Saturasi Oksigen & Sekresi Berat Setelah ETT Suction

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Oxygen saturation and secretionweight after endotracheal suctioningKonstantinos Giakoumidakis, Zoi Kostaki, Evridiki PatelarouGeorge Baltopoulos and Hero Brokalak

AbstractEndotracheal suctioning is a common aspect of nursing care to mechanically-ventilated p atients. The aim of this study was to investigate the effects o f tw osuctioning techniques on oxygen saturation (SaO^) and the amount of drainedsecretions. A quasi-experim ental study of 103 mechanically-ventilated patientswas conduct ed from tw o tertiary hospitals in Greece. Two suctioning techniqueswere applied to each patient: with normal saline instillation and without. Normalsaline instillation was associated w ith increased secretions' weight (p


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Endotracheal suctionine is used to maintain m echanicau y-ventilated patients' airway for optimal uentilation and oxygnation

drained weights of secretion (Bostick andWendelgass, 1987; Ackerman and Gugerty,1990; Gray et al, 1990). However, the clinicalsignificance of this finding was unclear becausethe weight increase could be attributed toretrieval of instilled saline and not mucus.Contrary to these findings, Lerga et al.(1997) did not observe statistically significantassociation between secretions' weight andnormal saline instillation.

The primary aim of this study was toinvestigate the effects of two differentsuctioning procedures (without normal salineinstillation and w ith no rmal saline instillation)on a patient's SaO-, level in arterial blood. Asecondary aim was to examine theassociationbetween the type of suctioning procedure andthe amount ofdrained secretions through thedirterence in secretion weight obtained whensuctioning without and with normal salineinstillation. The routine use of normal salineduring suctioning worldwide despite thecontroversial data in the literature underlinesthe necessity and the significance of thisstudy.MethodsData were collected over three and a half years,from June 2004 to November 2007.

Design and settingsThe study was quasi-experimental, amongmechanically ventilated patients in the ICUof two general, tertiary hospitals in Athens,Greece. Inclusion criteria in the study were: Mechanical ventilation by an endotrachealor tracheostomy tube Existence of at least one of the followingindicators of suctioning; sawtooth patternon the flow-volume loop on the monitorscreen of the ventilator and/or the presenceof coarse crackles over the trachea, increasedpeak inspiratory pressure during volume-controlled mechanical ventilation ordecreased tidal volume during pressure-controlled ventilation, deterioration ofSaO, and/or arterial blood gas values,visible secretions in the airway andsuspected aspiration of gastric or upper-airway secretions (American Association forRespiratory Care, 2010) Existence of an arterial line for receivingarterial blood samples in order to measurepatients' arterial blood gasses Continuous haemodynamic monitoring Systematic administration of bronchodilatorsand/or mucolytic agents, in order to securemore hom ogeneity ofour study population,based on the therapeutic effect of these

medicines on patient oxygnation andairway clearance.In addition, patients with the followin

conditions were excluded: Age 18 years old or younger Haemodynamic instability Chronic pulmonary or kidney disease Tracheobronchial anomaly or trauma Use of muscle-relaxation medication Application of endotracheal suctioning ithe last 90minutes.In total, the study population consisteof 210 consecutive mechanically-ventilatepatients, out of whom 103 met the inclusiocriteria and constituted our final study samplThis small proportion (103/210) mighbe explained by the several inclusion anexclusion criteria that were defined to ensurhigher homogeneity ofour studied sample.Data collectionA short three-unit questionnaire on basidemographic characteristics and clinicapatient data was used for data collectiopurposes. The first unit included informatioon demographic and clinical characteristic(age, gender, length of ICU stay in dayduration of intubation in days, ventilatomodes, type and size of artificial airway. Acu

1346 British |oiirn.il ol Nursnig. 2(ll(I.Vol 2(1. No


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Physiology and Chronic Health Evaluation II(APACHE II), Glasgow Coma Scale (GCS)score, history of chronic obstructive pulmonarydisease (COPD), 24-hour fluid balance,presence or absence of respiratory infection,white blood cells count, administration ofbronchodilators or/and mucolytic agents).Thesecond unit included information on theapplied endotracheal suctioning technique(without normal saline instillation or withinstillation of 5 ml normal saline) and thethird unit included information on patientoxygnation parameters (SaO,) and weight ofdrained secretions.SaO, values were recorded before theprocedure, aswell as 1 and 15 minutes after theendotracheal suctioning, by analysing arterialblood samples on a blood gases machine. Thesecretions weight was measured accordinglyafter the application of each suctioning

