Evaluation of tracheostomy suctioning procedure among nursing and respiratory therapy students: wearable manikin vs. standard manikin

Introduction

This study aims to evaluate cognitive load (CL), emotional levels (EL), and stress levels (SL) of students when using a wearable manikin vs. a standard manikin for tracheostomy suctioning (TS).

Methods

This study was approved by the Institutional Review Board. Subjects were recruited by email. Subjects completed a baseline demographics questionnaire, then they were randomized into two groups: wearable manikin group (WMG) or standard manikin group (SMG). For the WMG, an actor simulated a patient by wearing the device. In phase I, both groups were educated on how to perform TS by video and offered hands-on practice. Then I put through a tracheostomy suctioning clinical simulation and completed a post sim-survey. In phase II, the same survey was repeated after encountering a real patient as part of their clinical rotation.

Results

A total of 30 subjects with a mean age 26.0 ± 5.5 years participated. 20 (66.7%) were respiratory care students and 10 (33.3%) were nursing students. In the WMG, the median stress level dropped significantly post phase II compared to post phase I [2(1,4) vs.3(1,5), p = 0.04]. There were no significant changes in median CL, confidence, and satisfaction levels between post phase II and post phase I (p > 0.05). In the SMG, the satisfaction level increased significantly post phase II compared to post phase I [5(4,5) vs.4(2,5), p = 0.004], but there were no significant changes in CL, SL, and confidence levels between post phase I and phase II. There was no significant difference in mean EL scores over time and these changes did not differ by group. Subjects in the WMG showed a higher mean competency score than those in the SMG (85.5 ± 13.6 vs. 78.5 ± 20.8, p = 0.14, Cohen's d = 0.4), yet not significant.

Conclusion

Our results showed that the WMG is beneficial in helping bridge the gap of learning TS from the sim setting to the real-world clinical setting. More studies with higher sample size and use of other CL scales that assesses the different types of CL are needed to validate our findings.

The impact of death rattle on bereaved families: not the sound itself, but the resonance with their feelings

BACKGROUND

This study aimed to explore (i) the consistency between physician-rated and bereaved family-perceived intensity of death rattle, (ii) the relationship between intensity of death rattle and the bereaved family's distress and (iii) the bereaved family's experience and feelings related to suctioning for death rattle.

METHODS

We used matched data for deceased patients from a prospective cohort study of cancer patients admitted to a palliative care unit, and their bereaved families from a nationwide questionnaire survey in Japan. The intensity of death rattle using Back's score was evaluated prospectively by physicians and retrospectively by bereaved families.

RESULTS

In total, 1122 bereaved families answered (response rate: 66.7%). Of these, 297 reported the development of death rattle. The maximum intensity of death rattle evaluated by physicians and perceived by bereaved families was poorly correlated (Spearman correlation coefficient 0.188, P = 0.082). The optimal cut-off point of Back's score for detecting high-level distress was 1/2, with a low accuracy of prediction (area under the curve 0.62). More than 70% of bereaved families indicated suctioning reduced the intensity of death rattle, made patients comfortable and themselves relieved, whereas a similar proportion felt patients were in distress during suctioning. Families who felt suctioning was gently performed and discussed well whether to do suctioning with health care providers felt less needs for improvement.

CONCLUSIONS

Bereaved family-perceived intensity of death rattle did not correlate to physician-evaluated intensity, and the intensity of death rattle itself seemed to poorly correlate to family distress. Gently performed suctioning based on sufficient discussion with families can help reduce family-perceived patient discomfort.

Is paediatric endotracheal suctioning by nurses' evidence based? An International Survey

BACKGROUND

Endotracheal suction (ETS) is essential in intubated patients to prevent tube occlusion and is one of the most common nursing interventions performed in intensive care.

AIMS AND OBJECTIVES

To explore how paediatric ETS practices reflect evidence-based practice (EBP) recommendations in paediatric intensive care units (PICU) worldwide.

