[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.

The effects of open and closed system endotracheal suctioning methods on suctioning frequency, amount of secretion, and haemodynamics: A single-blind, randomised, 2 × 2 crossover trial

BACKGROUND

Several studies have revealed that clinicians cannot suction all available secretion in the trachea and perform more frequent suctioning with a closed suctioning system (CSS) than with an open suctioning system (OSS). There are also studies claiming that the CSS is as effective as the OSS, based on either the amount of secretion, the frequency of suctioning, or haemodynamic parameters alone. However, there is no study examining all at once.

OBJECTIVES

This study aims to determine whether the CSS is as effective for secretion removal, suctioning frequency, tidal volume (VT), and peripheral oxygen saturation (SpO2) as the OSS.

METHODS

The study used a single-blind, randomised, 2 × 2 crossover (2-method, 2-arm, 2-period) design. One hundred intubated patients were randomly assigned to two study arms. Thirty-four were randomised to the CSS on the first day and the OSS on the second day (AB arm), and 35 were randomised to the OSS on the first day and the CSS on the second day (BA arm). A 12-h washout period was set between them. Haemodynamic parameters were measured just before suctioning and in the 5th minute after suctioning. The secretions obtained after suctioning were weighed, and the frequency of suctioning was recorded.

RESULTS

There were no effects of method, period, or carryover on suctioning frequency and amount of secretion in the 2 × 2 crossover design t-test (p > 0.05). In the OSS, there was a weak, linear, and negative correlation between the amount of secretion and SpO2, and between VT and SpO2 measured before and after suctioning (p < 0.05 for all).

CONCLUSIONS

Open and closed suctioning systems were similar in terms of haemodynamic alterations, amounts of secretion, and frequency of suctioning. The CSS was as effective as the OSS.

REGISTRATION NUMBER

NCT04053751.

Short-term effects of endotracheal suctioning in post-cardiac arrest patients: A prospective observational cohort study

Background

Endotracheal suctioning (ETS) is required in critically ill patients but may lead to adverse physiologic effects. The aim of this study was to investigate risk factors associated with adverse respiratory and circulatory effects of ETS, in post-cardiac arrest patients receiving controlled ventilation.

Methods

Patients with return of spontaneous circulation after out-of-hospital cardiac arrest were followed the first five days in the intensive care unit (ICU). For each ETS procedure performed, data were extracted from the electronic ICU records 10 min before and until 30 min after the procedure. Adverse events were defined as heart rate > 120 beats/min, systolic blood pressure > 200 or < 80 mmHg or SpO₂ < 85%. Multivariate logistic regression was applied with SpO₂ < 85% and systolic blood pressure < 80 mmHg as primary outcomes.

Results

For the 36 patients included in the study, the median number of ETS-procedures per patient was 13 (range 1–33). Oxygen desaturation occurred in 10.3% of procedures and severe hypotension in 6.6% of procedures. In the multivariate analysis, dose of noradrenaline, light sedation and oxygen desaturation prior to suctioning were associated with increased risk of oxygen desaturation. Doses of noradrenaline, suction with manual ventilation, suction in combination with patient repositioning, and first day of treatment in the ICU were significantly associated with severe hypotension.

Conclusions

The risk of circulatory and respiratory deterioration during ETS in post-cardiac arrest patients is increased the first day of ICU care, and related to sedation, dose of noradrenaline and pre-procedure hypoxemia.

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.

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.

Effect of open versus closed endotracheal suctioning on intracranial pressure in severe brain-injured children: Study protocol for a randomized controlled trial

AIM

To compare the effects and safety of open and closed endotracheal suction in children with severe brain injury.

DESIGN

A single-blinding, single-centre randomized controlled trial (RCT).

METHODS

The children with severe brain injury admitted to the intensive care unit (ICU) from 1 September 2020-31 August 2022 will be included. And a total of 172 children with severe brain injury are expected to be included. The intracranial pressure, SpO₂ and heart rate before suctioning, at the end of suction, and at 5 and 10 min after suction, the estimated sputum volume for each suction, the incidence of ventilator-associated pneumonia, the duration of mechanical ventilation and the length of ICU stay will be analysed.

RESULTS

This present RCT has been prospectively registered in China Clinical Trial Registry (http://www.chictr.org.cn, ChiCTR2000030963). This present study is expected to provide reliable evidence to the airway management in children with severe brain injury.

Endotracheal suction interventions in mechanically ventilated children: An integrative review to inform evidence-based practice

OBJECTIVE

The objective of this study was to review and critically appraise the evidence for paediatric endotracheal suction interventions.

DATA SOURCES

A systematic search for studies was undertaken in the electronic databases CENTRAL, Medline, EMBASE, and EBSCO CINAHL from 2003.

STUDY SELECTION

Included studies assessed suction interventions in children (≤18 ys old) receiving mechanical ventilation. The primary outcome was defined a priori as duration of mechanical ventilation. Secondary outcomes included adverse events and measures of gas exchange and lung mechanics.

DATA EXTRACTION

Data extraction were performed independently by two reviewers. Study methodological quality was assessed using Cochrane's risk of bias tool for randomised trials or the Newcastle-Ottawa Scale for observational studies. Overall assessment of the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations criteria.

RESULTS

Overall 17 studies involving 1618 children and more than 21,834 suction episodes were included in the review. The most common intervention theme was suction system (five studies; 29%). All included trials were at unclear or high risk of performance bias due to the inability to blind interventionists. Current evidence suggests that closed suction may maintain arterial saturations, normal saline leads to significant transient desaturation, and lung recruitment applied after suction offers short-term oxygenation benefit.

LIMITATIONS

Lack of randomised controlled trials, inconsistencies in populations and interventions across studies, and imprecision and risk of bias in included studies precluded data pooling to provide an estimate of interventions effect.

CONCLUSIONS

Based on the results of this integrative review, there is insufficient high-quality evidence to guide practice around suction interventions in mechanically ventilated children.