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Instillment of
Saline in
Suctioning
Anna Elizondo, Jennifer Garred, Ana
Hopkins, Lorelei Mahrer, Xochitl Monge,
Sarah Naves, Paige Perry Lauren Powell,
& Leah Silver
PICOT Question
During endotracheal (ET) or tracheostomy tube suctioning, does the utilization of
saline increase the efficacy of extracting secretions when compared with traditional
dry suctioning in hospitalized patients that have either an endotracheal or
tracheostomy tube?
PICOT:
P Patients with endotracheal or tracheostomy tubes
I Use of saline to increase the efficacy of extracting secretions
C Compared to dry suctioning
O Improved efficacy of extracting secretions
T During patient hospitalization
Artificial and positive pressure ventilation induce increased production of bronchial secretions
Airway suctioning is one of the most common treatments performed to intubated patients and is most
often done by nurses
Some nurses believe that instillation of normal saline before suctioning is effective in lubricating and
removing pulmonary secretions
Other nurses believe that it contributes to more unstable patients, excessive coughing, and
pneumonia
Problem
There are no clear guidelines for nurses regarding suctioning with saline
There are many nurses who use saline before suctioning and many who do not
Purpose
SYNOPSIS OF CURRENT
FINDINGS
FOR NSI
MIXED STANCE
AGAINST NSI
Brokalaki, 2011)
Systematic Review of
Descriptive Studies (Level V)
(Ayhan, Tastan, Iyigun, Akamca, Arikan, & Sevim, 2015)
(Favretto, Silveira, Canini, Garbin, Martins, Dalri, 2012)
Oxygenation: Decreased
oxygenation; lower SpO2 after one
minute and fifteen minutes when
using NSI
Type of Article
AGAINST NSI
Controlled Clinical Trial with
Randomization (Level II)
(Akbaryan Deheki, Sanagoo, Amri, Moghaddam,
Vakili, Nasiri, & Jouybari, 2014).
(Adib, Ghanbari, Alavi, & Leyli, 2014)
Strengths
FOR NSI
Controlled Clinical Trial with
Randomization (Level II)
(Caruso, Denari, Ruiz, Demarzo, & Deheinzelin,
2009)
Limitations
Similar participant
characteristics
NSI was the only independent
variable that contributed to
VAP
Long study time
Type of Article
Strengths
AGAINST NSI
Experimental (Level III)
(Rafiee, Iranmanesh, Sabzevari, 2011)
(Zahran & El-Razik, 2011)
MIXED STANCE
Experimental (Level III)
(Giakoumidakis, Kostaki, Patelarou, Baltopoulos, &
Brokalaki, 2011)
Limitations
Type of Article
Strengths
MIXED STANCE
Systematic Review of
Descriptive Studies (Level
V)
Limitations
Only female nurses
No pediatric studies were
included
Only English studies were
used
Study took place in a single
location
Evidence of saline still
remains contradictory
Type of Article
AGAINST NSI
Qualitative Studies (Level
VI)
(Leddy & Wilkinson, 2015)
Strengths
Consistent with findings
from other studies
High response rates from
RNs (94%) and RRTs (97%)
Minimal risk study
Limitations
Geographical proximity of
participants
Lacks institution diversity
Not enough participants to
be considered a large study
Type of Article
Findings
AGAINST NSI
Controlled Clinical Trial with
Randomization (Level II)
(Akbaryan Deheki, Sanagoo, Amri, Moghaddam, Vakili,
Nasiri, & Jouybari, 2014).
(Adib, Ghanbari, Alavi, & Leyli, 2014)
FOR NSI
Controlled Clinical Trial with
Randomization (Level II)
(Caruso, Denari, Ruiz, Demarzo, & Deheinzelin, 2009)
Conclusions
Type of Article
Findings
AGAINST NSI
Experimental (Level III)
(Rafiee, Iranmanesh, Sabzevari, 2011)
(Zahran & El-Razik, 2011)
MIXED STANCE
Experimental (Level III)
(Giakoumidakis, Kostaki, Patelarou,
Baltopoulos, & Brokalaki, 2011)
Conclusions
Decreased oxygenation
saturation
Increased HR
PaCO2 increased
Reduction in PaO2
Type of Article
Findings
MIXED STANCE
Systematic Review of
Descriptive Studies (Level V)
(Ayhan, Tastan, Iyigun, Akamca, Arikan, &
Sevim, 2015)
(Favretto, Silveira, Canini, Garbin, Martins, Dalri,
2012).
