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

Effects of Natural Sound Therapy on Pain and Agitation Induced by Endotracheal Suctioning: A Real-World Study

BACKGROUND

Music therapy has been used as a complementary intervention to provide synergistic analgesia for various procedures.

OBJECTIVE

To evaluate the effects of natural sound therapy on pain intensity and agitation scores in intubated adult Chinese patients who received endotracheal suctioning in a critical care unit.

METHODS

A prospective, real-world, randomized, double-blind, controlled study was conducted from July 2021 through February 2022 among intubated surgical intensive care unit patients in a Chinese hospital. Patients were randomly assigned to a control group receiving conventional treatment or an intervention group receiving natural sound therapy plus conventional treatment (50 patients in each group). Patients' pain intensity and agitation levels were analyzed before, during, immediately after, 5 minutes after, and 15 minutes after completion of endotracheal suctioning. Pain intensity was assessed with the Critical-Care Pain Observation Tool (CPOT); agitation was assessed with the Richmond Agitation-Sedation Scale (RASS).

RESULTS

According to CPOT scores, patients in the intervention group had significant relief of pain intensity during, immediately after, and 5 minutes after endotracheal suctioning compared with patients in the control group (all P < .001). The RASS scores showed that agitation levels were significant lower in the intervention group than in the control group during (P = .002) and immediately after (P < .001) endotracheal suctioning.

CONCLUSIONS

In this real-world study, natural sound therapy was part of a holistic bundle of interventions used to reduce pain and agitation in surgical intensive care unit patients during endotracheal suctioning.

[Suctioning in intubated and tracheotomized patients : A narrative review]

BACKGROUND

Endotracheal suctioning in intubated or tracheotomized critically ill patients is a daily task of various professional groups in intensive and emergency medicine; however, a German language summary of current evidence is lacking.

OBJECTIVE

The aim is to develop a narrative overview of current evidence on endotracheal suctioning of intubated or tracheotomized patients in the clinical setting.

MATERIAL AND METHODS

A literature search was conducted in the databases Cinahl, Cochrane Library, Livivo, and Medline via PubMed by nurses with an academic degree. In addition, a hand search and applying the snowball principle were performed. Following a successful critical appraisal, all English and German language publications addressing endotracheal suctioning in the context of hospital care were included.

RESULTS

A total of 23 full texts were included. After developing 6 main topics on endotracheal suction 19 articles were considered in the reporting. The results showed, among others, that routine deep suctioning once per shift is contraindicated and that the catheter should be advanced no more than 0.5-1 cm beyond the distal end of the tube or tracheal cannula. Closed suction catheters offer advantages, especially for staff protection, although studies are heterogeneous. Further training of staff is obligatory.

CONCLUSION

Few conclusive studies on endotracheal suction could be found; however, with the available evidence initial conclusions can be drawn which should be considered in, for example, internal standard operating procedures. Further research is needed.

Investigation of pain associated with endotracheal aspiration and affecting factors in an intensive care setting: A prospective observational study

BACKGROUND

Endotracheal aspiration is a painful nociceptive procedure. There is still a gap in the literature on studies to determine the pain level and nursing interventions for aspiration.

OBJECTIVES

This study evaluated pain during endotracheal aspiration and examined the factors affecting pain.

METHODS

This prospective observational study was conducted with 105 inpatients meeting the inclusion criteria in the internal intensive care unit of a public hospital. Two hundred ten aspiration procedures were monitored for pain and other variables. ASPMN 2019 Position Statement recommendations were followed in designing the study and determining the procedure. The pain score range obtained from The Critical Care Pain Observation Tool was 0-8. A score of 2 or more is considered to indicate the presence of pain. The primary outcome measures were pain associated with endotracheal aspiration and affecting factors in this study. The generalised linear mixed model established for aspiration procedure-associated pain and affecting factors was analysed.

RESULTS

Patients' mean pain score was 1.24 ± 2.05 before, 3.07 ± 2.17 during, and 2.35 ± 1.94 after aspiration and 0.89 ± 1.40 at 15 min after aspiration. The pain rate was 26.1% before, 71% during, and 60.9% after the aspiration procedure and 18.8% after 15 min. There was a statistically significant difference between all pain scores evaluated. The difference in aspiration-related pain scores by age, respiratory diseases, sedation status, aspiration pressure, and tube diameter was statistically significant.

