When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?

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Volume 31, Issue 1, January 2018, Pages 3-9

https://doi.org/10.1016/j.aucc.2017.02.069Get rights and content

The Cochrane Library, PROSPERO, the National Health Service Centre for Reviews and Dissemination, PubMed and Cumulative Index to Nursing and Allied Health (CINAHL) databases were systematically searched. Subject headings included “suctioning, endotracheal”, “suction”, “sodium chloride”, “normal saline” and “paediatrics”. Additional references were sourced from hand searches of journal article reference lists and Google Scholar.

An integrative, systematic approach was used to qualitatively synthesise study results in the context of paediatric intensive care nursing practice. Data were extracted using a standardised data extraction form. Quality assessment was performed independently by two reviewers.

Three studies met pre-defined inclusion criteria. Quality of all study methods was 75% on the Mixed Method Appraisal Tool, although reporting quality varied. Overall, there was a scarcity of high quality evidence examining NSI and paediatric endotracheal suction. Outcome measures included oxygen saturation (SpO2), serious adverse events (author/s defined) and ventilation parameters (author/s defined). Endotracheal suction with NSI was associated with a transient decrease in blood oxygen saturation; research protocols did not include interventions to mitigate alveolar derecruitment. Studies were not powered to detect differences in endotracheal tube (ETT) occlusion or ventilator associated pneumonia (VAP).

NSI was associated with a transient decrease in oxygen saturation. In children with obstructive mucous, NSI may have a positive effect. Practices which maximise secretion removal and mitigate the negative physiological interactions of ETS have been poorly evaluated in the paediatric population. High quality, powered, clinical trials are needed to determine the safety and efficacy of normal saline instillation and to inform clinical practice.

Each year 50% of children (<18years) admitted to Australian and New Zealand intensive care units require intubation and mechanical ventilation.1, 2 Placement of the endotracheal tube (ETT), to facilitate mechanical ventilation impairs mucociliary clearance.3 In combination with humidification of inspired gas, endotracheal suction (ETS) is a key secretion management technique in the paediatric intensive care unit (PICU).4 Performed to maintain airway patency and prevent retained respiratory secretions,5 ETS is not without complications. The adverse clinical effects of ETS may include hypoxia and atelectasis due to pulmonary derecruitment; hypotension related to increased intrathoracic pressure and reduced cardiac output; and bradycardia associated with vagal nerve stimulation.6, 7, 8

The effectiveness of ETS is impacted upon by the hydration of the airway mucous. If there is insufficient humidification of ventilator gas or obstructive mucous plugs the efficacy of ETS is reduced.9 Normal saline instillation (NSI) with paediatric ETS is a long standing nursing intervention which has been practised for more than two decades.10, 11, 12 NSI as an intervention is postulated to have several effects including: hydrating and mobilising airway secretions, stimulating the cough response and lubricating the suction catheter.13, 14 NSI is thought to enhance the removal of mucous plugs and reduce surface tension in the distal airways.10, 15 However, the majority of these claims are untested and effect of NSI on secretion rheology and airway mucosa is not clearly articulated in the literature.

In general, the prevalence of NSI use as an intervention with ETS in the PICU is largely unknown. Data obtained from a 1996 cross-sectional survey found more than 96% of PICU nurses used NSI as an intervention with ETS.10 However, current usage rates are not published. Newer research has found NSI usage to be significantly associated with open suction when compared with closed suction (1397 vs 572, p < 0.01).5 However given open suction is associated with improved secretion clearance,16 and thick

Due to the lack of randomised clinical trials (RCT) and the variability of study design an integrative approach was used to qualitatively synthesise research findings. The integrative method allows for the combination of diverse study methodologies, providing a comprehensive review of the topic as it pertains to clinical practice. The format for the review was based on Whittemore and Knafl’s23 five stage integrative review process of: problem identification, literature search, data evaluation,

Fig. 1 outlines the flow of articles included in the review in accordance with thePreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.29 The systematic search yielded 551 citations. The potential relevance of each citation was examined, and 501 citations were excluded as irrelevant. The full papers of the remaining 50 citations were assessed to select articles directly concerned with NSI and paediatric ETS. Three articles were included and 47 articles were

This integrative review is the first to synthesise research findings on the topic of NSI intervention with paediatric ETS. Despite only three studies meeting the review’s inclusion criteria, the findings of the review capture the current state of knowledge and identifies gaps in the evidence. Oxygenation and SAE were the primary outcomes of included studies.

