DuCanto’s SALAD

[VFlutter]

To each their own like you said. If it works for you then keep on with what you're doing I guess. I'm curious though, after flying for a pediatric team for many years why you think this technique would be of benefit in pediatric airways? The last thing I want to do when managing a peds airway with an already limited view, based on limited size of mouth opening it to jam more stuff in there before I get the best view I can obtain.....

To clarify, I approach every airway with the mentality, and set up, that I may need to SALAD or use a bougie. I follow the suction catheter with my C-Mac as i progressively identify structures until i get a view and confirm that the airway is indeed dry then ditch the suction and either pass the tube or the bougie. I only SALAD when it is needed. But if I am using VL then i want to do my best to keep it VL and not contaminate my camera.

As mentioned one of the downsides of SALAD, especially in peds, is it becomes a lot of stuff in the mouth. With the C-Mac it does not really limit the view but does make passing a tube more difficult. I tend to place a bougie, pull the DuCanto, and pass the tube. My last Peds airway was a trauma patient with multiple prior failed attempts and a vomit/blood filled airway with on-going bleeding. SALAD was the only way I could get a view.

I agree with keeping things simple and for many patients the above is overkill however I personally prefer to start will all my cards on the table and practice a standard approach that I can downgrade if not needed. The more you do it the more it becomes muscle memory. For me, I do not feel it distracts or complicates the procedure and works well when you need it.

 

[Carlos Danger]

So, here's the thing about airway management: 95% of the time, pretty much anything will work. You can use sloppy technique, you can use a poorly-sized ET and a poorly-sized blade, you can DL 15 times, you can forget to get your suction ready, you can use roc, you can use sux, you can position poorly, you can let the sats get to 60% and the Co2 get to 100, and none of this will effect the outcome. Or you can just use an LMA or an OPA. Either the patient is healthy enough that they can tolerate all that with little problem, or they are sick enough that it makes little difference; there is not much in-between. This is a big part of why research on airway management is so difficult.

Along those lines, 95% of airways are pretty easy to manage. Again, little of what we do matters here - pretty much anything will work. The people who have trouble with these airways are usually horribly trained or experienced, which unfortunately IME is not a small percentage (though also NOT a majority) of EMS personnel. Or they have just encountered the 5% or so of legitimately difficult airways, which would be a challenge for anyone but the most experienced operators. It is important to recognize that the people who have good airway success rates here are not necessarily experts in airway management.

Frankly, until you have managed a few thousand airways, you don't know what you are talking about. You just just aren't experienced enough to know what you don't know. I know that statement makes me sound like a ****, and that is not my intention, but it is reality. Like anything else, experience matters.

The point is: technique matters. Crutches are just that; crutches. They will get you by just fine probably 98% of the time. Using a suction on dry airways is stupid - it prevents you from learning to use your right hand for more important things that might make a real difference on the airways where you really need good ELM technique. Using a bougie on every tube will keep you from learning to scope properly, which again, might really matter on that few %.

 

[CANMAN]

So, here's the thing about airway management: 95% of the time, pretty much anything will work. You can use sloppy technique, you can use a poorly-sized ET and a poorly-sized blade, you can DL 15 times, you can forget to get your suction ready, you can use roc, you can use sux, you can position poorly, you can let the sats get to 60% and the Co2 get to 100, and none of this will effect the outcome. Or you can just use an LMA or an OPA. Either the patient is healthy enough that they can tolerate all that with little problem, or they are sick enough that it makes little difference; there is not much in-between. This is a big part of why research on airway management is so difficult.

Along those lines, 95% of airways are pretty easy to manage. Again, little of what we do matters here - pretty much anything will work. The people who have trouble with these airways are usually horribly trained or experienced, which unfortunately IME is not a small percentage (though also NOT a majority) of EMS personnel. Or they have just encountered the 5% or so of legitimately difficult airways, which would be a challenge for anyone but the most experienced operators. It is important to recognize that the people who have good airway success rates here are not necessarily experts in airway management.

Frankly, until you have managed a few thousand airways, you don't know what you are talking about. You just just aren't experienced enough to know what you don't know. I know that statement makes me sound like a ****, and that is not my intention, but it is reality. Like anything else, experience matters.

The point is: technique matters. Crutches are just that; crutches. They will get you by just fine probably 98% of the time. Using a suction on dry airways is stupid - it prevents you from learning to use your right hand for more important things that might make a real difference on the airways where you really need good ELM technique. Using a bougie on every tube will keep you from learning to scope properly, which again, might really matter on that few %.

Remi, I think a lot of people sadly don’t have the routine and frequent exposure to the O.R. to realize all of the points made in this post, and I couldn’t agree more. I know I thought I was decent at airway management until I started rotating through the the O.R. every quarter, and then finally realized how much finesse & technique I was lacking and what was truly important vs. what’s not. I am grateful I worked for a program that provided us this exposure as a mandated standard because in those 5 years I gained so much knowledge and skill from the MDA’s and CRNA’s I had the pleasure of shadowing.

