Benefits and harms of normal saline instillation before endotracheal suctioning in mechanically ventilated adult patients in intensive care units: A systematic literature review and meta-analysis

OBJECTIVES

This systematic review aimed to identify the effects of normal saline instillation before endotracheal suctioning on clinical outcomes in critically ill patients on a mechanical ventilator.

RESEARCH METHODOLOGY

This review was based on the guidelines of the National Evidence-based Healthcare Collaborating Agency in Korea and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Six electronic databases were searched for relevant literature. Other sources were also searched, including the reference lists of identified reports and previous systematic reviews. After the initial literature search, a two-step retrieval process was performed to select eligible studies. Then, data were collected using a newly developed form, and the risk of bias was assessed using the checklists of the Joanna Briggs Institute. Data were analyzed using both narrative syntheses and meta-analyses.

RESULTS

In total, 16 studies: 13 randomized controlled trials and three quasi-experimental studies, were included. From the narrative syntheses, instilling normal saline before endotracheal suctioning was associated with a decrease in oxygen saturation, prolonged time for oxygen saturation to recover to baseline, decreased arterial pH, increased secretion amount, reduced incidence of ventilator-associated pneumonia, increased heart rate, and increased systolic blood pressure. Meta-analyses showed a significant difference in heart rate at five minutes after suctioning but no significant differences in oxygen saturation at two and five minutes after suctioning and heart rate at two minutes after suctioning.

CONCLUSION

This systematic review indicated that instilling normal saline before performing endotracheal suctioning has more harmful effects than benefits.

IMPLICATIONS FOR CLINICAL PRACTICE

As recommended in the current guidelines, it is necessary to refrain from routine normal saline instillation before endotracheal suctioning.

Updating the Evidence: Suctioning Practices of Physiotherapists in Ontario

Purpose: The purpose of this article is to describe current tracheal suctioning practices of physiotherapists in the province of Ontario and to determine what factors influence these practices. Method: A cross-sectional online survey was conducted. An online survey link and quick response code were mailed to Ontario physiotherapists who were actively providing patient care and were authorized to perform tracheal suctioning as identified by the College of Physiotherapists of Ontario. Results: Ninety physiotherapists participated in the survey (23% response rate). Most (66%) suctioned in an intensive care setting, and many (41%) reported frequently using a closed endotracheal suctioning system. Hyperoxygenation was frequently performed before suctioning by 48% of participants, and only 18% frequently hyperoxygenated after suctioning. Most participants reported infrequently performing saline instillation (52%) and infrequently hyperinflating before suctioning (79%). Clean gloves were reported as the personal protective equipment most frequently worn across all suctioning approaches, and goggles and sterile gloves were least often worn while suctioning. Previous suctioning experience had the most influence on suctioning practices, and limited access to equipment had the least influence. Conclusions: Some of the tracheal suctioning practices of physiotherapists in Ontario vary from evidence-based clinical guidelines.

Increasing suction pressure during endotracheal suctioning increases the volume of suctioned secretions, but not procedure-related complications: A comparative study in open system endotracheal suctioning

OBJECTIVES

To compare the effect of three different suction pressures (80 mmHg, 150 mmHg, 250 mmHg) with the open system suction method in terms of the volume of secretions and complications development in intubated intensive care patients.

RESEARCH METHODOLOGY/DESIGN

This study was planned as a prospective, experimental, self-controlled design. The study sample included 47 patients. Data were collected using a data collection and patient follow-up form from patient records.

SETTING

Single adult intensive care unit in a university hospital.

RESULTS

Fifty five percent of the patients were male, 61.7% were older than 65 years and 38.32% had lung infection. The amount of suctioned secretions tended to increase significantly with increasing negative pressure and there was a significant difference between the pressures in terms of the median volume of suctioned secretions (p < 0.001). There was no significant difference between the suction pressures in terms of oxygen desaturation, hypertension rates (p > 0.05). Tachycardia, bradycardia, hypoxaemia, tracheal mucosal damage or mucosal bleeding were not observed during suctioning with three different suction pressures.

CONCLUSION

It may be assumed that 250 mmHg suction pressure, via compliance with open system suction method related procedures, is being more effective and equally safe for secretion cleaning in comparison to the 80 and 150 mmHg suction pressures.

Normal saline instillation before suctioning: A meta-analysis of randomized controlled trials

BACKGROUND

For airway management of intensive care unit (ICU) patients who are intubated, a 5-10-mL bolus of sterile normal saline (NS) solution is commonly instilled into an endotracheal or tracheostomy tube before suctioning. However, NS instillation has been associated with adverse events such as dyspnea, increasing heart rate, decreasing of oxygenation, blood pressure, and other vital parameters.

OBJECTIVE

To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the necessity of NS instillation before suctioning in ICU patients.

DATA SOURCES

The PubMed, Embase, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry were searched for studies published before May 2016.

REVIEW METHODS

RCTs evaluating the outcome of NS instillation before suctioning in ICU patients undergoing endotracheal intubation or tracheostomy were included. Individual effect sizes were standardised, and a meta-analysis was conducted to calculate the pooled effect size by using a random-effect model. The primary outcome was the oxygen saturation immediately and 2 and 5min after suctioning. The secondary outcomes were the heart rate and blood pressure after suctioning.

RESULTS

We reviewed 5 RCTs including 337 patients. Oxygen saturation was significantly higher in the non-NS group than in the NS group 5min after suctioning. The pooled mean difference in oxygen saturation was -1.14 (95% confidence interval: -2.25 to -0.03). The heart rate and blood pressure did not differ significantly between the non-NS and NS groups.

CONCLUSION

NS instillation before suctioning does not benefit patients undergoing endotracheal intubation or tracheostomy. Moreover, it reduces oxygen saturation 5min after suction. However, our reviewed studies had a low methodological quality. Thus, additional studies involving large-scale RCTs are warranted.

Normal saline instillation before endotracheal suctioning: "What does the evidence say? What do the nurses think?": Multimethod study

PURPOSE

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.

METHODS

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 intensive care nurses.

RESULTS

The systematic review identified 7 studies. Nearly all of the studies had a self-controlled clinical trial design. Normal saline instillation before endotracheal suctioning was demonstrated to decrease patient oxygenation in most studies (P < .05). However, the impact of normal saline on hemodynamics and the incidence of ventilator-associated pneumonia remain unclear. Most nurses (87.7%) apply normal saline instillation.

CONCLUSION

Although the effects of normal saline instillation on hemodynamics and pneumonia incidence remain controversial, this procedure significantly decreases the oxygenation. Therefore, the use of this procedure is not recommended. However, normal saline instillation is used frequently by nurses to manage thick and tenacious secretions in clinical practice. Additional studies are needed to determine the effectiveness of applications that may be alternatives to normal saline instillation in the management of these secretions.