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Intracranial Effects of Endotracheal Suctioning in

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Journal of Neurosurgical Anesthesiology

Vol. 14, No. 1, pp. 5054
2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Intracranial Effects of Endotracheal Suctioning in the Acute Phase

of Head Injury
Marco Gemma, Concezione Tommasino, Marco Cerri, Antonella Giannotti, Barbara Piazzi, and
Tosca Borghi
University of Milano, Institute of Anesthesiology and Intensive Care, Neurointensive Care Unit, IRCCS San Raffaele Hospital,
Milano, Italy

Summary: In patients with head injury, endotracheal suctioning (ETS) is a potentially

dangerous procedure, because it can increase intracranial pressure (ICP). The purpose of
this prospective nonrandomized study was to evaluate the impact of ETS on intracranial
dynamics in the acute phase of head injury. Seventeen patients with severe head injury
(Glasgow Coma Score 8, range 48), sedated and mechanically ventilated, were
studied during the first week after trauma. Single-pass ETS maneuver (with a 16-French
catheter, negative pressure of 100 mm Hg, and duration of less than 30 seconds) was
performed 60 seconds after the FiO2 was increased to 100%. After ETS, FiO2 was
maintained at 100% for another 30 seconds. Before and after ETS, arterial blood gases
and jugular oxygen saturation (SjO2), ICP, and mean arterial pressure (MAP) were
measured and cerebral perfusion pressure (CPP) was calculated. A total of 131 ETS
episodes, which consisted of repeated assessment of each patient, were analyzed. Six
patients in 20 cases coughed and/or moved during ETS because of inadequate sedation.
After ETS, ICP increased from 20 12 to 22 13 mm Hg in well-sedated patients and
from 15 9 to 28 9 mm Hg in patients who coughed and/or moved (mean change, 2
6 versus 13 6 mm Hg, P <.0001). CPP and SjO2 increased in well-sedated patients
(from 78 16 to 83 19 mm Hg, and from 71 10 to 73 13%, respectively) and
decreased in patients who reacted to ETS (from 79 14 to 72 14 mm Hg and from 69
7 to 66 9%, respectively), and the differences were significant (mean change, CPP:
5 14 versus -7 15 mm Hg, P .003; (SjO2) 2 5 vs. 3 5%, P<.0001). In
well-sedated patients, endotracheal suctioning caused an increase in ICP, CPP, and SjO2
without evidence of ischemia. In contrast, in patients who coughed or moved in response
to suctioning, there was a slight and significant decrease in CPP and SjO2. In the case of
patients with head injuries who coughed or moved during endotracheal suctioning, we
strongly suggest deepening the level of sedation before completing the procedure to
reduce the risk of adverse effects. Key Words: Endotracheal suctioningIntracranial
pressureCerebral perfusion pressureJugular oxygen saturationHead
injurySedation

Endotracheal suctioning (ETS) is a nursing procedure

frequently performed on mechanically ventilated patients

to prevent pulmonary complications. In patients with head

injuries, however, ETS is a potentially dangerous procedure, because it can transiently increase ICP (15).
Several modalities have been advocated to reduce secondary brain damage during endotracheal suctioning (6
12), and recommendations for ETS in patients with head

Address correspondence and reprint requests to Concezione Tommasino, M.D., University of Milano, Department of Anesthesia, IRCCS San
Raffaele Hospital, Via Olgettina, 6020132 Milano, Italy. Accepted for
publication May 1, 2001.

