Peer Reviewed

Rescue ventilation: Resolving a “cannot mask ventilate, cannot intubate” situation during exchange of a combitube for a definitive airway


Rich JM, Mason AM, Tillmann HA, Foreman M
Pinnacle Partners in Medicine, Department of Anesthesiology and Pain Management, Baylor University Medical Center, Dallas, Texas, USA


Our anesthesia care team was called to care for a patient who was admitted to the emergency department with the esophageal-tracheal double-lumen airway device (Combitube, Tyco Healthcare, Nellcor, Pleasanton, California) in place, which needed to be exchanged for a definitive airway because the patient required an extended period of mechanical ventilation. Several techniques were attempted to exchange the esophageal-tracheal Combitube (ETC) without success. First, we attempted direct laryngoscopy with the ETC in place after deflation of the No. 1 proximal cuff and sweeping the ETC to the left. We were prepared to use bougie-assisted intubation but could not identify any airway anatomy. After removal of the ETC, we unsuccessfully attempted ventilation/intubation with a laryngeal mask airway (LMA Fastrach, LMA North America, San Diego, California). Our third attempt was insertion of another laryngeal mask airway (LMA Unique, LMA North America) with marginal ventilation, but we again experienced unsuccessful intubation using a fiberscope. The ETC was reinserted after each intubation attempt because mask ventilation was impossible. Before proceeding with cricothyrotomy, we repeated direct laryngoscopy but without the ETC in place. We identified the tip of the epiglottis, which allowed for bougie-assisted intubation. This obviated the need for emergency cricothyrotomy.


Rich, J. M., Mason, A. M., Tillman Hein, H. A., & Foreman, M. (2009). Rescue ventilation: Resolving a “cannot mask ventilate, cannot intubate” situation during exchange of a combitube for a definitive airway. AANA Journal, 77(5), 339-342.

Successful blind digital intubation with a bougie introducer in a patient with an unexpected difficult airway


Rich, J. M. (2008). Successful blind digital intubation with a bougie introducer in a patient with an unexpected difficult airway. Proceedings (Baylor University. Medical Center), 21(4), 397–399.

Combitube, Self-Inflating Bulb, and Colorimetric Carbon Dioxide Detector to Advance Airway Management in the First Echelon of the Battlefield, The Military Medicine


Rich, James M

Thierbach, Andreas

Frass, Michael


Combat lifesavers and Army medics are regular combat soldiers who possess skills that enable them to provide lifesaving assistance to combat casualties. Although their training is not equal to that of paramedics, combat lifesavers and Army medics are trained to assess casualties for airway obstruction, as well as the presence or absence of spontaneous ventilation. They are also familiar with the same basic airway maneuvers that are required for blind insertion of the esophageal-tracheal double-lumen airway (ETDLA). Use of the ETDLA in combination with an esophageal detector device and a colorimetric carbon dioxide detector would require skill similar to that which they already possess in performing many mission-essential and combat lifesaver tasks. Because the U.S. Army has introduced the ETDLA for use, it is important that providers at all echelons understand the dynamics of the ETDLA. Inclusion of the ETDLA, esophageal detector device, and colorimetric carbon dioxide detector in combination with the bag-valve ventilation device could provide a viable alternative to mouth-to-mouth rescue breathing with the oral airway, as currently used by combat lifesavers on the battlefield. Improved airway management, in conjunction with other lifesaving measures, could potentially improve survival rates for combat casualties and assist in stabilizing them for evacuation to higher echelons of combat medical care. 



Rich, J. M., Thierbach, A., & Frass, M. (2006). The combitube, self-Inflating bulb, and colorimetric carbon dioxide detector to advance airway management in the first echelon of the battlefield. Military Medicine,171(5), 389-395. doi:10.7205/milmed.171.5.389

Dexmedetomidine as a sole sedating agent with local anesthesia in a high-risk patient for axillofemoral bypass graft: A case report


James M. Rich, CRNA, MA 


In this case report, the author describes the use of dexmedetomidine as a sole sedating agent in conjunction with local anesthesia for major vascular surgery, and it describes the indications, dosing, off-label uses, pharmacodynamics, pharmacokinetics, and common adverse effects of dexmedetomidine. 


Rich, J. M. (2005). Dexmedetomidine as a sole sedating agent with local anesthesia in a high-risk patient for axillofemoral bypass graft: A case report. AANA Journal, 73(5), 357-360.

Recognition and management of the difficult airway with special emphasis on the intubating LMA-Fastrach/whistle technique: a brief review with case reports


Rich, J. M. (2005). Recognition and management of the difficult airway with special emphasis on the intubating LMA-Fastrach/whistle technique: a brief review with case reports. Proceedings (Baylor University. Medical Center), 18(3), 220–227.

The SLAM Emergency Airway Flowchart: A new guide for advanced airway practitioners


James M. Rich, CRNA, MA
Andrew M. Mason, MB, BS, MRCS, LRCP
Michael A. E. Ramsay, MD, FRCA 


The SLAM Emergency Airway Flowchart is intended to prevent the 3 reported primary causes of adverse respiratory events (inadequate ventilation, undetected esophageal intubation, and difficult intubation). The flowchart's 5 pathways are primary ventilation, rapid-sequence intubation, difficult intubation, rescue ventilation, and cricothyrotomy. It is intended for use with adult patients by advanced airway practitioners competent in direct laryngoscopy, tracheal intubation, administration of airway drugs, rescue ventilation, and cricothyrotomy. 


Rich, J. M., Mason, A. M., & Ramsay, M. A. (2004). The SLAM Emergency Airway Flowchart: A new guide for advanced airway practitioners. AANA Journal,72(6), 431-439.

The critical airway, rescue ventilation, and the Combitube

James M. Rich, CRNA, MA

Andrew M. Mason, MB, BS, MRCS, LRCP

Tareg A. Bey, MD

Peter Krafft, MD, PhD

Michael Frass, MD


Part One: In part one of this review article, the authors discuss the proper use of the esophageal-tracheal Combitube (ETC) in combination with the self-inflating bulb and/or portable carbon dioxide detector to resolve critical airway situations. In addition, critical airway events and rescue ventilation options; ETC design, technical aspects, training, insertion, and ventilation; determining ETC location; and monitoring ETC lung ventilation are reviewed.


Rich, J. M., Mason, A.M., Bey, T.A., Krafft, P., & Frass, M. (2004). The critical airway, rescue ventilation and the Combitube: Part 1. AANA Journal,72(1), 17-27.

Part Two: In part two of this review article, the authors discuss esophageal-tracheal Combitube (ETC) advantages, contraindications, and reported complications in prehospital, emergency medicine, and anesthesia settings. Safe methods to exchange the ETC for a definitive airway also are described.


Rich, J. M., Mason, A.M., Bey, T.A., Krafft, P., & Frass, M (2004). The critical airway, rescue ventilation and the Combitube: Part 2. AANA Journal,72(2), 115-124.