Intensive care suction for intubated and non-intubated patients, including saline instillation
AARC Clinical Practice Guideline: Endotracheal suctioning of mechanically ventilated patients with artificial airways (2010) Respir Care, 55, 6, 75864
www.rcjournal.com/cpgs/pdf/06.10.0758.pdf
AARC Clinical Practice Guideline: Nasotracheal suctioning and endotracheal suctioning of mechanically ventilated patients with artificial airways (2004) Respir Care, 49, 9, 1080
www.rcjournal.com/cpgs/pdf/09.04.1080.pdf
AARC Clinical Practice Guideline: Suctioning of the patient in the home (1999) Respir Care, 44, 1, 99,
www.rcjournal.com/cpgs/pdf/01.99.99.pdf
Ackerman MH, Mick DJ (1998). Instillation of normal saline before suctioning in patients with pulmonary infections: a prospective randomized controlled trial. Am J Crit Care, 7, 261-6.
Ackerman MH (1996) A review of normal saline instillation. Dim Crit Care Nurs, 15, 1, 31-35
23% vials are contaminated during opening.
suction with saline instillation dislodged more bacteria from endotracheal tube than suction without saline.
AARC outcomes - improved breath sounds, reduced peak inspiratory pressure (VC), increased tidal volume (PC), increased SaO2, increased secretion removal
Bodenham AR (2002) Removal of obstructing blood clot from the lower airway: an alternative suction technique. Anaesthesia, 57, 40-3
Bostick J, Wendelgass ST (1987) Normal saline instillation as part of the suctioning procedure. Heart Lung, 16, 532-6.
Brierly S et al (2003) Safety and tolerance of HFCWO in hospitalised critical care patients. Respir Care, 48, 11, 1112
Branson RD (2007) Secretion management in the mechanically ventilated patient. Respir Care, 52, 10, 13281342
www.rcjournal.com/contents/10.07/10.07.1328.pdf
Brown SE (1983) Prevention of suction-related arterial oxygen desaturation. Chest, 83, 621-8
intermittent suction reduces effectiveness by reducing flow from 18-20 L/min to 8-9 L/min
Buchanan (1986) The effect of hyperinflation, inspiratory hold and oxygenation on cardiopulmonary status during suction. Heart Lung,15,127-34.
Callaghan SP (1994) Minitracheostomy: an alternative to 'blind' endotracheal suctioning. Dim Crit Care Nurs, 13, 38-43
Caruso P et al (2009) Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Med, 37(1):32-8
www.ncbi.nlm.nih.gov/pubmed/19050607?dopt=AbstractPlus
instillation of isotonic saline before tracheal suctioning decreases the incidence of ventilator-associated pneumonia
Cereda M et al (2001) Closed system endotracheal suctioning maintains lung volume during volume-controlled mechanical ventilation. Int Care Med, 27, 648-54
closed suctioning avoids suction-related volume loss
Clark (1990) Effects of endotracheal suctioning on mixed venous oxygen saturation and heart rate in critically ill adults. Heart Lung, 19, 552-57.
oxygenation pre- and post-suction is recommended
Chatila W, Hall JB, Manthous CA (1995) The effect of pulmonary secretions on respiratory mechanics in intubated patients. Respir Care, 40, 1048-51
suction does not reduce airways resistance
Chulay M (1988) Arterial blood gas changes with a hyperinflation and hyperoxygenation suctioning intervention. Heart Lung, 17, 654-61
manual hyperinflation with suction prevents desaturation in the majority of patients
Copnell B (1995) Endotracheal suctioning. Am J Crit Care, 4, 100-5
criteria for suction
Czarnik RE, Stone KS et al (1991) Differential effects of continuous versus intermittent suction on tracheal tissue. Heart Lung, 20, 144-51.
Day T (2000) Tracheal suctioning: when, why and how. Nurs Times, 96, 20, 13-15.
Day T, Wainwright S, Wilson-Barnett J (2001) An evaluation of a teaching intervention to improve the practice of endotracheal suctioning in intensive care units. J Clin Nurs, 10, 682-96.
Day T, Farnell S, Wilson-Barnett J (2002) Suctioning: a review of current research recommendations. Int Crit Care Nurs, 18, 2, 79-89
www.sciencedirect.com/science?_ob=ArticleListURL&_method=list&_ArticleListID=1805059705&_sort=r&_st=13&view=c&_acct=C000228598&_version=1&_urlVersion=0&_userid=10&md5=fa18fd74e0d3312b37f793a8c16e1f48&searchtype=a
Dean B (1997) Evidence-based suction management in A and E. Acc Emerg Nurs, 5, 92-8
catheters, technique, complications
Donald KJ (2000) Setting safe and effective suction pressure: the effect of using a manometer in the suction circuit. Int Care Med, 26, 15-19
Dyhr T (2002) Lung recruitment manoeuvres are effective in regaining lung volume and oxygenation after open endotracheal suctioning in ARDS. Crit Care, 7, 55-62
ccforum.com/content/7/1/55
catheters, technique, complications
Fernαndez M (2004) Changes in lung volume with three systems of endotracheal suctioning with and without pre-oxygenation. Int Care Med, 30, 12, 2210-15
springerlink.metapress.com/(4nt0hn55kegoqri5o1po2rub)/app/home/contribution.asp?referrer=parent&backto=issue,10,29;journal,21,297;browsepublicationsresults,615,1574
Glass & Grap (1995) Ten tips for safer suctioning. Am J Nurs, 95, 5, 51-3
Grap & Glass (1994) Effect of lung injury on heart rate, mean arterial pressure and SaO2 changes during suctioning. Int Crit Care Nurs, 10, 171-8.
