Descriptive study to assess clinical indicators for endotracheal suctioning in 42 conveniently selected adult patients receiving mechanical ventilation

March 7, 2019 Critical Thinking

Descriptive study to assess clinical indicators for endotracheal suctioning in 42 conveniently selected adult patients receiving mechanical ventilation.. The most frequently identified cues were the crackles over the trachea (88%), saw tooth waveform (33%), coughing (29%), and visible secretions (5%). This study concluded that patient on mechanical ventilator should be routinely assessed for coarse crackles over the trachea which is the most common indicator for endotracheal suctioning.26
Systematic review and meta-analysis of randomized controlled trials that compared impact of closed versus open endotracheal suctioning systems for mechanically ventilated adults. The random effects model was used select to sixteen trials with 1,929 participants were included. The result implied that when compared with open endotracheal suctioning system; closed endotracheal suctioning system was associated with a reduced incidence of ventilator associated pneumonia and was not associated with reduction of mortality or reduced length of mechanical ventilation. The study concluded that based on current, limited evidence, it is unlikely that, closed endotracheal suctioning system is inferior to open endotracheal suctioning system regarding ventilator associated pneumonia prevention; however, further trials at low risk of bias are needed to confirm or refute this finding.27
Single-blinded clinical trial was carried out to compare the effects of shallow and deep endotracheal tube suctioning on respiratory rate, arterial blood oxygen saturation and number of suctioning in intensive care units. Convenience sampling was performed for enrolling 37 patients in the study. The results of this research showed that in order for effective airway clearance in the shallow suctioning group, in 56.8% of the subjects (21 people), one time suctioning and in 43.2% subjects (16 people), two times suctioning was required. However, in the deep suctioning group, in 81.1% of the participants (30 people), one time suctioning and in 18.9% (7 people), two times suctioning was required. The study results concluded that the number of suction needed to effectively clear airway in the shallow suctioning group is significantly higher than in the deep suctioning group .28
The comprehensive review study to determine the role of saline instillation in suctioning adult intensive care unit patients: an evidence-based practice review. The study population was randomly selected consisting of patients 18 years or older, who are intubated requiring mechanical ventilation, and are admitted in the ICU. Most of the findings suggested not to use saline when suctioning. This study does not support the use of saline instillation when suctioning an artificial airway.29
This clinical trial was conducted on 40 patients in ICU, aiming to compare the effects of the open and closed system suctioning methods on blood pressure, mean arterial pressure, heart rate, and percentage of arterial oxygen saturation, time, and costs in patients under mechanical ventilation. Total coverage sampling was used to select the participants. Significant changes were observed in heart rate (P = 0.025) and percentage of arterial oxygen saturation (P < 0.001). The mean lengths of time in open and closed suctioning methods were 5.59 ± 0.211 and 4.34 ± 0.039 seconds, respectively (P < 0.001). Therefore, this study concludes that closed method can replace open suction method in caring of severely critically ill patients.30
Comparative study was conducted regarding clinical experience and incidence of ventilator- associated pneumonia by the use of closed suction system versus open suction-system. In this study the adult patients on mechanical ventilation were consecutively selected. Air entry and de-saturation events during suction were monitored. The result shows that no differences in airway colonization at admission between the groups were detected. The closed suction systems group had a higher Simplified Acute Physiology Score (SAPS) III and also a non-significant increase in ventilator associated pneumonia incidence. This study concluded that a high frequency of circuit contamination in the closed suction systems group paralleled with experienced secretions clearance problems seem unfavorable and in concordance with previous studies.31
In a quantitative cross-sectional survey, to compare critical care nurses’ knowledge and adherence within different groups. The principles of inductive content analysis were used on 101 critical care nurses to analyze the barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. The mean score in the knowledge test was 59.9%. More experienced nurses performed significantly better than their less-experienced colleagues (p = 0.029). The overall, self-reported adherence was 84.0%. This study concluded that main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge and guidance.32