50

INTRACRANIAL EFFECTS OF ETS IN HEAD INJURY

injuries exist (13). However, there are few data on the
cerebral effects of ETS in the very early phase of head
injury, when patients are at higher risk for intracranial
catastrophe, and when even transient increases in ICP may
have potentially harmful effects.
The purpose of this investigation was to evaluate the
impact of ETS on intracranial dynamics during the first
week after trauma in adult patients with severe head injuries.
MATERIALS AND METHODS
We prospectively studied consecutive adult patients
who were admitted to our Neurointensive Care Unit between January 1, 1998 and December 31, 1998 because of
severe head injury (Glasgow Coma Scale score <8), who
were managed according to standard therapeutic
schema (14). The study protocol was approved by the
local Ethics Committee, and family members or legal
guardians provided informed consent.
Patients were studied only during the first week after
head trauma, and were enrolled provided that they were
sedated and mechanically ventilated. Only routine ETS,
planned as part of the nursing procedure, was analyzed;
unplanned ETS, prompted by tracheal tube obstruction
from secretions, was not considered. Patients with severe
pulmonary failure caused by thoracic trauma or preexisting disease, or with GCS 3, were not included.
Intracranial pressure (intraventricular or subdural catheter, zeroed at the external acoustic meatus) and invasive
blood pressure (radial artery, zeroed at the level of the
right atrium) were continuously monitored and recorded
on McLab (AD Instruments, Castle Hill, Australia). Cerebral perfusion pressure was calculated as the difference
between the mean arterial blood pressure (MAP) and the
ICP. Jugular bulb oxygen saturation (SjO2, jugular bulb
catheter verified by radiography) and arterial blood gases
were intermittently measured (i-STAT; Hewlett Packard,
Boblingen, Germany). Sedation was achieved by administration of propofol (26 mg/kg/h) or diazepam (0.11
mg/kg/h) and no muscle relaxants were used. Drug infusion rate was not modified if respiration was synchronous
with the ventilator; BP, HR, and ICP were stable over time
(at least 30 minutes), and no cough and/or movement occurred during the previous ETS. If the patient moved or
coughed during and/or after ETS, sedative infusion rate
was increased, and the next ETS was not considered for
the study.
Monitored variables were measured before starting
ETS, then the FiO2 was increased to 100% for 60 seconds

51

and single-pass ETS was performed by sterile standard

technique through an appropriate hole in the catheter
mount. A 16F disposable multilumen catheter (Vygon,
Ecquen, France) was employed and a negative pressure of
100 mm Hg was applied. The catheter was inserted into
the side port of the endotracheal tube, and the duration of
the single-pass ETS was less than 30 seconds. After ETS,
FiO2 was maintained at 100% for 30 seconds, ICP and
MAP were registered, and blood samples were drawn.
The study was performed with the patients in the supine
position, with 30 head-up tilt. During ETS, ventilatory
mode and intravenous sedative infusion rates were left
unchanged, and no further sedative drugs were administered. Neither head rotation, bronchial saline instillation,
or hyperinflation were performed. Adverse effects during
or after ETS (such as coughing or moving) were recorded.
Statistical Analysis
Because of the rapid change in each patients clinical
status as well as the changes in medical regimens over the
data collection period, each ETS episode was treated as a
single observation for statistical analysis. Data were analyzed by one-way analysis of variance. The change in each
monitored variable (ICP, MAP, CPP and SjO2) induced by
ETS was calculated and differences between groups were
analyzed with unpaired Student t test and Bonferroni correction (as post hoc analysis). A P .05 was considered
significant. Data are presented as mean SD.
RESULTS
Seventeen patients (12 males) aged 44 18 years
(range, 1777) were enrolled. Table 1 illustrates for each
patient the principal cause of head trauma, surgical treatment, GCS on admission, and GCS at discharge from the
Neurointensive Care Unit (Table 1). ETS episodes with
missing data were excluded. A total of 131 ETS episodes
fulfilled the study criteria and were considered for analysis. Six patients in 20 cases coughed and/or moved during
the ETS; these episodes were labeled as inadequate sedation and are considered separately.
Arterial blood gases (PaO2, PaCO2) and pHa are presented in Table 2. PaCO2 was lower in patients with
ICP>20 mm Hg, and, according to study protocol, PaO2
increased after ETS (Table 2). Table 3 illustrates ICP,
MAP, CPP and (SjO2) values before and after ETS and
their mean changes. ETS increased ICP, and the increase
was more pronounced when sedation was inadequate
(mean change, 13 6 versus 2 6 mm Hg, P <.0001).
Furthermore, when sedation was inadequate, CPP (mean