CONCLUSIONS

The pain score due to aspiration procedure increased significantly in intensive care unit inpatients and is an important risk factor for patient safety. More focus is needed on the causes and measures of aspiration-related pain.

Inter-Professional-Compassionate pain management during endotracheal suctioning: a valuable lesson from a Chinese surgical intensive care unit

Objective

To compare the effects of a pain management program and routine suctioning methods on the level of pain presence and agitation in Chinese adults admitted to the intensive care unit. To disseminate the results from the implementation of the evidence-informed pain management interventions for reducing pain presence and agitation during endotracheal tube suctioning (ETS) and translate the key finding to clinical nursing practice.

Methods

A quasi-experimental study of a two-group post-test design was conducted in adults admitted after surgery to a surgical intensive care unit (SICU) of the Second Affiliated Hospital of Kunming Medical University, Yunnan, China in 2018. Fifty-two adults who met the study eligibility were included after consent, 26 in each group. Patients in the control group received usual care while patients in the intervention group received interventions to reduce agitation and pain-related ETS. The impacts of the intervention on the level of pain presence and agitation were measured at 5 measuring time points using the Chinese versions of Critical-Care Pain Observation Tool (CPOT) and Richmond Agitation Sedation Scale (RASS).

Results

The level of pain presence in the intervention group statistically significantly decreased during, immediately after, and 5 min after suctioning. The level of agitation in the intervention group significantly decreased during and immediately after suctioning.

Conclusions

The findings provide support for the positive pain-relieving effects of the evidence-informed pain-related ETS management interventions when compared with the usual ETS practice. The study interventions were sufficiently effective and safe to maintain patent airway clean and patent as standardized suctioning and helps pain relief. So, evidence-based pain-related ETS management intervention is worthy of recommending to utilize in SICU patients as well as other patients who required suctioning. It is worth noting that integrating pre-emptive analgesia prescription and administration with non-pharmacological intervention plays a critical role in achieving pain relief.

Evaluation of the effect of endotracheal aspiration at different head heights on oxygenation of the brain by non-invasive method in intensive care patients

OBJECTIVES

To determine the effect of endotracheal aspiration at different head heights on oxygenation brain by non-invasive method in neurosurgery intensive care patients.

BACKGROUND

Head elevation of mechanical ventilator-dependent neurosurgery patients and the possible risks of endotracheal aspiration are closely related to the clinical conditions of the patients.

DESIGN

A prospective quasi-experimental study with repetitive measurements in a single group.

METHODS

In the study, neurosurgery intensive care patients were adjusted to a head height of 15, 30 and 45° (n = 46, power analysis %90). Cerebral oxygenation levels were determined with a non-invasive device at each head height before and in the 1st, 5th and 30th min of endotracheal aspiration. Data were collected with Patient Information Form and cerebral oxygenation device based on NIRS technology. This study performed according to the TREND reporting guidelines for non-randomized/quasi experimental study.

RESULTS

The highest cerebral oxygenation value was obtained at 30 min. The decrease in the cerebral oxygenation levels of the patients was highest in the 1st min after endotracheal aspiration, at a head height of 15 degrees for the right cerebral region and at a head height of 30 degrees for the left cerebral region. The increase in oxygenation of the right and left cerebral regions occurred highest at a head height of 45 degrees.

CONCLUSIONS

The ideal head height should be 45 degrees during and after endotracheal aspiration in regard to maintaining cerebral oxygenation in neurosurgery intensive care patients. It is extremely important to monitor the cerebral oxygenation status of patients, with non-invasive measurement tools during and after endotracheal aspiration, to prevent secondary complications.

RELEVANCE TO CLINICAL PRACTICE

This study reveals the importance of raising the head 45 degrees in the best preservation of cerebral oxygenation values in neurosurgery intensive care patients. Intensive care nurses should pay attention to maintaining this head height.

