Until now, suction has generally been in nurses’ toolboxes for oral care and seizure patients. That changes today.
Changes in patient status such as altered mental status, trauma, and medications can cause blood or vomitus-filled airway. As nurses, we need to do something about this, because airway management is for nurses too! SALAD (suction-assisted laryngoscopy airway decontamination) is an airway management approach for contaminated and difficult airways. This is an important tool for nurses to understand and use.
Contaminated airways lead to pulmonary aspiration which increases patient morbidity and mortality significantly. Pulmonary aspiration occurs in 0-22% of patients that are unfasted, e.g. emergency department patients. Contaminants can be defined as blood, secretions, and vomitus.
Can’t we just position the patient laterally if they are vomiting/bleeding/etc? Not always, cervical spine precautions and active CPR (for example) contraindicate it. But also, how often do you have an additional set of hands to help you roll a patient at the drop of a hat?
SALAD begins with grasping a rigid suction catheter (most often a Yankaur, but a large bore suction catheter works best) in a ‘reverse grip’ with the end of the catheter pointing down and away from the user. A standard grip is optimal when not positioned at the head of the bed. Then, in a sweeping motion, enter the airway and clear out as much contaminant as possible. Keep the suction catheter in place to compress the tongue into the lower jaw with a down and slightly upward motion, this will give you the ultimate view and environment to place an oropharyngeal airway (OPA) or a laryngeal mask airway (LMA). If you chose not to place an airway adjunct, that is just fine! You now have a clean and pristine airway for face mask ventilation with a bag valve mask (BVM).
SALAD is meant for true airway emergencies, so it is important to practice this each time you are managing an airway as these are unpredictable. Consider practicing on a manikin ahead of time too. Practice will benefit patients and increase confidence and skill in time of need.
- SALAD is for nurses too!
- Clean out that contaminated airway with a reverse grip holds on a suction catheter. Get that tongue out of your way.
- Then pick your poison: OPA, LMA, BVM.
DuCanto J, Serrano KD, Thompson RJ. Novel airway training tool that simulates vomiting: suction-assisted laryngoscopy assisted decontamination (SALAD) system.West J Emerg Med. 2017;18(1):117-20.
Fiore M, Marmer S, Steuerwald M, Thompson R, Galgon R. Three airway management techniques for airway decontamination in massive emesis: A manikin study. West J Emerg Med. 2019; doi: 10.5811/westjem.2019.6.42222