Placement of endotracheal and tracheostomy tubes

Mary Frances D. Pate

Crit Care Nurse 2004;24:13-14
2004 American Association of Critical-Care Nurses
Published online http://www.cconline.org

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LetterstotheEditor
Letters to the Editor are welcome
and encouraged. Letters must
address topics that have previously
appeared in Critical Care Nurse.
Keep your letters concise. Letters are
subject to editing. Include your
name, credentials, title (optional),
city and state, and e-mail (for veri-
fication, not publication). Send to
Letters to the Editor, Critical Care
Nurse, 101 Columbia, Aliso Viejo,
CA 92656; fax to (949)362-2049;
or e-mail to ccn@aacn.org.
The role of institutional
review boards
As a researcher and institutional
research board (IRB) member, I read
the article, Protecting Patients Dur-
ing Clinical Research (February
2004:53-59), with great interest,
and I am appreciative of the exem-
plars the author gives as potential
pitfalls in the clinical setting. How-
ever, I disagree that the IRB is the
first level of protection of a patients
rights during clinical research.
The IRB is only one of the safe-
guards (albeit one of the most
important institutional safeguards)
for protection of patient rights. The
first, and most important, safeguard
is the ethics of the researcher. A
researchers ethics carry a project
from identification of the topic to
publication of the study.1 In addition,
researchers with high ethical stan-
dards do not view the IRB in an
adversarial context, but rather as a
double check for the protection of
human subjects. I have undergradu-
ate student research assistants, and
if they learn nothing else during the
12 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
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course of their study with me, they
learn the application of ethical stan-
dards during research in the clinical
setting. Learning by example; it is just
that simple.
A second of item of concern in
the article is the response to a dilemma
in Table 5:
Scenario: Karen, a nurse on your
unit, states that she will be collect-
ing data from her patients and
their medical records for a school
project. When asked, she states
she doesnt think her protocol
needs approval from the institu-
tional review board and that she is
under a deadline.
Response: Immediately tell Karen
that this violates federal law and
hospital policy. Notify your nurse
manager or advanced practice nurse
to back up your position. Direct
Karen to the coordinator of the insti-
tutional board for protocol review.
Telling someone they are in vio-
lation of federal law and hospital
policy without further investigation
could be uncomfortable and embar-
rassing for both parties. A better
response might be to ask Karen to
provide a written explanation of the
project and a signed form from the
instructor and nurse manager allow-
ing Karen to collect the data. The
nature of the project determines the
need for IRB approval. If a written
explanation of the project and signed
form from the instructor and nurse
manager are not available, phone
calls could be made to obtain clarifi-
cation. If the instructor and nurse
manager are not immediately avail-
able, waiting for clarification would
be the preferred option.
Thank you for sharing these
aspects of clinical research with prac-
ticing nurses.
Reference
1. Burns N, Grove S. The Practice of Nursing
Research: Conduct, Critique, & Utilization. 4th
ed. Philadelphia, Pa: Saunders; 2001.
Alyce S. Ashcraft, RN, PhD, CS, CCRN
Lubbock, Tex
The author responds:
I totally agree with the readers state-
ment that a researchers ethics are the
first line of research protection for human
subjects. However, the IRB mechanism is
our regulatory system that attempts to
ensure this process. My statement in the
article is framed on the basis of the cur-
rent rash of highly publicized ethical vio-
lations by researchers. We need the first
line checks and balances of the IRB. I
agree also with your statement that ethi-
cal researchers see the IRB as their ally,
not adversary.
If there was time to handle the situa-
tion in Table 5 in a more politically cor-
rect way, I would agree. This scenario is
based on an actual situation in which
the staff nurse literally had her clip-
board out and was already collecting
data from her assigned patients for her
study on the night shift. Protecting the
patients who unbeknownst to them were
research subjects was the priority. I
appreciate the readers thoughtful com-
ments on my article. Together we can all
ensure protection of patients during clin-
ical research.
Jacqueline Fowler Byers, RN, PhD, CNAA
Orlando, Fla
Low-dose steroid replacement
in severe sepsisresponse
In response to the Letter to the
Editor by Doson Chua in the April
issue (2004:16), I disagree with her
statement that the use of steroid
therapy is currently advocated for
use in all patients with severe sepsis.
A large, well-done, randomized clini-
cal trial1 demonstrated that empiric
use of steroids in patients with
severe sepsis or septic shock was
associated with a significant reduc-
tion in mortality. However, this ben-
efit was limited to patients who
failed to increase their cortisol levels
by 9 in response to corticotrophin
stimulation test. Among this group,
there was a 10% absolute reduction
in mortality when treated appropri-
ately. The evidence therefore indicates
(1) a corticotrophin stimulation test
on all patients with severe sepsis or
septic shock and then (2) empirically
treating patients with severe sepsis or
septic shock (50 mg hydrocortisone
every 6 hours plus 0.1 mg of Flurinet
twice daily). In patients with cortisol
increases by less than 9 in response
to the stimulation test (nonrespon-
ders), steroids should be continued
for 1 week and then discontinued.
