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Suction Assisted Laryngoscopy Airway Decontamination (SALAD) is incremental step-wise approach to the management of a massively contaminated airway.[1]

An example of a SALAD training setup. An advanced airway mannikin has been modified with standard garden hose and fixings to connect the oesophagus to a bilge pump situated in a reservoir of artificial vomit.

Emergency airway management is often complicated by the presence of blood, emesis or other contaminants in the airway. For example in out-of-hospital cardiac arrest (OHCA), vomiting and regurgitation have a reported incidence of 20–30%.[2][3] The traditional approach to the contaminated airway involves suctioning the airway and repositioning the patient, which can effectively manage airway soiling in many, but not all, cases. [4][5] However, traditional airway management education has not included the integration of a simultaneous suctioning and airway decontamination skill set as a technique that can be deployed in the setting of large volume contamination and clinicians frequently underestimate the importance of suction as part of airway management.[1][6][7]

This has led to the development of the SALAD technique, and the creation of modified airway manikins to allow for practice in these techniques.[8]


History

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SALAD was developed as a simulation exercise in 2014 in multiple US academic emergency medicine departments, culminating in its presentation at the 2015 Social Media and Critical Care Conference (SMACC) which raised the profile of the technique internationally. Following its introduction to the international community at SMACC, multiple medical educators introduced the technique in their own institutions and services across Australasia, Europe and Asia.

Technique

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The SALAD technique consists of the following steps:[1][8]

Step Description
1. Optimally position the patient to maximise the probability of intubation success (e.g. external auditory meatus level with sternal notch).
2. Hold the suction catheter (wide-bore, rigid) in a clenched-fisted right hand, with the distal end of the catheter pointing caudad and posterior, to enable manipulation of the tongue and mandible as required. The curve of the rigid suction catheter should mirror the curve of the structures of the upper airway
3. Lead with suction to enable identification of relevant anatomical structure (posterior portion of tongue, epiglottis, vallecular and laryngeal outlet) and follow with the laryngoscope (particularly important with video laryngoscopes to avoid contaminating the optics).
4. In order to facilitate placement of the tracheal tube, the suction catheter is moved across to the left side of the mouth and the suction catheter 'parked' in the top of the oesophagus to provide continuous suction during the remainder of the intubation attempt. This can be achieved either by sliding the catheter under the laryngoscope blade, or by briefly removing the catheter and inserting it to the left of the laryngoscope blade.
Catheter moved to left-side
of the patient's mouth and
'parked' in the oesophagus
5. Insert the index finger of the right hand into the right-hand side of the oropharynx to create a 'channel' for tracheal tube delivery (known as the SALAD poke).
6. Insert the index finger of the right hand into the right-hand side of the oropharynx to create a 'channel' for tracheal tube delivery (known as the SALAD poke).
7. Inflate the cuff on the tracheal tube to prevent further contamination of the lower airway.
8. Suction down the tracheal tube with a flexible suction catheter prior to ventilation to remove any residual contaminant prior to ventilation.

Note that these images are using a hand-operated suction device, but the principle for motorised suction is the same.

SALAD research

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At present, there have been no large, randomised controlled trials (RCTs) of SALAD versus conventional emergency airway management strategies in real patients. The sporadic incidence of massive airway contamination during intubation attempts mean that an RCT of SALAD versus usual care is likely to be unfeasible to conduct. However, there is a growing body of lower quality evidence (simulation studies, and studies utilising observational data from patients) that are encouraging in terms of increasing clinician's confidence in managing severely contaminated airways [8][9] and improving intubation success rates as well as time to successful intubation [10][11][12][13] in cases of significant airway soiling.

