A Multisite Survey of Suctioning Techniques and Airway Management Practices

Oral care of intubated patients, challenging task of ICU nurses: a survey of knowledge, attitudes and practices

INTRODUCTION

Patients' health outcomes can be positively affected by the oral care provided by intensive care unit (ICU) nurses. Providing effective oral care for intubated patients is a challenging task. The purpose of this study was to examine the knowledge, attitudes, and practices(KAP) of oral care among ICU nurses for intubated patients, as well as the underlying factors that influence these behaviors.

METHOD

This cross-sectional survey was conducted on 200 nurses from adult ICUs in referral hospitals located in the central eighth area of healthcare management in Iran. The timeframe for data collection was April to June in 2023. Data were collected by questionnaires which consisted of four sections: demographic information, knowledge, attitudes and practices of oral care for intubated patients. The Pearson Correlation Coefficient was employed to determine the correlation between KAP and its main variables, which were distributed normally.

RESULTS

The result showed that nurses were 32.19 ± 6.23 years old, with an average total work experience of 8.91 ± 5.54 years and an average ICU work experience of 5.89 ± 4.31 years. The mean KAP score were17.66 ± 3.04, 15.46 ± 4.23, and 7.57 ± 2.21, respectively. The knowledge of nurses was significantly impacted by their level of education (p = 0.04), and an increase in work experience each year was associated with improved attitudes among nurses (p = 0.04). A significant association was found between the nurses' oral care practice, knowledge (p = 0.03), and attitude (p = 0.04).

CONCLUSION

This study revealed that ICU nurses possess a moderate level of knowledge, a higher-than-average level of practice, and they have a favorable attitude towards giving oral care to intubated patients. Therefore, providing continuous education about oral care is essential for ICU nurses.

Oral Care Practice, Perception, and Attitude of Nurses in Intensive Care Units in Korea: A Questionnaire Survey

Background: This cross-sectional study investigated the factors influencing oral care in patients in intensive care units (ICUs) by identifying the current oral care practice status, perceptions, and attitudes of ICU nurses in Korea. Methods: This study surveyed 240 nurses with work experience in the ICU using a self-report questionnaire consisting of 22 items on the status, perception, and attitude towards oral care in the ICU. Results: A total of 227 questionnaires were analyzed. The average age of the participants was 29.79 ± 5.92 years, and the medical ICU was the most type of ICU. The factors affecting the attitude towards oral care and its importance in ICU patients were the experience of working as a nurse (r = 0.336, p < 0.01), ICU work experience (r = 0.218, p < 0.01), and oral care practice frequency (r = 0.167 p < 0.05); these were found to be statistically significant. Conclusions: In this study, the interest of the nurses in oral care practice and education was high, but professional education and the regular implementation of oral care practices were insufficient. To address these problems, it will be necessary to improve oral care practices through dental intervention and education about oral care methods focused on ICU patients.

Effectiveness of Continuous Cuff Pressure Control in Preventing Ventilator-Associated Pneumonia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Microaspiration of subglottic secretions is the main pathogenic mechanism for ventilator-associated pneumonia (VAP). Adequate inflation of the endotracheal cuff is pivotal to providing an optimal seal of the extraluminal airway. However, cuff pressure substantially fluctuates due to patient or tube movements, which can induce microaspiration. Therefore, devices for continuous cuff pressure control (CCPC) have been developed in recent years. The purpose of this systematic review and meta-analysis is to assess the effectiveness of CCPC in VAP prevention.

DATA SOURCES

A systematic search of Embase, the Cochrane Central Register of Controlled Trials, and the International Clinical Trials Registry Platform was conducted up to February 2022.

STUDY SELECTION

Eligible studies were randomized controlled trials (RCTs) and quasi-RCTs comparing the impact of CCPC versus intermittent cuff pressure control on the occurrence of VAP.

DATA EXTRACTION

Random-effects meta-analysis was used to calculate odds ratio (OR) and 95% CI for VAP incidence between groups. Secondary outcome measures included mortality and duration of mechanical ventilation (MV) and ICU stay. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.

