The SALAD Technique: A Revolution in Contaminated Airway Management

Airway management in emergency situations remains one of the most critical challenges faced by emergency physicians. Among the most dreaded scenarios is the intubation of a patient with contaminated airways, whether due to vomiting, blood, or other secretions. In these situations, the SALAD (Suction Assisted Laryngoscopy and Airway Decontamination) technique emerges as an innovative and promising approach.

 

This article aims to explore the SALAD technique in depth, its foundations, practical implementation, advantages, limitations, and its potential impact on emergency medicine practice.

 

 

 

 What is the SALAD Technique?

 

SALAD stands for “Suction Assisted Laryngoscopy and Airway Decontamination”. This technique, developed by Dr. James DuCanto, an anesthesiologist at Aurora St. Luke’s Medical Center in Milwaukee, Wisconsin, aims to facilitate endotracheal intubation in conditions of severe airway contamination [1].

The fundamental principle of SALAD relies on the simultaneous and coordinated use of a laryngoscope and a rigid suction catheter. This approach allows for active cleaning of the airways while maintaining optimal visualization of the larynx, thus offering an elegant solution to a complex problem.

 

 Physiological and Anatomical Foundations

 

To understand the effectiveness of the SALAD technique, it is essential to recall certain elements of anatomy and physiology of the upper airways.

 

Anatomy of the Upper Airways

 

The upper airways include the following structures:

– The oral cavity

– The pharynx (divided into nasopharynx, oropharynx, and laryngopharynx)

– The larynx

The larynx, in particular, plays a crucial role in protecting the lower airways. The epiglottis, a cartilaginous structure located at the entrance of the larynx, acts as a “flap” to prevent aspiration during swallowing [2].

 

Physiology of Airway Protection

 

Under normal circumstances, several mechanisms protect the lower airways from aspiration:

1. 1. The cough reflex
   2. The closure of the vocal cords
   3. The swallowing reflex

However, these mechanisms can be compromised in various clinical situations, notably:

– Altered state of consciousness

– Neurological pathologies

– Intoxications

– Traumas

In these cases, the risk of aspiration increases considerably, making endotracheal intubation both necessary and complex [3].

 

 The SALAD Technique in Detail

 

Necessary Equipment

 

Performing the SALAD technique requires specific equipment:

1. 1. **Laryngoscope**: Preferably a video laryngoscope, which offers better visualization and facilitates coordination with suction.

1. 2. **Rigid suction catheter**: Often called a “SALAD catheter”, it is wider (14-16 Fr) and more rigid than standard suction catheters. This rigidity allows for more precise manipulation and more effective suction.

1. 3. **High-flow suction system**: Capable of generating negative pressure of at least 300 mmHg and managing large volumes of fluids quickly.

1. 4. **Endotracheal tube**: Prepared according to standard protocols, with a guide if necessary.

 

Step-by-Step Procedure

 

The SALAD technique proceeds according to the following steps:

1. 1. **Patient positioning**:

   – Place the patient in the “sniffing” position to optimize the alignment of the oral, pharyngeal, and laryngeal axes.

   – This position facilitates visualization of the larynx and insertion of the endotracheal tube.

1. 2. **Insertion of the suction catheter**:

   – Insert the SALAD catheter along the patient’s left cheek, up to the oropharynx.

   – Activate continuous suction.

1. 3. **Laryngoscopy**:

   – Insert the laryngoscope on the right side of the mouth, moving the tongue to the left.

   – Gradually advance the laryngoscope while simultaneously suctioning any secretions or debris encountered.

1. 4. **Dynamic suction**:

   – Perform back-and-forth movements with the suction catheter while progressing with the laryngoscope.

   – This maneuver allows for effective cleaning of the airways and maintains a clear visual field.

1. 5. **Visualization of the larynx**:

   – Once the larynx is visualized, maintain suction to keep a clear view.

   – Adjust the position of the suction catheter as needed.

1. 6. **Intubation**:

   – Proceed with endotracheal intubation using the usual technique.

   – The suction catheter can be left in place during tube insertion to continue cleaning the airways if necessary.