STUDY DESIGN AND METHODS

A cross-sectional electronic survey linked to a real patient suction episode. Nurses completed the survey following a recent ETS episode. Evidence-based practice (EBP) was defined based on four of the American Association for Respiratory Care (AARC) best evidence recommendations: pre-oxygenation before suction, use of a suction catheter no more than half the diameter of the tracheal tube, shallow depth of suction, and the continuous suction applied upon withdrawal of the catheter. Participants included PICU nurses who performed ETS in children (0-17 years) excluding preterm neonates.

RESULTS

Four hundred forty-six complete surveys were received from 20 countries. Most nurses (80%, 367/446) reported that their units had local guidelines for ETS. The most common reason for suctioning (44%) was audible/visible secretions. Over half of ETS episodes (57%) used closed suction. When exploring the individual components of suction, 63% (282/446) of nurses pre-oxygenated their patient prior to suction, 71% (319/446) suctioned no further than 0.5 cm past end of the endotracheal tube (ETT), 59% (261/446) used a catheter no more than half the diameter of the ETT, and 78% (348/446) used continuous negative pressure. 24% of nurses gave patients an additional bolus of sedative, analgesic, and/or muscle-relaxant medication prior to suction; this decision was not related to the child's history of instability with suction, as there was no significant difference in those who reported patients had a history of being unstable with suction (P = .80). 26% (117/446) of nurses complied with all four EBP components in the reported suctioning episode.

CONCLUSIONS

Considerable variation in paediatric endotracheal suctioning practices exists internationally. Although most nurses applied single components of evidence-based recommendations during ETT suctioning, just a quarter applied all four elements.

RELEVANCE TO CLINICAL PRACTICE

Nurses' need to consider and strive to apply EBP principles to common nursing interventions such as ETS.

Palliative care physicians' perspectives of management for terminally ill cancer patients with death rattle: a nationwide survey

Death rattle occurs during the last days of life, and relatives of those afflicted frequently report that it is very distressful. However, there is no effective treatment for it. The purpose of this study was to investigate the perceptions of Japanese palliative care physicians in clinical practice in Japan. We conducted a nationwide survey of 268 physicians via an anonymous, self-report questionnaire. We assessed pharmacological and non-pharmacological management and anticholinergic agent choice. One hundred eighty-nine physicians (70.5%) returned the questionnaires. Fifty-five participants (29.1%) treating patients with Type-1 (real death rattle) and 36 participants (19%) treating patients with Type-2 (pseudo-death rattle) death rattle reported that they would frequently administer an anticholinergic agent. One-fourth would administer scopolamine butylbromide or scopolamine hydrobromide. In conclusion, more Japanese palliative care physicians thought that anticholinergic agents might be effective for treating Type-1 death rattle rather than Type-2. Further clinical trials of these agents are needed.

Airway Management and Ventilator-Associated Events

Airway management techniques are aimed at reducing complications associated with artificial airways and mechanical ventilation, such as retained secretions. The impact of airway management techniques on ventilator-associated events (VAEs) varies considerably by modality. Closed-suction techniques are generally recommended but have limited, if any, impact on VAEs. Normal saline instillation during suctioning is not recommended. Devices designed specifically to remove biofilm from the inside of endotracheal tubes appear to be safe, but their role in VAE prevention is uncertain. Subglottic secretion clearance by artificial cough maneuvers is promising, but more research is needed to assess its clinical feasibility. Continuous cuff-pressure management appears to be effective in reducing microaspiration of subglottic secretions.

Physiologic Effects of Nasal Aspiration and Nasopharyngeal Suctioning on Infants With Viral Bronchiolitis

BACKGROUND

There is limited evidence supporting an optimum method for removing mucus from the airways of hospitalized infants with bronchiolitis. This study was designed to evaluate short-term physiologic effects between nasal aspiration and nasopharyngeal suctioning in infants.

