# DuCanto’s SALAD



## VentMonkey (Sep 25, 2018)

I wanted to know if anyone’s agency out there practices either, or both, techniques.

If so, how do you like it/ them? What don’t you like about either item or technique? What do you find easiest? Are they truly as helpful as they appear to be.

I have a lot of respect for Jim DuCanto and folks like him. IMO, he’s attempting to help revolutionize the prehospital airway management playing field for the _astute_ providers.

I really want to pitch both techniques to my program and I’m looking for some feedback, thanks.


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## DesertMedic66 (Sep 25, 2018)

The SALAD technique is utilized by Air Methods for all of their new hire training/orientation. They use the DuCanto cath and have a SALAD manikin.


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## NomadicMedic (Sep 25, 2018)

I made a salad manikin and we teach/use it, along with DuCanto caths.


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## VFlutter (Sep 25, 2018)

Like said it is an Air Methods standard so we use the SALAD technique and DuCanto catheter. The DuCanto catheter is awesome and I think better than similar large bore yaunkers like the BigStick. The SALAD technique is very useful and has saved me a few times.

I usually lead with my suction and follow with my camera until i identify if there is vomit/blood then suction and pull out or bury the suction to the left. If they do not need continuous suction then I just pull the yaunker. With the DuCanto it can be a lot of stuff in the mouth, especially smaller people and kids, and hard to pass your tube.

The ability to intubate with the DuCanto, pass a bougie, and then tube is amazing and for great those traumatic airways when you can suction just enough to get a brief glimpse of the cords.

DuCanto, Pocket Bougie, and C-Mac makes me a very confident intubator in almost any situation.


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## StCEMT (Sep 25, 2018)

Honestly, we dont practice any method. A bougie is required and that's the extent of it. I am going to try to put some various airway stuff together to see if we can't update our intubation SOG a bit.

I have had one airway this happened on this year right as I had VL and ETT in hand. Fortunately it was watery and not chunky, but I like the idea of having the tools to use DuCanto's method as a more flexible approach.


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## VentMonkey (Sep 25, 2018)

NomadicMedic said:


> I made a salad manikin and we teach/use it, along with DuCanto caths.


I’d love to build a “vomikin”.

I think I’m to the point where I don’t think things such as the SALAD technique, DuCanto’s catheter, bougies, and the like should be optional for any prehospital advanced airway manager.

Anyone who disagrees should stick to routine blind airway placement. They have no business performing endotracheal intubation.


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## NomadicMedic (Sep 25, 2018)

VentMonkey said:


> I’d love to build a “vomikin”.
> 
> I think I’m to the point where I don’t think things such as the SALAD technique, DuCanto’s catheter, bougies, and the like should be optional for any prehospital advanced airway manager.
> 
> Anyone who disagrees should stick to routine blind airway placement. They have no business performing endotracheal intubation.




I found a cheap, used airway manikin and then I started messin' about with hoses and pumps.  I'll post some pics when I get back from a couple of days off.


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## Carlos Danger (Sep 25, 2018)

I think the suction catheter looks cool, definitely an improvement. 

But as far the "SALAD technique", I don't know……I was taught to replace the Yankauer with an ETT and shove it in the esophagus during heavy vomiting many years ago, so it isn't really a new idea. 

And just like always using a bougie, I'm not sure leading with the suction for every intubation is necessarily a good idea. You don't need a bougie or suction in the vast majority of intubations, so it just seems like we are adding extra steps to something that instead we should be trying to simplify.


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## VFlutter (Sep 25, 2018)

Remi said:


> And just like always using a bougie, I'm not sure leading with the suction for every intubation is necessarily a good idea. You don't need a bougie or suction in the vast majority of intubations, so it just seems like we are adding extra steps to something that instead we should be trying to simplify.



Agree to a certain extent however personally I train for the worst possible scenario, Anatomically difficult airway with massive airway contaminate, and develop that muscle memory. It is easy enough to ditch the suction or not use the bougie for basic intubations but i rather be comfortable using all of the above when i truly need it.


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## NPO (Sep 26, 2018)

I pitched the DuCanto catheter to my department last month and they agreed to make the switch. The guy heading up our clinical department was aware of the SALAD technique, but not very familiar with it. After we had all agreed to switch to the new catheters we decided to roll them out and do a SALAD training all at once during our 1st Quarter in-service. I am going to build a vomikin for the training.

I may even suggest the Bougie-to-Go and make it a two-fer to try and increase the willingness of people to use the bougie. I think some of the negative stigma still applies.


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## NomadicMedic (Sep 26, 2018)

Remi said:


> I think the suction catheter looks cool, definitely an improvement.
> 
> But as far the "SALAD technique", I don't know……I was taught to replace the Yankauer with an ETT and shove it in the esophagus during heavy vomiting many years ago, so it isn't really a new idea.
> 
> And just like always using a bougie, I'm not sure leading with the suction for every intubation is necessarily a good idea. You don't need a bougie or suction in the vast majority of intubations, so it just seems like we are adding extra steps to something that instead we should be trying to simplify.



