Decreasing the Adverse Effects of Endotracheal Suctioning During Mechanical Ventilation by Changing Practice

Abstract

BACKGROUND: Little is known about the incidence of and risk factors for adverse effects from endotracheal suctioning. We studied the incidence and risk factors, and evaluated the effect of suctioning practice guidelines. METHODS: During a 3-month period, in 79 mechanically ventilated subjects, we recorded the adverse effects in 4,506 suctioning procedures. Then practice guidelines were implemented, and 1 year later, during another 3-month period, in 68 subjects, we recorded the adverse effects in 4,994 suctioning procedures. RESULTS: In the first period, adverse effects occurred frequently: oxygen desaturation in 46.8% of subjects and 6.5% of suctionings, hemorrhagic secretions in 31.6% of subjects and 4% of suctionings, blood pressure change in 24.1% of subjects and 1.6% of suctionings, and heart rate change in 10.1% of subjects and 1.1% of suctionings. After guidelines implementation, all complications, both separately and all together, were reduced. The incidence of all complications together decreased from 59.5% to 42.6% of subjects, and from 12.4% to 4.9% of procedures (both P < .05). PEEP > 5 cm H 2 O was an independent risk factor for oxygen desaturation. Receiving > 6 suctionings per day was a risk factor for desaturation and hemorrhagic secretions. The use of guidelines was independently associated with fewer complications. CONCLUSIONS: Endotracheal suctioning frequently induces adverse effects. Technique, suctioning frequency, and higher PEEP are risk factors for complications. Their incidence can be reduced by the implementation of suctioning guidelines.

Endotracheal Suctioning May or May Not Have an Impact, But It Does Depend on What You Measure!

“…For example, the shallow suctioning method may be more effective for secretion clearance when combined with open suctioning (ventilator circuit disconnection should result in an expiratory flow bias, due to the elastic recoil from passive expiration), as opposed to when combined with closed suctioning, where the negative pressure from the closed suction generated within the ventilator circuit may trigger ventilator breaths and generate an inspiratory flow bias (dependent on ventilator mode) and move or "blow" airway secretions away from the suction catheter tip. 6 SEE THE ORIGINAL STUDY ON PAGE 1588 In this issue of RESPIRATORY CARE, Maggiore et al advocate the shallow suctioning method, 17 as part of a package of airway care to reduce the short-term adverse effects of airway suctioning. However, the airway care recommendations proposed by Maggiore et al 17 require discussion.…”

“…6 SEE THE ORIGINAL STUDY ON PAGE 1588 In this issue of RESPIRATORY CARE, Maggiore et al advocate the shallow suctioning method, 17 as part of a package of airway care to reduce the short-term adverse effects of airway suctioning. However, the airway care recommendations proposed by Maggiore et al 17 require discussion. The potential for short-term adverse effects with endotracheal suctioning may include arterial oxygen desaturation, changes in blood pressure and heart rate, and local trauma to the airway.…”

“…8 There is no evidence that links these short-term physiological changes with important patient outcomes such as mortality, mechanical ventilation duration, or ventilator-associated pneumonia, 18 so there is no evidence to support either open or closed suctioning. Of note, the data collection period for the report from Maggiore et al 17 was over a decade ago (between 2000 to 2001). The clinical relevance of these findings must be extrapolated on the basis of current practice.…”

“…The clinical relevance of these findings must be extrapolated on the basis of current practice. In the methods reported by Maggiore et al, 17 these were based on evidence published 16 after the trial had been conducted. Maggiore et al 17 advocate that the shallow endotracheal suctioning method 16 would be less deleterious, compared with standard or deep endotracheal suctioning.…”

“…In the methods reported by Maggiore et al, 17 these were based on evidence published 16 after the trial had been conducted. Maggiore et al 17 advocate that the shallow endotracheal suctioning method 16 would be less deleterious, compared with standard or deep endotracheal suctioning. However, the shallow suctioning method described by Maggiore et al 17 utilized closed suctioning (clinicians were to advance the suction catheter and insertion was stopped if an obstacle was met, and the suction catheter was withdrawn approximately 1 cm.…”