DATA SYNTHESIS

Eleven RCTs with 2,092 adult intubated patients were included. The use of CCPC was associated with a reduced risk of VAP (OR, 0.51). Meta-analyses of secondary endpoints showed no significant difference in mortality but significant differences in durations of MV (mean difference, -1.07 d) and ICU stay (mean difference, -3.41 d) in favor of CCPC. However, the risk of both reporting and individual study bias was considered important. The main issues were the lack of blinding, potential commercial conflicts of interest of study authors and high heterogeneity due to methodological differences between studies, differences in devices used for CCPC and in applied baseline preventive measures. Certainty of the evidence was considered "very low."

CONCLUSIONS

The use of CCPC was associated with a reduction in VAP incidence; however, this was based on very low certainty of evidence due to concerns related to risk of bias and inconsistency.

Assessment of knowledge regarding tracheostomy care and management of early complications among healthcare professionals

•

Healthcare workers should be well versed in identifying tracheostomy management, its complications and responding accordingly.

•

Doctors and nurses (131 = 52%) possessed good knowledge about various aspects of tracheostomy care and management.

•

The poorest scores were regarding cuff pressure (38.9%), suction pressure (39.4%) and first response in tube blockade (31.1%).

•

Higher scores were found in age group 26 to 30 years (54.2%) and those having 1-3 years of clinical experience (41.2%).

•

No statistically significant assoiation of knowledge regarding tracheostomy care was apparent with age, gender or years of practice.

Introduction

Tracheostomy is commonly performed surgical procedure in ENT practice. Postoperative care is the most important aspect for achieving good patient outcomes. Unavailability of standard guidelines on tracheostomy management and inadequate training can make this basic practice complex. The nursing staff and doctors play a very important role in bedside management, both in the ward and in the intensive care unit (ICU) setup. Therefore, it is crucial that all healthcare providers directly involved in providing postoperative care to such patients can do this efficiently.

Objectives

The objective of this study is to assess the knowledge regarding identification and management of tracheostomy-related emergencies and early complications among healthcare professionals so as to improve practice and further standardization.

Methods

Cross-sectional observational study included two hundred and fifty-four doctors and nurses from four large tertiary care hospitals. The questions used were simple and straightforward regarding tracheostomy suctioning, cuff care, cuff management, tube blockage, and feeding management in patients with tracheostomy.

Results

Based on evidence from our study, knowledge level regarding tracheostomy care ranges from 48% to 52% with knowledge scores above 50% being considered satisfactory. Significant gaps in knowledge exist in various aspects of tracheostomy care and management among healthcare professionals.

Conclusion

Our findings demonstrated an adequate knowledge level among health care professionals ranging from 48% to 52% with knowledge scores above 50% being considered satisfactory and revealed that gaps in knowledge still exist in various aspects of tracheostomy care and management.

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.

British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units

BACKGROUND

Patients who are critically ill are at increased risk of hospital acquired pneumonia and ventilator associated pneumonia. Effective evidence based oral care may reduce the incidence of such iatrogenic infection.

AIM

To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients.

DESIGN

A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion.

METHODS

The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration. The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable.

RESULTS

The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use.

CONCLUSION

Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort.

RELEVANCE TO CLINICAL PRACTICE

Effective oral care is integral to safe patient care in critical care.

Impact of deep oropharyngeal suctioning on microaspiration, ventilator events, and clinical outcomes: A randomized clinical trial

AIMS

To evaluate a deep oropharyngeal suction intervention (NO-ASPIRATE) in intubated patients on microaspiration, ventilator-associated events and clinical outcomes.

DESIGN

Prospective, two-group, single-blind, randomized clinical trial.

METHODS

The study was conducted between 2014 - 2017 in 513 participants enroled within 24 hr of intubation and randomized into NO-ASPIRATE or usual care groups. Standard oral care was provided to all participants every 4 hr and deep oropharyngeal suctioning was added to the NO-ASPIRATE group. Oral and tracheal specimens were obtained to quantify α-amylase as an aspiration biomarker.

RESULTS

Data were analysed for 410 study completers enrolled at least 36 hr: NO-ASPIRATE (N = 206) and usual care (N = 204). Percent of tracheal specimens positive for α-amylase, mean tracheal α-amylase levels over time and ventilator-associated events were not different between groups. The NO-ASPIRATE group had a shorter hospital length of stay and a subgroup with moderate aspiration at baseline had significantly lower α-amylase levels across time.

CONCLUSION

Hospital length of stay was shorter in the NO-ASPIRATE group and a subgroup of intervention participants had lower α-amylase across time. Delivery of standardized oral care to all participants may have been an intervention itself and possibly associated with the lack of significant findings for most outcomes.

