characterized by high success rates in emergency situations. We recommend the use of a laryngoscope for insertion and strict adherence to the manufacturer's guidelines in order to maximize success and minimize potential injury.