 

[Carlos Danger]

Remi, I think a lot of people sadly don’t have the routine and frequent exposure to the O.R. to realize all of the points made in this post, and I couldn’t agree more. I know I thought I was decent at airway management until I started rotating through the the O.R. every quarter, and then finally realized how much finesse & technique I was lacking and what was truly important vs. what’s not. I am grateful I worked for a program that provided us this exposure as a mandated standard because in those 5 years I gained so much knowledge and skill from the MDA’s and CRNA’s I had the pleasure of shadowing.

I flew for over 10 years and had over 150 field tubes before I went into anesthesia, with only sporadic opportunities in the OR. Just in case anyone thought I didn’t understand what it was like in the field.

While OR time is a great opportunity, I think if as much manikin and lab time was spent practicing basic techniques as was spent bending the bougie in different ways and practicing the SALAD thing, we would all be better off.

 

[Peak]

@Remi I'm always surprised by the prevalence of poor technique in the field by the same groups who also tout the latest and greatest thing they bought at a recent expo.

We have a 25 week gestation sim baby, and when it comes to tubing that thing (just like real premies) good basic DL technique is key to success. The same crews who complained that we woudn't let them use video laparoscopy on a teen sim or some other more advanced technique also don't have the skill to intubate what I think is our easiest mannequin to visualize.

Advanced techniques and tools are great, but whether it is the intention or not the field providers I have worked with are letting their basic skills slip.

 

[VentMonkey]

I don't really view either the technique or device as crutches. I also could not agree more about the basic fundamentals of airway management taking precedence among novice providers prior to engaging in such activities.

I just can't see myself as the one to doubt that these tools aren't more of a help than a hindrance. Is it yet another way for someone to make a fast buck? Perhaps, but I feel a lot better giving some open-minded considerations to the applications of either, if not, both device and technique having heard good things about them from many of my peers.

Again, I don't doubt simple routine training, and having mastered (or, in many prehospital providers cases- nearly mastered) the fundamentals of the skills themselves is of the utmost importance. I, however, prefer to keep an open ear to all things that seem to be creating more positive feedback in my career field than not.

Will it work with every product out there? Undoubtedly not. Are a device, and technique developed by a well-respected anesthesiologist worth picking up on? I believe so. So are many of the tips and tricks I have learned throughout my field time from peers, and various other providers...to include those on this forum.

 

[Tigger]

Frankly, until you have managed a few thousand airways, you don't know what you are talking about. You just just aren't experienced enough to know what you don't know. I know that statement makes me sound like a ****, and that is not my intention, but it is reality. Like anything else, experience matters.

I doubt I will even get to 100 tubes in my entire career with the way things are going for EMS. There is no way, quarterly OR time (which is allegedly coming) notwithstanding, that I will ever come to mastering intubation. I feel my only remote chance of competency is to learn a method in which there is a high chance of success more often than not. And maybe crap technique will get you through most intubations, but that certainly has not been my experience. Sloppy technique seems to yield a failed attempt. I guess the whole "single technique mastery" idea speaks to me pretty clearly. I'm not going to have enough attempts to build up the experience needed to develop "bailout methods."

Also, I don't suction dry airways. I might stick the suction in real quick before the blade to make sure some unseen loogie doesn't goober up the camera, but that's really it.

 

[Carlos Danger]

I doubt I will even get to 100 tubes in my entire career with the way things are going for EMS. There is no way, quarterly OR time (which is allegedly coming) notwithstanding, that I will ever come to mastering intubation. I feel my only remote chance of competency is to learn a method in which there is a high chance of success more often than not. And maybe crap technique will get you through most intubations, but that certainly has not been my experience. Sloppy technique seems to yield a failed attempt. I guess the whole "single technique mastery" idea speaks to me pretty clearly. I'm not going to have enough attempts to build up the experience needed to develop "bailout methods."

I don't mean that you need to have thousands of airways to be a competent airway manager. You won't ever reach real expertise without that kind of volume, but there's lots of evidence that shows acceptable success rates among EMS folks who have far less experience than that.

Everyone keeps saying "I want to maximize my chances on every airway". Good. We all should. The best way to do that is to spend your manikin time dropping 50 or 100 tubes with attention to impeccable technique, and practicing transitioning from a simple, easy DL to needing to ventilate or suction or switch to an adjunct. I promise that will do more to improve overall airway skills than spending that manikin time practicing 10 different ways to preload a bougie.

 

[VentMonkey]

@Remi I came across this and it reminded me of what you’d mentioned in an earlier post:
http://openairway.org/wp-content/uploads/2016/04/Kingma-et-al-Four-methods-ETI-Poster-ICEM-2016.pdf

I also advocate for NOT using a stylet in the ETT.

I’m not incredibly familiar with why this technique is a preferred method of yours.

Could you share with those of us unfamiliar of its advantages that you’ve found?

 

[Tigger]

I don't mean that you need to have thousands of airways to be a competent airway manager. You won't ever reach real expertise without that kind of volume, but there's lots of evidence that shows acceptable success rates among EMS folks who have far less experience than that.

