By Paul Mazurek
As a member of a fairly progressive air medical transport program, I am fortunate to have access to a number of very interesting tools utilized in airway management. I am afforded the opportunity to practice my skills in a variety of settings including the operating room, surgical skills lab and a simulation center. I have been exposed to various techniques and devices to assist with direct laryngoscopy, video laryngoscopy as well as devices deemed as “rescue airways.”
Being the type of person that I am, I tend to migrate to those devices that are the easiest to use or at least have the fewest moving parts. A tool of particular interest to me that falls in to this category is the S.A.L.T® (Supraglottic Airway Laryngopharyngeal Tube; ECOLAB, Columbus, MS). Whether or not it is going to change the landscape of airway management for the better has yet to be decided. All that can be offered at this point are anecdotal reports. This month’s column is no different.
My disclaimer
Before going any further, it is important to understand that I am not a paid sponsor nor have any financial interest in this product. My interest lies solely in the successful placement of a cuffed tube in to the trachea when required to do so in the performance of my job. It is therefore important that the device I use improves my chances for first pass success.
The tool and its uses
To my knowledge, very little literature exists surrounding the S.A.L.T. This airway device has been the subject of several “blogs” and forums. Opinions on its effectiveness has been mixed.
It is slightly heavier than a standard oral pharyngeal airway (OPA), has a hollow center, a blunt end and a subtle curve (less pronounced than the standard OPA). When properly inserted, the blunt end will occlude the esophagus and seat against the corniculate cartilage. At that point, the distal opening should be flush with the glottic opening.
The S.A.L.T. is designed for use by both basic (BLS) and advanced (ALS) providers. As a BLS device, it is inserted the same way that one would insert an OPA. As an ALS device, the hollow opening allows for endotracheal tube placement. It is FDA approved and retails for around $18.95.
Anecdotally speaking
While I definitely make all attempts to align my practice with current standards of care and evidence-based medicine, there is definitely something to be said for those individuals brave enough to report their individual successes and pitfalls with relation to equipment, procedures and techniques. Some of the most interesting articles that I have read were the “what worked best for me” type. Until the “jury is out” with respect to more definitive findings, all that I can offer is my personal experience (which is fairly interesting if I do say so myself).
As a program, we have only had the S.A.L.T in service for several months. Training consisted of manikin and simulator work. Initial response was quite positive. It was simple to use and worked quite well on a variety of manikins.
Survival Flight’s meager statistics include six attempts at tracheal intubation: four in the pre-hospital setting and two attempts inside the hospital. Of these attempts, five involved successful endotracheal tube placement. All six times the S.A.L.T was placed; clinicians reported improved patient oxygenation and chest rise with mask ventilation. Of the five successful attempts at intubation, four were placed in what we might call “textbook fashion” (i.e., according to manufacturers recommendations).
The most interesting insertion attempt was the first attempt. It involved a 74 year-old female passenger of a small sedan involved in a head-on collision at approximately 60 miles per hour. The patient had an altered level of consciousness, use of accessory muscles to breathe and profuse bleeding from her mouth and nose. Two prior attempts at tracheal tube placement via direct laryngoscopy had failed and the patient’s oxygen saturation had dropped in to the mid-60’s. Placement of the S.A.L.T. and subsequent mask ventilation resulted in recovery of oxygen saturation to the mid-90’s.
Initial intubation attempt was unsuccessful. The tracheal tube was pulled and a tracheal tube introducer (i.e. “bougie”) was placed through the S.A.L.T. Tracheal ring “clicking” was felt. The S.A.L.T. was removed and a standard 7.5 mm endotracheal tube was placed successfully over the tracheal tube introducer. While not within the manufacturer’s recommendations for tracheal tube placement, it worked in this instance on a patient with a grade IV Cormack-Lehane view and a grossly soiled airway.
One in-hospital placement involved an adolescent trauma with a suspected high cervical fracture. Placement of the S.A.L.T followed unsuccessful attempts at tracheal intubation via direct laryngoscopy, video laryngoscopy and attempts at fiber-optic endotracheal tube (ETT) placement. The S.A.L.T was easily placed and the patient manually ventilated which resulted in an immediate rise in oxygen saturations. A 7.0 ETT was easily placed in to the trachea and placement verified.
Conclusion
While still a fairly new device, the S.A.L.T. airway potentially shows promise. There have been mixed reviews on its effectiveness and capabilities. As with any blind-insertion device, it is not fool proof. Education and frequent practice is required. While there are no standardized troubleshooting maneuvers, more work and experience with the device will produce this. For more information on the device visit saltairway.com.