1. 7. **Verification of tube position**:

   – Confirm the position of the endotracheal tube using usual methods (auscultation, capnography, etc.).

 

The Basics of The Salad Technique – a free tutorial with Jim DuCanto, MD (youtube.com)

 

 

Variations of the Technique

 

Several variations of the SALAD technique have been described:

1. 1. **Sequential SALAD**:

   – Rapid alternation between suction and laryngoscopy rather than performing them simultaneously.

   – Can be useful when only one operator is available or in cases of extreme contamination.

1. 2. **Two-operator technique**:

   – One operator manages suction while the other performs laryngoscopy and intubation.

   – Can improve efficiency in particularly difficult situations.

1. 3. **SALAD with integrated suction laryngoscope**:

   – Use of specially designed laryngoscopes with an integrated suction channel.

   – Simplifies the procedure by combining the two instruments.

 

 Advantages of the SALAD Technique

 

The SALAD technique presents several significant advantages compared to traditional approaches to contaminated airway management:

1. 1. **Improved visualization**:

   – Continuous suction allows for maintaining a clear visual field, facilitating identification of anatomical structures.

   – Particularly useful in cases of active bleeding or persistent vomiting.

1. 2. **Reduced risk of aspiration**:

   – By actively cleaning the airways during the procedure, SALAD minimizes the risk of pulmonary aspiration.

   – This aspect is crucial for preventing post-intubation complications such as aspiration pneumonia [4].

1. 3. **Increased first-attempt success rate**:

   – Better visualization translates into a higher rate of successful first-attempt intubations.

   – Reduces the need for multiple attempts, thus limiting airway trauma and hypoxemia [5].

1. 4. **Reduced apnea time**:

   – By allowing for faster and more efficient intubation, SALAD minimizes the time during which the patient is not ventilated.

   – Particularly beneficial in patients with rapid desaturation.

1. 5. **Improved staff safety**:

   – Continuous suction reduces the risks of healthcare personnel exposure to the patient’s body fluids.

   – A non-negligible aspect in the current context of universal precautions.

1. 6. **Versatility**:

   – Applicable in various clinical situations: cardiac arrests, upper gastrointestinal bleeding, overdoses, etc.

   – Can be adapted to different types of laryngoscopes and suction equipment.

 

 Challenges and Limitations

 

Despite its many advantages, the SALAD technique also presents certain challenges and limitations:

1. 1. **Learning curve**:

   – Requires specific training and regular practice to be mastered effectively.

   – May initially be more difficult to execute than standard intubation techniques.

1. 2. **Coordination**:

   – Demands excellent hand-eye coordination, especially if a single operator performs the procedure.

   – Can be particularly challenging in high-stress situations.

1. 3. **Specific equipment**:

   – Requires a rigid suction catheter and a high-flow suction system, which may not be available in all contexts.

   – The use of a video laryngoscope, although not mandatory, is strongly recommended.

1. 4. **Cost**:

   – Specialized equipment may be more expensive than standard intubation equipment.

   – May represent a barrier to adoption in resource-limited environments.

1. 5. **Risk of trauma**:

   – Inappropriate use of the rigid suction catheter can potentially cause soft tissue injuries.

   – Emphasizes the importance of adequate training and careful technique.

1. 6. **Limitations in certain pathologies**:

   – May be less effective in some cases of abnormal airway anatomy or severe laryngeal pathologies.

   – Does not replace the need for other advanced airway management techniques in certain complex cases.

 

 Evidence and Research

 

Although the SALAD technique is increasingly adopted in clinical practice, the evidence base is still developing. Several studies have nevertheless demonstrated its effectiveness:

1. 1. DuCanto et al. (2017) conducted a mannequin study comparing SALAD to traditional suction. They found a significant improvement in larynx visualization time and intubation success rate with SALAD [6].

1. 2. A retrospective study by Carlson et al. (2019) in an emergency department showed an increase in first-attempt intubation success rate from 78% to 91% after the introduction of the SALAD technique [7].

1. 3. Sukeyuki et al. (2020) reported a case series of successful use of SALAD in managing patients with massive upper gastrointestinal bleeding, highlighting its usefulness in these critical situations [8].