procedure, using a pair of precision scales.Endotracheal suctioning was performedaccording to standard principles, as describedby the Emergency and Intensive Care NursingDepa rtment of the Hellenic Nurses'Association(2006). Patients were hyperoxygenated with100% oxygen for 1 minute. The n, using acatheter with the maximum size of 14Fr,regarding the size of the artificial airway,patients were suctioned with negative pressureof 150 niniHg and sterile technique for15 seconds. For the selection of the appropriatesuction catheter size, the authors used thefollowing formula: Fr = [Artificial airway size(mm) - 2] X 2 (H ellenic Nurse s' Association,2006; Pedersen et al, 2009).Blood gases were taken 1 and 15 minutesafter the procedure, using a disposable 2.5 mlsyringe (Three-Piece Luer Lock Syringes,Frank Healthcare Co. Ltd) that had beenfiushed with h eparin. The authors chose thefirst minute with the aim of testing thedirect outcome of the applied proceduresand the fifteenth minute to identify therecovery time of the oxygnation parameter.All blood samples from each patient wereanalysed on blood gases machines of the same

type (ABL 70(1 Series Blood Gas Analyzer,Rad iome ter). The drained secretions werecollected using a specific collector and allsamples were weighed on precision scales ofthe same type. Two m ethods of suctioningwere carried out in each patient, allowingfor a 90-minute interval between the twomethods. No more secretions and significanthaemodynamic and oxygen transport changeswere the criteria for stopping suctioning.The first method was suctioning without theuse of normal saline (which we referred to

Table 1 . Demograph ic andclinical sample characteristicsof the study population

HospitalAB

GenderMaleFemale

Type of artificial airwayEndotracheal tubeTracheostomy tube

Ventiiation m odesCM VSIMVSpontaneousUse of bronchodilatorsUse of mucolyt ic agents

Age (years)Length of stay (days)Duration of intubation at thetime of suctioning (days)Apache Ii ScoreGlasgow Coma ScaieCMV: controlled mechanical ventilatiorSD: standard deviation

38 (36,9)65 (63,1)35 (34,0)68 (66,0)67 (65,0)36 (35,0)49 (47.6)37 (35.9)17(16,5)90 (87.4)29 (28.2)Mean (SD)63,0 (21.1)12,6(16.9)11.2(15.5)10.3 (6.9)6.1 (3.8)

SIMV: synchronized intermittent mandatory ventilation

as procedure 1) and the second method wassuctioning with instillation of 5 ml normalsaline 0.9% (p rocedu re 2 ). Aspirations werecarried out only after specific indications forsuctioning, which have been mentioned in theinclusion criteria of this study.

The researchers obtained the data basedon the medical and nursing patient records,as well as via their personal contact with thepatients. The APACH E II and GC S scoresware calculated for each patient using datacollected through hospital records.Data analys isThe normality assumption for continuousvariables was evaluated by using both theKolmogorov-Smirnov criterion (p>0.05for all variables) and normal probabilityplots. Quantitative variables are presented asmean (standard deviation-SD) and median

CLINICAL FOCUS

(interquartile rangc-lK), while categoricvariables are presented as absolute and relatifrequencies. The Wilcoxon sigiied-rank test wused to identify differences betweeti groups oweight of secretions. Th e authors also applithe Wilcoxon signed-rank test to investigateSaO,, values differentiate immediately befoand after (at 1 and 15 minutes) each proceduseparately and to comparatively assess the twsuctioning procedures. All tests of statisticsignificance were two-tailed, and p-values less than 0.05 were considered significant. Tstatistical analysis was performed using SPSS 14.0).Ethical cons iderat ionsPermission to condiit t this study was obtainefrom the ethical committees of the hospitaand an informed consent was obtained froeach patients next of kin. Th e study has beconducted in full accordance with ethicprinciples, including the World MedicAssociation (WMA) Declaration of Helsin(WMA, 2011), and as aforementioned, eacsuctioning was carried out only after specifindications and according to patient needs.ResultsSixty-six percent of the sample was femawith a mean age of 63 (standard deviatio(SD) 21.1) years old.The patients'mean GCscore was estimated at 6.1 (3.8) and the meAPACHE II score was 10.3 (6.9).The meICU length of stay and duration of intubatio(at the time of suctioning) were 12.6 (16.and 11.2 (15.5) days, respectively. In additio65% of the patients had an endotrachetube and the remaining ones (35%) had tracheostomy tube. Most patients receiveither synchronized intermittent mandatoventilation (SIMV) (35.9%), or c ontrollmechanical v entilation (CMV ) (47.6%). detailed distribution of the study populatioaccording to specific demographic and cliniccharacteristics is depicted in Inhlc I.