AARC Clinical Practice Guidelines: Artificial Airway Suctioning

Artificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial airway is a common procedure performed worldwide on a daily basis. As such, it is imperative that clinicians are familiar with the most-effective and efficient methods to perform the procedure. We conducted a systematic review to assist in the development of evidence-based recommendations that pertain to the care of patients with artificial airways. From our systematic review, we developed guidelines and recommendations that addressed questions related to the indications, complications, timing, duration, and methods of artificial airway suctioning. By using a modified version of the RAND/UCLA Appropriateness Method, the following recommendations for suctioning were developed for neonatal, pediatric, and adult patients with an artificial airway: (1) breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, and an acute increase in airway resistance may be an indicator for suctioning in neonates; (2) as-needed only, rather than scheduled, suctioning is sufficient for neonatal and pediatric patients; (3) both closed and open suction systems may be used to safely and effectively remove secretions from the artificial airway of adult patients; (4) preoxygenation should be performed before suctioning in pediatric and adult patients; (5) the use of normal saline solution should generally be avoided during suctioning; (6) during open suctioning, sterile technique should be used; (7) suction catheters should occlude < 70% of the endotracheal tube lumen in neonates and < 50% in pediatric and adult patients, and suction pressure should be kept below -120 mm Hg in neonatal and pediatric patients and -200 mm Hg in adult patients; (8) suction should be applied for a maximum of 15 s per suctioning procedure; (9) deep suctioning should only be used when shallow suctioning is ineffective; (10) routine bronchoscopy for secretion removal is not recommended; and (11) devices used to clear endotracheal tubes may be used when airway resistance is increased due to secretion accumulation.

Investigation of the airway management practice of emergency department ward nurses: a nationwide survey in China

OBJECTIVES

To investigate the airway management equipment and clinical practice in emergency department wards in China, and to explore the factors that influenced the nurses' airway management practice.

DESIGN

Cross-sectional study.

SETTING

A nationwide survey covering the seven administrative regions of China (North China, Northeast China, East China, Central China, South China, Southwest China and Northwest China).

PARTICIPANTS

The nurses had to be registered nurses who worked in adult emergency department wards of the selected hospitals.

MEASURES

An online survey was designed, piloted and distributed to the members of the Emergency Medicine Committee of the Chinese Nursing Association, and the nurses from the members' hospitals were invited to participate. The questionnaire was used to determine nurses' clinical practice scores of airway management in emergency wards.

RESULTS

Finally, we collected 995 valid questionnaires from 31 provinces and 143 districts in China. Among them, 361 (36.28%) nurses responded that their departments used open suction system (OSS) in clinical work, the major barrier for closed suction system (CSS) reported by 630 respondents (63.32%) was cost. Significant differences in all three scores were found in age, nursing experience years, technical title, airway management training experience and nursing specialist (all p<0.05). Correlations were found among airway management attitude, practice of sputum aspiration and practice of ventilator care bundles (r=0.655, r=0.543 and r=0.763, all p<0.001).

CONCLUSIONS

Chinese emergency department managers need to identify better methods for assessing equipment availability in OSS. CSS can be a choice when costs, status of the individual patient and severity of disease are comprehensively considered. Emergency department nurses' scores of airway management practice were affected by demographic and job-related characteristics; regular training should be encouraged, and equipment and resources should be guaranteed to improve airway management quality and optimise patient outcomes.

Risk Factors of Eye Complications in Patients Treated in the Intensive Care Unit

In critically ill patients, normal eye protection mechanisms, such as tear production, blinking, and keeping the eye closed, are impaired. In addition, many other factors related to patients' severe condition and treatment contribute to ocular surface disease. Reducing risk factors and proper eye care can have a significant impact on incidences of eye complications and patient quality of life after discharge from the intensive care unit (ICU). The aim of the study was to determine risk factors for ocular complication, especially those related to nursing care. The study was conducted in the ICU of a university hospital. Methods for estimating and analyzing medical records were used. The patient's evaluation sheet covering 12 categories of risk factors for eye complications was worked out. The study group included 76 patients (34 patients with injuries and 42 without injuries). The Shapiro-Wilk test, the Spearman's rank correlation test, the Mann-Whitney U test and the Friedman's ANOVA test were used. The level of significance was set at α = 0.05. The most important risk factors for eye complications in the study group were: lagophthalmos (p < 0.001), sedation (p < 0.01), use of some cardiological drugs and antibiotics (p < 0.01), mechanical ventilation (p < 0.05), use of an open suctioning system (p < 0.01), presence of injuries (p < 0.01) including craniofacial trauma (p < 0.001), high level of care intensity (p < 0.01), failure to follow eye care protocol (p < 0.001), length of hospitalization at the ICU (p < 0.001), and the frequency of ophthalmological consultations (p < 0.001). There was no correlation between the incidence of these complications and the age and gender of the patients. The exposure of critically ill patients to eye complications was high. It is necessary to disseminate protocols and guidelines for eye care in ICU patients to reduce the risk factors.