Larger-scale prospective randomized studies are needed to confirm these promising results and definitively establish the superiority of SALAD compared to traditional techniques in various clinical situations.

 

 Training and Implementation

 

Successful adoption of the SALAD technique in clinical practice requires a structured approach to training and implementation:

 

Training

 

1. 1. **Simulation**:

   – Use of high-fidelity mannequins to practice the technique in realistic scenarios.

   – Allows for developing technical skills without risk to patients.

1. 2. **Practical workshops**:

   – Hands-on training sessions, often integrated into advanced airway management training.

   – Opportunity to practice under direct expert supervision.

1. 3. **Instructional videos**:

   – Online resources demonstrating the technique and its variations.

   – Useful for review and refreshing knowledge.

1. 4. **Continuous education**:

   – Regular practice and update sessions to maintain skills.

   – Integration into continuing medical education programs.

 

Implementation

 

1. 1. **Standardized protocols**:

   – Development of clear protocols for using SALAD in different clinical scenarios.

   – Integration into existing difficult airway management algorithms.

1. 2. **Equipment**:

   – Ensure availability of necessary materials (SALAD catheters, high-flow suction systems).

   – Consider acquiring video laryngoscopes if not already available.

1. 3. **Audit and feedback**:

   – Establishment of a system to track SALAD uses and their results.

   – Use of data to continuously improve practice and identify additional training needs.

1. 4. **Multidisciplinary integration**:

   – Collaboration between emergency physicians, anesthesiologists, and intensivists for a coherent approach.

   – Can improve overall adoption and effectiveness of the technique.

 

 Conclusion

 

 

The SALAD technique represents a significant advancement in contaminated airway management in emergency medicine. By innovatively combining laryngoscopy and continuous suction, it offers an elegant solution to a major clinical challenge.

 

The potential benefits of SALAD are numerous: improved visualization, reduced risk of aspiration, increased first-attempt intubation success rate, and improved safety for both the patient and healthcare personnel. These benefits are particularly valuable in critical situations where every second counts.

 

However, like any advanced technique, SALAD presents challenges, particularly in terms of learning curve and specific equipment needs. Adequate training and regular practice are essential to master this approach and fully benefit from it.

 

As research continues to refine our understanding and application of SALAD, it is clear that this technique has the potential to become a standard tool in the emergency physician’s arsenal for difficult airways. Its integration into airway management protocols could contribute to improving patient outcomes and reducing complications related to emergency intubation.

 

Ultimately, SALAD perfectly illustrates how innovation in emergency medicine can arise from the creative combination of existing techniques to address persistent clinical challenges. As we continue to explore and refine this approach, it is likely that SALAD will play an increasing role in airway management in emergency medicine in the years to come.

 

 

 

Références

 

 

1. DuCanto J, Serrano KD, Thompson RJ. Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD) System. West J Emerg Med. 2017;18(1):117-120.

 

2. Standring S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. Elsevier; 2016.

 

3. Sakles JC, Augustinovich CC, Patanwala AE, Pacheco GS, Mosier JM. Improvement in the safety of rapid sequence intubation in the emergency department with the use of an airway continuous quality improvement program. West J Emerg Med. 2019;20(4):610-618.

 

4. Driver BE, Klein LR, Schick AL, Prekker ME, Reardon RF, Miner JR. The occurrence of aspiration pneumonia after emergency endotracheal intubation. Am J Emerg Med. 2018;36(2):193-196.

 

5. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71-78.

 

6. DuCanto J, Serrano KD, Thompson RJ. Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD) System. West J Emerg Med. 2017;18(1):117-120.

 

7. Carlson JN, Zocchi M, Marsh K, et al. Procedural experience with intubation: results from a national emergency medicine group. Ann Emerg Med. 2019;74(6):786-794.

 

8. Sukeyuki Y, Toshi-hiro Y, Hiroaki F, et al. Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD): A Case Series of Massive Upper Gastrointestinal Bleeding. Prehosp Disaster Med. 2020;35(6):675-678.

 

9. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175.

 

10. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011;106(5):632-642.