The iiuiin associations between the tyof suctioning procedure and the weight drained secretions are summarized in 'liihlThe weight of secretions was greater after thapplication of suctioning with normal salinthan without normal saline (p


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was a statistically significant result. The weightof drained secretions associated with normalsaline instillation was almost two times greatercompared to the procedure without normalsaline instillation. Table 3 shows the change inSaO., values 1 and 15 minutes after the suction,for both endotracheai suctioning procedures,compared with the baseline values (before thesuction). Th e comparative differences of Sa O,were not statistically significant either 1 or15 minutes after the suctioning procedure.The differences of SaOj (prior to and 1 or15 minutes after the procedure) owing toeach suctioning are summarized in Table 4. Inparticular, suctioning without normal salinewas correlated with a statistically significantdecrease in SaO, (p


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values between the two methods at 45 secondsand at all times thereafter, and Ackerman andMick (1998) reported a statistically significantdecrease in SaO,, 4, 5 and 1(J minutes aftersuction ing in patients rece iving instillation of a5 ml bolus of normal saline compared to thosewho did not.In addition, contrary to the author s' findings,Akgul and Akyolcu (2002) concluded thatnormal saline instillation was not associatedwith any significant decrease in SaO, levels5 minutes after the procedure, a result thatis consistent with other studies (Gray et al,1990; Reynolds et al, 1990). In add ition, Ji etal (2002) revealed that the suctioning withoutnormal saline instillation caused decreasedSaO., after suctioning, but this change was notstatistically significant.Another important finding of this studywas the association between the increased

suctioned secretions' weight and the type ofsuction, in particular, endotracheal suctioningwith instillation of 5 ml normal saline wascharacterized by aspiration of greater amountsof secretion than suctioning without normalsaline instillation. In line with the authors'results, Bostick and Wendelglass (1987)observed a statistically significant differencein the mean sputum weights between threepatient suc tioning grou ps. Th e investigatorsconcluded that patients in groups with normalsaline instillation had significantly greaterweights of drained secretion, but the clinicalsignificance of this finding was unclear becausethe weight increase may have been a result ofthe retrieval of instilled saline and not mucus.

In addition. Gray et al (1990) found astatistically significant difference in drainedsecretions' weight between the two suctioningmethods. In particular, suctioning withnormal saline instillation caused a significantly

greater amount of material to be aspired thansuctioning without normal saline instillation.Ackerman and Gugerty (1990) also correlatedthe amount of drained secretions with theapplied suctioning techn ique. The y founda statistically significant increase of 1.25 gill the sputum weights of patients who hadreceived a 5 ml normal saline instillationbefore suctioning.Lerga et al (1997) studied 25 patients withprevious pulmonary disease who underwentcardiac surgery. In contrast with the authors'study results, they revealed that the amountof suctioned secretions was similar using bothtechniques, with and without normal salineinstillation.At this point, it is important to emphasizethat it is possible that the instillation of normalsaline did affect the fina l associations, acting as aconfounding variable. As a result, it is difficult to

assume a causal association between the type ofsuctioning and the amount of drained secretions.It is also difficult to answer with confidencewhether normal saline instillation causes theremoval of a greater amount of secretion or thevolume of instilled isotonic saline counts withthe weight of secretions. Moreover, Demersand Sakland (1973) revealed that the instillationof normal saline is not effective in thinningor liquefying secretions because mucus andwater in bulk forms are immiscible and occupyseparate phases in vitro, even after rigorousshaking.Therefore, instillation and rapid removalby suctioning is of dubious value. This view isconfirmed by Raymond (1995).LimitationsTo the best of the authors' knowledge, thisstudy was the first to examine the effect ofendotracheal suctioning type (without or withnormal saline instillation) on oxygen saturation