heart rate and BP increase significantly during suction
Gray JF (1990) The effects of bolus normal saline instillation in conjunction with endotracheal suctioning. Respir Care, 35, 785-90.
saline may help dislodge encrusted secretions or encourage coughing
Guglielminotti J (1998) Effects of tracheal suctioning on respiratory resistances. Chest, 113, 1335-8
suction does not reduce resistance, but may reduce intrinsic PEEP
Guglielminotti J (2000) Bedside detection of retained tracheobronchial secretions in patients receiving mechanical ventilation. Chest, 118,1095-9
sawtooth pattern on flow-volume loop indicates secretions
Halm MA, Krisko-Hagel K (2008) Instilling normal saline with suctioning: beneficial technique or potentially harmful sacred cow? Am J Crit Care, 17, 5, 469-72
ajcc.aacnjournals.org/cgi/content/full/17/5/469
argument against routine use of saline instillation.
best interventions for thick secretions are hydration, humidification and mobilization
Heinze H et al (2011) Functional residual capacity-guided alveolar recruitment strategy after endotracheal suctioning in cardiac surgery patients. Crit Care Med, 39, 5, 1042-9
journals.lww.com/ccmjournal/toc/2011/05000
benefit from a post-suction recruitment manoeuvre can be identified by measuring FRC
Henley C, Draper A (2002) Endotracheal suction of mechanically ventilated patients: a brief review of the literature. ACPRC Journal, 35, 29-31
overview including saline, open vs. closed catheters
Hess DR (1999) Managing the artificial airway. Respir Care, 44, 759-73
Hicky J (2006) Manually ventilating and suctioning in-line with a SensorMedics 3100B high frequency oscillatory ventilator bench test. AARC Conference, Texas
www.cardinal.com/mps/focus/respiratory/abstracts/abstracts/ab2006/OF-06-157.asp
method for manual hyperinflation and suction without losing airway pressure with HFO
Howard (1994) Endotracheal suctioning and the neonate. Paed Nurs, 6,7,14-17
greater negative pressure doesn't remove more secretions
Isea (1993) Controlled trial of a continuous irrigation suction catheter vs conventional intermittent suction catheter. Chest, 103, 1227-30.
www.chestjournal.org/cgi/content/abstract/103/4/1227 (abstract only)
continuous-irrigation catheters show improved clearance
Jenkin A (1996) The nasopharyngeal airway. Acc Emerg.Nurs, 4, 16-20
technique of insertion and use
Jevon P (2001) Insertion of an oropharyngeal airway. Nurs Times, 97, 43, 39-40
Johnson KL (1994) Closed versus open endotracheal suctioning. Crit Care Med, 22, 658-66
closed suction causes fewer physiological disturbances
Jubran A, Tobin M (1994). Use of flow-volume curves in detecting secretions in ventilator dependent patients. Am J Respir Crit Care Med, 150, 7669.
Judson (1994) Mobilization of secretions in ICU. Respir Care, 39, 213-25.
saline instillation may be beneficial
Kinloch D, Rock L (1999) Instillation of normal saline during endotracheal suctioning. Am J Crit Care, 8, 231-240
saline instillation can have an adverse effect on oxygenation if used routinely
Klein P, Kemper M et al (1988) Attenuation of the hemodynamic responses to chest physical therapy. Chest, 93, 38-42.
narcotic analgesic before suction attenuates haemodynamic disturbance
Knipper (1986) Minimizing complications of tracheal suctioning. Focus Crit.Care, 13, 4, 23-6
debunks myth of safety of boxed gloves
Leur JP, Zwaveling JH, Loef BG et al (2003) Endotracheal suctioning versus minimally invasive airway suctioning in intubated patients. Int Care Med, 29, 426-32
shallow suctioning is less damaging than deep suctioning
Leur JP, Zwaveling JH, Loef BG, Schans CP (2003) Patient recollection of airway suctioning in the ICU: routine versus a minimally invasive procedure. Int Care Med, 29, 433-6.