Conclusions
Type of Article
Findings
AGAINST NSI
Qualitative Studies (Level VI)
(Leddy & Wilkinson, 2015)
Conclusions
Pre-survey
4 hour training
session
Post-survey
Reassessment
Cost Analysis
Banner University Medical Center:
Evidence-based Recommendation
Banner ICU RN: $34.94/hr
Banner Respiratory
(Glassdoor, 2016)
Training Hours: 4 hour training
Therapist: $22.00/hr (Glassdoor, 2016)
Training Hours: 4 hour training
session for endotracheal suctioning
session for endotracheal
Total Cost: $139.76 per trained nurse
suctioning
Total Cost: $88.00 per trained
a week
No overtime because less than or
respiratory therapist a week
equal to 40 hours
(12 hrs X 3 days = 36 hrs + 4 hrs = 40 hrs)
(U.S. Department of Labor, n.d.)
Cost Analysis
Hospital-acquired Infections in the
United States
Estimated $9.8 billion a year
(Waknine, 2013)
Ventilator-associated Pneumonia:
second most common reason
(31.6%)
(Waknine, 2013)
(Winters, 2013)
(Medscape, 2016)
Ventilator-associated
Pneumonia: average $40,144
per case
(Medscape, 2016)
Cost Analysis
Additional Costs of NSI:
Normal Saline Syringes
Cost per 1 Syringe: $1.23
Frequency of Use: 57 of 65
nurses report using NSI when
suctioning
Bronchospasm:
Albuterol: $40.82/90mL
(Vallerand, Sanoski, & Deglin, 2013)
Dislodgement of bacteria in
lower airways
Causes VAP: $40,144
(American Association for Respiratory Care, 2010)
Excessive coughing
Increased hypoxia
Bronchospasm
Dislodgement of the bacterial biofilm that colonizes the
ETT into the lower airway
Pain, anxiety, dyspnea
Dry Suctioning
Not associated with a decreased
incidence of VAP
(Caruso et al., 2009; Favretto et al., 2012)
Dry Suctioning
Oxygen desaturation and increased
heart rate is less marked
(Rafiee et al., 2011)
Evaluation/SMART Outcomes
Hospital Outcomes
Teach ICU nursing staff about evidence-based endotracheal suctioning by having the nurses attend an
education session of 4 hours and then evaluating the knowledge gained through a survey within a month of
the instructional program.
Evaluate efficacy of implementation of endotracheal suctioning by auditing the NSI use by ICU nursing staff for 1
month and then 6 months after the education session.
The hospital will initiate a formal protocol outlining the use of evidence-based endotracheal suctioning within 6-7
months.
Patient Outcomes
Patients will have a improved hemodynamic parameters in the form of higher oxygen saturation immediately
after the endotracheal suctioning once the nurses attend the endotracheal educational program and employ
evidence-based nursing techniques.
Summary
Question: Do we as nurses use saline during ET/tracheostomy suctioning or do we use dry suctioning to more effectively
extract secretions?
ET suctioning is a common nursing practice, yet there are no definitive guidelines stating whether or not nurses should
be suctioning with saline.
The result? Some nurses use saline instillation when suctioning their patients and some do not (Adib, Ghanbari, Alavi, & Leyli, 2014;
Caparros & Forbes, 2014).
Some studies are against the use of saline instillation as it can decrease the patients oxygen saturation and can also
cause an increase in HR, BP, and RR (Akbaryan et al., 2014).
However, there are also recent studies that indicate saline use before suctioning is beneficial in that it decreases the
incidence of VAP (Ayhan et al., 2015; Caruso et al., 2009; Favretto et al., 2012).
Therein lies the problem; there is a lack of definitive evidence for the use of NSI before suctioning.
Despite there being mixed findings in relation to this issue, The American Association for Respiratory Care on ET
Suctioning (2014) has outlined best practice for ET suctioning which concludes that:
The majority of studies used to update current guidelines state NSI is not likely beneficial and may be harmful or even
detrimental to the patients
NSI with suctioning is not recommended to be routinely performed
Summary Continued
This recommendation can be applied to a specific hospital facility using Rogers diffusion of innovations theory whereby
Through persuasion and decision making, they can decide whether or not they will adopt or reject the
intervention
This application process should take approximately 6-7mo from start to finish
In terms of cost, given that NSI is not recommended based on current evidence and can even be harmful to patients,
any additional costs associated with the implementation of the new protocol are worthwhile for the hospital to
acquire as the adverse events associated with NSI could instill an even greater cost burden to the facility.