Journal of Neurosurgical Anesthesiology, Vol. 14, No. 1, 2002

52

M. GEMMA ET AL.
TABLE 1. Clinical data for patients receiving endotracheal suctioning

Patient

Gender

Age
(yr)

Mechanism
of trauma

Principal lesion

Craniotomy

GCS a

GCS d

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

F
M
M
M
F
F
M
M
M
F
M
F
M
M
M
M
M

46
17
34
67
56
77
39
34
17
74
35
56
21
50
44
31
49

Pedestrian impact
Vehicular crash
Fall
Vehicular crash
Pedestrian impact
Pedestrian impact
Vehicular crash
Fall
Vehicular crash
Pedestrian impact
Vehicular crash
Vehicular crash
Vehicular crash
Vehicular crash
Fall
Vehicular crash
Vehicular crash

Intraparenchymal hemorrhage
DAI
Cerebral contusion
Cerebral contusion
Multiple cerebral contusions
Multiple cerebral contusions
DAI
SAH
DAI
Cerebral contusion
Multiple cerebral contusions
DAI
Multiple cerebral contusions
Multiple cerebral contusions
Multiple cerebral contusions
Brain swelling
DAI

Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No

4
7
7
7
8
6
4
7
6
8
5
8
8
4
4
6
5

8
14
15
15
11
6
11
14
10
11
13
11
15
3
6
10
11

GCS Glasgow Coma Scale Score on admission to (GCS a) and at discharge from (GCS d) the neurointensive care unit; DAI diffuse axonal injury;
SAH subarachnoid hemorrhage.

change - 7 15 mm Hg) and SjO2 (mean change 3 5%)

showed a significant reduction from well-sedated patients
(P .003, and P <.0001, respectively) (Table 3).
DISCUSSION
A basic postulate in the care of head injury is the prevention of secondary brain damage. From this point of
view, endotracheal suctioning is a potentially dangerous
procedure, because it can cause transient intracranial hypertension (15) and reduce cerebral perfusion pressure,
in particular when autoregulation has already been disturbed by head trauma (15). For such a reasons, several
modalities have been advocated to reduce secondary brain
damage, such as hyperventilation before ETS (11), use of
sedation and/or muscle relaxants (79,12), or lidocaine
administration (6,10).
In the present study, ETS always increased ICP. The
increase, however, was small and not clinically significant

in adequately sedated patients (no cough, no movements

during ETS), and several studies suggest that the increase
in ICP after ETS is secondary to vasodilatation and an
increase in cerebral blood flow (5,16,17).
In a previous study, Kerr et al. reported that suctioning
causes an increase in cerebral oxygenation, probably from
an increase in flow in response to the stimulation (5). In
our patients, SjO2 was maintained only when sedation was
adequate. When the patients were not adequately sedated,
cerebral perfusion pressure and cerebral oxygenation significantly decreased after ETS. It is conceivable that an
initial increase in flow with resultant increase in ICP may
ultimately lead to a decrease in SjO2 if CPP is significantly
reduced as a result of the elevation in ICP.
Our study was not set to test the hypothesis that inadequate sedation during ETS induces cerebral hypoperfusion; however, our observations suggest a hypothesis that
should be tested on an a priori basis.
Our results could imply that the increase in ICP was not

TABLE 2. Blood gas analysis (PaO2, PaCO2) and pHa before (pre-ETS) and after endotracheal suctioning (post-ETS)
ICP 20 mm Hg
(n 89)

PaCO2 mm Hg
PaO2 mm Hg
pHa

ICP >20 mm Hg
(n 42)

pre-ETS

post-ETS

pre-ETS

post-ETS

36.6 5.6
163 41
7.419 0.037

37.1 5.7
268 112
7.419 0.042

34.2 3.8*
148 34
7.442 0.036

34.3 3.9*
225 96
7.441 0.035

* P < 0.05 from ICP 20 mm Hg; P < 0.05 from before ETS
ETS episodes divided according to the intracranial pressure (ICP) before ETS.

