Three Airway Management Techniques for Airway Decontamination in Massive Emesis: A Manikin Study

Abstract

IntroductionEmesis occurs during airway management and results in pulmonary aspiration at rates of 0.01% – 0.11% in fasted patients undergoing general anesthesia and 0% – 22% in non-fasted emergency department patients. Suction-assisted laryngoscopy and airway decontamination (SALAD) involves maneuvering a suction catheter into the hypopharynx, while performing laryngoscopy and endotracheal intubation. Intentional esophageal intubation (IEI) involves blindly intubating the esophagus to control emesis before endotracheal intubation. Both are previously described techniques for endotracheal intubation in the setting of massive emesis. This study compares the SALAD and IEI techniques with the traditional approach of ad hoc, rigid suction catheter airway decontamination and endotracheal intubation in the setting of massive simulated emesis.MethodsSenior anesthesiology and emergency medicine (EM) residents were randomized into three trial arms: the traditional, IEI, or SALAD. Each resident watched an instructional video on the assigned technique, performed the technique on a manikin, and completed the trial simulation with the SALAD simulation manikin. The primary trial outcome was aspirate volume collected in the manikin’s lower airway. Secondary outcomes included successful intubation, intubation attempts, and time to successful intubation. We also collected pre- and post-simulation demographics and confidence questionnaire data.ResultsThirty-one residents (21 anesthesiology and 10 EM residents) were randomized. Baseline group characteristics were similar. The mean aspirate volumes collected in the lower airway (standard deviation [SD]) in the traditional, IEI, and SALAD arms were 72 (45) milliliters per liter (mL), 100 (45) mL, and 83 (42) mL, respectively (p = 0.392). Intubation success was 100% in all groups. Times (SD) to successful intubation in the traditional, IEI, and SALAD groups were 1.69 (1.31) minutes, 1.74 (1.09) minutes, and 1.74 (0.93) minutes, respectively (p = 0.805). Overall, residents reported increased confidence (1.0 [0.0–1.0]; P = 0.002) and skill (1.0 [0.0–1.0]; P < 0.001) in airway management after completion of the study.ConclusionThe intubation techniques provided similar performance results in our study, suggesting any one of the three can be employed in the setting of massive emesis; although this conclusion deserves further study. Residents reported increased confidence and skill in airway management following the experience, suggesting use of the manikin provides a learning impact.

Soiled Airway Tracheal Intubation and the Effectiveness of Decontamination by United Kingdom Paramedics (Satiated2): A Randomised Controlled Manikin Study

“…SALAD was shown to improve intubation success rates and clinician confidence and reduce time to intubation in a Taiwanese study (16). An American study compared senior anaesthetists and emergency doctor use of SALAD with conventional management and intentional oesophageal intubation to control massive emesis and found all three produced similar results, so SALAD appears equivalent to other techniques used to manage soiled airways (17). The overall body of literature, although small and largely based on manikin studies, indicates that SALAD is a useful technique for dealing with a severely soiled airway.…”

Simulation in airway management teaching and training

“…Besides training purposes, these simulators are now widely used for training purposes and as an innovative way to answer many research questions related to airway management; for example, the effect of an aerosol box during airway management reduces healthcare practitioner exposure, and so on. [ 33 34 35 36 37 ]…”

“…After reading the full text, 36 relevant studies were included in this review. [ 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 ]…”

An Approach to Improve the Effectiveness of the Video-Assisted Intubating Stylet Technique for Tracheal Intubation: A Case Series Report

“…Direct high-flow oxygenation has been shown to remove secretions and improve the visualization of the airway during application of the VS technique [ 37 ]. For emergency or significant vomitus or secretions, the SALAD technique (suction-assisted laryngoscopy for airway decontamination) can be helpful [ 38 , 39 , 40 ]. During the regular induction of anesthesia and tracheal intubation processes, both regular flexible suction catheters and rigid Yankauer suction tips are commonly used to remove any substances that could impede the visibility of the airway.…”