The risks associated with continuing to use saline during suctioning include adverse effects associated with
oxygenation, respiration rate, ventilation, and alterations in hemodynamic parameters post suctioning. In
using dry suctioning, the patient benefits from a less marked change in oxygen desaturation and less of an
increase in HR (Akbaryan et al., 2014; American Association for Respiratory Care, 2010; Ayhan et al., 2015; Giakoumidakis et al., 2011; Rafiee et al.,
2011; Zahran & El-Razik 2011).
SUMMARY
Overall, in spite of what nurses believe to be the most effective form of suctioning,
in keeping with current best practice, nurses SHOULD NOT instill the use of saline
before suctioning to improve the efficacy of extracting secretions. Further clinical
trials are crucial to effectively determine if saline instillation use with suctioning an
artificial airway is deemed harmful, so that it can then be strictly enforced as a
mandatory clinical guideline for all hospitals to include in their standardized
protocol (Caparros & Forbes, 2014).
Case Study
You are working on a medical-surgical unit. One of your patients is a 50 year-old
man who was just transferred from the intensive care unit. He has a history of
pneumonia and had a tracheostomy tube placed 2 days ago.
His vital signs are:
BP: 150/94 mmHg
HR: 110 beats/min
RR: 30 breaths/min
Oxygen saturation: 80%
(Assessment Technologies Institute, n.d.)
Practice Questions
Which of the following is your priority intervention for this patient at this time?
A. Prepare to obtain a specimen for arterial blood gases
B. Suction the patients airway
C. Assist the patient to semi-Fowlers position
Practice Questions
Which of the following is your priority intervention for this patient at this time?
A. Prepare to obtain a specimen for arterial blood gases
Although it is essential to monitor this patients ABG values, this is not your highest priority action at this time.
Practice Questions
You gather the equipment youll need to perform tracheal suctioning, explain the
procedure to the patient, and perform hand hygiene. You don clean gloves, a
gown, goggles, and a mask. You open your suction catheter kit. Just before you
suction the patients airway, which of the following actions should you perform?
A. Hyperoxygenate the patient
B. Adjust the suction pressure to 150 mm Hg
C. Inspect the lumen of the tracheostomy tube
Practice Questions
You gather the equipment youll need to perform tracheal suctioning, explain the
procedure to the patient, and perform hand hygiene. You don clean gloves, a
gown, goggles, and a mask. You open your suction catheter kit. Just before you
suction the patients airway, which of the following actions should you perform?
A. Hyperoxygenate the patient
To help prevent a decline in oxygen saturation during suctioning, increase the supplemental oxygen to 100% or as prescribed
by the provider.
Practice Questions
While suctioning the patients tracheostomy, you note that his pulmonary
secretions are quite thick. Which of the following interventions should you decide
to add to the patients nursing care plan to help thin the secretions?
A. Perform chest physiotherapy
B. Instill sterile normal saline solution into the airway
C. Increase fluid intake
Practice Questions
While suctioning the patients tracheostomy, you note that his pulmonary
secretions are quite thick. Which of the following interventions should you decide
to add to the patients nursing care plan to help thin the secretions?
A. Perform chest physiotherapy
Although chest physiotherapy may help in mobilizing secretions, it will not reduce their viscosity.
Results
After suctioning your patients vital signs are:
BP: 122/90 mmHg
HR: 82 beats/min
RR: 16 breaths/min
Oxygen saturation: 95%
QUESTIONS?
References
Adib, M., Ghanbari, A., Alavi, C. E., & Leyli, E. K. (2014). Effect of endotracheal suctioning with and without normal saline on
hemodynamic and respiratory parameters in patients undergoing mechanical ventilation in ICUs of hospitals supervised by Guilan University of
Medical Sciences . Biomedical and Pharmacology Journal, 7(2), 515-523. doi: 10.13005/bpj/519
Akbaryan Deheki, N., Sanagoo, A., Amri, P., Moghaddam, S., Vakili, M. A., Nasiri, H., & Jouybari, L. M. (2014). Comparing the
effect of using normal saline, N-acetyl cysteine and not using them in endotracheal tube suction on physiologic parameters and
the amount of secretions in intubated patients under mechanical ventilation. Iran J Crit Care Nurs., 6(4), 152-159.