METHODS

Sixteen infants requiring hospitalization for supportive management of bronchiolitis were instrumented with transcutaneously measured partial pressure of carbon dioxide ([Formula: see text]) and [Formula: see text] monitoring. Electrical impedance tomography (EIT) was used to estimate changes in inspiratory and end-expiratory lung volume loss and recovery. Subjects were suctioned with both nasal aspiration and nasopharyngeal suctioning methods in a randomized order (8 received nasal aspiration followed by nasopharyngeal suctioning, and 8 received nasophayrgeal suctioning followed by nasal aspiration). Noninvasive gas exchange and EIT measurements were obtained at baseline (pre-suction) and at 10, 20, and 30 min following each suctioning intervention. Sputum mass was obtained following suctioning, and clinical respiratory severity scores, before and after suctioning, were computed.

RESULTS

There were no differences in inspiratory EIT (P = .93), change in end-expiratory lung impedance (ΔEELI; P = .53), [Formula: see text] (P = .41), [Formula: see text] (P = .88), heart rate (P = .31), or breathing frequency (P = .15) over the course of suctioning between nasal aspiration and nasopharyngeal suctioning. Sputum mass (P = .14) and clinical respiratory score differences before and after suctioning (P = .59) were not different between the 2 suctioning interventions. Sputum mass was not associated with ΔEELI at 30 min for nasal aspiration (ρ = 0.11, P = .69), but there was a moderate positive association for nasopharyngeal suctioning (ρ = 0.50, P = .048).

CONCLUSIONS

Infants with viral bronchiolitis appeared to tolerate both suctioning techniques without adverse short-term physiologic effects, as indicated by the unchanged gas exchange and estimated lung volumes (EIT). Nasopharyngeal suctioning recovered 36% more sputum than did nasal aspiration and there was moderate correlation between sputum mass and end-expiratory lung impedance change at 30 minutes post-suction with nasopharyngeal that was not present with nasal aspiration. It is possible that a subset of patients may benefit from one type of suctioning over another. Future research focusing on important outcomes for suctioning patients with bronchiolitis with varying degrees of lung disease severity is needed.

Effects of Manual Rib Cage Compressions on Mucus Clearance in Mechanically Ventilated Pigs

BACKGROUND

Manual rib cage compression is a chest physiotherapy technique routinely used in clinical practice. However, scientific evidence remains scarce on the effects of manual rib cage compression on airway clearance and oxygenation in mechanically ventilated patients.

METHODS

Anesthetized pigs were intubated via the trachea and mechanically ventilated. To create atelectasis, artificial mucus was infused into the airway. Each pig was randomly assigned to 1 of 2 groups: closed suctioning alone (control group, 7 pigs), or manual rib cage compression combined with closed suctioning (manual rib cage compression group, 8 pigs). Hard and brief rib cage compression synchronized with early expiratory phase was tested. Mucus clearance and oxygenation were assessed after the intervention. Sequential changes of hemodynamics were assessed after the intervention.

RESULTS

During hard manual rib cage compression, the mean ± SD peak expiratory flow increased to 44 ± 7 L/min compared with 31 ± 7 L/min without treatment (P < .001). Manual rib cage compression combined with endotracheal suctioning increased mucus clearance compared with closed suctioning alone (mucus amounts, 5.5 [3.4-9.4] g vs 0.7 [0.5-2.0] g; P = .004); however, it did not improve gas exchange and radiologic findings. There were no significant differences in hemodynamic variables between the 2 groups.

CONCLUSIONS

Our findings indicated that hard and brief manual rib cage compression combined with closed suctioning was safe and led to improvement of mucus clearance; however, no effectiveness was confirmed with regard to oxygenation and ventilation.