Our findings can be examined through an evidence based practice lens. In the PICU, nurses base clinical decisions on knowledge, experience and evidence.42 However, the current lack of evidence has contributed to PICU nurses making NSI and ETS decisions in a vacuum of evidence. To date, researchers investigating paediatric ETS and NSI have predominately applied prospective observational or descriptive methods due to the challenges associated with the design and execution of a RCT within the PICU.

Research findings regarding the efficacy and safety of NSI during ETS in the PICU were synthesised. We found that NSI as an intervention was associated with a transient desaturation event. However evidence concerning the efficacy of NSI is inconsistent and limited by age or methodological problem. To progress knowledge regarding the benefits and risks of NSI with paediatric ETS, we propose an adequately powered RCT needs to be undertaken to provide definitive information on the safety and

Review design: JO, MM, MC; data collection and analysis: JO, MM and manuscript preparation: JO, MM, MC, AS.

To answer the Continuing Professional Development Questions – go to page 10 http://dx.doi.org/10.1016/S1036-7314(17)30515-5

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American Association for Respiratory Care

Endotracheal suction is one of the most common and harmful procuedres performed on mechanically ventilated children. The aim of the study was to establish the feasibility of a randomised controlled trial (RCT) examining the effectiveness of normal saline instillation (NSI) and a positive end-expiratory pressure recruitment manoeuvre (RM) with endotracheal suction in the paediatric intensive care unit.
Pilot 2 × 2 factorial RCT.
The study was conducted at a 36-bed tertiary paediatric intensive care unit in Australia.
Fifty-eight children aged less than 16 years undergoing tracheal intubation and invasive mechanical ventilation.
(i) NSI or no NSI and (ii) RM or no RM with endotracheal suction . The primary outcome was feasibility; secondary outcomes were ventilator-associated pneumonia (VAP), change in end-expiratory lung volume assessed by electrical impedance tomography, dynamic compliance, and oxygen saturation-to-fraction of inspired oxygen (SpO2/FiO2) ratio.
Recruitment, retention, and missing data feasibility criteria were achieved. Eligibility and protocol adherence criteria were not achieved, with 818 patients eligible and 58 enrolled; cardiac surgery was the primary reason for exclusion. Approximately 30% of patients had at least one episode of nonadherence. Children who received NSI had a reduced incidence of VAP; however, this did not reach statistical significance (incidence rate ratio = 0.12, 95% confidence interval = 0.01–1.10; p = 0.06). NSI was associated with a significantly reduced SpO2/FiO2 ratio up to 10 min after suction. RMs were not associated with a reduced VAP incidence (incidence rate ratio = 0.31, 95% confidence interval = 0.05–1.88), but did significantly improve end-expiratory lung volume at 2 and 5 min after suction, dynamic compliance, and SpO2/FiO2 ratio.
RMs provided short-term improvements in end-expiratory lung volume and oxygenation. NSI with suction led to a reduced incidence of VAP; however, a definitive RCT is needed to test statistical differences. A RCT of study interventions is worthwhile and may be feasible with protocol modifications including the widening of participant eligibility.
Endotracheal suction is an invasive airway clearance technique used in mechanically ventilated children. This article outlines the methods used to develop appropriate use criteria for endotracheal suction interventions in mechanically ventilated paediatric patients.
The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop paediatric appropriate use criteria. This included the following sequential phases of defining scope and key terms, a literature review and synthesis, expert multidisciplinary panel selection, case scenario development, and appropriateness ratings by an interdisciplinary expert panel over two rounds. The panel comprised experts in the fields of paediatric and neonatal intensive care, respiratory medicine, infectious diseases, critical care nursing, implementation science, retrieval medicine, and education. Case scenarios were developed iteratively by interdisciplinary experts and derived from common applications or anticipated intervention uses, as well as from current clinical practice guidelines and results of studies examining interventions efficacy and safety. Scenarios were rated on a scale of 1 (harm outweighs benefit) to 9 (benefit outweighs harm), to define appropriate use (median: 7 to 9), uncertain use (median: 4 to 6), and inappropriate use (median: 1 to 3) of endotracheal suction interventions. Scenarios were than classified as a level of appropriateness.