American Association for Respiratory Care (2010). AARC Clinical Practice Guidelines: Endotracheal suctioning of mechanically
ventilated patients
with artificial airways 2010. Respiratory Care, 55(6): 75864.
Assessment Technologies Institute. (n.d.). Airway management. Retrieved from
http://www.atitesting.com/ati_next_gen/skillsmodules/content/airway-management/casestudies.html
References Continued
Ayhan, H., Tastan, S., Iyigun, E., Akamca, Y., Arikan, E., & Sevim, Z. (2015). Normal saline instillation before endotracheal
suctioning: what does the evidence say? what do the nurses think?: Multimethod study. Journal of Critical Care, 30(4),
762-767. doi:10.1016/j.jcrc.2015.02.019 [doi]
Caparros, A. C. S., & Forbes, A. (2014). Mechanical ventilation and the role of saline instillation in suctioning adult intensive care unit
patients: An evidence-based practice review. Dimensions of Critical Care Nursing, 33(4), 246-253.
Caruso, P., Denari, S., Ruiz, S. A., Demarzo, S. E., & Deheinzelin, D. (2009). Saline instillation before tracheal suctioning decreases the
incidence of ventilator-associated pneumonia. Critical Care Medicine, 37(1), 32-38. doi:10.1097/CCM.0b013e3181930026 [doi]
Favretto, D. O., Silveira, R., Canini, S., Garbin, M., Martins, F., Dalri, M. (2012). Endotracheal suction in intubated critically ill adult
patients undergoing mechanical ventilation: a systematic review. Latin American Journal of Nursing, (20)5, 997-1007. Retrieved from:
http://www.scielo.br/scielo.php?pid=s0104-11692012000500023&script=sci_arttext
Giakoumidakis, K., Kostaki, Z., Patelarou, E., Baltopoulos, G., & Brokalaki, H. (2011).Oxygen saturation and secretion weight after
endotracheal suctioning. British Journal Of Nursing, 20(21), 1344-1351.
References Continued
Glassdoor (2016). Banner health. Retrieved from
https://www.glassdoor.com/Salary/Banner-Health-Tucson-Salaries-EI_IE11958.0,13_IL.14,20_IM869.htm
Leddy, R., & Wilkinson, J. M. (2015). Endotracheal suctioning practices of nurses and respiratory therapists: how well do they align
with clinical practice guidelines? Canadian Respiratory Journal of Respiratory Therapy, 51(3), 60-64.
Medscape (2016). Ventilator-assisted pneumonia overview of nosocomial pneumonias. Retrieved from
http://emedicine.medscape.com/article/304836-overview
Moore Medical LLC (2016). Retrieved from
https://www.mooremedical.com/Index.cfm?Ntk=all&No=0&Search=Search&Ns=Searchorder
%7C0%7C&Ntx=mode+matchpartialmax&Ntt=normal+saline##
Rafiee, H., Iranmanesh, S., Sabzevari, S. (2011). Comparison of the endotracheal tube suctioning with and without normal saline
solution on heart rate and oxygen saturation. Iranian Journal of Critical Care Nursing, 4(3), 117-120. Retrieved from
http://www.inhc.ir/browse.php?a_code=A-10-20-2&slc_lang=en&sid=1
References Continued
Rogers, E. M. (2003). Diffusion of innovation. New York, NY: Free Press.
United States Department of Labor (2016). Wage and hour division. Retrieved from
http://www.livescience.com/39510-icu-treatment-overused.html
Vallerand, A.H., Sanoski, C. A. & Deglin, J.H. (2013). Daviss drug guide for nurses (13th ed.). Philadelphia: F.A. Davis Company.
Waknine (2013). Hospital infections cost billions, study shows. Retrieved from http://www.medscape.com/viewarticle/810372
Winters (2016). Critical care may not be always be the right choice. Retrieved from
http://www.livescience.com/39510-icu-treatment-overused.html
Wunsch, H., Wagner, J., Herlim, M., Chong, D. H., Kramer, A. A., & Halpern, S. D. (2013). ICU occupancy and mechanical ventilator
use in the united states. Critical Care Medicine, 41(12), 2712-2719. doi:10.1097/CCM.0b013e318298a139 [doi]
Zahran, E. M., & El-Razik, A. A. (2011). Tracheal suctioning with versus without saline instillation. Journal of American Science,
7(8), 23-32.