The SALAD technique is performed once the patient has been adequately sedated and paralyzed if necessary. Pre-oxygenation and standard intubation preparation are performed. Proactive suctioning of the airway is at the heart of this maneuver, utilizing a rigid suction catheter to decontaminate the airway of blood, fluid, or emesis prior to full insertion of the laryngoscope blade into the laryngopharynx. The suction catheter is left at the esophageal inlet, preventing aspiration of gastric contents, or in this patient’s case, nasopharyngeal blood. The laryngoscope is slowly inserted, preventing fogging or collection of fluid on the camera if utilizing a video approach to intubation. At this point, if there are continued fluid collections in the laryngopharynx, a second suction catheter can be utilized prior to attempting passage of the endotracheal tube. Once adequate secretions have been alleviated from the area, passage of the endotracheal tube can be done. Once the endotracheal tube has been secured, consistent suctioning must be ensured until the fluid collections have been controlled.

There are certain considerations that must be taken into account when utilizing the SALAD technique. Firstly, the physician should be proficient in this maneuver to avoid impeding the view of the vocal cords with the rigid suction device. Secondly, especially with significant hemorrhaging into the airway, monitoring of the volume of suctioned contents should be done. As in this case, 400 mL of blood had been suctioned in less than two minutes. Adequate replacement of blood products should be considered when massive hemorrhaging such as this occurs. Lastly, active suctioning for the entirety of an intubation attempt may lead to increased risk of hypoxemia. 10 Direct laryngoscopy is the preferred method of intubation when there is a large amount of fluid collected in the airway. Video laryngoscopy can be performed; however, there is a significant risk that the camera may become obstructed with the laryngopharyngeal contents, preventing an adequate view of the vocal cords. An additional operator should be present at the airway for any intubation deemed to be difficult, notably when using the SALAD technique.

The SALAD maneuver is an efficient approach to the airway where contamination with blood, secretions or emesis is suspected. With increasing literature favoring the use of this technique in the aforementioned circumstances, consideration of SALAD to secure the airway in high-aspiration-risk scenarios should be applied.

Dr. Glauser is professor of emergency medicine at Case Western Reserve University at MetroHealth Cleveland Clinic in Cleveland, Ohio.