The oesophageal–tracheal Combitube Small Adult™An alternative airway for ventilatory support during gynaecological laparoscopy

Abstract

SummaryAirway management during gynaecological laparoscopy is complicated by intraperitoneal carbon dioxide inflation, Trendelenburg tilt, increasing airway pressures and pulmonary aspiration risk. We investigated whether the oesophageal±tracheal Combitube 37 Fr SAe is a suitable airway during laparoscopy. One hundred patients were randomly allocated to receive either the Combitube SAe (n 49) or tracheal intubation (n 51). Oesophageal placement of the Combitube was successful at the first attempt [16 (3) s]. Peak airway pressures were 25 (5) cmH 2 O. An airtight seal was obtained using air volumes of 55 (13) ml (oropharyngeal balloon) and 10 (1) ml (oesophageal cuff). Significant correlations were observed between patient's height and weight and the balloon volumes necessary to produce a seal. Similar findings were recorded for the control group, with tracheal intubation being difficult in three patients. The Combitube SAe provided a patent airway during laparoscopy. Non-traumatic insertion was possible and an airtight seal was provided at airway pressures of up to 30 cmH 2 O. Laparoscopic procedures require increased abdominal pressure and the steep Trendelenburg position in order to visualise the pelvic structures. Consequently, tracheal intubation has been the standard airway for these procedures. However, tracheal intubation has inherent risks and limitations. Although the laryngeal mask airway (LMA) has been used successfully in a large number of these procedures [1,2], there are still considerable theoretical concerns about the use of the LMA for laporoscopy. These concerns include the fact that in 4± 33% of LMA placements, more than one insertion attempt is required [3,4]; the LMA does not provide an airtight seal around the larynx (the usual leak pressures being 15±20 cmH 2 O) [5,6], and finally, in 10±15% of patients the oesophagus is included within the rim of the LMA, directly exposing the oesophagus to positive airway pressures [7,8].

Current status of the Combitube™: a review of the literature

“…Recently, Hartmann et al 36 published a study of the Combitube 37 F SA as an alternative airway for ventilatory support during gynecologic laparoscopy. Airway management was performed with either the Combitube (n ϭ 49) or tracheal intubation (n ϭ 51) during gynecologic laparoscopy.…”

Comparison of mouth-to-mouth resuscitation and Combitube ventilation in a bench model

“…Blostein and Ochs have reported on the successful use of the Combitube when rapid-sequence intubation has failed [3,15]. The Combitube may also be used as a valuable tool in routine general anesthesia [4,5,[16][17][18][19].…”

“…MTM is simple to learn but not always sufficient, especially in cases where prolonged ventilation is needed; ET is highly effective but not as easy in handling. The Combitube has been developed to overcome this problem and provides easy intubation, even by individuals not trained in ET, and effective ventilation comparable to conventional ET [3][4][5][6][7][8]. As already shown by Pepe et al, subsequent retraining is a very important factor in successful emergency ventilation [9].…”

Anesthesia and the gastrointestinal tract

“…The ETC may protect against the risk of aspiration and has been given a role in the American Society of Anesthiologists (ASA) practice guidelines for the management of the difficult airway [71]. Complications of its use, such as esphageal lacerations, subcutaneous emphysema [72], sore throat, hematoma, and dysphagia, appear to have been related to blind insertions rather than insertions under direct vision [73,74].…”