IMPACT

This trial compared usual care to oral care with a deep suctioning intervention on microaspiration and ventilator-associated events, as this has not been systematically studied. Further research on the usefulness of α-amylase as an aspiration biomarker and the role of oral suctioning, especially for certain populations, is indicated.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02284178.

Study protocol: A randomized controlled trial assessing the avoidance of endotracheal suction in cardiac surgical patients ventilated for ≤ 12 hr

AIMS

To assess the safety and efficacy of avoiding endotracheal suction in postoperative cardiac surgical patients mechanically ventilated for ≤ 12 hr.

DESIGN

A prospective, single centre, single blind, non-inferiority, randomized controlled trial evaluating the safety and efficacy of avoiding suction in uncomplicated, postoperative, adult cardiac surgical patients mechanically ventilated for ≤ 12 hr.

METHODS

Randomization will be performed on return to intensive care (ICU) with allocation to either usual postoperative care including suction or to usual care with no suction (intervention arm). The primary outcome is the ratio of partial pressure of oxygen (PaO₂ ) to fraction of inspired oxygen (FiO₂ ) (P/F) 6 hr after extubation. Pain assessments will be performed before, during and after endotracheal suction (ETS) and the patient experience will be investigated with a brief interview the following day. Ethics approval was received in October 2015.

DISCUSSION

Endotracheal suction is performed as part of airway management but has potential complications and there is little robust evidence to guide practice. This study will add to the evidence base about the need and benefit of endotracheal suction in this patient cohort.

IMPACT

As there is currently no published evidence about the safety of avoiding endotracheal suction. This study will provide the first evidence about avoidance of endotracheal suction in patients ventilated for less than 1 day. If non-inferior, the results have the capacity to change nursing practice by avoiding a potentially unnecessary procedure, it will build on the body of knowledge about the patient experience.

Nursing oral suction intervention to reduce aspiration and ventilator events (NO-ASPIRATE): A randomized clinical trial

AIM

The primary aim of this study is to compare an oropharyngeal suction intervention versus usual care on microaspiration in intubated patients. Secondary aims are to evaluate the intervention on ventilator-associated condition rates, time to occurrence and compare tracheal-oral α-amylase ratios between groups.

DESIGN

Prospective randomized clinical trial.

METHODS

The study received funding from the National Institutes of Health in February 2014 and Institutional Review Board approval in July 2013. Over 4 years, a convenience sample of 600 orally intubated, ventilated adult patients will be enrolled within 24 hr of intubation. The target sample is 400 participants randomized to the two groups. The intervention involves enhanced suctioning of the mouth and oropharynx every 4 hr, while the usual care group receives a sham suctioning. The research team will deliver usual oral care to all patients every 4 hr and collect oral and tracheal specimens every 12 hr, to quantify α-amylase levels to detect aspiration of oral secretions. Study completers must be enrolled at least 36 hr (baseline and three paired samples). Outcomes include α-amylase levels, percent of positive specimens, ventilator-associated conditions, length of stay, ventilator hours, and discharge disposition.

DISCUSSION

Enrolment has closed, and data analysis has begun. Subgroup analyses emerged, contributing to future research knowledge.

IMPACT

Standardized interventions have reduced but do not address all risk factors associated with ventilator-associated conditions. This study provides the potential to reduce microaspiration and associated sequelae in critically ill, intubated patients.

Factors That Affect Oral Care Outcomes for Institutionalized Elderly

The aim of this study was to evaluate the effect of an oral care intervention program on the incidence of pneumonia and fever as a surrogate endpoint. In addition, we tried to determine the oral care risk factors for the incidence of fever. We provided an oral care program for the elderly at one private nursing home in July 2013. The maximum capacity of the nursing home was 60 residents. The body temperatures of all residents were measured twice a day and were summarized as the incidence of fever over a one-month period, which was used as the dependent variable. The residents' life conditions, number of teeth, and prescribed diet were used as independent variables. The factors that affected the incidence of fever were the number of remaining teeth, a prescribed diet of sliced food, the meal care level, and the oral Candida levels. These risk factors affected the incidence of fever independently or interactively with oral care. Some risk factors for the incidence of fever were enhanced by the oral care program. It is important to evaluate and control these factors before the implementation of an oral care program.