Delivery room handling of the newborn

For newly born babies, especially those in need of intervention at birth, actions taken during the first minute after birth, the so-called "Golden Minute", can have important implications for long-term outcomes. Both delivery room handling, including identification of maternal and infant risk factors and provision of effective resuscitation interventions, and antenatal care decisions regarding antenatal steroid administration and mode of delivery, are important and can affect outcomes. Anticipating risk factors for neonates at high risk of requiring resuscitation can decrease time to resuscitation and improve the prognosis. Following a review of maternal and fetal risk factors affecting newborn resuscitation, we summarize the current recommendations for delivery room handling of the newborn. This includes recommendations and rationale for the use of delayed cord clamping and cord milking, heart rate assessment [including the use of electrocardiogram (ECG) electrodes in the delivery room], role of suctioning in newborn resuscitation, and the impact of various ventilatory modes. Oxygenation should be monitored by pulse oximetry. Effects of oxygen and surfactant on subsequent pulmonary outcomes, and recommendations for provisions of appropriate thermoregulatory support are discussed. Regular teaching of delivery room handling should be mandatory.

Tracheostomy speaking valve modification in children: A standardized approach leads to widespread use

BACKGROUND

Tracheostomy is associated with negative effects on voice, speech, and feeding/swallowing. Speaking valves have beneficial effects in these areas but are often contra-indicated in children with airway problems due to high transtracheal pressure (TTP). Valves are modified by drilling to reduce excessive TTP. We hypothesized that a standardized approach to assessment and valve modification by drilling improves valve tolerance and allows widespread successful use.

METHODS

Following development of a standardized multidisciplinary protocol for patient selection, valve modification and valve prescription at our center, we retrospectively collected information from clinical notes relating to clinical indication and medical history of all children undergoing speaking valve assessment from February 2014 to June 2017. We designed a questionnaire which was delivered to the parents of children receiving both modified and standard valves enquiring about voice, feeding, communication, and suctioning.

RESULTS

Data on 45 children were collected. Thirteen had normal TTP and were given standard valves and 32 had high TTP, all of whom had their valves modified resulting in good tolerance. 17 Children were on positive pressure ventilation at the time of placement. The survey response rate was 83%. Parents report a high degree of satisfaction with modified valves and report positive effects in terms of voice, speech, and feeding/swallowing similar to those reported for standard valves.

CONCLUSIONS

Speaking valves can be successfully and safely modified in children, providing valves to many patients previously deemed unsuitable. We report positive parental experiences of these modified valves in line with those reported with standard valves.

Effect of Expressed Breast Milk versus Swaddling versus Oral Sucrose Administration on Pain Associated with Suctioning in Preterm Neonates on Assisted Ventilation: A Randomized Controlled Trial

Objective:

The objective of our study was to assess the pain associated with suctioning in preterm neonates on assisted ventilation and comparing the use of expressed breast milk (EBM), sucrose, and swaddling to alleviate pain.

Methods:

Study design: A randomized controlled clinical trial.

Inclusion Criteria:

Preterm neonates on assisted ventilation.

Exclusion Criteria:

Major congenital anomalies and severe encephalopathy.

Study Duration and Site:

6 months in level III neonatal Intensive Care Unit. In the first phase, we used premature infant pain profile (PIPP) score to assess pain associated with suctioning in preterm neonates on assisted ventilation. In the second phase, the effect of EBM, swaddling, and sucrose on pain relief during suctioning in neonates on assisted ventilation was assessed.

Results:

There was a significant increase in pain associated with suctioning in preterm neonates on assisted ventilation (preprocedure PIPP score 7.90 ± 2.50; procedural PIPP score 13.63 ± 2.57; P < 0.05). The postintervention mean procedural PIPP score was not significantly different between the EBM, swaddling, and sucrose groups (P = 0.24).

Conclusions:

Suctioning is painful for preterm neonates on assisted ventilation. There was no difference between EBM, swaddling, and sucrose in relieving pain associated with suctioning.

