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The Combitube as rescue device: recommended use of the small adult size for all patients six feet tall or shorter
CORRESPONDENCE
that children with normal mental status, normal neurologic examinations, and normal CT scan results after blunt head trauma can generally be discharged home from the ED.4 As we detailed in the article,1 our study was aimed at identifying children with traumatic brain injuries in need of acute intervention, not those associated with long-term neurocognitive deficits. Nathan Kuppermann, MD, MPH Division of Emergency Medicine Department of Pediatrics Michael Palchak, MD James Holmes, MD, MPH Division of Emergency Medicine University of California–Davis School of Medicine Sacramento, CA doi:10.1016/j.annemergmed.2004.01.032
Supported by a Hibbard E. Williams grant (University of California– Davis School of Medicine), a Faculty Research grant (University of California–Davis School of Medicine), and a Children's Miracle Network grant. 1. Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003;42:492-506. 2. Brieman L, Friedman JH, Olshen RA, et al. Classification and Regression Trees. Washington, DC: Chapman & Hall; 1994. 3. Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol. 2002;32:228-231. 4. Spencer MT, Baron BJ, Sinert R, et al. Necessity of hospital admission for pediatric minor head injury. Am J Emerg Med. 2003;21:111-114.
The Combitube as Rescue Device: Recommended Use of the Small Adult Size for All Patients Six Feet Tall or Shorter
elective cases. The 41F size is significantly stiffer than the 37F Small Adult size. Numerous studies have pointed out that the 37F Small Adult size is easier to insert than the standard 41F Adult size, and that the smaller size works well in patients up to 6.0 feet tall.2-7 The Small Adult size has been used successfully even in patients with a height of up to 198 cm (6.5 feet).4 Cumulatively, these operating room studies have not reported a single insertion failure in 886 cases using the Small Adult size.2-7 For EMS systems and others using the Combitube, the Small Adult size should be routinely used unless the patient is taller than 6 feet.3,4,6 Richard M. Levitan, MD Department of Emergency Medicine Hospital of the University of Pennsylvania Philadelphia, PA Michael Frass, MD University of Vienna Vienna, Austria doi:10.1016/j.annemergmed.2003.12.034 1. Davis DP, Valentine C, Ochs M, et al. The Combitube as a salvage airway device for paramedic rapid sequence intubation. Ann Emerg Med. 2003;42: 697-704. 2. Hartmann T, Krenn CG, Zoeggeler A, et al. The oesophageal-tracheal Combitube Small Adult. Anaesthesia. 2000;55:670-675. 3. Urtubia RM, Aguila CM, Cumsille MA. Combitube: a study for proper use. Anesth Analg. 2000;90:958-962. 4. Walz R, Davis S, Panning B. Is the Combitube a useful emergency airway device for anesthesiologists? [letter]. Anesth Analg. 1999;88:233. 5. Krafft P, Nikolic A, Frass M. Esophageal rupture associated with the use of the Combitube [letter]. Anesth Analg. 1998;87:1457. 6. Gaitini LA, Vaida SJ, Mostafa S, et al. The Combitube in elective surgery: a report of 200 cases. Anesthesiology. 2001;94:79-82. 7. Rabitsch W, Krafft P, Lackner FX, et al. Evaluation of the oesophageal-tracheal double-lumen tube (Combitube) during general anaesthesia. Wien Klin Wochenschr. 2004;116:90-93.
To the Editor:
In reply:
We read with interest the article by Davis et al1 in the November 2003 issue of Annals on the utility of the Combitube as a rescue ventilation device for failed rapid sequence intubation in a large emergency medical services (EMS) system. Three of 61 Combitube insertions failed, for an overall success rate of 95%. Although it is mentioned in the Methods section that the paramedic could choose which size Combitube to insert (37F Small Adult or the standard 41F Adult size), there is no identification of which size was used in the insertion failure cases. There is also no mention of what size Combitube was used in the 58 successful insertions. Insertion failure has been commonly reported with the standard Adult size Combitube both in EMS studies and
I greatly appreciate Dr. Levitan and Dr. Frass’ interest in our article. I was especially intrigued by the authors’ use of a Small Adult Combitube for all patients to minimize pharyngeal trauma during insertion. Although we did not record Combitube sizes during the trial, our current protocols are consistent with manufacturer recommendations. If these were followed, all enrolled patients would have undergone insertion of a Large Adult Combitube. Concerns about soft tissue injury during Combitube insertion have been expressed previously, with an early report coming from our own system.1 The manufacturer recommends use of a tongue blade rather than a laryngoscope to facilitate insertion. This reflects the
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ANNALS OF EMERGENCY MEDICINE
44:1
J U LY 2 0 0 4
that children with normal mental status, normal neurologic examinations, and normal CT scan results after blunt head trauma can generally be discharged home from the ED.4 As we detailed in the article,1 our study was aimed at identifying children with traumatic brain injuries in need of acute intervention, not those associated with long-term neurocognitive deficits. Nathan Kuppermann, MD, MPH Division of Emergency Medicine Department of Pediatrics Michael Palchak, MD James Holmes, MD, MPH Division of Emergency Medicine University of California–Davis School of Medicine Sacramento, CA doi:10.1016/j.annemergmed.2004.01.032
Supported by a Hibbard E. Williams grant (University of California– Davis School of Medicine), a Faculty Research grant (University of California–Davis School of Medicine), and a Children's Miracle Network grant. 1. Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003;42:492-506. 2. Brieman L, Friedman JH, Olshen RA, et al. Classification and Regression Trees. Washington, DC: Chapman & Hall; 1994. 3. Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol. 2002;32:228-231. 4. Spencer MT, Baron BJ, Sinert R, et al. Necessity of hospital admission for pediatric minor head injury. Am J Emerg Med. 2003;21:111-114.