Lewis RM (2002) Airway clearance techniques for the patient with an artificial airway. Resp Care, 47, 808-17
review of current research, including prevention of infection
Lewis RM (2002) Airway clearance tachniques for the patient with an artificial airway. Respir Care, 47, 7, 808-17
www.rcjournal.com/contents/07.02/07.02.0808.cfm
Lorente L (2006) Tracheal suction by closed system without daily change versus open system. Int Care Med, 32, 4, 538-44
springerlink.metapress.com/(4nt0hn55kegoqri5o1po2rub)/app/home/contribution.asp?referrer=parent&backto=issue,9,37;journal,4,297;browsepublicationsresults,615,1574
closed suction without daily change is optimal if suction is required for < 4 days
Maggiore SM (2003) Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury. Am J Resp Crit Care Med, 167, 1215-24.
ajrccm.atsjournals.org/content/167/9/1215.full?sid=f879f9fa-5558-4a5a-b23b-edd24ae64279
suction-induced atelectasis in acute lung injury can be prevented by a recruitment manoeuvre (pressure support at 40 cm H2O) during suction, and minimized by avoiding disconnection
Martinez et al (1994) Increased resistance of hygroscopic condenser humidifiers when using closed circuit suction. Crit Care Med, 22, 1668-73.
saline may get into HME
Masry AE, Williams PR, Chipman DW et al (2005) The impact of closed endotracheal suctioning systems. Respir Care, 50, 345-53
closed suctioning can decrease PEEP during suctioning
McEleney M (1998) Endotracheal suction. Prof Nurse, 13, 373-6.
comprehensive review article
Ntoumenopoulos G (2008) Mucus on the move: embed it or expel it--the patient, the clinician, and now the ventilator. Respir Care, 53, 10, 1276-9.
Odell et al (1993) Endotracheal suction for adult non-head-injured patients. A review of the literature. Int.Crit.Care Nurs, 9, 274-78.
ONeal PV, Grap MJ, Thompson C et al (2001) Level of dyspnoea experienced in mechanically ventilated adults with and without saline instillation prior to endotracheal suctioning. Int Crit Care Nurs, 17, 356-63
Paratz JD, Stockton, KA (2009) Efficacy and safety of normal saline instillation: A systematic review. Physiotherapy, 95, 4, 241-250
little evidence of benefit but minimal evidence of risk
Preusser BA (1988) Effects of two methods of preoxygenation on mean arterial pressure, cardiac output, peak airway pressure and postsuctioning hypoxemia. Heart Lung, 17, 290-9.
preoxygenation by ventilator or bag both helpful
Rossoff LJ (1995) Is handwashing really needed in an intensive care unit? Crit.Care Med, 23, 1211-6
half of boxed gloves are contaminated
Quirke S (1998) A comparative study of nosocomial colonisation with closed suction catheter changes at 24 vs 48 hours. Care Crit.Ill, 14, 116-20
closed circuit catheter best used for 48 hours
Schreuder FM, Jones UF (2004) The effect of saline instillation on sputum yield and oxygen saturation measurement in adult intubated patients (abstract). Physiotherapy, 90, 108-9
single study design showing increased sputum yield with saline instillation
Seymour CW, Cross BJ, Cooke CR (2009) Physiologic impact of closed-system endotracheal suctioning in spontaneously breathing patients receiving mechanical ventilation. Respir Care, 54, 3, 367-74
www.rcjournal.com/contents/03.09/03.09.0367.pdf
pre-oxygenation maintains oxygenation during and after suction
adverse effects of suction last longer in sedated and paralysed patients than in weaning patients.
Siempos II, Vardakas KZ, Falagas ME (2008) Closed tracheal suction systems for prevention of ventilator-associated pneumonia. Br J Anaesth, 100, 3, 299-306.
bja.oxfordjournals.org/cgi/content/full/100/3/299
meta-analysis showing no benefit of closed over open suction: no difference in mortality or length of stay; closed system showed longer time on IPPV and higher colonisation rates.
Takahashi N (2004) Anatomic evaluation of postural bronchial drainage of the lung with special reference to patients with tracheal intubation. Chest, 125, 935 44
www.chestjournal.org/cgi/content/full/125/3/935?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&volume=125&firstpage=935&resourcetype=HWCIT
Turnock C (1997) ICU syndrome. Br J Int Care, 7, 144-7
suction can cause 'great fear' when performed without warning
Unoki T (2004) Effects of expiratory rib cage compression combined with endotracheal suctioning on gas exchange in mechanically ventilated rabbits with induced atelectasis. Resp Care, 49, 896-901
rib cage compression probably exacerbates atelectasis
Wainright SP, Gould D (1996) Endotracheal suction. J Clin Nurs, 5, 389-98
White et al (1990) The physiologic basis for continuous mixed venous oxygen saturation monitoring. Heart Lung, 19, 548-51.
suction increases oxygen demand by an average 27%
Wood CJ (1998) Endotracheal suctioning: a literature review. Int Crit Care Nurs,14, 1246.
Young-Ra J, Hee-Seung K, Park J-H (2002) Instillation of normal saline before suctioning in patients with pneumonia. Yonsei Med J, 43, 5, 607-12
saline instillation can cause desaturation if used routinely
AARC = American Association for Respiratory Care
ACPRC = Association of Chartered Physiotherapists in Respiratory Care
ARDS = acute respiratory distress syndrome
FRC = functional residual capacity
HME = heat moisture exchanger
HFO = high frequency oscillation
SaO2 = saturation of haemoglobin with oxygen in arterial blood
PC = pressure control
PEEP = positive end-expiratory pressure
VC = volume control