Woman in respiratory distress.

PATIENT PRESENTATION

A 56‐year‐old woman in acute respiratory distress was transferred to our emergency department (ED) from outpatient radiology with a presumed allergic reaction to the iodinated contrast just administered. Physical examination was notable for a tachypneic, obese female in severe respiratory distress. Lung examination was limited due to her habitus. She had only mild lower extremity edema, with no oropharyngeal airway swelling appreciated. B‐type natriuretic peptide (BNP) was only mildly elevated at 218 pg/mL.

During rapid sequence intubation, laryngoscopy (Figure 1, Video 1) was complicated by copious watery secretions obscuring airway visualization that would re‐accumulate soon after suction catheter removal. Suction‐assisted laryngoscopy was then performed (Figure 2, Video 1), with adequate visualization of the vocal cords and subsequently successful intubation with the suction catheter left in place in the esophagus.

FIGURE 1

Epiglottis (arrow) with copious pulmonary secretions (asterisk) obscuring vocal cord visualization

FIGURE 2

Suction catheter inserted into proximal esophagus (asterisk), with clearance of the continued secretions allowing for airway visualization (arrowhead)

DIAGNOSIS

Flash pulmonary edema requiring suction‐assisted laryngoscopy airway decontamination (SALAD)

Direct visualization of pulmonary secretions during intubation can be a useful diagnostic tool pointing toward pulmonary edema as the cause of undifferentiated acute respiratory failure. Laboratory findings, such as BNP elevation, can take up to 1 hour to become abnormal, , and chest radiography has been shown to have only moderate sensitivity for congestive heart failure.

The SALAD technique is a method of inserting a rigid suction catheter into the proximal esophagus to serve as a form of continual drainage, with the suction catheter moved to the left corner of the patient's mouth, held in place by the laryngoscope blade. Although traditionally described as a method to clear profuse esophageal secretions or emesis, here, it helped to clear pooling tracheal secretions.

VIDEO S1. Video laryngoscopy demonstrating continual clearance of airway secretions with suction catheter left in esophagus and successful bougie catheter placement

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