Comparison of airway management practices between registered nurses and respiratory care practitioners

Mechanical insufflation-exsufflation for invasively ventilated critically ill patients-A focus group study

INTRODUCTION

Mechanical Insufflation-Exsufflation (MI-E) is used as an airway clearance intervention in primary care (home ventilation), long-term care (prolonged rehabilitation after intensive care, neuromuscular diseases, and spinal cord injury), and increasingly in acute care in intensive care units (ICU).

AIM

We sought to develop in-depth understanding of factors influencing decision-making processes of health care professionals regarding initiation, escalation, de-escalation, and discontinuation of MI-E for invasively ventilated patients including perceived barriers and facilitators to use.

METHODS

We conducted focus groups (3 in the Netherlands; 1 with participants from four European countries) with clinicians representing the ICU interprofessional team and with variable experience of MI-E. The semi-structured interview guide was informed by the Theoretical Domains Framework (TDF). Two researchers independently coded data for directed content analysis using codes developed from the TDF.

RESULTS

A purposive sample of 35 health care professionals participated. Experience varied from infrequent to several years of frequent MI-E use in different patient populations. We identified four main themes: (1) knowledge; (2) beliefs; (3) clinical decision-making; and (4) future adoption.

CONCLUSION

Interprofessional knowledge and expertise of MI-E in invasively ventilated patients is limited due to minimal available evidence and adoption. Participants believed MI-E a potentially useful intervention for airway clearance and inclusion in weaning protocols when more evidence is available.

RELEVANCE TO CLINICAL PRACTICE

This focus group study provides an overview of current practice, knowledge and expertise, and barriers and facilitators to using MI-E in mechanically ventilated patients. From these data, it is evident there is a need to develop further clinical expertise and evidence of efficacy to further understand the role of MI-E as an airway clearance technique for ventilated patients.

Intensive care nurses' knowledge and practice of evidence-based recommendations for endotracheal suctioning: a multisite cross-sectional study in Changsha, China

BACKGROUND

Endotracheal suctioning is one of the most frequently performed invasive procedures by intensive care nurses. Nurses should have adequate knowledge and skills to perform endotracheal suctioning based on the best evidence. Little is known about intensive care nurses' knowledge and practice of evidence-based endotracheal suctioning in Chinese hospitals. The purpose of this study was to investigate intensive care nurses' knowledge and practice of evidence-based recommendations regarding endotracheal suctioning. Specifically, the study aimed to examine (1) intensive care nurses' awareness of and adherence to endotracheal suctioning guidelines and (2) factors influencing their level of awareness and adherence.

METHODS

A cross-sectional survey of 310 staff nurses working in intensive care units was carried out at Changsha, China. Data on participants' characteristics, awareness of, and adherence to the endotracheal suctioning guidelines were collected through online questionnaires. Following univariate descriptive statistics, the Mann-Whitney U test and Kruskal-Wallis H test were performed using Software Package Statistical Analysis Version 23.0.

RESULTS

A total of 281 nurses completed and returned the survey (response rate = 90.6 %). One-half to three-quarters of the nurses knew 21 of the 26 evidence-based practices and believed their practices followed the guidelines. Over half of them were unaware of the difference between open and close suctions and the pros and cons of using hyperinflation. Almost 50 % of nurses believed some of their clinical practices did not follow the evidence-based recommendations, such as not routinely using normal saline and using 80-120 mmHg suction pressure during endotracheal suctioning. Nurses with endotracheal suctioning training demonstrated significantly higher awareness of endotracheal suctioning recommendations and higher adherence levels than untrained nurses.

CONCLUSIONS

The study findings revealed that Chinese intensive care nurses lacked awareness of several essential evidence-based endotracheal suctioning practices, and there were gaps between their current practice and the guideline recommendations. Further research should emphasize revealing barriers and facilitators of implementing evidence-based endotracheal suctioning practices as well as developing context-suitable interventions for guideline implementation.

Competences in the training of nurses to assist the airway of adult patients in urgency and emergency situations

Objective:

construction and validation in appearance and content of the competence frameworks and of the Entrustable Professional Activities to develop skills in the training of nurses to assist the airway of adult patients in urgency and emergency situations.

Method:

a descriptive and methodological study developed in four phases: in the first, a workshop was held, composed of experts, for the construction of the competence frameworks; in the second, the material was validated using the Snowball Technique and the Delphi Technique, in the third, content analysis and calculation of the Content Validation Index were conducted; and in the fourth phase, the Entrustable Professional Activities were built, validated in simulated workshops.

