Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia*

Caruso, Pedro; Denari, Silvia D C; Ruiz, Soraia A. Lusvardi; Demarzo, Sérgio Eduardo; Deheinzelin, Daniel

doi:10.1097/ccm.0b013e3181930026

Cited by 102 publications

(79 citation statements)

References 38 publications

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“…Caruso et al 7 found that routine suctioning based on indications described in the guidelines 1 of the American Association of Respiratory Care, along with instillation of physiological saline, reduced the risk for ventilatorassociated pneumonia by 54% in a sample of critically ill patients. The authors 7 hypothesized that suctioning and/or coughing induced after the instillation of physiological saline may have contributed to the reduced risk for infection. Blamoun et al 8 included regular endotracheal suctioning, defined as suctioning every 4 hours, as part of an expanded ventilator bundle and were successful in reducing the rates of ventilator-associated pneumonia to zero.…”

Section: Introductionmentioning

confidence: 99%

Clinical Indicators for Endotracheal Suctioning in Adult Patients Receiving Mechanical Ventilation

Sole

Bennett

Ashworth

2015

American Journal of Critical Care

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A closed-book, multiple-choice examination following this article tests your under standing of the following objectives:1. Identify the recommended assessment parameters to determine the need for endotracheal suctioning in patients receiving mechanical ventilation. 2. Explain the potential for inaccurate assessment of the need for endotracheal suctioning based on the most frequently used clinical indicators. 3. Discuss which clinical assessments, according to study findings, best indicate the need for endotracheal suctioning, and why.To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue. " No CE test fee for AACN members.Background Critically ill patients who need mechanical ventilation require endotracheal suctioning. Guidelines recommend coarse crackles over the trachea and/or the presence of a sawtooth pattern on the flow-volume loop of the ventilator waveform as the best indicators. Objective To determine clinical cues for endotracheal suctioning in patients who require mechanical ventilation. Methods A descriptive study of 42 adult patients receiving mechanical ventilation. After baseline endotracheal suctioning with a closed-system device, patients were assessed hourly up to 4 hours for guideline-based cues for endotracheal suctioning and lung sounds were auscultated. Endotracheal suctioning was done when cues were detected or 4 hours after baseline suctioning. Secretions were collected, measured, and weighed. Results Most patients were male (62%) and white (93%). Mean age was 51 years, and mean duration of mechanical ventilation was 7.5 days. The median time to endotracheal suctioning was 2 hours, and a mean of 4.4 mL of secretions was removed. Three patients had no cues identified but had 1.0 mL or more of secretions. The most frequent cues were crackles over the trachea (88%), sawtooth waveform (33%), coughing (29%), and visible secretions (5%). Cues resolved and physiological parameters improved after suctioning. Coarse lung sounds did not improve.Conclusions Patients receiving mechanical ventilation should be routinely assessed for coarse crackles over the trachea, the most common indicator for endotracheal suctioning. Despite common practice, assessment of lung sounds to identify the need for suctioning is not supported. by AACN on May 11, 2018 http://ajcc.aacnjournals.org/ Downloaded from C ritically ill patients treated with mechanical ventilation require an artificial airway, either an endotracheal tube or a tracheostomy tube. These patients often retain tracheobronchial secretions because of impaired cough reflex, decreased mucociliary clearance, and, possibly, increased mucus production. Endotracheal suctioning is essential to remove retained tracheobronchial secretions, and nurses and respiratory care practitioners assume the responsibility for removal. The 2010 clinical practice guidelines 1 for endotracheal suctioning of the American Association of Respiratory Care specify that endotracheal suctioning should be done when clinically ind...

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Section: Introductionmentioning

confidence: 99%

Clinical Indicators for Endotracheal Suctioning in Adult Patients Receiving Mechanical Ventilation

Sole

Bennett

Ashworth

2015

American Journal of Critical Care

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“…14 One recent study 15 in adults showed fewer cases of microbiologically proven VAP when saline instillation occurred before suctioning (relative risk reduction, 54%) and no association between saline use and endotracheal tube obstruction. Other respiratory interventions such as physiotherapy may have contributed to a reduction in their VAP rate.…”

Section: Discussionmentioning

confidence: 99%

A Bedside Decision Tree for Use of Saline With Endotracheal Tube Suctioning in Children

Owen

Woods

O'Flynn

et al. 2016

Critical Care Nurse

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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 common 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 desaturation (P < .001). Patient factors associated with adverse events include younger age (P < .001), a cuffed endotracheal 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.

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“…Caruso's 2009 study of 262 adult patients found a VAP risk reduction of 54% with routine saline instillation. 61 A limitation of that study may be that HMEs were utilized to provide humidification, possibly necessitating saline instillation for secretion thinning.…”

Section: Saline Instillationmentioning

confidence: 99%

Pediatric Airway Maintenance and Clearance in the Acute Care Setting: How To Stay Out of Trouble

2011

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1424RESPIRATORY CARE • SEPTEMBER 2011 VOL 56 NO 9Traditional airway maintenance and clearance therapy and principles of application are similar for neonates, children, and adults. Yet there are distinct differences in physiology and pathology between children and adults that limit the routine application of adult-derived airway-clearance techniques in children. This paper focuses on airway-clearance techniques and airway maintenance in the pediatric patient with acute respiratory disease, specifically, those used in the hospital environment, prevailing lung characteristics that may arise during exacerbations, and the differences in physiologic processes unique to infants and children. One of the staples of respiratory care has been chest physiotherapy and postural drainage. Many new airway clearance and maintenance techniques have evolved, but few have demonstrated true efficacy in the pediatric patient population. Much of this is probably due to the limited ability to assess outcome and/or choose a proper disease-specific or age-specific modality. Airway-clearance techniques consume a substantial amount of time and equipment. Available disease-specific evidence of airway-clearance techniques and airway maintenance will be discussed whenever possible. Unfortunately, more questions than answers remain.

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Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia*

Abstract: Instillation of isotonic saline before tracheal suctioning decreases the incidence of microbiological proven VAP.

Cited by 102 publications

References 38 publications

Clinical Indicators for Endotracheal Suctioning in Adult Patients Receiving Mechanical Ventilation

Clinical Indicators for Endotracheal Suctioning in Adult Patients Receiving Mechanical Ventilation

A Bedside Decision Tree for Use of Saline With Endotracheal Tube Suctioning in Children

Pediatric Airway Maintenance and Clearance in the Acute Care Setting: How To Stay Out of Trouble

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