Comparing the Effects of Two Different Levels of Hyperoxygenation on Gas Exchange During Open Endotracheal Suctioning: A Randomized Crossover Study

BACKGROUND

Endotracheal suctioning is required for mechanically ventilated patients to maintain a patent airway. Studies show that open endotracheal suctioning affects respiratory mechanics and gas exchange. The aim of this study was to compare the effectiveness of hyperoxygenation with F_IO2 + 0.20 above baseline and hyperoxygenation with F_IO2 1.0 in preventing hypoxemia, and to determine the impact of open endotracheal suctioning on the pulmonary ventilation of critical subjects receiving mechanical ventilatory support.

METHODS

This prospective randomized crossover study was conducted in the ICU. Sixty-eight mechanically ventilated subjects with F_IO2 ≤ 0.6 and requiring endotracheal suctioning were included in this study. Open endotracheal suctioning was performed using 2 different intervention sequences: hyperoxygenation of 0.20 above baseline F_IO2 (F_IO2 + 0.20) and 1.0 hyperoxygenation (F_IO2 1.0). Oxygenation was assessed via oxygen saturation as measured by pulse oximetry (S_pO2 ), and changes in lung ventilation were measured via alveolar gas volume (V̇_A), alveolar minute volume (V̇_{A min}), carbon dioxide (CO₂) production (V̇_CO2 ), mixed exhaled partial pressure of CO₂ (P_̄ECO2 ), exhaled tidal CO₂ volume (V_TCO₂), end-tidal CO₂ (P_ETCO2 ), anatomical dead space to tidal volume ratio (V_D/V_T), and anatomical dead space volume of each breath (V_D) using volumetric capnography, and breathing frequency (f), heart rate, and mean arterial pressure using a multiparameter monitor.

RESULTS

S_pO2 levels were significantly higher within interventions (F_IO2 + 0.20 and 1.0) 1 min before and after suction. Also, there was a significant increase in P_ETCO2 , P_̄ECO2 , heart rate, and mean arterial pressure immediately after the procedure compared with baseline, and in V_TCO₂, only for F_IO2 + 0.20. Baseline values were not found to be significantly different between the groups in case of any dependent variable.

CONCLUSIONS

In mechanically ventilated adult subjects, hyperoxygenation with F_IO2 + 0.20 above baseline prevents hypoxemia. Also, transient changes in pulmonary ventilation with open circuit suctioning were confirmed by volumetric capnography analysis. (Trial registration: ClinicalTrials.gov NCT02440919).

How to perform open tracheal suction via an endotracheal tube

Rationale and key points Tracheal suction involves the removal of pulmonary secretions from the respiratory tract using negative pressure under sterile conditions. Practitioners should be aware of the indications for, and risks associated with, open tracheal suction via an endotracheal tube. ▶ Respiratory assessment of the patient should be carried out to identify when tracheal suction is required. ▶ A suction pressure of 80-120mmHg is recommended, and suction should last no longer than 15 seconds. ▶ Reassurance and support should be given to the patient to minimise any discomfort and distress that might result from tracheal suction. Reflective activity Clinical skills articles can help update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will change your practice when performing open tracheal suction via an endotracheal tube. 2. How you could use this resource to educate your colleagues. Subscribers can upload their reflective accounts at: rcni.com/portfolio .

Endotracheal Suctioning of the Critically Ill Child

Endotracheal suctioning is an essential intervention for the care of an intubated child and is one of the most commonly performed interventions in pediatric intensive care. Despite this, much of the research related to endotracheal suctioning is dated and the bulk of it conducted in preterm infants and adults. This paper will review research related to endotracheal suctioning that involves or relates to children in intensive care to provide a current review of the literature in this field. It will conclude with recommendations for practice where possible and identify areas for further research.

Endotracheal Tube Seal and Suction Performance in a Novel Biorealistic Tracheal Model

BACKGROUND

Endotracheal tube (ETT) cuffs create a seal to protect against secretion entry to the lungs. Cuff inflation currently is recommended at 20-30 cm H2O pressure. ETT designs have variable seal performance in bench studies using rigid tracheal models lacking the dynamic characteristics of the human trachea. We compared ETT designs within a new, biorealistic tracheal model to assess cuff and suction performance in the setting of a compliant trachea.