Longer term use of steroids may
cause increased morbidity.
Reference
1. Anne D, Sebille V, Charpentier C, et al.
Effects of treatment with low dose of hydro-
cortisone and fludrocortisone on mortality
in patients with septic shock. JAMA.
2002;288:862-871.
Karen Aloe, RN, MSN, CCRN, CNS
Long Island, NY
Placement of endotracheal
and tracheostomy tubes
I recently read the article, Air-
way Management (April 2004:93-
Downloaded from ccn.aacnjournals.org at Mobile User on May 16, 2013
96), and noticed that information
related to depth of endotracheal tube
(ETT) and tracheostomy tube (TT)
suctioning was not addressed. It is
still common practice for nurses to
insert suction catheters until they
meet resistance and then apply suc-
tion. The resistance felt is when the
catheter meets the carina or bronchial
mucosa. Inserting a suction catheter
to this point can cause negative con-
sequences for the patient.
Alternately, some nurses insert
suction catheters until resistance is
met, and then pull the catheter back
before applying suction. Unfortu-
nately, meeting resistance and then
pulling back before suctioning is
not a solution.1 Research suggests
that catheter contact rather than suc-
tion is responsible for mucosal dam-
age.2 Studies in kittens have shown
that inserting a catheter to resistance
caused as much damage as insertion
to resistance with the subsequent
addition of suction.3 The effect of deep
suctioning is tracheal mucosal dam-
age, including epithelial denude-
ment, hyperemia, loss of cilia, edema,
fibrosis, and granuloma formation.
This damage occurs when tissue is
pulled into the catheter tip holes,
and increases the risk of infection
and bleeding for the patient. The
purpose of suctioning is to remove
secretions that are not accessible to
bypassed cilia. Therefore, insertion
of suction catheters only as far as the
end of the placed ETT and TT has
been recommended.2,4 Nurses may
argue that though shallow suctioning
appears to be less injurious to mucosa,
it may also be a less effective method
of removing secretions. However,
there is no reason to suspect that
mucocilliary transport below the tip
of the ETT or TT should function
abnormally. Therefore, larger vol-
umes of aspirates would be collected
in shallow-suctioning. Once deep-
suction is initiated, the resulting
damage to cilia may necessitate the
need for continued deep suctioning.2
When an adult patient is endotra-
cheally intubated, the distal portion
of the tube sits between 3 and 7 cm
above the carina.5 In neonates, the
end of the ETT is frequently placed
just 1 to 2 cm above the carina.
Therefore, suction catheters should
be inserted to a predetermined
length. Passing suction catheters no
further than 1 cm past the length of
the ETT or TT can avoid contact
with the trachea and carina.6 Resis-
tance should not be met. If resistance
is met, the suction catheter should
be withdrawn at least 0.5 cm before
applying suction.7 There are various
methods of predetermining suction
catheter depth1 and these methods
should be incorporated into proto-
cols for practice.
References
1. Pate MF, Zapata T. How deeply should I go
when I suction an endotracheal (ETT) or
tracheostomy tube (TT)? Crit Care Nurse.
April 2002;22:130-131.
2. Bailey C, Buckley T, Kattwinkel J, Teja K.
Shallow versus deep endotracheal suction-
ing in young rabbits: pathologic effects on
the tracheobronchial wall. Pediatrics.
1988;82:746-751.
3. Kleiber C, Krutzfield N, Rose EF. Acute his-
tologic changes in the tracheobronchial
tree associated with different suction
catheter insertion techniques. Heart Lung.
1988;17:10-14.
4. Turner BS, Loan LA. Tracheobronchial
trauma associated with airway manage-
ment in neonates. AACN Clin Issues.
2000;11:283-299.
5. Chang VM. Protocol for prevention of com-
plications of endotracheal intubation. Crit
Care Nurse. October 1995;15:19-20, 23-27.
6. Swartz K, Noonan DM, Edwards-Beckett J.
A national survey of endotracheal suction-
ing techniques in the pediatric population.
Heart Lung. 1996;25:52-60.
7. Lynn-McHale DJ, Carlson KK, eds. AACN
Procedure Manual for Critical Care. 4th ed.
Philadelphia, Pa: WB Saunders Company;
2001:41-48.
