critical care medicine
How To Insert an Esophageal Tracheal Double Lumen Tube (Combitube) or a King Laryngeal Tube
Step by Step Description of Combitube or King Laryngeal Tube Insertion
Clear the oropharynx, as necessary, of obstructing secretions, vomitus, or foreign material. Pre-oxygenate the patient with How To Do a Percutaneous Cricothyrotomy , if possible. Select the appropriately sized Combitube or King laryngeal tube and note the appropriate cuff inflation volume for King tubes. This information is on the tube packaging and the cuff of the tube itself. Inflate and deflate the cuffs to check that there are no leaks. Apply a small amount of sterile, water-soluble lubricant to the deflated cuffs. Lift the chin and tongue with your non-dominant hand. Grasp the tongue and chin between your thumb inside the mouth and your fingers on the underside of the chin, and lift up. Insert the Combitube or King tube into the mouth. Insert the Combitube with a midline orientation. Insert the King tube initially at the corner of the mouth 45 to 90 degrees of rotation off-center, and then rotate it to midline position when the tip of the tube is past the tongue. Do not force either tube; you may cause soft tissue damage. If resistance is encountered, pull back somewhat and re-advance the tube, trying to follow the posterior pharyngeal wall. You may need to remove the tube, alter its curvature, and then reinsert it. At the proper distance of insertion (as confirmed by markings on the tube), the proximal (ventilating) lumen will open over the laryngeal opening, and the distal lumen will have entered the esophagus (in most cases). Release your hand from the tube before inflating the cuffs. Inflate the cuffs. When using a King laryngeal tube, use the manufacturer’s recommended volume. When using a Combitube, inflate the distal balloon first using 10 to 15 mL, then inflate the proximal (pharyngeal, blue) balloon using 50 to 85 mL. Connect a bag-valve apparatus to the ventilating lumen (on the Combitube, the blue [pharyngeal] lumen). Begin ventilation (8 to 10 breaths/minute, each about 500 mL and lasting about 1 second). Assess lung ventilation by auscultation and chest rise. Check end-tidal carbon dioxide to confirm tube placement. Auscultation for Combitube placement is often difficult and unreliable, so rely more on capnometry. However, during cardiac arrest, capnometry may not reliably indicate proper tube placement. If assessment suggests inadvertent tracheal placement of a Combitube, try ventilating through the distal cuff. 