A prospective observational study nested within a crossover trial to identify changes in heart rate, mean arterial pressure, and oxygen saturation after open and closed endotracheal suctioning randomly in four intensive care unit. In total, 197 complete endotracheal suctioning procedures (103 OSS and 94 CSS) were monitored. Changes in heart rate and mean arterial pressure were comparable after using closed system suction and open system suction, whereas in Spo2, slightly better values were monitored 3 and 5 minutes after open system suction, these differences being rather small (0.3%-0.7%) and clinically not relevant. This study concludes that as changes in heart rate, mean arterial pressure, and Spo2 were comparable and mild during and after closed system suction and open system suction, hence both systems can be considered equally safe.33
In this randomized crossover study examining that the end-expiratory lung volume recovers more slowly after closed endotracheal suctioning than after open suctioning in 20 patients post cardiac surgery. Closed suctioning and open suctioning was performed in random order, 30 minutes apart. The result showed that reductions in lung impedance during suctioning were less for closed suctioning than for open suctioning. However, at all points post suctioning, end-expiratory lung impedance recovered more slowly after closed suctioning than after open suctioning. Therefore, the use of closed suctioning cannot be assumed to be protective of lung volumes post suctioning. Consideration should be given to restoring end-expiratory lung impedance after either suction method via a recruitment maneuver.34
In a systematic review, to evaluate endotracheal suction in intubated critically ill adult patients undergoing mechanical ventilation. 17 Randomized controlled trial was included. The results of the studies allowed the grouping of evidence into six categories of intervention related to endotracheal suction: research-based endotracheal suction compared to normal endotracheal suction, in one study; routine endotracheal suction compared to minimally-invasive endotracheal suction, in two studies; open system endotracheal suctioning compared to closed system endotracheal suctioning, in eight studies; change of closed system at 24 compared to 48 hours, in two studies; daily change of the closed system compared to non-routine change, in one study; and saline instillation compared to non-saline instillation, in three studies. The study concludes that interventions were undertaken analyzing outcomes referent to hemodynamic alterations, alterations in blood gases, microbial colonization and nosocomial infection, quantity of secretion suctioned, pulmonary alterations, memory of the experience of endotracheal suction on the part of the patient, and discomfort related to the suction.35
Non-participant structured observational study which aimed at the development of standard practice guidelines for open and closed system suctioning. 48 nurses employed in the cardiovascular surgery intensive care unit of a state hospital were included in this study by total coverage sampling. The findings implied that there was a significant difference between the mean scores of the answers for the use of open and closed system suctioning before and after training. In addition, all steps of both suctioning procedures were carried out correctly during the third observation. The study concluded that compliance of the nurses to the standard practice guidelines for open and closed suctioning and their knowledge levels on the subject were increased after training, while the implementation of standards was satisfactory.36
Action research study to evaluate effect of simulation-based interprofessional educational module on adult suctioning to provide multi professional groups of students the opportunity to collaborate in applying basic suctioning skills within complex patient care situations. Total coverage sampling was used to assess 48 nurses. The result showed that four major themes emerged: instructors’ role expectations, prior student learning, student collaboration, and instructor communication. This study concludes that development of the educational module using action research allowed for further development of a pedagogical approach to inter professional education to increase its effectiveness.37
Descriptive cross sectional study to assess the level of knowledge on endotracheal suctioning among staff nurses and student nurses in Narayana Medical College and hospital. Convenient sampling technique was followed to included 30 samples. The study finding reflects that with regard to level of knowledge of endotracheal suctioning among staff nurses 1(7%) had inadequate knowledge, 11(73%) had Moderate knowledge, and 3(20%) had adequate knowledge. Among nursing students 3(20%) had inadequate knowledge, and 12(80%) had moderate knowledge. The present study concluded that comparing the level of knowledge between staff nurses and nursing students, Staff nurses have adequate level of knowledge than nursing students regarding endotracheal suctioning.38One of the measures to keep the airway open is suctioning of endotracheal tube in patients under ventilation. This procedure can be accompanied with some complications. Selection of appropriate method of suctioning can prevent incidence of acute complications.

