This is Jim DuCanto's talk at the airway session at The Big Sick 2018 in Zermatt. It centers on his SALAD technique of continued suctioning throughout the intubation period. More talks to be found at https://scanfoam.org/

1. Airway Decontamination—
The “Dark Side” of Airway
Management
#TBS18
James DuCanto, M.D.
Director of Simulation Center
Aurora St. Luke’s Medical Center
Milwaukee, Wisconsin, USA
Twitter @jducanto
Facebook SALAD Simulation

2. Disclosures
Dr. DuCanto is the inventor of
the SALAD Mannequin (from
Lifeform/Nasco) and the
DuCanto Suction Catheter (from
SSCOR) and receives royalties on
these products.
Links to the creation of your own
SALAD Mannequin as well as the
commercially available simulation
system will be provided at the end of
the presentation.

3. Goal of this presentation…
Why is Airway Contamination important?
Airway Contamination is one of the major causes of
failure in first-pass tracheal intubation attempts in
Emergency and Critical Care airway management.
New tools and skills available for management of
airway.
Learn the methods to handle this problem?
Use of a simulation system to model airway
decontamination during airway management.

4. Two sides of the “coin” in our modern
conception of airway management…
• Ventilation (the “Bright Side”)
• Decontamination (the “Dark Side”)

5. Ventilation: The “Bright” Side of the
Airway Management Coin
• Ventilation-Centered Airway Management
– Core principal of all current airway algorithms
– Does not specifically address the steps required to
decontaminate the airway

6. Limitations of Current Algorithms
• Ventilation centered algorithms can
encourage ventilation in the presence of a
grossly contaminated airway, ensuring
aspiration of airway contaminants
• Decontamination of the airway is an
important and poorly defined step in airway
management

7. The presence of airway contaminants:
• Negates ventilation by mask or supraglottic
airways
• Negates apneic oxygenation (NODESAT)

8. • Negates all methods of airway endoscopy
“Fluids are the ENEMY of all airway Management” – Richard Levitan, M.D.
A major determinant in failure of first pass intubation
attempts

9. Observational study of 906 consecutive patients
intubated with a video laryngoscope in an single-
center academic ICU between January 2012 and
January 2016.
Results: Top two determinants of first attempt failure
at tracheal intubation with video laryngoscopy were
presence of blood in the airway followed by airway
edema.

10. How frequently do contaminated
airways occur in resuscitation?
Prospective observational study of all OOHCA> 18 yo calendar year 2013

11. Introducing…SALAD
Suction
Assisted
Laryngoscopy
Airway
Decontamination
Let the Suction Catheter do the work of initial
laryngoscope entry and alignment with larynx.

12. Fundamental Points of SALAD
• Rigid suction catheter utilized to assist:
Laryngoscope blade insertion
Tongue control and readjustments (if needed)
Ongoing decontamination of fluids
• Avoid mistakes in emergency airway
management Poor tongue control
Insertion of laryngoscope in grossly
contaminated airway
Strategy for ongoing airway decontamination

13. Basic SALAD Demonstration from First-Person Camera
Vantage

14. The “Standard Equipment” since 1907:
The Yankauer Suction Catheter
• Yankauer (Created 110 years ago this year
2017!)
– Innovation of Sidney Yankauer, M.D.,
Otolaryngologist Mount Sinai Hospital, New York
City, circa 1907
• Intended for intraoral surgery
• Many design variations

15. • Intended to remove blood (liquid phase)
without removing the growing clot to speed
surgical hemostasis
– Small holes in tip prevent entraining tissue into
catheter
– Size of holes in tip vary substantially between
models and manufacturers

16. Conmed: The Big-Yank™ Suction System
1998, commercially available)7/ 1/ 17, 4:57 AMency Medical Products
U of M:
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performance and standar dization needs. When every second counts, the patented two-piece design allows you to conduct your standar d suction
or viscous matter .
or and tubing all pr e-attached. (Canister not included.) The unit also features a control vent for added functionality .
Cost: $ 16 USD Approx.

17. LS4™ Lipsky/Schultz Super Suction
System
Circa 2005.

18. Yankauer (1907)
Hi-D (1987)
S3 (2010)
DuCanto (2016)
Evolution of Rigid Suction Catheters

19. SSCOR Hi-D® (Available since 1987)
Features:
-Large internal diameter in tip (0.25 in/6.6 mm)
-Vent hole
-Shape compatible for use with standard direct
laryngoscopy blades
-Side ports at distal tip to prevent tissue
entrainment