KEY POINTSI Endotracheal suctioning is a worldwide practice in intensive care units, which aims toremove secretions and maintain a patent artificial airwayI Although the instillation of normal saline during suctioning is a common technique, itseffectiveness and safety remain questionablei The endotracheal suctioning is associated with oxygnation disordersi Neither suctioning without normal saline, nor suctioning with normal saline instillation, issuperior to the other regarding patient SaO^ levelsI Although the instillation of normal saline is associated with greater drained secretionsweight, the value of this finding is controversial because the increased weight could resultfrom aspirated normal salineI Nurses should avoid the instillation of normal saline in their suctioning protocols

and the amount of suctioned pulmonasecretions in intensive care patients in GreecHowever, this study had some limitations.Firstly, although the small sample siof 103 patients seems appropriate whcompared with similar studies undertakpreviously (Ackerman and Gugerty, 199Ackerman, 1993; Akgul and Akyolcu, 2002;et al, 2002; Ridhng et al, 2003), this threatethe vaHdity of the study and impedes tability to generalize the findings to criticalill and mechanically-ventilated patientreated in a wide range of ICUs. Secondlthe quasi-experimental design of this studand the lack of randomization affect iexternal and internal validity. Finally, thstudy was conducted in two general ICUof two hospitals which mean that themight be differences regarding the applietherapeutic protocols and the medic

nursing and physiotherapy care planninwhich could affect the homogeneity of thprovided care. Th e limitations in the studin conjunction with the conflicting findinfrom the literature review indicate the neefor further research, with experimental desigand randomization, larger sample size anmore sample homogeneity.ConciusionThe results of the authors' study showed thendotracheal suctioning is associated wioxygnation disorders, either without or winormal saline instillation prior to suctioninThe significant decrease in SaO,, valu1 minute after the applied procedure (eithwithout or with normal saline instillatioindicates the direct negative outcome causeby the interruption of mechanical ventilatioin conjunction with the application of aunpleasant procedure which temporariimpedes the patient's oxygnation anventilation. In addition, the significant decreaof SaO, values 15 minutes after the suctioninwith normal saline instillation indicates tprolonged negative impact of normal saliinstillation given the late return of SaO, valuat baseline. Nevertheless, neither the proceduwithout normal saline, nor the procedure winormal saline was superior, as was indicated bthe comparisons of SaO, levels. In particulthe authors found no statistically or clinicalsignificant differences in SaO^ levels betwethe two suctioning techniques.

Also, the instillation of normal saline the trachea seems to cause the removal a greater amount of pulmonary secretiothan the applied technique without normsaline instillation. However, the value of th

1350 Uritish Journal ot'Nursing, 2010,Vol 20, No


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CLINICAL FOCUSIk f

finding is controversial because the increasedweight of patients' secretions could resultfrom the aspirated normal saline. In any case,although this study d etected associations w hichreach statistical significance, their clinicalinsignificance cannot be ignored, based on theextremely small differences regarding the SaO,values and the weight of drained secretions.From the literature review the authorsconclude that, during the last 20 years, theassessment of the clinical benefits in conjunctionwith the complications of endotrachealsuctioning, which is among the mostcommon nursing interventions toimprove therespiratory function of mechanically-ventilatedICU patients, is a point of great interest.Endotracheal suctioning is often accompaniedby the instillation of isotonic saline to thetrachea inorder toease flow and the removalof secretions from the airway. Nevertheless, theauthors observe that this technique remainscontroversial and causes scientific skepticismconcerning its safety and effectiveness.The instillation of normal saline solutionduring endotracheal suctioning may notbe beneficial and may actually be harmful.Although the instillation of isotonic salinesolution is a common practice in critical caresettings wo rldwide , its negative effect on patientoxygnation and its debatable benefit on theamou nt of drained secretions should enco uragenurses to avoid the application of this technic]uein their suctioning protocols.This should not bea routine method for the removal of pulmonarysecretions by an artificial airwayConflict of interest: none