This study aimed to systematically review studies that investigated the effects of normal saline instillation before endotracheal suctioning and to determine the views of nurses concerning this procedure. This study was carried out in 2 stages as a systematic review and a descriptive study. In the first stage, the Medline and CINAHL databases were searched. The second stage of the study consisted of a survey of 65 conveniently selected intensive care nurses. Normal saline instillation before endotracheal suctioning was demonstrated to decrease patient oxygenation in most studies (P < .05). Most nurses (87.7%) apply normal saline instillation. This study concluded that the practice of normal saline instillation is not recommended as it decreases oxygenation. Additional studies are needed to determine the effectiveness of applications that may be alternatives to normal saline instillation.39
Descriptive study to evaluate the knowledge of the American Association of Respiratory Care, evidence-based guidelines on the endotracheal suctioning technique among Italian intensive care nurses of 16 ICUs in 11 Italian hospitals. The questionnaire was sent to conveniently selected 379 nurses, with 65% of questionnaires returned completed. The total percentage of correct answers was 58%, and nobody completed the questionnaire without mistakes. Moreover, only 2.5% (n = 6) of the nurses gave 9/10 correct answers. Correct answers were more common amongst the more experienced ICU nurses. The study concluded that Italian ICU nurses’ knowledge of guidelines on endotracheal suctioning was not complete; however, experienced nurses demonstrated a better knowledge of the subject.40
This is an exploratory descriptive study in which a quantitative approach was used, in two ICUs to assess the knowledge about endotracheal suctioning among intensive care nursing professionals.. The sample consisted of 27 conveniently selected professionals of whom 51.9% were male. The results showed that globally, the knowledge of professionals was qualified as fair (73.2% correct), but worryingly, it was considered poor in five areas with differing results among the professional categories. Taking into account that incorrect knowledge generates inappropriate behavior, it is inferred that the practice of these subjects may compromise patient’s safety. The studied individuals showed knowledge deficits in some aspects of endotracheal suctioning, a fact that deserves investment regarding teaching and nursing.41
In a descriptive study conducted at six ICUs in Ontario, surveys were distributed to conveniently selected 90 Registered nurses and 90 registered respiratory therapists to assess the suctioning practices based on clinical practice guidelines. Of these, 83 completed surveys were received from Registered nurses and 87 from registered respiratory therapists, corresponding to a response rate of 94% and 97%, respectively. The findings implied that there were few statistically significant differences between these two groups with regard to questions relating to artificial airways suctioning practice. The study concluded that differences were observed in awareness of ventilator-assisted pneumonia rates, routine preoxygenation of patients, and awareness of protocols for mouth care and checking of endotracheal tube cuff pressures.42
This is a quantitative research to evaluate the practices of nursing professionals in intensive care regarding endotracheal aspiration by open system: with 25 participants who were purposively selected. The findings revealed that there are divergences between the available evidence and the practices found in the ICUs surveyed. The average of the total adhesion index was 51.33%, indicating an unsatisfactory adhesion to the best available practices for the realization of endotracheal suctioning by open system. It was concluded that the professionals do not perform the procedure in a satisfactory way, being necessary interventions that promote behavioral changes through continuous education aiming to improve the quality of care provided..43
In this descriptive, comparative design, to assess airway management practices among the registered nurses and respiratory care practitioners were recruited to complete an online survey of self-reported practices. A total of 85 conveniently selected participants completed the survey. The results indicated that the practices of registered nurses and respiratory care practitioners differed in many ways. The nurses assumed responsibility for oral antisepsis, whereas the respiratory care practitioners managed the endotracheal tube. The 2 groups shared responsibility for oral and endotracheal suctioning. The study concluded that knowledge of current guidelines for endotracheal suctioning was lacking, opportunities exist to develop shared policies and procedures based on current evidence.44
Prospective study to determine decrease in adverse effects of endotracheal suctioning during mechanical ventilation by changing practice in 147 mechanically ventilated patients selected by total coverage sampling. The findings implied that the more frequent effects were oxygen desaturation and hemorrhagic secretions; followed by blood pressure changes and heart rate modifications. After guidelines implementation, all complications together were reduced. The study concluded that implementation of practice guidelines reduced rate of complications.45
In a structured, non-participatory, observational study to assess critical-care nurses’ Endotracheal Suctioning practices. The sample included purposively selected 40 nurses from mixed medical-surgical intensive-care unit. The most significant discrepancies were observed in practices related to infection-control. The findings also revealed that the critical-care nurses were not following current Endotracheal suctioning recommendations. The study concluded that educational interventions, clinical guidelines and adequate support need to be provided to critical-care nurses to improve their professional capabilities and current practice. Regular auditing and prompt feedback would be beneficial.46
An observational study exploring the competency of the Jordanian intensive care nurses towards endotracheal tube and oral care practices for mechanically ventilated patients. The sample included conveniently selected 147 intensive care nurses. The result showed that over three-quarters of the participants were observed to hyperoxygenate before suctioning. Over half of the sample were observed to remove bite-block or oropharyngeal airways before administering oral care. The concluded that there is inadequacy in endotracheal suctioning practices47