I think teaching a solid technique that can be used in a stepwise fashion makes sense. I see too many providers revert back to old/bad habits as soon as things start to go sideways. Why not teach to always lead with suction and always use a Bougie? For occasional intubators, it makes sense to stack the deck in their favor.


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## Carlos Danger (Sep 26, 2018)

NomadicMedic said:


> I think teaching a solid technique that can be used in a stepwise fashion makes sense. I see too many providers revert back to old/bad habits as soon as things start to go sideways. *Why not teach to always lead with suction and always use a Bougie?* For occasional intubators, it makes sense to stack the deck in their favor.



I agree that we should try to stack the deck in favor of the occasional intubator, which is exactly why I don't support the idea of adding extra, unnecessary steps to the procedure. By using a bougie and suction on every intubation, you are literally requiring tools and steps that are not necessary the large majority of the time. How is that helpful?

Here's the thing: Among new or occasional intubators, the large majority of difficulty with intubation comes from not properly recognizing or visualizing the anatomy. Another common difficulty is in visualizing the glottis but not being able to pass the ETT. Both of these problems can be mitigated by using good progressive laryngoscopic technique along with external laryngeal manipulation. Because the problem of anatomic visualization (getting a view of the glottis) is a far more common one than massive airway contamination, I think the best use of your right hand is ELM, rather than suctioning a pharynx that has nothing in it to suction.

As far as the bougie: Even though I don't share the opinion, I can definitely see why so many people think using a bougie on every tube is a good idea. A bougie does, objectively, make many intubations easier. How can that be a bad thing? For two reasons: First, it *usually* simply isn't necessary, so it adds an unnecessary step. Second: Again, the large majority of difficulty with intubation comes from not properly recognizing or visualizing the anatomy. This is usually a technique problem, which should be addressed rather than covered up with another tool. The bougie does indeed make proper airway instrumentation and axis manipulation less important, which is a good thing if you are legitimately having trouble with an airway. It might not be the best thing though, if you are trying to improve your laryngoscopy technique. Requiring new intubators to use the bougie on every intubation because some intubations are difficult is like requiring someone learning IV's to use a vein finder or ultrasound on every IV start, because some IV starts are difficult.

IMO, prehospital airway management training and protocols should focus on preparation, solid, basic technique (positioning, progressive laryngoscopy, ELM), and quick, smooth transition to use of a bougie or suction when necessary. I also advocate for NOT using a stylet in the ETT.


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## CANMAN (Sep 26, 2018)

Remi said:


> I agree that we should try to stack the deck in favor of the occasional intubator, which is exactly why I don't support the idea of adding extra, unnecessary steps to the procedure. By using a bougie and suction on every intubation, you are literally requiring tools and steps that are not necessary the large majority of the time. How is that helpful?
> 
> Here's the thing: Among new or occasional intubators, the large majority of difficulty with intubation comes from not properly recognizing or visualizing the anatomy. Another common difficulty is in visualizing the glottis but not being able to pass the ETT. Both of these problems can be mitigated by using good progressive laryngoscopic technique along with external laryngeal manipulation. Because the problem of anatomic visualization (getting a view of the glottis) is a far more common one than massive airway contamination, I think the best use of your right hand is ELM, rather than suctioning a pharynx that has nothing in it to suction.
> 
> ...



Agree with both posts 110%. We actually focus on teaching these exact things in the cadaver lab for the CCEMT-P program I instruct for. I think now a days there are too many people coming up with a "new technique" or something fancy to rework a procedure, and a lot of people who already may struggle doing the basics well now feel like they have to implement this "cool" stuff. You guys must be seeing some really nasty stuff on the regular, because I can't remember the last time in my flight career, time in the trauma bay, or frankly the last EMS call at my ground part-time job where I wasn't able to control the airway, and/or intubate with just standard equipment, preparation, and technique. I think everything mentioned in Remi's post will do far more for people's airway management skills they trying to pull off something fancy in an already bad situation. We see some pretty nasty airways in the trauma center I have to rotate in, and every single person ends up getting an airway without SALAD or these DuCanto's. While I think they appear to be a better device and pull more volume, we just don't have them and things go down just fine when needed and performed by experienced airway managers.


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## Tigger (Sep 27, 2018)

https://emcrit.org/emcrit/failed-airway-algorithm-2018/

Food for thought at least.