METHODS

Three ETT designs (Mallinckrodt Hi-Lo, KimVent Microcuff, and Sheridan/HVT) were tested for performance by simulant leakage below the cuff and air leakage (measured as return tidal volume ≥ 80% delivered) over a range of cuff (5-25 cm H2O) and end-expiratory pressure (PEEP 0-15 cm H2O). Subglottic suction channel performance was tested in 2 ETTs (TaperGuard Evac [Covidien] and ISIS HVT [Teleflex]) as time to evacuate the simulant.

RESULTS

All ETT cuffs provided effective seals at an inflation pressure of 12 cm H2O when PEEP was ≤ 5 cm H2O. The Microcuff ETT sealed at the lowest pressure of 6 cm H2O, whereas the Sheridan/HVT cuff sealed at 12 cm H2O (P = .01). With a PEEP of 15 cm H2O, a reciprocal increase in air leak occurred, requiring a cuff inflation up to 22 cm H2O to maintain a return tidal volume at ≥ 80% delivered. Suction channel performance improved in the lateral position compared with supine for both ETT designs during continuous 15 mm Hg suction pressure (P = .001).

CONCLUSIONS

Within a novel model with normal trachea compliance, we found all ETT designs tested to seal at lower than current recommended cuff pressures.

The effect of facilitated tucking position during endotracheal suctioning on physiological responses and coping with stress in premature infants: a randomized controlled crossover study

OBJECTIVE

Premature infants respond more intensively to pain compared with term infants. Facilitated tucking position as a non-pharmacological method of pain in infants has been suggested; however, its effect on acute procedural pain such as endotracheal suctioning remains to be studied. This study examined the effect of facilitated tucking position during suctioning on physiological responses and coping with stress in premature infants.

METHODS

This was a randomized controlled crossover study. Thirty-four premature infants received an order of either suctioning with intervention - suctioning without intervention, or suctioning without intervention - suctioning with intervention. Neonatal Infant Pain Scale (NIPS) was used to collect the data.

RESULTS

No statistical significant difference was seen between intervention and non-intervention cases in terms of the average time duration to reach the pain score to one or zero, and also, in the average of changes in oxygen saturation. However, changes in heart rate were less in intervention cases.

CONCLUSION

The effect of facilitated tucking position on coping with stress was not found in this study. This non-pharmacological strategy can be suggested because of its effect on reducing changes in heart rate during painful procedure. It is suggested to replicate the study with larger number of samples.

Lung volume changes during cleaning of closed endotracheal suction catheters: a randomized crossover study using electrical impedance tomography

BACKGROUND

Airway suctioning in mechanically ventilated patients is required to maintain airway patency. Closed suction catheters (CSCs) minimize lung volume loss during suctioning but require cleaning post-suction. Despite their widespread use, there is no published evidence examining lung volumes during CSC cleaning. The study objectives were to quantify lung volume changes during CSC cleaning and to determine whether these changes were preventable using a CSC with a valve in situ between the airway and catheter cleaning chamber.

METHODS

This prospective randomized crossover study was conducted in a metropolitan tertiary ICU. Ten patients mechanically ventilated via volume-controlled synchronized intermittent mandatory ventilation (SIMV-VC) and requiring manual hyperinflation (MHI) were included in this study. CSC cleaning was performed using 2 different brands of CSC (one with a valve [Ballard Trach Care 72, Kimberly-Clark, Roswell, Georgia] and one without [Portex Steri-Cath DL, Smiths Medical, Dublin, Ohio]). The maneuvers were performed during both SIMV-VC and MHI. Lung volume change was measured via impedance change using electrical impedance tomography. A mixed model was used to compare the estimated means.

