Does running the suction for the whole laryngoscopy pull oxygen out of the patient faster than suctioning only when needed? One pilot trial asked. Its answer is narrower than the headlines.
The question came from a practice shift. Suction-assisted laryngoscopy (SALAD) and large-bore rigid catheters have made continuous suction during intubation common. Deep tracheal suctioning in already-intubated patients is known to drop saturations, and nobody had tested whether hypopharyngeal suction during RSI does the same.
When the median fall in both arms is zero, the trial had almost no events to compare. That is a floor effect. It can show that continuous suction did not cause desaturation in patients who were never going to desaturate. It cannot show what happens in the patient with a shunt, a low reserve, or a contaminated airway.
Who was missing. Enrollment was a convenience sample that depended on a research assistant being present. The crash intubations, done before anyone could enroll them, are the patients most likely to desaturate and least likely to be in the data.
Which catheter. Only about a quarter of intubations used a large-bore catheter such as the DuCanto. The device that made continuous suction a standard technique is the one least represented.
Absence of a difference in a pilot study is not evidence of equivalence. The authors say as much in their own conclusion.
Suction what needs suctioning. A soiled airway costs first-pass success and drives aspiration, and this trial gives no reason to hold back. What it does not license is suction running in the hypopharynx of a clean airway because it might help.
Keep the tip above the cords. The desaturation literature is about suction inside the airway. During laryngoscopy, the catheter clears the hypopharynx and stays out of the trachea.
The rest of the oxygenation plan still decides the outcome. Head-up positioning, full preoxygenation, apneic oxygenation, and a defined desaturation threshold for abandoning the attempt are unchanged by this study.
One small, unblinded pilot with a primary outcome that rarely occurred. It is a reasonable basis for not changing practice in either direction, and a weak basis for a rule.