Mary Frances D. Pate, RN, DSN
Portland, Ore
CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 13
LetterstotheEditor
The author responds:
This reader brings up an important
element of the suctioning procedure to
which there is no consensus. The ideal
suction catheter insertion depth through
either an ETT or TT remains both an
area of controversy and research inter-
est. The reader is correct in that the
adverse consequences of deep suctioning
have been well described in the litera-
ture for many years.1-5 Animal research
has demonstrated tracheobronchial
trauma as a result of deep versus shal-
low suctioning.2 Limited data suggest
that restricting suction catheter
advancement to 1 cm beyond the tip of
the artificial airway does not compro-
mise secretion removal effectiveness.3
Clearly, mechanical trauma to the
airway and mucosal surface is not just
related to the suction catheter insertion
depth, but also suctioning frequency,
suction pressure levels used, ETT or TT
movement, positive pressure effects of
mechanical ventilation, and, to a lesser
extent, suction catheter tip design, as
most suction catheters in use today have
incorporated safety features to minimize
risk of tissue trauma when suction is
applied. Van de Leur and coworkers4
recently studied 383 adults requiring
endotracheal intubation randomized to
either minimally invasive (29-cm suc-
tion catheter) or routine (49-cm suction
catheter) catheter suctioning. They
found no difference in the suction meth-
ods relative to duration of intubation,
intensive care unit stay, intensive care
unit mortality, and incidence of pul-
monary infection. Suction-related
adverse events (increased pulse pressure
rate, decreased saturation via pulse
oximetry, blood in mucus, and systolic
blood pressure increase) occurred more
frequently with routine deep suctioning
versus shallow suctioning. In another
recent study5 of 27 high-risk infants
14 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
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randomized to either shallow or deep
ETT suctioning, there were no signifi-
cant differences between the 2 methods
in either heart rate and oxygen satura-
tion before, during, or after ETT suc-
tion.5
The vast majority of studies on this
subject have focused on infants and
neonates receiving ventilation. Spence
and coworkers6 conducted an extensive
literature search of controlled trials
using random or quasi-random alloca-
tion of neonates receiving ventilatory
support via an ETT to either deep or
shallow endotracheal suctioning. They
found that there was no evidence to
conclusively answer the question as to
whether shallow suctioning is preferred
over deep suctioning in neonates and
infants, and further high-quality
research would be required. Given the
published and anecdotal evidence of
adverse effects of deep suctioning, this
type of proposed study would ethically
only be considered when the standard
practice includes deep suctioning tech-
nique.
Indeed, as noted by other
researchers interested in suctioning
techniques and airway management,
collaborative, research-based policies
and procedures must be developed and
implemented to ensure best practices
for intubated patients.7 There are
instances when deep suctioning may
be reasonable such as the use of
directional-tip catheters for suctioning
the left main stem bronchus. Several
suction catheter manufacturers have
added depth markers along the
catheters (both open and closed suction
catheter systems) to aid clinicians who
wish to limit insertion depth. Many
hospitals utilize pre-measured suction
catheter depth guides or cards at the
bedside. This may be particularly help-
ful with neonatal and pediatric ETTs
and TTs. Until a more definitive
answer to this question is known, the
available evidence would favor avoid-
ing routine deep suctioning practice.
References
1. Thambrian AK, Ripley SH. Observations on
tracheal suction: an experimental study. Br J
Aneasth. 1966;38:459.
2. Kleiber C, Krutzfield N, Rose EF. Acute histo-
logic changes in the tracheobronchial tree asso-
ciated with different suction catheter insertion
techniques. Heart Lung. 1988;17:10-14.
3. Bailey C, Kattwinkel J, Teja K, Buckley T. Shal-
low versus deep endotracheal suctioning in
young rabbits: pathologic effects on the tra-
cheobronchial wall. Pediatrics. 1988;82:746-
751.
4. Van de Leur JP, Zwaveling JH, Loef BG, Van
der Schans CP. Endotracheal suctioning ver-
sus minimally invasive airway suctioning in
intubated patients: a prospective randomized
controlled trial. Intensive Care Med.
2003;29:426-432.
5. Youngmee A, Yonghoon J. The effects of the
shallow and the deep endotracheal suctioning
on oxygen saturation and heart rate in high-
risk infants. Int J Nurs Stud. 2003;40:97-104.
6. Spence K, Gillies D, Waterworth L. Deep ver-
sus shallow suction of endotracheal tubes in
ventilated neonates and young infants. In: The
Cochrane Library, Issue 1. Chichester,
United Kingdom: John Wiley & Sons, Ltd;
2004.
7. Sole ML, Byers JF, Ludy JE, Zhang Y, Banta
CM, Brummel K. A multisite survey of suction-
ing techniques and airway management prac-
tices. Am J Crit Care. 2003;12:220-230.
Robert E. St. John, RN, MSN, RRT,
CCRN, CS
St Louis, Mo