Conceptualized by Jim DuCanto, SALAD comprises a set of techniques to optimize airway management.
Airway management is often complicated with the occurrence of airway contamination in the form of blood or regurgitated material, especially in cases of out-of-hospital-cardiac arrest (OHCA). A 2011 review of major complications of hospital based airway management in the United Kingdom sited aspiration as the primary cause of death in operating room and intensive care unit tracheal intubations (NAP4 Study 1). The incidence of regurgitation and aspiration that occurs during rescue for OHCA has been quantified between 25-30% in the peer-reviewed literature. (2) Airway contamination has been recognized as a significant cause of failure in first-attempt tracheal intubation in a study of intensive care airway management (6), potentially increasing the occurrence of adverse events during airway management such as severe hypoxemia, hypotension, aspiration and cardiac arrest (7). A recent innovation in airway management includes the proactive use of suction during basic and advanced airway management in the form of the Suction Assisted Laryngoscopy & Airway Decontamination (SALAD Technique) to address the problem of massive airway contamination (5).
The SALAD technique is intended to prevent massive aspiration during emergency airway management through the use of preemptive suctioning of the upper airway prior to basic and advanced life support maneuvers, and to further utilize the rigid suction catheter to assist the insertion of oral airways, SGAs and laryngoscopes with mechanical distraction of the tongue into the floor of the mouth and elevation of its base from the posterior pharyngeal wall.
Utilizing proactive suctioning of the oropharynx and hypopharynx as the initial step in emergency airway management will reduce the potential to force aspiration of airway contaminants during face mask ventilation and ventilation through SGAs. The method by which the rigid suction catheter is utilized to assist the insertion of an OPA, SGA or laryngoscope is in the manner of a laryngoscope blade itself: Compress the tongue into the floor of the mouth, distract the lower mandible inferiorly and lift the base of tongue off the posterior pharyngeal wall. During laryngoscopy, the rigid suction catheter is maintained in the upper esophageal inlet to decontaminate the hypopharynx during visualization of the larynx and tracheal tube delivery.
Continually suctioning the hypopharynx of blood, emesis and secretions during laryngoscopy has been found to reduce the chance of failure to intubate in two peer-reviewed case reports (3, 4).
Peer reviewed literature of the SALAD Technique encompass 6 studies in simulation that demonstrate increased confidence and proficiency among study participants in managing a simulated contaminated airway, and two clinical case reports of successful use in the management of severely contaminated airways.
Recommendation for the use of SALAD in the Prehospital Environment
SALAD can be considered in specific clinical circumstances relating to copious secretions, blood, or emesis, but the operator must be technically proficient in order to not impair the view of the airway with the suction device. Use of the SALAD technique has focused on the management of contaminated airways, however, the proactive use of a rigid suction catheter to create oropharyngeal and hypopharyngeal space during OPA, SGA or laryngoscope insertion suggest that the technique may have wider application in emergency airway management to facilitate basic and advanced airway management.
The Techniques
Learn about the Salad Techniques
Devices
Specific Equipment to Optimize SALAD Performance
Literature
A collection of SALAD Literature & Links
Frequently Asked Questions
About the SALAD Creators
Find out about Jim and the SALAD Team
Refs
-
Cook T, Wodall N, Frerk C. 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 1: anaesthesia. Brit J Anaesthesia. 2011;106(5):617–31), and an audit of the occurrence of regurgitation during rescue for OHCA in France 2013 revealed an incidence of 25%, paralleling other literature on the issue.
-
(Simons, Reed W.; Rea, Thomas D.; Becker, Linda J.; Eisenberg, Mickey S. (2007-09-01). “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.
-
Choi, In-Sung, Young-Woong Choi, Sang-Hyuk Han, and Ji-Heui Lee. “Successful Endotracheal Intubation Using Suction-Assisted Laryngoscopy Assisted Decontamination Technique and a Head-Down Tilt Position during Massive Regurgitation.” Soonchunhyang Medical Science 26, no. 2 (2020): 75-79.
-
Frantz, Eric, Nima Sarani, Andrew Pirotte, and Bradley S. Jackson. “Woman in respiratory distress.” Journal of the American College of Emergency Physicians Open 2, no. 1 (2021).
-
Root, Christopher W., Oscar JL Mitchell, Russ Brown, Christopher B. Evers, Jess Boyle, Cynthia Griffin, Frances Mae West et al. “Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A Technique for Improved Emergency Airway Management.” Resuscitation Plus (2020): 100005.
-
Joshi, Raj, Cameron D. Hypes, Jeremy Greenberg, Linda Snyder, Josh Malo, John W. Bloom, Harsharon Chopra, John C. Sakles, and Jarrod M. Mosier. “Difficult airway characteristics associated with first-attempt failure at intubation using video laryngoscopy in the intensive care unit.” Annals of the American Thoracic Society 14, no. 3 (2017): 368-375.
-
Sakles, John C., Stephen Chiu, Jarrod Mosier, Corrine Walker, and Uwe Stolz. “The importance of first pass success when performing orotracheal intubation in the emergency department.” Academic Emergency Medicine 20, no. 1 (2013): 71-78.