RESULTS

During cleaning of the valveless CSC, significant decreases in lung impedance occurred during MHI (-2563 impedance units, 95% CI 2213-2913, P < .001), and significant increases in lung impedance occurred during SIMV (762 impedance units, 95% CI 452-1072, P < .001). In contrast, cleaning of the CSC with a valve in situ resulted in non-significant lung volume changes and maintenance of normal ventilation during MHI and SIMV-VC, respectively (188 impedance units, 95% CI -136 to 511, P = .22; and 22 impedance units, 95% CI -342 to 299, P = .89).

CONCLUSIONS

When there is no valve between the airway and suction catheter, cleaning of the CSC results in significant derangements in lung volume. Therefore, the presence of such a valve should be considered essential in preserving lung volumes and uninterrupted ventilation in mechanically ventilated patients.

Laboratory test of a visual sputum suctioning system

BACKGROUND

Conventional sputum suctioning is a routine clinical practice, but complications may arise from the blind manipulation of the catheter. Recently, a visual sputum suctioning system (VSSS) was developed, and we tested this new system in a laboratory setting.

METHODS

We used coagulant concentrations of 1.5% and 3.0% to simulate mucus and sputum. Conventional single-lumen and triple-lumen catheters were inserted separately into a beaker for sputum suctioning (15 s, 200 mm Hg). A micro-imaging fiber was integrated into the triple-lumen catheter to create the VSSS. The single-lumen catheter and the VSSS were inserted separately into the mouth cavity, the nasal cavity, the tracheostomy tube, and the endotracheal tube of a human analog model for further comparisons.

RESULTS

As the suction channel of the triple-lumen catheter was reduced by 46.8%, the amount of simulant it suctioned was significantly less than that suctioned by the single-lumen catheter. However, under real-time guidance, the VSSS suctioned more simulant than the conventional single-lumen catheter in the human analog model.

CONCLUSION

Sputum suctioning with the VSSS was feasible. Because of its real-time imaging guidance, the efficiency of the VSSS procedure was greater than that of the conventional single-lumen catheter. Therefore, this system may provide a new platform for sputum suctioning.

The effects of closed tracheal suctioning plus volume guarantee on cerebral hemodynamics

OBJECTIVE

To compare the effects of open tracheal suctioning (OS) plus intermittent mandatory ventilation (IMV) vs. closed tracheal suctioning (CS) plus volume guarantee ventilation (VG) on changes in mean cerebral blood-flow velocity (CBFv) of ventilated very low birth weight (VLBW) infants.

STUDY DESIGN

A total of 75 normotensive, ventilated VLBW infants (with normal cranial ultrasounds) had monitoring of mean CBFv, PCO2 and mean arterial blood pressure (MABP) before, during and after 220 tracheal suctioning sessions during the first week of life. Multiple linear regression analysis was used to determine the factor(s) influencing the magnitude of relative changes from baseline in mean CBFv after suctioning.

RESULT

In all, 49 VLBW infants receiving IMV had monitoring during 124 OS sessions between July 2002 and May 2005; 26 VLBW infants receiving VG had monitoring during 96 CS sessions between January 2006 and July 2007. The average magnitude of relative changes in mean CBFv was significantly less with CS+VG, and was associated with the magnitude of relative changes in PCO2 and suctioning-ventilator group.

CONCLUSION

The average magnitude of relative changes in mean CBFv was reduced in VLBW infants with CS+VG vs. OS+IMV.

Recruitment and retention of lung volume

Both a reduction in tidal volume and alveolar recruitment may be necessary to prevent ventilator-induced lung injury in the management of patients with acute respiratory distress syndrome. The lung collapse associated with endotracheal suctioning produces hypoxaemia, but it also causes de-recruitment, potentially aggravating lung injury. A study conducted by Dyhr and colleagues demonstrates the benefit of lung recruitment manoeuvres after suctioning, which help to improve oxygenation and restore lung volume more rapidly. Although this intervention appears safe and beneficial, the precise role of lung volume recruitment manoeuvres remains to be elucidated.