Clinical CommunicationPiriform Sinus Perforation During Esophageal-Tracheal Combitube Placement
Introduction
Endotracheal intubation is the preferred and most definitive method of airway management for nearly all patients in cardiopulmonary arrest [1]. However, in the prehospital setting, technical factors such as improper positioning, poor lighting, and motion artifact can limit its successful use. In addition, many Emergency Medical Services (EMS) systems limit or do not permit its use. Numerous alternative airway devices have been developed, including the Esophageal-Tracheal Combitube® (Sheridan Catheter Corp., Argyle, NY). This device is a rigid double-lumen tube inserted blindly through the mouth into the pharynx. In most instances, the distal tube lodges in the proximal esophagus. A small distal balloon and a large proximal (pharyngeal) balloon are then inflated. The patient is then ventilated through vents in the side of the tube between the balloons. If the tube has been placed blindly into the trachea, no breath sounds will be auscultated and the patient should then be ventilated through the second port. This second port in conjunction with the distal balloon functions as an endotracheal tube. There are few reported complications from the use of the Combitube®. These have centered on improper tube placement and health care provider failure to recognize improper tube placement. We report a case of piriform sinus rupture related to placement of the Esophageal-Tracheal Combitube® by EMS personnel.
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Case Report
On the day of admission, a 71-year-old female with a history of chronic obstructive pulmonary disease awoke with tongue swelling. The patient was allergic to morphine and was taking enalapril, fluoxetine, ipratropium bromide, and hydrochlorothiazide. On the way to her physician’s office, the patient developed acute respiratory distress and became apneic. Upon arrival of prehospital care personnel, bystander cardiopulmonary resuscitation was in progress, and the patient was unresponsive, apneic,
Discussion
Successful advanced cardiac life support depends on the prompt establishment of a patent airway. In previous studies, the Combitube® has been shown to be capable of being placed more rapidly than an endotracheal tube with equal effectiveness in ventilation 2, 3, 4, 5. Studies on the use of the Combitube® have reported few complications. Improper placement with inability to ventilate the patient, which resolved with withdrawal of the tube, has been reported [6]. Baraka and Salem [7]reported a
Summary
This case presents a 71-year-old female patient with severe angioedema of the tongue. Piriform sinus rupture resulted after insertion of the Esophageal-Tracheal Combitube® during cardiac arrest, leading to massive subcutaneous emphysema. The Combitube® is a valuable adjunct in the management of the difficult airway, however, caution is required to avoid trauma to the pharyngeal structures.
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