The Combitube as Rescue Device: Recommended Use of the Small Adult Size for All Patients Six Feet Tall or Shorter
elective cases. The 41F size is significantly stiffer than the 37F Small Adult size. Numerous studies have pointed out that the 37F Small Adult size is easier to insert than the standard 41F Adult size, and that the smaller size works well in patients up to 6.0 feet tall.2-7 The Small Adult size has been used successfully even in patients with a height of up to 198 cm (6.5 feet).4 Cumulatively, these operating room studies have not reported a single insertion failure in 886 cases using the Small Adult size.2-7 For EMS systems and others using the Combitube, the Small Adult size should be routinely used unless the patient is taller than 6 feet.3,4,6 Richard M. Levitan, MD Department of Emergency Medicine Hospital of the University of Pennsylvania Philadelphia, PA Michael Frass, MD University of Vienna Vienna, Austria doi:10.1016/j.annemergmed.2003.12.034 1. Davis DP, Valentine C, Ochs M, et al. The Combitube as a salvage airway device for paramedic rapid sequence intubation. Ann Emerg Med. 2003;42: 697-704. 2. Hartmann T, Krenn CG, Zoeggeler A, et al. The oesophageal-tracheal Combitube Small Adult. Anaesthesia. 2000;55:670-675. 3. Urtubia RM, Aguila CM, Cumsille MA. Combitube: a study for proper use. Anesth Analg. 2000;90:958-962. 4. Walz R, Davis S, Panning B. Is the Combitube a useful emergency airway device for anesthesiologists? [letter]. Anesth Analg. 1999;88:233. 5. Krafft P, Nikolic A, Frass M. Esophageal rupture associated with the use of the Combitube [letter]. Anesth Analg. 1998;87:1457. 6. Gaitini LA, Vaida SJ, Mostafa S, et al. The Combitube in elective surgery: a report of 200 cases. Anesthesiology. 2001;94:79-82. 7. Rabitsch W, Krafft P, Lackner FX, et al. Evaluation of the oesophageal-tracheal double-lumen tube (Combitube) during general anaesthesia. Wien Klin Wochenschr. 2004;116:90-93.
To the Editor:
In reply:
We read with interest the article by Davis et al1 in the November 2003 issue of Annals on the utility of the Combitube as a rescue ventilation device for failed rapid sequence intubation in a large emergency medical services (EMS) system. Three of 61 Combitube insertions failed, for an overall success rate of 95%. Although it is mentioned in the Methods section that the paramedic could choose which size Combitube to insert (37F Small Adult or the standard 41F Adult size), there is no identification of which size was used in the insertion failure cases. There is also no mention of what size Combitube was used in the 58 successful insertions. Insertion failure has been commonly reported with the standard Adult size Combitube both in EMS studies and
I greatly appreciate Dr. Levitan and Dr. Frass’ interest in our article. I was especially intrigued by the authors’ use of a Small Adult Combitube for all patients to minimize pharyngeal trauma during insertion. Although we did not record Combitube sizes during the trial, our current protocols are consistent with manufacturer recommendations. If these were followed, all enrolled patients would have undergone insertion of a Large Adult Combitube. Concerns about soft tissue injury during Combitube insertion have been expressed previously, with an early report coming from our own system.1 The manufacturer recommends use of a tongue blade rather than a laryngoscope to facilitate insertion. This reflects the
9 2
ANNALS OF EMERGENCY MEDICINE
44:1
J U LY 2 0 0 4