S183 INTRODUCTION: The esophageal / tracheal Combitube[trade mark sign] (Kendall - Sheridan, Mansfield, MA) is an effective device for providing adequate gas exchange. However, tracheal suctioning is impossible with the Combitube[trade mark sign] placed in the esophageal position. To eliminate this disadvantage, we re-designed the Combitube[trade mark sign] by creating an enlarged hole in the pharyngeal lumen that allows fiberoptic access, tracheal suctioning and tube exchange over a guide wire. METHODS: The two anterior, proximal perforations of regular Combitubes[trade mark sign] were replaced by a larger, ellipsoid-shaped hole. After approval by the IRB, 20 patients with normal airways (Mallampati I or II) were studied. During general anesthesia, patients were esophageally intubated with the Combitube[trade mark sign]. A flexible bronchoscope was inserted and guided via the modified hole and glottic opening down the trachea. For the replacement procedure, a J tip guide wire was introduced through the bronchoscope. The bronchoscope and the Combitube[trade mark sign] were then removed and a standard endotracheal tube (ETT) was advanced over a guide catheter. RESULTS: Bronchoscopic evaluation of the trachea and guided replacement of the Combitube[trade mark sign] by an ETT was successful in all 20 study patients. Average time needed to perform airway exchange was 90 +/- 20 s (mean +/- SD). Arterial oxygen saturation and end-tidal CO2 remained normal in all patients. No case of laryngeal trauma was observed during intubation or airway exchange procedure. CONCLUSIONS: The re-designed Combitube[trade mark sign] enables fiberoptic bronchoscopy, fine-tuning of its position in the esophagus and guided airway exchange in patients with normal airways. Further studies are warranted to demonstrate its value in patients with abnormal airways.