The RAND Corporation/University of California, Los Angeles Appropriateness Method provides a thorough and transparent method to inform development of the first appropriate use criteria for endotracheal suction interventions in paediatric patients.
Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria for endotracheal suction interventions used in paediatric populations.
The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and two rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results, and expert consultation.
Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely presuction and postsuction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the subspecialty population ‘patients with highly infectious respiratory disease’. Routine application of 0.9% saline for nonrespiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances.
Appropriate use criteria for endotracheal suction in the paediatric intensive care have the potential to impact clinical decision-making, reduce practice variability, and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.
The objective of this study was to review and critically appraise the evidence for paediatric endotracheal suction interventions.
A systematic search for studies was undertaken in the electronic databases CENTRAL, Medline, EMBASE, and EBSCO CINAHL from 2003.
Included studies assessed suction interventions in children (≤18 ys old) receiving mechanical ventilation. The primary outcome was defined a priori as duration of mechanical ventilation. Secondary outcomes included adverse events and measures of gas exchange and lung mechanics.
Data extraction were performed independently by two reviewers. Study methodological quality was assessed using Cochrane's risk of bias tool for randomised trials or the Newcastle–Ottawa Scale for observational studies. Overall assessment of the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations criteria.
Overall 17 studies involving 1618 children and more than 21,834 suction episodes were included in the review. The most common intervention theme was suction system (five studies; 29%). All included trials were at unclear or high risk of performance bias due to the inability to blind interventionists. Current evidence suggests that closed suction may maintain arterial saturations, normal saline leads to significant transient desaturation, and lung recruitment applied after suction offers short-term oxygenation benefit.
Lack of randomised controlled trials, inconsistencies in populations and interventions across studies, and imprecision and risk of bias in included studies precluded data pooling to provide an estimate of interventions effect.
Based on the results of this integrative review, there is insufficient high-quality evidence to guide practice around suction interventions in mechanically ventilated children.
The objective of this study was to determine the incidence of endotracheal tube (ETT) suction–related adverse events (AEs) and to examine associations between AEs and patient and suction characteristics. Secondary objectives were to describe ETT suction practices in an Australian paediatric intensive care unit (PICU).
A prospective, observational study was undertaken in a mixed cardiac and general PICU. Children were eligible for inclusion if they were intubated and mechanically ventilated. Data on patient and suction variables (indication for ETT suction, number of suction episodes per mechanical ventilation episode, indication for normal saline instillation [NSI] and NSI dose) including potential predictive variables (age, Paediatric Index of Mortality 3 [PIM3], NSI, positive end-expiratory pressure, and hyperoxygenation) were collected. The main outcome variable was a composite measure of any AE.
A total of 955 suction episodes were recorded in 100 children. AEs occurred in 211 (22%) ETT suctions. Suction-related AEs were not associated with age, diagnostic category, or index of mortality score. Desaturation was the most common AE (180 suctions; 19%), with 69% of desaturation events requiring clinician intervention. Univariate logistic regression showed the odds of desaturation decreased as the internal diameter of the ETT increased (odds ratio [OR]: 0.59; 95% confidence interval [CI]: 0.37–0.95; p = 0.028). Multivariable modelling revealed NSI was significantly associated with an increased risk of desaturation (adjusted OR [aOR]: 3.23; 95% CI: 1.99–5.40; p < 0.001) and the occurrence of an AE (aOR: 2.76; 95% CI: 1.74–4.37; p < 0.001). Presuction increases in fraction of inspired oxygen (FiO2) was significantly associated with an increased risk of experiencing an AE (aOR: 2.0; 95% CI: 1.27–3.15; p = 0.003).
ETT suction–related AEs are common and associated with NSI and the requirement for pre-suction increases in FiO2. Clinical trial data are needed to identify high-risk patient groups and to develop interventions which optimise practice and reduce the occurrence of ETT suction–related AEs.