Long-Term Effects of Saline Instilled During Endotracheal Suction in Pediatric Intensive Care: A Randomized Trial

BACKGROUND

Saline instillation is still used to assist in removal of secretions from endotracheal tubes in some pediatric intensive care units.

OBJECTIVE

To compare the effect of using either no saline, quarter-normal (0.225%) saline, or normal (0.9%) saline during endotracheal suctioning of children receiving ventilatory support in a pediatric intensive care unit.

METHOD

An unblinded, randomized trial with 3 treatment groups was conducted with 427 children who received ventilatory support for at least 12 hours. Children were randomly assigned to receive no saline, 0.225% saline, or 0.9% saline during routine endotracheal suctioning.

RESULTS

The primary outcome was the number of hours of invasive mechanical ventilation; oxygen therapy and length of stay in the unit were secondary outcomes. There were 138 children randomly assigned to the no-saline group, 141 to the 0.225% saline group, and 148 to the 0.9% saline group. In Kaplan-Meier intention-to-treat analysis, the median (interquartile range) number of hours of invasive mechanical ventilation was 32 (20-68), 43 (21-86), and 40 (20-87) in the no-saline, 0.225% saline, and 0.9% saline groups, respectively. Although the no-saline group received fewer hours of invasive ventilation, oxygen therapy, and intensive care than the other groups combined, the differences were not statistically significant.

CONCLUSION

Using no saline was at least as effective as using either 0.225% or 0.9% saline in endotracheal suctioning. The optimal policy may be to routinely use no saline with endotracheal suctioning in children but allow the occasional use of 0.9% saline when secretions are thick.

Comparison of endotracheal tube cuff pressure values before and after training seminar

It is recommended that endotracheal cuff (ETTc) pressure be between 20 and 30 cm H₂O. In this present study, we intend to observe average cuff pressure values in our clinic and the change in these values after the training seminar. The cuff pressure values of 200 patients intubated following general anesthesia induction in the operating theatre were measured following intubation. One hundred patients whose values were measured before the training seminar held for all physician assistants, and 100 patients whose values were measured after the training seminar were regarded as Group 1 and Group 2, respectively. Cuff pressures of both groups were recorded, and the difference between them was shown. Moreover, cuff pressure values were explored according to the working period of the physician assistants. There was no significant difference between the groups in terms of age, gender and tube diameters. Statistically significant difference was found between cuff pressure values before and after the training (p < 0.001). Average pressure measure for Group I was 54 cm H₂O, while average pressure in Group II declined to 33 cm H₂O. It was observed that as the working period and experience of physician assistants increased, cuff pressure values decreased, however no statistically significant different was found (p < 0.375). We believe that clinical experience does not have significant effects on cuff pressure and that training seminars held at intervals would prevent high cuff pressure values and potential complications.

Knowledge and practice of intensive care nurses for endotracheal suctioning in a teaching hospital in western Turkey

OBJECTIVES

This study was conducted to determine intensive care nurses' knowledge and practice levels regarding open system endotracheal suctioning and to investigate if there is a relationship between nurses' demographic characteristics and their knowledge and practice.

RESEARCH METHODOLOGY/DESIGN

The study was conducted as a cross-sectional and non-participant structured observational design. Data were collected using a 45-item structured and self-administered questionnaire and a 31-item observational checklist. The study sample included 72 nurses.

SETTING

Three adult intensive care units in a teaching hospital.

RESULTS

The nurses' mean scores of knowledge and practice were 23.79±3.83 and 12.88±2.53. Their level of knowledge was very good in 59.7%, good in 34.7%, and the level of practice was fair in 79.2% and good in 18.1%. The relationship between the type of unit and the nurses' knowledge scores was statistically significant (p=0.013). The correlation between the nurses' scores of knowledge and practice was not statistically significant (r=0.220; p=0.063).

CONCLUSION

This study suggests that the knowledge level of most of the nurses was good and their practice level was fair. Intensive care nurses must perform suctioning procedures safely and effectively to ensure delivery of quality of care and eliminate complications.