Ackerman MH (1993) The effect of saline lavage prior tosuctioning. AmJ Cril dm 2(4): 326-30Ackcrjiian MH. Gugerty B(1990) The effect of normalsaline bolus instillation inartificial airways. TIte Journal../.SOHJV8(2): 14-7Ackerman MH. Mick DJ (1998) Instillation of normalsaline before suctioning in patients with pulmonaryinfections: a prospective randomized controlled trial..4m I Cril Care 7(4): 261-6Akgiil "S , Akyolcu N (2002) Effects of normal saline onendotTacheal s uctioning. J C / I ' H Nuri 11(6): 82630American Association for Respiratory Care (2010) AARCClinical Practice Cuidelines. Endotracheal suctioningof" mec hanica lly ventilated p atients with artificialairways 2010. Rcspir Cm 55(6): 75H-64Blackwood B (1999) Normal saline instillation withendotracheal suctioning: primum non nocere (first dono harm). I A d , > Niirs 29(4): 928-34Bostick J. Wendelgass ST (1987) Normal saline instillationas part of the suctioning procedure: effects on PaO2and amount of secretions. Hear! Lung 16(.S): 532-7Branson RD (2007) Secretion management in themechanically ventilated patient. Respir Care 52(10):1328-42Bugla.ss E (1999) Tracheostomy care: trachal suctioningand humidification. BrJ Nim 8(8): .S()0-4Caruso P. Denari S, Ruiz SA. Demarzo SE. DeheinzelinD (2009) Saline instillation before trachea! suctioningdecreases the incidence of ventilator-associatedpneumonia. Crit Care M c d 37{\): 32-8Celik SA. Kalian N (2006) A current conflict: use of

isotonic sodium chloride solution on endotrachealsuctioning in critically ill patients. Dimciis Cril CareNcs25(l): 11-4Deniers RR. Saklad M(1973) Minimizing the harmfuleffects of mechanical a.spiration. Heart L m n ; 2(4): 542-5Gray JE, Maclntyre NR.Kronenberger'WG (1990)The effects of bolus normal-saline instillation inconjunction with endotracheal suctioning. Respir Care35(8): 785-90CUglielminotti J. Desmont.s JM. Dureuil B(1998) Eflectsof trachal suctioning on respiratory resistances inmechanically ventilated patients. Ciie.n 113(5): 1335-8Hagler DA. Traver GA (1994) Endotracheal saline andsuction catheters: sources of ower airway contamination.AmJ Cril Care 3(6): 444-7Halpern NA. Pastores SM (2010) Critical care medicinein theUnited States 2000-2005: an analysis of bednumbers, occupancy rates, payer mi.\. and costs. CrilGircAicrf 38(1): 65-71Hellenic Nunes' Association (2008) Guidehne: Opensuctioning method on padent with endotrachcMl tube.http://tinyurl.com/d38fzy6 (Accwsed 16 November 2011)Ji YR. Kim HS. Park JH (2002) Instillation of normalsaline before suctioning in patients with pneumonia.Yoiisei MedJ 43(5): 607-12Kinloch D (1999) Instillation of normal saline duringendotracheal suctioning: effects on mixed venousoxygen satura tion. .>l/ii / Cril Care 8(4): 23140Lerga C, Zapata MA.Herce A, Martinez A, Margall

MA. Asiain MC (1997) |Eiidotracheal suctioningsecretions: effects of instillation of normal seruliiijerm liilemifa 8(3): 129-37Morrow H M . Argent AC (2008) A comprehensive reviof pdiatrie en dotracheal suctioning: Effects, indicatioancl clinical practice. Pediair Cril Care Me d 9(5): 46Pedersen CM, Rosendahl-Nielsen M, Hjermind j , EgeI (2009) Endotracheal suctioning of the .idult intubapatientwhat is the evidence? httetnive Crii Care25(1): 21-30 Epub 2008Raymond SJ (1995) Normal saline instillation befsuctioning: helpful or harmful? A review of tliterature. Am / Cril Care 4(4): 267-71Reynolds P. Hoffman LA. Schlichtig R.Davies PA. ZuTG (1990) Effects of normal saline instillation osecretion volume, dynamic ctimpliance. and oxygsaturation. .4i Re v Respir Di s 141(3): A.S74Ridling DA. M.irtin LI). Bnitton SL (200.1) Endotrachsuctioning with or without instillation of isotosodium chloride ilution incritically ill children. ACm Care 12(3): 212 -9Sole ML . BycrsJF, Ludy J E . Zhang Y , Banta CM, BrummK (2003) A multisite survey of suctioning techniqand airway management practices. Am / Oi(12(3): 22IKOWorld Medical Association (2011) WMA DeclarationHelsinki - Ethical Principles for Medical ReseaIin\il \ i i ig Hiunan Subjects, http:/ / t inyurl.cocf6rwcin (Accessed 14 November 2011)

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