SALAD

Suction Assisted Laryngoscopy & Airway Decontamination

“Without an airway, you’ve got nothing”  Dr Tim Leeuwenburg 

Airway Decontamination

Airway-related complications significantly increase as the number of laryngoscopic attempts increase1.

Airway contamination is one of the major causes of failure in first pass tracheal intubation attempts2. Blood and vomitus in the airway have been identified as a predictor of difficult intubation 3,4,5,6,7. Yet, decontamination of the airway is a poorly defined step in airway management8.

The Yankauer suction tip, developed in 1907 by an American ENT surgeon (Sidney Yankauer) was originally designed to help clear the surgical field during a tonsillectomy and has become the most commonly used medical instrument in the world with its use expanding to include many surgical procedures, as well as in-hospital and prehospital oropharyngeal suctioning. New generation suction catheters provide greater efficiency in clearing the airway.

Dr James DuCanto, MD, is a well-known anaesthetist with a special interest of innovating and improving airway management. He is the inventor of the SALAD (Suction Assisted Laryngoscopy & Airway Decontamination) simulator and the SSCOR DuCanto Catheter.

During simulation Jim noticed that the HI – D catheter was awkward to work with when using hyper curved laryngoscopes. So he modified the design of the HI – D catheter which allows for very efficient suctioning of contaminants (thick liquid, blood and small particles) and made a series of prototypes of different shapes that follow the anatomic curve of the tongue. Then through a process of refinement, testing and development the current SSCOR DuCanto Catheter was born. This suction catheter allows for decontamination of the hypopharynx and oropharynx with the minimal amount of moves with the minimal amount of time. The larger internal diameter of the suction catheter plays an important part to flow speeds for the removal of airway contaminants. The rigid nature of the catheter also allows for manipulation of the airway structures (check out the podcast with Scott Weingart below).

Checkout this great podcast9  by Scott Weingart – he interviews James Ducanto and obtains greater insights to the development of the SSCOR DuCanto Catheter and the SALAD technique.10

Feedback from the community has helped Jim to continue to develop and refine the SSCOR DuCanto Catheter and the SALAD technique. The catheter is now available together with 3 or 6ft x 9/32″ connecting tubing. As seen in the adjacent video,11 flow speeds are enhanced when using the DuCanto catheter along with the large bore connecting tubing.

The community recognise that airway decontamination is an important problem. This  “drive” has spurred some to develop “home made” SALAD simulator kits, which go someway to teach the SALAD technique as far and wide reaching as possible.

Commercial version of the simulator is available.

Race Video

“Without an airway, you’ve got nothing” ​

Airway decontamination is without a doubt an important step in airway management. 

“Value lies in the ability to make a clinically meaningful impact.”

By enhancing the speed and efficiency to decontaminate a soiled airway, the SALAD technique and the SSCOR DuCanto Catheter are great examples of how design can enhance the way we teach, and the care that we provide.

SALAD is Served

Jim demonstrates the SALAD technique12 using the SSCOR DuCanto Catheter

Play Video

The "Bloody" Recipe

Great video (below) by Adam LaChappelle demonstrating the Blood Hell SALAD13

Financial Disclosures

Unless otherwise stated at the top of the post, related parties have no relevant financial disclosures or conflict of interest.

References

  1. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesthesia & Analgesia. 2004 Aug 1;99(2):607-13
  2. Joshi R, Hypes CD, Greenberg J, et al. Difficult airway characteristics associated with first-attempt failure at intubation using video laryngoscopy in the intensive care unit. Annals of the American Thoracic Society. 2017 Mar;14(3):368-75.
  3. DuCanto, J., Serrano, K. D., Thompson, R. J. (2017). Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System. The western journal of emergency medicine, 18(1), 117–120. doi:10.5811/westjem.2016.9.30891
  4. Combes X, Jabre P, Jbeili C, et al. Prehospital standardization of medical airway management: Incidence and risk factors of difficult airway. Acad Emerg Med. 2006;13:828-34.
  5. Gaither J, Spaite D, Stolz U, et al. Prevalence of difficult airway predictors in cases of failed prehospital endotracheal intubation. J Emerg Med. 2014;47:294-300.
  6. Mosier J, Stolz U, Chiu S, et al. Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy. J Emerg Med. 2012;42:629-34.
  7. Burns B, Habig K, Eason H, et al. Difficult intubation factors in prehospital rapid sequence intubation by an Australian helicopter emergency medical service. Air Med J. 2016;35:28-32.
  8. Jost D, Minh PD, Galinou N, et al. What is the incidence of regurgitation during an out-of-hospital cardiac arrest? Observational study. Resuscitation. 2015 Nov 1;96:70.
  9. Weingart S. Podcast 196 – Having a Vomit SALAD with Dr. Jim DuCanto – Airway Management Techniques during Massive Regurgitation, Emesis, or Bleeding. EMCrit Blog. Published on April 3, 2017. Accessed on August 10th Available at [https://emcrit.org/emcrit/having-a-vomit-salad-with-ducanto/ ].
  10. Root CW, Mitchell OJ, Brown R, Evers CB, Boyle J, Griffin C, West FM, Gomm E, Miles E, McGuire B, Swaminathan A. Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A Technique for Improved Emergency Airway Management. Resuscitation Plus. 2020 May 27:100005.
  11. The Race [Internet]. Sscor.com. 2019 [cited 14 August 2019]. Available from: http://www.sscor.com/race/
  12. SSCOR DuCanto Catheter Intro and Demonstration [Internet]. YouTube. 2017 [cited 14 August 2019]. Available from: https://www.youtube.com/watch?v=IPJFshx0i5I
  13. LaChappelle A. The Blood Hell SALAD [Internet]. Twitter. 2019 [cited 14 August 2019]. Available from: https://urlzs.com/zhxRm