Results:

the competence frameworks were built and validated, with a resulting CVI≥0.85 in all the items. The Entrustable Professional Activities were validated by experts regarding their applicability; of these, 44% stated they were applicable in simulated environments, 100% that they were useful content and with appropriate language, 22% suggested the insertion of new items to assess competence, 11% reported the difficulty of assessing competence individually in the clinical settings, and 11% of the experts referred to the need for prior training of the teacher/facilitator to use it.

Conclusion:

the study resulted in the construction of competence frameworks and six Entrustable Professional Activities relating them to the domains of essential competences in the training of nurses to assist the airway of adult patients in urgency and emergency situations. The participation of experts in the construction and validation of this material was essential to guarantee the theoretical and practical relevance of the result.

Assessing Resident Diagnostic Skills Using a Modified Bronchiolitis Score

Background

Resident milestones are objective instruments that assess the resident's growth, progression in knowledge, and clinical diagnostic reasoning; but they rely on the subjective appraisal of the supervising attending. Little is known about the use of standardized instruments that may complement the evaluation of resident diagnostic skills in the academic setting.

Objectives

Evaluate a modified bronchiolitis severity assessment tool by appraising the inter-rater variability and reliability between pediatric attendings and pediatric residents.

Methods

Cross-sectional study of children under 24 months of age who presented to a Community Hospital's Emergency Department with bronchiolitis between January-June 2014. A paired pediatric attending and resident evaluated each patient. Evaluation included age-based respiratory rate (RR), retractions, peripheral saturation, and auscultation. Cohen's kappa (K) measured inter-rater agreement. Inter-rater reliability (IRR) was assessed using a one-way random, average measures intra-class correlation (ICC) to evaluate the degree of consistency and magnitude of disagreement between inter-raters. Value of >0.6 was considered substantial for kappa and good internal consistency for ICC.

Results

Twenty patients were evaluated. Analysis showed fair agreement for the presence of retractions (K=0.31), auscultation (K=0.33), and total score (K=0.3). The RR (ICC=0.97), SpO₂ (ICC=1.0), auscultation (ICC=0.77), and total score (ICC=0.84) were scored similarly across both raters, indicating excellent IRR. Identification of retractions had the least agreement across all statistical analysis.

Conclusion

The use of a standardized instrument, in conjunction with a trained resident-teaching staff, can help identify deficiencies in clinical competencies among residents and facilitate the learning process for the identification of pertinent clinical findings.

Knowledge and Practices of Endotracheal Suctioning amongst Nursing Professionals: A Systematic Review

Introduction

Ventilator-associated pneumonia, a common cause of mortality and morbidity, is commonly seen among patients with endotracheal intubation due to unsafe suctioning practices by health professionals.

Objective

A systematic review was conducted to explore the gaps in the existing practices of nurses and thus proposing comprehensive guidelines for safe practice.

Materials and methods

A two-phase strategy was adopted to identify the studies through a comprehensive electronic search in PubMed, Google Scholar, ProQuest, Ovid, and Helinet Summon by using predefined keywords within a year limit of 2002–2016. The quality of studies was reviewed using tools endorsed by Joanna Briggs Institute. This review was conducted according to the guidelines described in the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Qualitative data were described through the process of metasynthesis. Quantitative analysis was performed to combine the competent quantitative evidences to identify knowledge and practices of endotracheal suctioning (ETS).

Results

Thirty studies had been subjected for metasynthesis, among which six provided relevant information for quantitative analysis. Quantitative analysis of the studies reported that only 36% of the nurses had assessed patients prior to suctioning and had knowledge about the size of the suction catheter while only 46% were aware of the appropriate suction pressure to be used for ETS. Handwashing compliance prior to suctioning was observed in only 62% of the nurses. It is reported that, despite the awareness on possible complications, nurses fail to adhere to the recommended practice guidelines.

Conclusion

The current review would explore the best evidence-based practices (EBPs) among nurses related to ETS, which would ensure quality care to critically ill patients.

How to cite this article

Pinto HJ, D'silva F, Sanil TS. Knowledge and Practices of Endotracheal Suctioning amongst Nursing Professionals: A Systematic Review. Indian J Crit Care Med 2020;24(1):23–32.

