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Background Endotracheal tube suctioning is necessary for patients receiving mechanical ventilation.
Studies examining saline instillation before suctioning have demonstrated mixed results.
Methods A prospective study to evaluate whether saline instillation is associated with an increased risk of
suctioning-related adverse events in patients 18 years old or younger requiring mechanical ventilation through
an endotracheal tube for at least 48 hours when suctioned per protocol using a bedside decision tree.
Results A total of 1986 suctioning episodes (1003 with saline) were recorded in 69 patients. The most com-
mon indication for use of saline was thick secretions (87% of episodes). In 586 suctioning episodes, at least 1
adverse event occurred with increased frequency in the saline group (P < .001). Normal saline was more
likely to be associated with hemodynamic instability (P = .04), bronchospasm (P < .001), and oxygen desatu-
ration (P < .001). Patient factors associated with adverse events include younger age (P < .001), a cuffed endo-
tracheal tube (P = .001), endotracheal tube diameter of 4.0 mm or less (P < .001), respiratory or hemodynamic
indication for intubation (P < .001), underlying respiratory disease (P < .001), and longer duration of mechanical
ventilation (P < .001). Saline instillation (P < .001), endotracheal tube size of 4.0 mm or less (P = .03), and
comorbid respiratory diseases (P = .03) were associated with an increased risk of adverse events.
Conclusions Saline instillation before endotracheal tube suctioning is associated with hemodynamic
instability, bronchospasm, and transient hypoxemia. Saline should be used cautiously, especially in children
with a small endotracheal tube and comorbid respiratory disease. (Critical Care Nurse. 2016;36[1]:e1-e10)
B
ecause of changes in respiratory mechanics and mucociliary function, intubated patients
have impaired ability to clear airway secretions1 and often require suctioning via their endo-
tracheal tube to remove sputum in an effort to prevent occlusion and ventilator-associated
infections. Specific indications for suctioning the endotracheal tube include coarse crackles over the
trachea, increased peak inspiratory pressure or decreased tidal volume, oxygen desaturation, and acute
respiratory distress.2 It is hypothesized that instilling saline before suctioning the endotracheal tube
may help remove retained pulmonary secretions by liquefying mucus, stimulating a vigorous cough,
and preventing encrustation of the endotracheal tube.3
Suctioning done No
Consider instillation
Suctioning pass of normal saline to
stimulate spontaneous
or artificial cough
Figure 1 Decision tree for normal saline instillation. Based on Children’s Hospital of Boston Medical/Surgical Intensive Care Unit
Practice Guidelines, Institute for Healthcare Improvement Campaign to Save 100,000 Lives, Pediatric Node, July 2005.
Demographic information obtained for each patient for each suctioning pass. In our unit, nurses have the abil-
included age, sex, endotracheal tube size, the presence ity to suction outside of the decision tree in extenuating
of a cuffed endotracheal tube, duration of mechanical circumstances such as suspected occlusion of the endotra-
ventilation, length of PICU stay, Pediatric Index of Mor- cheal tube or as a rescue maneuver in the context of acute
tality 2 (PIM2) score,11 primary reason for intubation hypoxemia or hypercarbia. Impending occlusion of the
(hemodynamic instability, trauma, respiratory disease, endotracheal tube was suspected if there was an abrupt
neurological disease, or out-of-hospital cardiac arrest), decrease in breath sounds, a change in the end-tidal
location of intubation (PICU, other unit within the hos- carbon dioxide waveform, a loss of inspired tidal volume,
pital, or outlying hospital), and whether the patient had or an increase in peak pressure on the ventilator.
a pulmonary comorbid condition such as asthma or If criteria were met for suctioning with saline (Fig-
chronic lung disease. ure 1), then generally 1 to 2 mL of normal saline, from
a prepackaged vial, was instilled into the endotracheal
Suctioning Protocol tube and suctioning was performed. The suctioning
Upon study entry, the bedside caregiver continued to protocol includes hyperoxygenation at a minimum of
suction the endotracheal tube per unit protocol and used 10% above the patient’s baseline unless contraindicated,
the saline decision tree to determine if saline was warranted suctioning pressures of 80 to 120 mm Hg depending on
e4 CriticalCareNurse
Vol 36, No. 1, FEBRUARY 2016 www.ccnonline.org
Table 2 Association of adverse events with saline use among 1986 episodes of endotracheal tube suctioninga
The frequency of adverse events also varied by indication) was somewhat underrepresented (83% vs
indication for saline use within this group of suctioning 90%) and the indication no results without saline was
events (Table 3). Saline use for presence of thick secre- more frequent (8.6% vs 4.4%) in the adverse event
tions in the endotracheal tube (the most common group (P < .001).
Multivariable Analysis of Any Adverse Event ventilation did not remain associated with adverse
During Suctioning events. Because thick secretions were the indication
Two-level logistic regression modeling was performed for use of saline in 87% of the suctioning events in this
to account for clustering of data at the ventilation epi- group, saline indication subsets were not included in
sode level (69 episodes in 62 patients) to further evaluate the multivariable analysis.
whether saline instillation was independently associated
with adverse events (Table 4). Three factors remained Discussion
associated with adverse events: saline instillation (odds We found a concerning frequency of adverse events
ratio, 2.78; 95% CI, 1.79-4.32; P < .001), an endotracheal associated with all suctioning episodes as well as with
tube size of 4.0 mm or less (odds ratio, 2.90; 95% CI, saline suctioning events in our sample of pediatric
1.13-7.45; P = .03), and the presence of a comorbid respi- patients. We believe ours is the first pediatric study to
ratory disease (odds ratio, 1.78; 95% CI, 1.06-2.99; P = demonstrate a significant increase in the risk of clini-
.03). Sex, age, the presence of a cuffed endotracheal cally significant hemodynamic deterioration requiring
tube, reason for intubation, and duration of mechanical physician intervention after a saline suctioning pass.