This action research study aimed to improve application of closed suction in intensive care unit. 60 ICU nurses were selected through convenience sampling, 30 of whom were chosen by random sampling. The result indicated that the frequency of using the open suction method, according to the connectedness of closed suction to patients, was 60% before the intervention and 57.1% after that. The study concluded that action research is a suitable way to change and improve nurses’ performance, since in this method, taking the advantage of the staff’s comments and involving them in the study makes it plausible to bring about changes faster.48
This randomized controlled trial was conducted to evaluate the longitudinal effects of single-dose simulation education with structured debriefing and verbal feedback on knowledge and skills of critical care nurses’ endotracheal suctioning. Participants were randomly allocated to intervention (n?=?20) and control (n?=?20) groups using a computer-generated randomization list. The results indicated that after simulation education, the average skill score increased from 58.5% to 65.0% of total score in the intervention group but decreased from 63.1% to 62.7% in the control group. The study concluded that single-dose simulation education with structured debriefing and verbal feedback was insufficient to change critical care nurses’ knowledge and skills in adhering to current Endotracheal suctioning guidelines.49
In Khartoum teaching hospital, a descriptive cross-sectional hospital based study was conducted to assess the knowledge and practice of ICU nurses regarding endotracheal suctioning in mechanically ventilated patients. The nurses were selected by total coverage (42nurses) sampling technique. The result showed that the majority of nurses working in Khartoum teaching hospital (35.7%) have 2 months – 1yearworking experience, (85.7%) have poor knowledge level, (76.7%) have fair practice level, and there is no significant relationship between working experience and levels of knowledge and practice. This study concluded that nurses have better practice level than knowledge level which was not affected by the nurse’s length experience.50
An experimental study was conducted to assess the effectiveness of endotracheal suctioning protocol in terms of knowledge and practices of nursing personnel. Quasi experimental design was used in this study. Pre and post-implementation data from 30 purposively selected ICU nursing personnel was collected. Subsequent reinforcements were given until > 80% practice score was achieved. Findings of the study revealed that the mean post- implementation knowledge score and practice score of nursing personnel regarding endotracheal suctioning was significantly higher than the mean pre implementation knowledge and practice score (p<0.001). Hence, the protocol was effective in enhancing the knowledge and improving the practices of nursing personnel regarding the endotracheal suctioning.51
Non-participant structured observational design cross-sectional study was conducted to assess the knowledge and practice levels of intensive care nurses’ regarding open system endotracheal suctioning and to investigate if there is any relationship between the demographic characteristics and knowledge and practice. The study sample included 72 nurses from three adult intensive care units in the selected teaching hospital selected by total coverage sampling. The result showed that the mean scores of knowledge and practice were 23.79 ± 3.83 and 12.88 ±2.53. Their knowledge level was very good in around 59.7%, good in 34.7% and practice level was fair in around 79.2% and good in 18.1% of the participants. This study reflects that the knowledge level of most of the nurses is good and their practice level is fair. Intensive care nurses must perform suctioning procedures safely and effectively to ensure delivery of quality of care and eliminate complications.52
In a pre experimental study conducted to evaluate the effectiveness of planned teaching programme on the knowledge and practice of endotracheal suctioning among staff nurses in selected hospitals of Mangalore. The research design used in this study was one group pretest posttest design. The purposive sampling technique was used to select 30 staff nurse as samples. The result indicated that, there was a significant increase in the knowledge score in posttest. In the posttest, majority (100%) had good knowledge and none of them had poor knowledge on endotracheal suctioning. The posttest also showed that there is a significant increase in the practice scores, in which majority (100%) had good level of practice of performing endotracheal suctioning. The study concluded that regular in service education to the staff nurses can help in the prevention or reduction of complications that can occur during to suctioning.53
In this cross sectional study, the gap between knowledge and practice regarding standard endotracheal suctioning of conveniently selected 44 nurses working in three ICUs, was analyzed in three areas of prior, during and post suctioning.. The result indicated that in general, the average score of knowledge and performance were 19.59 and 8.75 respectively. This study revealed that despite acceptable knowledge, nurses’ performance in endotracheal suctioning is poor. This shows that education alone is not sufficient for observance of the standards.54
A descriptive study was conducted to assess the knowledge and practice of endotracheal suctioning among Neuro Nurses. 30 Neuro Nurses were selected from neuromedical ICU at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum. Convenient sampling technique was used for selecting sample. The result showed that the knowledge score of staff nurse with less ICU experience ranged from 10 to 14 with a mean of 12.06 (1.48). The knowledge of staff nurse with more ICU experience ranged from 11 to 14 with a mean of 12.08 (1.19). There was no statistically significant difference in the mean knowledge score of both groups. Based on the findings of the study it was concluded that Neuro Nurses have average knowledge about endotracheal suctioning but in practice they are not practicing some critical care elements. 55