Boas práticas de enfermagem a pacientes em ventilação mecânica invasiva na emergência hospitalara

RESUMO Objetivo Identificar os cuidados concebidos como boas práticas de enfermagem a pacientes em ventilação mecânica invasiva no contexto de emergência hospitalar. Método Estudo descritivo, qualitativo, realizado de junho a setembro de 2017. Participaram 16 enfermeiros da emergência geral de um hospital da região Sul do Brasil. Os cuidados, extraídos da literatura e classificados quanto ao nível de evidência, foram agrupados em categorias por similaridade e selecionados nos Grupos de Discussão. Resultados Os enfermeiros consideraram como boas práticas aos pacientes em ventilação mecânica invasiva um total de 13 cuidados, os quais estão relacionados ao tubo endotraqueal, ao ventilador e circuito, à prevenção de broncoaspiração, ao controle de infecção e à sedação, analgesia/sono, vigília/dor. Os cuidados foram extraídos de estudos com níveis de evidência IIb, IV e VI. Conclusão e implicações para a prática As boas práticas de enfermagem em ventilação mecânica invasiva, concebidas pelos enfermeiros da emergência, respaldam cientificamente a assistência ao paciente em suporte ventilatório invasivo, podendo ser aplicadas em contextos similares.

Electrodermal Activity Monitoring during Endotracheal Suction in Sedated Adult Intensive Care Unit Patients

BACKGROUND

Endotracheal suctioning of respiratory secretions is one of the most common causes of pain and discomfort in Intensive Care Unit environment. The electrical properties of the skin, also known as electrodermal activity (EDA), are considered as an indirect measure of autonomous nervous system.

AIM

This study explores EDA changes during endotracheal suction in sedated adult critical care patients; and compares these changes to other monitoring parameters.

MATERIALS AND METHODS

Skin conductance variability, selected hemodynamic and respiratory parameters, bispectral index (BIS) and ambient noise level, were monitored during 4 hour routine daytime intensive care nursing and treatment in an adult Intensive Care Unit. 4h-measurements were divided into 2 groups, based upon the sedation level (group A: Ramsay sedation scale 2-4 and group B: 5-6 respectively) of the patients. Selected recordings before and after endotracheal suction (stress events) were performed. Seven stress events from Group A and 17 from Group B were included for further analysis. Patients' demographics, laboratory exams and severity scores were recorded. Pain status evaluation before every event was also performed via 2 independent observers.

RESULTS

In both groups the rate of EDA changes was greater than in other monitoring parameters. Yet, in group A only selected parameters were significantly changed after the start of the procedure, while in group B, every parameter showed significant change (p<0.05). Groups were similar for other co-founding factors.

CONCLUSION

EDA measurements are more sensitive to stress stimuli, than cardiovascular, respiratory or even BIS monitoring. Deeper sedation seems to affect more the intensity of EDA changes during suction.

Comparison of the Effect of Open and Closed Endotracheal Suctioning Methods on Pain and Agitation in Medical ICU Patients: A Clinical Trial

Background

Endotracheal suctioning is a necessary procedure practiced by nurses in intensive care units to remove lung secretions. This procedure leads to higher oxygenation levels and reduced breathing difficulties. It also prevents atelectasis, pulmonary infections, and the accumulation of secretions.

Objectives

The present study aims to compare the effectiveness of open and closed endotracheal suction tube systems on pain and agitation in patients under mechanical ventilation.

Methods

A randomized controlled clinical trial was conducted in the general intensive care units of Khatam-ol-Anbia hospital and Sina hospital, Tehran, Iran, in 2015. In total, 60 patients who were qualified to be included in the study were randomly assigned to either the intervention group or the control group. When necessary, suction was carried out for each patient using the standard technique. The patients’ level of pain and agitation was measured in both groups at five stages (before, during, immediately after, 5 minutes after, and 15 minutes after the intervention) using the behavioral pain scale and the Richmond agitation sedation scale.

Results

Significant statistical differences in the pain and agitation at different times within each of the two groups were observed for both open and closed suction (P > 0.001). However, these changes at different times between the two groups was not significant (P < 0.05).

Conclusions

Although statistical differences were observed in the levels of pain and agitation in the two groups, the type of suction system did not have any effect on the level of pain and agitation of patients under mechanical ventilation. The researchers recommend that other studies with larger sample sizes should be carried out.

Breaking Down the Silos: An Interprofessional Approach to Education

An interprofessional practice gap was identified in relation to discharge care provided to patients with tracheostomies or laryngectomies. Using a case study method, this article presents an approach that administrators of educational programs can take to develop an instructive strategy to address the practice gap and improve patient care.

Clinical Indicators for Endotracheal Suctioning in Adult Patients Receiving Mechanical Ventilation

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.