Journal of Neurosurgical Anesthesiology, Vol. 14, No. 1, 2002

INTRACRANIAL EFFECTS OF ETS IN HEAD INJURY

53

TABLE 3. Intracranial pressure (ICP), mean arterial blood pressure (MAP), cerebral perfusion pressure (CPP), and jugular bulb
oxygen saturation (SjO2) before (pre-ETS) and after endotracheal suctioning (post-ETS) in patients divided according to level of
sedation. Delta changes for the listed variables are also reported
Good sedation
(n 111)

ICP mm Hg
MAP mm Hg
CPP mm Hg
SjO2 %

Inadequate sedation
(n 20)

pre-ETS

post-ETS

Delta change

pre-ETS

post-ETS

Delta change

20 12
98 15
78 16
71 10

22 13
105 18
83 19
73 13

26
7 12
6 14
25

15 9
94 10
79 14
69 7

28 9
100 15
72 14
66 9

13 6**
5 14
7 15*
3 5**

Legend: *P 0.003, and **P 0.0001 from good sedation group.

sustained by an increase in cerebral blood flow to maintain

the cerebral perfusion. The SjO2 reduction, however,
could also reflect an increase in metabolism in excess of
flow, because stress increases cerebral metabolism. A very
recent study has addressed the effects of endotracheal suctioning on cerebral oxygenation in patients with head
trauma and suggests that cerebral oxygen delivery is maintained during ETS (12). In this study, the GCS was much
lower as compared to our patients (3.5 1.7 versus 6.1
1.5 [range 48]), and no patient reacted to the endotracheal suctioning.
Sedation is very effective in managing intracranial hypertension and should be considered as one of the earliest
treatment modalities in such cases, provided that the drugs
chosen do not interfere with the cerebral hemodynamics
(18). In the incompletely paralyzed patient, endotracheal
suctioning may cause straining and an increase in both
intrathoracic and intraabdominal pressures (7). Several
studies advocate neuromuscular blockade to avoid ICP
increases after ETS (8,9,12). In our study, muscle relaxants were not used for several reasons. First, we believe
that neuromuscular blockade is a useful adjunct only in
patients whose intracranial hypertension is exacerbated by
motor activity not controlled by sedation (that is, patients
who are agitated, are exhibiting motor posturing, or are
bucking the ventilator). Second, we use ventilatory modalities, such as assisted support ventilation, which do not
require muscle paralysis. Finally, one of the few studies on
ICU course and outcome of severe head injury patients
demonstrated that prophylactic pharmacologic paralysis
is associated with lengthening of ICU stay and a higher
incidence of sepsis and pneumonia (19).
Recommendations for endotracheal suctioning in headinjured adults, based on review of the literature, include
oxygenating patients prior to suctioning, limiting suction
duration to 10 seconds, limiting suction passes to 12 per
procedure, using hyperventilation with caution, not rotat-

ing the head, keeping negative pressure under 120 mm

Hg, and not using suction catheters with outer-to-inner
diameter ratios greater than 0.5 (4,13). These recommendations were followed with small different modalities. In
all cases, we used a single suction pass to avoid phase
effect. A second suction pass performed within 2 minutes
of the first suction (data not shown; this was a pilot study)
induced further increases in ICP and MAP, effects that
have been frequently reported in the literature (4,5). ETS
lasted longer than 10 seconds (but always <30 seconds) to
attain efficient suctioning, and hyperoxygenation (FiO2
1) was maintained for the first 30 seconds after the procedure. Although the theoretical rational of hyperventilation has been proposed (11), we do not hyperventilate the
patients prior to ETS because we wish to avoid abrupt
reduction of carbon dioxide tension (20,21) and hyperinflation, which may affect the ICP response (1).
From our data we can conclude that in severe head
injury, endotracheal suctioning can be accomplished without secondary damage to the patients, provided that a good
level of sedation is maintained. It is possible that sedation
itself may be responsible for the abolition of a significant
rise in ICP. Although rigorous sedation measurement for
patients in the neurointensive care unit is a challenge (24),
we believe that adequate sedation is mandatory to avoid
relevant episodes of intracranial hypertension. In cases of
patients coughing or moving during endotracheal suctioning, we would strongly suggest deepening the level of
sedation before completing the procedure in order to reduce the risk of adverse effects.
References
1. Rudy EB, Turner BS, Baun M, et al. Endotracheal suctioning in
head-injured patients. Heart Lung 1991;20:66774.
2. Cruz J. Combined continuous monitoring of systemic and cerebral
oxygenation in acute brain injury: preliminary observations. Crit
Care Med 1993;21:122532.