References

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  1. ^ a b c Root, Christopher W.; Mitchell, Oscar J. L.; Brown, Russ; Evers, Christopher B.; Boyle, Jess; Griffin, Cynthia; West, Frances Mae; Gomm, Edward; Miles, Edward; McGuire, Barry; Swaminathan, Anand; St George, Jonathan; Horowitz, James M.; DuCanto, James (2020-03-01). "Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management". Resuscitation Plus. 1–2: 100005. doi:10.1016/j.resplu.2020.100005. ISSN 2666-5204. Retrieved 2020-10-25.
  2. ^ (Simons, Reed W.; Rea, Thomas D.; Becker, Linda J.; Eisenberg, Mickey S. (2007-09). "The incidence and significance of emesis associated with out-of-hospital cardiac arrest". Resuscitation. 74 (3): 427–431. doi:10.1016/j.resuscitation.2007.01.038. ISSN 0300-9572. PMID 17433526. {{cite journal}}: Check date values in: |date= (help)
  3. ^ Voss, Sarah; Rhys, Megan; Coates, David; Greenwood, Rosemary; Nolan, Jerry P.; Thomas, Matthew; Benger, Jonathan (2014-12-01). "How do paramedics manage the airway during out of hospital cardiac arrest?". Resuscitation. 85 (12): 1662–1666. doi:10.1016/j.resuscitation.2014.09.008. ISSN 1873-1570 0300-9572, 1873-1570. PMID 25260723. Retrieved 2019-03-04. {{cite journal}}: Check |issn= value (help)
  4. ^ Robinson, Michael; Davidson, Andrew (2014-08-01). "Aspiration under anaesthesia: risk assessment and decision-making". Continuing Education in Anaesthesia Critical Care & Pain. 14 (4): 171–175. doi:10.1093/bjaceaccp/mkt053. ISSN 1743-1816. Retrieved 2020-10-25.
  5. ^ Kluger, M. T.; Visvanathan, T.; Myburgh, J. A.; Westhorpe, R. N. (2005-06-01). "Crisis management during anaesthesia: regurgitation, vomiting, and aspiration". BMJ Quality & Safety. 14 (3): –4-e4. doi:10.1136/qshc.2002.004259. ISSN 2044-5423 2044-5415, 2044-5423. PMID 15933301. Retrieved 2020-10-25. {{cite journal}}: Check |issn= value (help)
  6. ^ Prekker, Matthew E.; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D. (2014-06). "The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation". Critical care medicine. 42 (6): 1372–1378. doi:10.1097/CCM.0000000000000213. ISSN 0090-3493. PMC 4902016. PMID 24589641. Retrieved 2020-10-25. {{cite journal}}: Check date values in: |date= (help)CS1 maint: PMC format (link)
  7. ^ Kozak, Richard J.; Ginther, Bret E.; Bean, Walter S. (1997-01-01). "Difficulties with portable suction equipment used for prehospital advanced airway procedures". Prehospital Emergency Care. 1 (2): 91–95. doi:10.1080/10903129708958795. ISSN 1090-3127. Retrieved 2020-10-25.
  8. ^ a b c DuCanto, James; Serrano, Karen; Thompson, Ryan (2017-01-19). "Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System". Western Journal of Emergency Medicine. 18 (1): 117–120. doi:10.5811/westjem.2016.9.30891. ISSN 1936-9018. Retrieved 2018-04-01.
  9. ^ Della Vella, Carmine; Thompson, Ryan J.; Serrano, Karen; Riess, Matthias L.; Ducanto, James (2018-12-01). "Suction-Assisted Laryngoscopy-Assisted Decontamination (SALAD) simulator for difficult airway management". Trends in Anaesthesia and Critical Care. 23: 32. doi:10.1016/j.tacc.2018.09.060. ISSN 2210-8440. Retrieved 2020-10-25.
  10. ^ Pilbery, Richard; Teare, M. Dawn (2019-06-01). "Soiled airway tracheal intubation and the effectiveness of decontamination by paramedics (SATIATED): a randomised controlled manikin study". British Paramedic Journal. 4 (1): 14–21. doi:10.29045/14784726.2019.06.4.1.14. ISSN 1478-4726. Retrieved 2019-07-17.
  11. ^ Lin, Li-Wei; Huang, Chi-Chieh; Ong, Jiann Ruey; Chong, Chee-Fah; Wu, Nai-Yuan; Hung, Shih-Wen (2019-11-15). "The suction-assisted laryngoscopy assisted decontamination technique toward successful intubation during massive vomiting simulation". Medicine. 98 (46). doi:10.1097/MD.0000000000017898. ISSN 0025-7974. PMC 6867733. PMID 31725637. Retrieved 2020-10-25.{{cite journal}}: CS1 maint: PMC format (link)
  12. ^ Ko, Shing; Wong, Oi Fung; Wong, Ching Hin Kevin; Ma, Hing Man; Lit, Chau Hung Albert (2019-11-04). "A pilot study on using Suction-Assisted Laryngoscopy Airway Decontamination techniques to assist endotracheal intubation by GlideScope® in a manikin simulating massive hematemesis". Hong Kong Journal of Emergency Medicine: 1024907919884206. doi:10.1177/1024907919884206. ISSN 1024-9079. Retrieved 2020-10-25.
  13. ^ Jensen, Matthew; Barmaan, Benjamin; Orndahl, Christine M.; Louka, Amir (2020-03-01). "Impact of Suction-Assisted Laryngoscopy and Airway Decontamination Technique on Intubation Quality Metrics in a Helicopter Emergency Medical Service: An Educational Intervention". Air Medical Journal. 39 (2): 107–110. doi:10.1016/j.amj.2019.10.005. ISSN 1067-991X. Retrieved 2020-10-25.
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