(c) Do not use force - if the tube does not insert easily, withdraw it and
retry; hyperventilate the patient between each attempt.
(d) Inflate the Number 1 (blue) pilot balloon with 100 ml of air using a
100 ml syringe. Inflate the Number 2 (white) pilot balloon with 15 ml of air using a 20 ml
(e) Ventilate through the primary Number 1 (blue) tube. If auscultation
of breath sounds is positive and auscultation of gastric sounds is negative, continue to
(f) If auscultation of breath sounds is negative and gastric insufflation
is positive, immediately begin ventilations through the shorter (white) Number 2
connecting tube. Confirm tracheal ventilation of breath sounds and absence of gastric
(g) If auscultation of breath sounds and auscultation of gastric
insufflation is negative, the Combitube may have been advanced too far into the
pharynx. Deflate the Number 1 balloon/cuff, and move the Combitube approximately 2
to 3 cm. out of the patient's mouth.
(h) Re-inflate the Number1 balloon with 100 ml of air and ventilate
through the longer Number 1 connecting tube. If auscultation of breath sounds is
positive and auscultation of gastric insufflation is negative, continue to ventilate.
(i) If breath sounds are still absent, immediately deflate both cuffs and
extubate the patient.
(j) Insert oropharyngeal or nasopharyngeal airway and hyperventilate
the patient with a bag-valve-mask (BVM) device.
e. Combitube Removal Procedure.
The Combitube should not be removed unless:
(a) Tube placement cannot be determined.
(b) The patient no longer tolerates the tube (begins to gag).
The patient vomits past either the distal or pharyngeal tube.
(d) There is a palpable pulse and the patient starts breathing on his
A physician or physician assistant (PA) is present to place an ETT.