20. DuCanto Suction Catheter
r designed for use during routine and em ergency
anagem ent. Uniquely suited for the SALAD technique.
R DuCanto Catheter is a new catheter that is unlike
Yankauer suction tips that are designed for controlled surgical
he SSCOR DuCanto Catheter was developed with both
d emergency airway management in mind. It has a larger
meter making it significantly less likely to clog and is shaped
opharyngeal anatomy. The hyper curved catheter is shaped
patient's airway making it easy to position the catheter and
other complementary devices used to clear a patient's airway.
t to general purpose rigid suction catheters based on the
design, this product is intended to serve as a simple and
ol to support routine and emergency airway management.”
uCanto, M.D.
y, the SSCOR DuCanto Catheter does not have a thumb port.
ng the vacuum control, the caregiver does not need to locate
heir thumb correctly positioned over the thumb port to clear a
rway and allows for continuous suction once connected to
source.
Request A Free QuoteRequest A Free Quote
Designed to fit the oropharyngeal anatomy.
Specifications:
Shaft diameter: .26” x .55” (6.6mm x 13.9mm)
Shaft length: 9.3” (236.22mm)
SSCOR Products Support & Services Com pany SSCOR Blog SSCOR SSPORTS! Shop SSCOR Products
3/SCOR DuCanto Catheter
6.6 mm Internal
diameter
SSCOR DuCanto Suction Catheter™
-Modified Hi-D with shape compatible for use with
both standard and hypercuved video laryngoscopes
-Vent hole removed

21. Learning & Practicing SALAD
• Modified airway
training mannequin
• Airway management
techniques taught in
the context of initial
and ongoing airway
decontamination

22. Simulation of Thick Liquid Airway Contamination

24. International partners in SALAD
Simulation and Practice

27. Is SALAD simulation
effective at teaching
airway decontamination
skills?

28. Go to:
Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted
Laryngoscopy Assisted Decontamination (SALAD) System
James DuCanto, MD, Karen D. Serrano, MD, and Ryan J. Thompson, MD
Aurora St. Luke’s Medical Center, Department of Anesthesiology, Milwaukee, Wisconsin
University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
University of Wisconsin, Department of Emergency Medicine, Madison, Wisconsin
Address for Correspondence: Ryan J. Thompson, MD, University of Wisconsin, Department of Emergency Medicine, 800 University Bay
Drive, Suite 310, Madison, WI 53705. Email: RThompson@medicine.wisc.edu.
Received 2016 May 15; Revised 2016 Aug 29; Accepted 2016 Sep 18.
Copyright : © 2017 DuCanto et al.
This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See:
http://creativecommons.org/licenses/by/4.0/
Abstract
Introduction
We present a novel airway simulation tool that recreates the dynamic challenges associated with
emergency airways. The Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD)
simulation system trains providers to use suction to manage emesis and bleeding complicating
intubation.
Methods
* † ‡
*
†
‡
irway Training Tool that Simulates Vomiting: Suction- Assist
West J Emerg Med. 2017 Jan; 18(1): 117–120.
Example of Likert Scale from the study:
I am confident in my ability to manage the airway of a
vomiting or hemorrhaging patient:
1 2 3 4 5
Not at all A little Somewhat Very Extremely
40 participants rated their knowledge and ability
regarding the management of contaminated airways
on a Likert Scale from 1 to 5 prior to the simulation
and following the simulation.

29. SALAD method for BLS
• SALAD Techniques applied to face mask
ventilation and extraglottic / supraglottic
airway use
• Can these techniques give us a safe solution to
continue face mask ventilation throughout the
traditionally apneic period of RSI?

31. In Conclusion….Future Aspirations of
SALAD Project (Joke Intentional)
• Circulate awareness of the SALAD Method and
simulation world-wide to improve Emergency
Airway Management
• Investigate the ability of Extraglottic devices to
divert fluid away from the larynx and trachea
• Reduce the potential for airway contamination
to cause failure to rescue in airway
management

32. Solve the Challenge of Solid Airway
Contaminant—A Challenging Clinical
Phenomena

33. Fish
Man almost diesafter Dover solejumpsdown histhroat
12 Oct 2017, 3:43pm
Man almost dies after
Dover sole jumps down his
throat
Register (https://secure.telegraph.co.uk/secure/regist
sole-jumps-throat-whole%2F)
Subscribe (http://www.telegraph.co.uk/subscriptions
(http://w w w.telegraph.co.uk /)
› News
News
"
Man almost diesafter Dov
By Helena Horton, October 13 2017

34. Fisherman Sam Qulliam (right, holding the fish he swallowed) almost died when a six-inch
Dover sole he had just caught jumped down his throat. He admitted today that he was kissing
it. He was saved by paramedic Matt Harrison (pictured with him today)

37. Links
• SALAD 2.0 https://vimeo.com/215727227
• General Description of system and demonstration by Jeff Hill of the University of
Cincinnati’s EM Program: http://www.tamingthesru.com/blog/airway/puke-with-
jim-ducanto-md
• Product page of SALAD Mannequin, Nasco:
https://www.enasco.com/product/LF03500UG
• University of Wisconsin HEMS Fellow with the “Static” Excercise
https://vimeo.com/128728558
• University of Wisconsin HEMS Fellow with the “Dynamic” Excercise
https://vimeo.com/128728463
• University of Wisconsin HEMS Attending takes on the SALAD Simulator
• https://vimeo.com/121892461
• System construction—how to build your own SALAD training system
• http://airwaynautics.com/category/intubation/