The occurrence of pressure damage in the oral cavity caused by endotracheal tubes

The aim of this observational study was to investigate the occurrence of pressure damage caused by endotracheal tubes (ETT) when the tube is repositioned from one corner of the mouth to the other every third day. For the assessment of oral condition and the eventual damage caused by ETT, a modified version of the Oral Assessment Guide (OAG) was used. The oral condition was assessed once per day in all adult patients who were orally intubated with a tube for over 24 hours. Thirty-eight patients were included in the study. Most patients ( n = 33, 86.8%) had no pressure damage. Five patients (13.2%) had pressure damage on the oral mucosa and lip caused by endotracheal tubes. The group with damage to the oral mucosa was treated with noradrenaline, had bleeding problems and clotting disorders and had significantly more intubated and study days. The assessment of the oral mucosa according to the OAG reflected the worsening oral condition in the group with pressure damage. Endotracheal tubes may need to be repositioned more often than every third day to avoid pressure damage in patients with a high risk of complications, and individually tailored care may need to be implemented.

Influence of Institutional Guidelines on Oral Hygiene Practices in Intensive Care Units

BACKGROUND

Maintaining oral hygiene is a key component of preventing ventilator-associated pneumonia; however, practices are inconsistent.

OBJECTIVES

To explore how characteristics of institutional guidelines for oral hygiene influence nurses' oral hygiene practices and perceptions of that practice.

METHODS

Oral hygiene section of a larger survey study on prevention of ventilator-associated pneumonia. Critical care nurses at 8 hospitals in Northern California that had more than 1000 ventilator days in 2009 were recruited to participate in the survey. Twenty-one questions addressed oral hygiene practices and practice perceptions. Descriptive statistics, analysis of variance, and Spearman correlations were used for analyses.

RESULTS

A total of 576 critical care nurses (45% response rate) responded to the survey. Three types of institutional oral hygiene guidelines existed: nursing policy, order set, and information bulletin. Nursing policy provided the most detail about the oral hygiene care; however, adherence, awareness, and priority level were higher with order sets (P < .05). The content and method of disseminating these guidelines varied, and nursing practices were affected by these differences. Nurses assessed the oral cavity and used oral swabs more often when those practices were included in institutional guidelines.

CONCLUSIONS

The content and dissemination method of institutional guidelines on oral hygiene do influence the oral hygiene practices of critical care nurses. Future studies examining how institutional guidelines could best be incorporated into routine workflow are needed.

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.

[Cuff pressure control at the intersinve care unit: influence of nursing professionals' training]

OBJETIVE

To analyze proper control of endotracheal cuff pressure in an intensive care unit. The specific objective is to verify whether training of nursing professionals improves monitoring endotracheal cuff pressure.

BASIC PROCEDURES

the study type is descriptive, observational and retrospective. All patients were admitted to the Critical Unit II of the Clínico San Carlos Hospital between May 2010-November 2011, requiring either a tracheal tube or tracheal cannula. Studied variables were: number of in range measures, number of intubated patients, or with tracheal cannula and register. Four cuts were made on all admitted patients admitted during the study period in order to measure endotracheal cuff pressure. Two cuts were performed before the professional nurses training and the other two cuts after a specific training with respect to endotracheal cuff pressure and Zero pneumonia.

RESULTS

There were 74 measurements. The first cut obtained 40.74% of measures in range. In the second cut 61.90% of measures were identified in range. In the third cut, it was found that 85.7% of measures were in range and in the fourth court, it was noted the 89.47% of measures were in range.

CONCLUSIONS

Monitoring of the endotracheal cuff pressure was inadequate before specific training of professionals. Nursing professionals training facilitates the correct measurement of the endotracheal cuff pressure, which improves patient safety.

Survey of Italian intensive care unit nurses' knowledge about endotracheal suctioning guidelines

BACKGROUND

Endotracheal suctioning is a common procedure performed by intensive care nurses in order to establish and maintain gas exchange, adequate oxygenation and alveolar ventilation in critically ill patients under mechanical ventilation. As this procedure is associated with several complications and risks nurses should have an adequate knowledge on how to perform the procedure according to the evidence-based practice. Previously only a few studies have analysed nurses' knowledge of the guidelines on endotracheal suctioning.

AIM

To evaluate the knowledge of the American Association of Respiratory Care (AARC, 2010) evidence-based guidelines on the endotracheal suctioning technique by Italian intensive care nurses in different hospitals.

MATERIALS AND METHODS

An anonymous questionnaire based on previous studies was sent to a selected sample composed of the intensive care unit (ICU) nurses of 16 ICUs in 11 Italian hospitals.