Everyone keeps saying "I want to maximize my chances on every airway". Good. We all should. The best way to do that is to spend your manikin time dropping 50 or 100 tubes with attention to impeccable technique, and practicing transitioning from a simple, easy DL to needing to ventilate or suction or switch to an adjunct. I promise that will do more to improve overall airway skills than spending that manikin time practicing 10 different ways to preload a bougie.

I have one way to use a bougie and that's it. I think we are arguing the same thing, that practicing a whole bunch of "gimmicky things" is silly. Have a solid technique that works and leave it at that.

 

[CANMAN]

@Remi I came across this and it reminded me of what you’d mentioned in an earlier post:
http://openairway.org/wp-content/uploads/2016/04/Kingma-et-al-Four-methods-ETI-Poster-ICEM-2016.pdf

I’m not incredibly familiar with why this technique is a preferred method of yours.

Could you share with those of us unfamiliar of its advantages that you’ve found?

If you optimize positioning prior to procedure, use good DL technique & ELM as needed you really should have a great view of the glotic opening and no need to use a stylette in the large majority of the airways (the 95% we discussed earlier). If you need a stylette to force the tube in then you have a less than perfect view, (Cormack-Lehane 1<) and at that point is where the bougie should come in vs. trying to cram in the tube with a stylette and cause cord trauma. (This is just my opinion, I'm sure Remi will have other justification)

 

[Carlos Danger]

@Remi I came across this and it reminded me of what you’d mentioned in an earlier post:
http://openairway.org/wp-content/uploads/2016/04/Kingma-et-al-Four-methods-ETI-Poster-ICEM-2016.pdf

I’m not incredibly familiar with why this technique is a preferred method of yours.

Could you share with those of us unfamiliar of its advantages that you’ve found?

About 1.5 years ago, I stopped using stylets out of frustration because the ones my employer stocked were just awful. They were the real skinny wiry ones with the adjustable "cap" that seats in the ET adapter at the proximal end that you could slide down the tube to adjust the length and assure that the stylet didn't protrude out the distal end. Problem was, it was really easy to slide the cap farther than you wanted it and make the stylet too short, and once you slide the cap down, you couldn't slide it back up, meaning you had to toss the stylet and get a new one. Even worse, once you put the stylet into the tube, it was very hard to get back out. It happened more than few times that I'd place a tube, and thought I was going to have to pull it and use a different one because the stylet just wouldn't come out. So one day I just stopped using them.

It does take some getting used to if you already have some experience intubating, because the feel of a tube with no stylet is very different than a styletted one. But by the time a month or so had passed, I was completely comfortable without using a stylet and actually came to prefer it. I even learned how to flex it to change the shape of it a little during an intubation. Another advantage is that stylets are associated with a much higher risk of airway trauma. I always ensured that the stylet did not protrude out the end of the tube anyway, but being able to document that I didn't even use one completely takes that question out of the equation. It slightly simplifies the process of preparing my equipment, and if I need to transition to using a bougie or glidescope, not having to remove the stylet is just one more task (albeit an admittedly small one) that I don't have to do during an already task-saturated time.

I am a full-time clinical coordinator and instructor for a CRNA program and I always have students for a month at a time. Usually they are early in their last year meaning they have developed pretty solid airway skills already, but are very dependent on routine and doing things the same way every time. During their first day or two with me when I am showing them how we do things, I always suggest that they try to go without a using stylet for the entire month. Most do, and while they are uncomfortable at first, they tell me by the time they leave that they'll never use a stylet again. I really think if we never introduced new intubators to stylets in the first place, it would have no negative effect at all on their eventual competency.

CANMAN hit the nail on the head above. If you align the oral, pharyngeal, and laryngeal axes using good positioning and laryngoscopic technigue, then the tube being rigid adds nothing at all. If you are unable to align those axes due to anatomy or an environment where good positioning is impossible, then a bougie (or VL, better yet) will do much more for you than a normal stylet.

As for the study......I'm always very skeptical of manikin studies. It also seems questionable that the anesthesia folks who average 29 tubes a month actually did worse in almost every category than the folks who do almost 10x fewer airways on average. That is very unusual so it just makes me wonder about the overall rigor and methodology.

 

[VentMonkey]

Weingart actually brings this up in one of his recent airway podcasts.

Essentially as @Tigger mentions we’re advocating for the same thing, however, the environments are remarkably different. He also touts the mastery of one single technique- whatever it may be.

Also worth mentioning~ in the prehospital setting many systems are mandating Bougies be used depending on the graded view. Some even want it on every airway.

 

[NPO]

We're starting SALAD training next month. Very excited.

 

[RocketMedic]

So there's an iPhone app called AirwayEX. Although it obviously doesn't give you the physical hand movements, I use it daily to maintain a good grip on the anatomy and general "direction" of airways, reckon it helps.

 

[NPO]

So there's an iPhone app called AirwayEX. Although it obviously doesn't give you the physical hand movements, I use it daily to maintain a good grip on the anatomy and general "direction" of airways, reckon it helps.

It's in Android too, for the men in the room.

 

[NomadicMedic]

It's in Android too, for the men in the room.

Shots fired.