View all citing articles on Scopus

Endotracheal suctioning is a common procedure performed by intensive care nurses in order to establish and maintain gas exchange, adequate oxygenation and alveolar ventilation in critically ill patients under mechanical ventilation. As this procedure is associated with several complications and risks nurses should have an adequate knowledge on how to perform the procedure according to the evidence-based practice. Previously only a few studies have analysed nurses’ knowledge of the guidelines on endotracheal suctioning.
To evaluate the knowledge of the American Association of Respiratory Care (AARC, 2010) evidence-based guidelines on the endotracheal suctioning technique by Italian intensive care nurses in different hospitals.
An anonymous questionnaire based on previous studies was sent to a selected sample composed of the intensive care unit (ICU) nurses of 16 ICUs in 11 Italian hospitals.
The questionnaire was sent to 379 nurses, with 65% of questionnaires returned completed. The total percentage of correct answers was 58%, and nobody completed the questionnaire without mistakes. Moreover, only 2.5% (n = 6) of the nurses gave 9/10 correct answers. Correct answers were more common amongst the more experienced ICU nurses.
Italian ICU nurses’ knowledge of guidelines on endotracheal suctioning was not complete; however, experienced nurses demonstrated a better knowledge of the subject.
This study aimed to adapt a guideline for endotracheal suctioning of adults with artificial airways in the perianesthesia setting in China.
This study was guided by the ADAPTE framework.
The development process consisted of setup, adaptation, and finalization phases. A heterogeneous consultant panel that included a patient representative was established to contribute guidance and suggestions regarding guideline development. Relevant evidence documents were searched, critically appraised, selected, and synthesized to develop the draft guideline. After revisions, the adapted guideline was evaluated by 20 external reviewers.
A 155-page adapted guideline was developed with 26 key recommendations (including 3 procedure phases and 17 points of care).
The adapted guideline provided the best evidence for endotracheal suctioning of adults with artificial airways and supported practitioner decisions about appropriate endotracheal suctioning practices for this population. The study also lays the groundwork for future projects on quality improvement and knowledge translation.
This experimental study was conducted to compare the effects of open and closed suctioning systems on pain in newborns receiving ventilation support. The study sample consisted of 42 babies (23 female, 16 male) hospitalized in the unit between December 2010 and December 2011 who met the selection criteria established for the study. Using the random sampling method, 20 of the babies were included in the closed suctioning system group and the remaining 22 were analyzed in the open suctioning system group. The data collection tools of the study were intervention monitoring form, data collection form, and documentation of the personal information on the babies; and the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) evaluated the babies' pain responses. The data were evaluated using SPSS 15 software. Most neonates were born preterm (≤37 weeks' gestation at birth; 69% [n = 29]). The mean (SD) birth weight, gestational age, and intensive care unit stay were 1.82 kg (1.1 kg), 31.9 (5.3) weeks, and 25.3 (2.9) calendar days, respectively. Results of the study revealed no statistically significant difference between the open suctioning and closed suctioning groups (p = .194). However, the N-PASS pain scores obtained before and during the suctioning processes were significantly different (p < .001). In conclusion, babies seem to experience pain during the suctioning process, according to N-PASS scores, and although not significant statistically, the level of pain felt during open suctioning was observed to be slightly higher compared with closed suctioning.
To compare closed and open endotracheal suction system in relation to ventilator-associated pneumonia in adult intensive care unit patients
Systematic review.
Of the 18 eligible studies identified through the search strategy, only 5 studies were included in the review. The two endotracheal suction systems show no differences in the incidence of ventilator-associated pneumonia (5 trials: odds ratio [OR], 0.92; Mantel-Haenszel [M-H], fixed; 95% confidence interval [95%CI], 0.72-1.18) or mortality rates (3 trials: OR, 0.89; M-H, fixed; 95%CI, 0.62-1.28).
Results from 5 studies showed that suctioning with either closed or open endotra-cheal suction did not have an effect on the incidence of ventilator-associated-pneumonia or mortality rates. Therefore, more rigorous and large-scale research is needed for further evaluation.