Journal of Neurosurgical Anesthesiology, Vol. 14, No. 1, 2002

54

M. GEMMA ET AL.

3. Rising CJ. The relationship of selected nursing activities to ICP. J

Neurosci Nurs 1993;25:3028.
4. Wainwright SP, Gould D. Endotracheal suctioning in adults with
severe head injury: literature review. Intensive Crit Care Nurs 1996;
12:3038.
5. Kerr ME, Weber BB, Sereika SM, et al. Effect of endotracheal
suctioning on cerebral oxygenation in traumatic brain-injured patients. Crit Care Med 1999;22:277681.
6. Donegan MF, Bedford RF. Intravenously administered lidocaine
prevents intracranial hypertension during endotracheal suctioning.
Anesthesiology 1980;52:5168.
7. Tsementzis SA, Harris P, Loizou LA. The effect of routine nursing
care procedures on the ICP in severe head injuries. Acta Neurochir
1982;65:15366.
8. Fanconi S, Duc G. Intratracheal suctioning in sick preterm infants:
prevention of intracranial hypertension and cerebral hypoperfusion
by muscle paralysis. Pediatrics 1987;79:53843.
9. Werba A, Weinstabl C, Petricek W, et al. Requisite muscle relaxation using vecuronium for tracheobronchial suction in neurosurgical intensive care patients. Anaesthetist 1991;40:32831.
10. Brucia JJ, Owen DC, Rudy EB. The effects of lidocaine on intracranial hypertension. J Neurosci Nurs 1992;24:20514.
11. Kerr ME, Brucia J. Hyperventilation in the head-injured patient: an
effective treatment modality? Heart Lung 1993;22:51622.
12. Kerr ME, Sereika SM, Orndoff P, et al. Effect of neuromuscular
blockers and opiates on the cerebrovascular response to endotracheal
suctioning in adults with severe head injuries. Am J Crit Care 1998;
7:20517.
13. Kerr ME, Rudy EB, Brucia J, et al. Head injured adults: Recom-

Journal of Neurosurgical Anesthesiology, Vol. 14, No. 1, 2002

14.

15.
16.

17.
18.
19.
20.
21.
22.

mendations for endotracheal suctioning. J Neurosci Nurs 1993;25:

8691.
Guidelines for the Management of Severe Head Injury. Brain
Trauma Foundation. American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. J Neurotrauma 1996;13:641734.
Miller JD, Pickard JD. Intracranial volume pressure studies in patients with head injury. Injury 1974;5:2658.
Fortune JB, Feustel PJ, Weigle C, et al. Continuous measurement of
jugular venous oxygen saturation in response to transient elevations
of blood pressure in head-injured patients. J Neurosurg 1994;80:
4618.
Contant CF Jr, Robertson CS, Crouch J, et al. Intracranial pressure
waveform indices in transient and refractory intracranial hypertension. J Neurosci Methods 1995;57:1525.
Hanowell LH, Thurston JD, Behrman KH, et al. Alfentanil administered prior to endotracheal suctioning reduces cerebral perfusion
pressure. J Neurosurg Anesthesiol 1993;5:315.
Hsiang JK, Chesnut RM, Crisp CB, et al. Early, routine paralysis for
intracranial pressure control in severe head injury: Is it necessary?
Crit Care Med 1994;22:14716.
Sherman C, Dacey R, Peirson D, et al. The use of hyperventilation
in head injury. Respiratory Care 1986;31:11217.
Kerr ME, Rudy EB, Weber BB, et al. Effect of short-duration hyperventilation during endotracheal suctioning on intracranial pressure in severe head-injured adults. Nurs Res 1997;46:195201.
De Jonghe B, Cook D, Appere-De-Vecchi G et al. Using and understanding sedation scoring systems: a systematic review. Intensive
Care Med 2000;26:275285.