Effects of endotracheal tube fixation methods on haemodynamic parameters during endotracheal suction: A single-blind non-randomized clinical trial study

AIM

This study aimed to determine the effect of the methods used in endotracheal tube fixation on haemodynamic parameters (systolic and diastolic blood pressure, heart rate and oxygen saturation) during endotracheal suction.

METHODS

The sample of this prospective, parallel two-armed, single-blind non-randomized clinical trial study included 86 intubated patients treated in the cardiovascular surgery intensive care unit between September 2016 and December 2017. The endotracheal tube was fixed with tube holders in the intervention group (n = 43), whereas the endotracheal tube was fixed with plasters in the control group (n = 43). The patients' haemodynamic parameters were measured before, during, at the end of suction, and 5 and 15 min after suction.

RESULTS

In comparison with the patients with plasters, patients with tube holders had significantly lower systolic blood pressure 15 min after endotracheal suction and significantly lower diastolic blood pressure during and at the end of endotracheal suction. Oxygen saturation of the patients with tube holder during, at the end, and following 5 min after endotracheal suction were higher than patients with plaster. Heart rate was not affected during endotracheal suction in both groups.

CONCLUSION

The study showed the tube holder affected the haemodynamic parameters during endotracheal suction less than the plaster.

Effects of Open and Closed Tracheal Suctioning on Pain in Mechanically Ventilated Patients

Background:

Painful care procedures are the most common cause of stress in patients admitted to Intensive Care Units (ICUs). Tracheal suctioning is the most painful experience for ICU patients. The present study was conducted to compare open and closed endotracheal suctioning in terms of their effect in pain in mechanically ventilated patients.

Materials and Methods:

The present clinical trial recruited 70 mechanically ventilated patients with tracheostomy in 2019. The eligible patients were randomly divided into open and closed suctioning groups. The pain was measured in the patients using the Critical Pain Observational Tool (CPOT) before and during suctioning as well as 10 and 30 min later. The data were analyzed using the repeated measures Analysis Of Variance (ANOVA), paired t-test, and Chi-squared test.

Results:

The pain score was significantly higher in the open suctioning group during (t = 2.59, p = 0.01) and 10 min after suctioning (t = 3.02, p = 0.004). No significant differences were observed in the pain score between the two groups 30 min after suctioning (t = 0.32, p = 0.75). The post hoc Least Significant Difference (LSD) test showed that the CPOT scores 10 min after suctioning was significantly higher than that before suctioning and significantly lower than that during suctioning (p = 0.001). The CPOT score 30 min after suctioning was also significantly lower than that 10 min after suctioning (p < 0.001).

Conclusions:

The present findings suggested a lower pain in the patients with closed suctioning compared to those with open suctioning.

The Effect of the Open and Closed System Suctions on Pain Severity and Physiological Indicators in Mechanically Ventilated Patients with Traumatic Brain Injury: A Randomised Controlled Trial

Objective

Tracheal suctioning can cause pain and physiological indicator variations in patients with traumatic brain injury (TBI). The aim of the present study was to compare pain severity and physiological indicator variations during the closed tracheal suction system (CTSS) and open tracheal suction system (OTSS) in patients with TBI.

Methods

This study was a clinical trial. Samples included all ventilated patients with TBI. The patients were randomly divided into the OTSS and CTSS groups. In both groups, the Critical Care Pain Observation Tool (CPOT) and physiological indicators were recorded by three nurses prior to suctioning, the end of suctioning and 5 min after suction completion. Data were analysed using the independent t-test and repeated measurement tests.

Results

A total of 112 patients participated in the present study. Before the interventions, the mean value of the Glasgow Coma Scale was 6.45±1.13, blood pressure 128.33±20.54, saturated oxygen in arterial blood (SpO₂) 96.74±2.76, respiratory rate (RR) 15.06±3.98, end-tidal CO2 (EtCO₂) 36.2±21.98, heart rate 82.18±42.33 and CPOT-based pain 0.43±0.94 in the patients. Independent t-test was used to compare CTSS and OTSS, suggesting significant differences with respect to the mean values of SpO₂, RR and EtCO₂ immediately after suctioning. This test showed significant differences between the two groups with respect to pain intensity at all three points of measurement. The two groups were also found to be significantly different with respect to RR measured 5 min after suctioning (p<0.05).

Conclusion

Compared to OTSS, CTSS can cause higher reductions in pain levels during and after suctioning in patients with head traumas and can also cause higher improvements in physiological indicators, such as RR, O₂ saturation and EtCO₂.