This study is also the first to report a significant increase suctioning is indeed associated with risk for deterioration
in the unexpected use of bronchodilators when saline is in the patient’s condition. On average, a patient experi-
used, suggesting that saline may be an airway irritant enced an adverse event with 26% of suctioning passes
causing bronchospasm immediately following a suction- whether or not saline was instilled. Although not all possi-
ing pass. Our study also identified potential risk factors ble complications were evaluated, we did note that oxygen
for suctioning-related adverse events including saline desaturation was the most likely adverse event, followed
instillation, endotracheal tube diameter of 4.0 mm or by bronchospasm and hemodynamic deterioration.
less, and the presence of a comorbid respiratory disease. Although most of these events were limited, they could
This study is one of the largest to date in children, prove catastrophic in patients intubated for hemodynamic
and we believe it is the first to quantify the number of instability where equilibrium is already tenuous.
suctioning passes per day along with the frequency of Our study further demonstrates a significant increase
saline administration in intubated patients when a bed- in adverse events (oxygen desaturation, hemodynamic
side decision tree is used. As expected, suctioning of instability, and bronchospasm) when suctioning with
the endotracheal tube continues to be a significant com- saline was chosen over dry suctioning, which holds true
ponent of even with logistic regression modeling. Many adult studies
Saline should be used cautiously,
patient care have demonstrated significant decreases in oxygenation
especially in young children with a small
within our when saline is administered just before a suctioning pass.
ETT and comorbid respiratory disease.
PICU, with In the one randomized controlled pediatric study, Ridling
approximately 5 suctioning passes per patient per day et al8 noted a significant decrease in Spo2 (approximately
that an endotracheal tube is in place. Furthermore, saline 5% vs 1%) at 1 and 2 minutes after a suctioning pass with
is used in approximately 50% of all suctioning passes, saline compared with dry suctioning passes; however, no
with thick secretions being the most common indication difference in Spo2 was noted at 10 minutes after suction-
for the use of suctioning. ing. Our findings support these data in that significantly
In the 2010 clinical practice guidelines of the Ameri- more suctioning passes were associated with oxygen desat-
can Association for Respiratory Care,2 the authors warn uration when saline was used, but there was no sustained
of hazards associated with endotracheal tube suctioning, difference in oxygen saturation 10 minutes after the suc-
including changes in lung compliance, capacity, and vol- tioning episode occurred, suggesting a very limited effect.
ume; hypoxia; trauma; bronchospasm; and hemodynamic We also identified 2 additional patient factors after
instability. Our study confirms that endotracheal tube multivariate adjustment (including clustering at the
References
1. Konrad F, Schreiber T, Brecht-Kraus D, Georgieff M. Mucociliary trans-
port in ICU patients. Chest. 1994;105(1):237-241.
2. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechani-
cally ventilated patients with artificial airways 2010. Respir Care. 2010;
55(6):758-764.
3. Demers RR, Saklad M. Minimizing the harmful effects of mechanical
aspiration. Heart Lung. 1973;2(4):542-545.
4. Paratz JD, Stockton KA. Efficacy and safety of normal saline instillation:
a systematic review. Physiotherapy. 2009;95(4):241-250.
5. Darlow BA, Sluis KB, Inder TE, Winterbourn CC. Endotracheal suction-
ing of the neonate: comparison of two methods as a source of mucus
material for research. Pediatr Pulmonol. 1997;23(3):217-221.
6. Shorten DR, Byrne PJ, Jones RL. Infant responses to saline instillations
and endotracheal suctioning. J Obstet Gynecol Neonatal Nurs. 1991;
20(6):464-469.
7. Beeram MR, Dhanireddy R. Effects of saline instillation during tracheal
suction on lung mechanics in newborn infants. J Perinatol. 1992;12(2):
120-123.
8. Ridling DA, Martin LD, Bratton SL. Endotracheal suctioning with or
without instillation of isotonic sodium chloride solution in critically ill
children. Am J Crit Care. 2003;12(3):212-219.
9. Drew JH, Padoms K, Clabburn SL. Endotracheal tube management in
newborn infants with hyaline membrane disease. Aust J Physiother.
1986;32(1):3-5.
10. Sherman JM, Davis S, Albamonte-Petrick S, et al. Care of the child with
a chronic tracheostomy. This official statement of the American Tho-
racic Society was adopted by the ATS Board of Directors, July 1999.
Am J Respir Crit Care Med. 2000;161(1):297-308.
11. Slater A, Shann F, Pearson G. PIM2: a revised version of the Paediatric
Index of Mortality. Intensive Care Med. 2003;29(2):278-285.
12. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition
of health care-associated infection and criteria for specific types of infec-
tions in the acute care setting. Am J Infect Control. 2008;36(5):309-332.
13. Hagler DA, Traver GA. Endotracheal saline and suction catheters: sources
of lower airway contamination. Am J Crit Care. 1994;3(6):444-447.
14. Rutala WA, Stiegel MM, Sarubbi FA Jr. A potential infection hazard
associated with the use of disposable saline vials. Infect Control. 1984;
5(4):170-172.
15. Caruso P, Denari S, Ruiz SA, Demarzo SE, Deheinzelin D. Saline instil-
lation before tracheal suctioning decreases the incidence of ventilator-
associated pneumonia. Crit Care Med. 2008;37(1):32-38.
16. Reeve JC. Instillation of normal saline before suctioning reduces the inci-
dence of pneumonia in intubated and ventilated adults. Aust J Physiother.
2009;55(2):136.
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