For me, I use the bougie every time. I don't get enough tubes to get particularly comfortable with any method, so the idea of having a "backup" plan does not make sense to me as I will no doubt be less comfortable with that procedure in the event it is needed. So, I work a single procedure that will get safely and efficiently allow me to intubate nearly all of the time. If that makes things somewhat more complicated and overkill, I am ok with that. I simply do not get the reps in on difficult airways to have a separate difficult airway procedure. Apparently Weingart calls that "single skill mastery" in the above, who knew. I treat every intubation like it is going to be super hard, and yes, sometimes it is annoying to have railroad a tube over a bougie when I have a grade 4 view. If the hands are available, I just have someone give me the tube and I place it. 

As for the Ducanto, it is awesome. It really is. Getting chunky vomit out is a pain and the Ducanto does make it easier. I trained to connect a 9.0 tube to suction at one point for this reason, turns out using the Ducanto is much more elegant. As for the SALAD technique, it does work but I would struggle to call it easy or as effective as it looks. I find keeping it in the esophagus is very difficult while intubating, it has a tendency to slip out. Never mind if chest compressions are occurring, you need someone to hold it in their for you, which the ELM person can certainly do.


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## VFlutter (Sep 27, 2018)

CANMAN said:


> I can't remember the last time in my flight career, time in the trauma bay, or frankly the last EMS call at my ground part-time job where I wasn't able to control the airway, and/or intubate with just standard equipment, preparation, and technique. I think everything mentioned in Remi's post will do far more for people's airway management skills they trying to pull off something fancy in an already bad situation



In my short HEMS career I have seen my fair share of massive hemoptysis, La Forte fractures w/ significant bleeding, pediatric airways, self inflicted GSW through the mouth, etc that I believe would have been significantly harder or failed with standard techniques. Personally, it works for me and I have the first pass success / lack of complications that support it. To each their own.


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## Carlos Danger (Sep 27, 2018)

VFlutter said:


> In my short HEMS career I have seen my fair share of massive hemoptysis, La Forte fractures w/ significant bleeding, pediatric airways, self inflicted GSW through the mouth, etc that I believe would have been significantly harder or failed with standard techniques. Personally, it works for me and I have the first pass success / lack of complications that support it. To each their own.



No one is saying that you’ll never run into a fluid-filled airway. Just that it makes no sense to suction a dry airway, especially when it prevents the use of other helpful techniques (ELM).


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## NPO (Sep 27, 2018)

I think the point is just to have the technique in your belt. There's no need to SALAD every airway, but having all of our equitpment at hand and ready, and making the decision to SALAD or intubate with your first look is beneficial.





Remi said:


> No one is saying that you’ll never run into a fluid-filled airway. Just that it makes no sense to suction a dry airway, especially when it prevents the use of other helpful techniques (ELM).


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## Carlos Danger (Sep 27, 2018)

NPO said:


> I think the point is just to have the technique in your belt. There's no need to SALAD every airway, but having all of our equitpment at hand and ready, and making the decision to SALAD or intubate with your first look is beneficial.


I don’t think that’s what they teach, though. Many folks are saying they lead with the suction on every intubation. It’s the dumbest thing I’ve ever heard of.


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## NPO (Sep 27, 2018)

That won't be how we teach it at my agency. More as a tool of needed type of thing. 





Remi said:


> I don’t think that’s what they teach, though. Many folks are saying they lead with the suction on every intubation. It’s the dumbest thing I’ve ever heard of.


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## CANMAN (Sep 28, 2018)

VFlutter said:


> In my short HEMS career I have seen my fair share of massive hemoptysis, La Forte fractures w/ significant bleeding, pediatric airways, self inflicted GSW through the mouth, etc that I believe would have been significantly harder or failed with standard techniques. Personally, it works for me and I have the first pass success / lack of complications that support it. To each their own.



 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.....


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## VFlutter (Sep 28, 2018)

CANMAN said:


> 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.


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## Carlos Danger (Sep 28, 2018)

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 %.


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## CANMAN (Sep 28, 2018)

Remi said:


> 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.
> 
> ...



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.


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## Carlos Danger (Sep 28, 2018)

CANMAN said:


> 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.


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## Peak (Sep 28, 2018)

@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.


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## VentMonkey (Sep 29, 2018)

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.


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## Tigger (Sep 29, 2018)

Remi said:


> 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.


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## Carlos Danger (Oct 1, 2018)

Tigger said:


> 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.


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## VentMonkey (Oct 1, 2018)

@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


Remi said:


> 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?


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## Tigger (Oct 1, 2018)

Remi said:


> 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.


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## CANMAN (Oct 2, 2018)

VentMonkey said:


> @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.
> ...



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)


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## Carlos Danger (Oct 2, 2018)

VentMonkey said:


> @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.
> ...



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.


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## VentMonkey (Oct 5, 2018)

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.


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## NPO (Jan 22, 2019)

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


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## RocketMedic (Jan 23, 2019)

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.


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## NPO (Jan 23, 2019)

RocketMedic said:


> 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.


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## NomadicMedic (Jan 25, 2019)

NPO said:


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



Shots fired.


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