RESULTS

The questionnaire was sent to 379 nurses, with 65% of questionnaires returned completed. The total percentage of correct answers was 58%, and nobody completed the questionnaire without mistakes. Moreover, only 2.5% (n = 6) of the nurses gave 9/10 correct answers. Correct answers were more common amongst the more experienced ICU nurses.

CONCLUSION

Italian ICU nurses' knowledge of guidelines on endotracheal suctioning was not complete; however, experienced nurses demonstrated a better knowledge of the subject.

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

BACKGROUND

Airway management, an essential component of care for patients receiving mechanical ventilation, is multifaceted and includes oral hygiene and suctioning, endotracheal suctioning, and care of endotracheal tubes. Registered nurses and respiratory care personnel often share responsibilities for airway management. Knowledge of current practices can help facilitate evidence-based practices to optimize care of patients receiving mechanical ventilation.

OBJECTIVES

To describe current practices for airway management of intubated patients and determine if practices differ between registered nurses and respiratory care practitioners.

METHODS

A descriptive, comparative design was used. Registered nurses and respiratory care practitioners who provided direct care to intubated patients receiving mechanical ventilation were recruited to complete an online survey of self-reported practices.

RESULTS

A total of 85 participants completed the survey. Most were experienced caregivers with a bachelor's degree and certification or registration in their field. Selected practices have improved, including increasing oxygen saturation before endotracheal suctioning, maintaining pressure of endotracheal tube cuffs, and providing oral hygiene and suctioning. The practices of registered nurses and respiratory care practitioners differed in many ways. The nurses assumed responsibility for oral antisepsis, whereas the respiratory care practitioners managed the endotracheal tube. The 2 groups shared responsibility for oral and endotracheal suctioning. Knowledge of current guidelines for endotracheal suctioning was lacking.

CONCLUSIONS

Practices in airway management have improved, but opportunities exist to develop shared policies and procedures based on current evidence.

Continuous control of tracheal cuff pressure for the prevention of ventilator-associated pneumonia in critically ill patients: where is the evidence?

PURPOSE OF REVIEW

Ventilator-associated pneumonia (VAP) is a major cause of death, morbidity and costs in ICUs. Several evidence-based clinical interventions have been increasingly described for its prevention. However, continuous control of tracheal cuff pressure (Pcuff) is rarely mentioned in the latest clinical guidelines. This review focuses on the available data about the management of Pcuff in the ICU, including discontinuous and continuous control, and its impact on the prevention of VAP.

RECENT FINDINGS

Current discontinuous monitoring and adjustment of Pcuff, even well performed, is inaccurate in maintaining Pcuff in the target range. Underinflation (Pcuff<20 cmH2O) of tracheal cuff is an independent risk factor for VAP through microaspiration of contaminated subglottic secretions into the lower respiratory tract. Two main types of devices, electronic and pneumatic, have been developed for the continuous control of Pcuff. Both have shown effectiveness in maintaining Pcuff in recommended range in ICU patients, but only the pneumatic device has provided a reduction in microaspiration and VAP incidence.

SUMMARY

Continuous controllers of Pcuff represent effective, easy to use and timesaving devices in today's busy ICU environment. However, further studies are required to determine the impact of continuous control of Pcuff on VAP incidence, patient outcomes, antimicrobial consumption and to compare pneumatic and electronic devices, before generalizing their use in routine practice.

Oral Care in Trauma Patients Admitted to the ICU: Viewpoints of ICU Nurses

Background:

Many patients with severe traumatic injuries are admitted to intensive care units (ICU). These patients usually require prolonged mechanical ventilation. These interventions require oral intubation and leave the mouth open which consequently impairs the natural antimicrobial activity in the mouth and airways. These patients are also prone to ventilator-associated pneumonia (VAP). Evidence shows that paying attention to oral hygiene in patients under mechanical ventilation is important in helping to prevent VAP.

Objectives:

The present study was conducted to assess the viewpoints and performance of ICU nurses at Birjand hospitals towards oral care of patients under mechanical ventilation.

Patients and Methods:

A cross-sectional study was conducted at ICUs of Imam-Reza and Vali-Asr hospitals, Birjand, Iran. Sampling was done through a census in which 53 ICU nurses participated. Descriptive statistics, Kolmogorov-Smirnov test, Mann-Whitney U tests and Kendall's correlation coefficient were used to analyze the data.

Results:

A total of 53 nurses participated in this study. Most of the nurses had been trained to provide oral care during their university education. According to the participants' opinions, oral care with an average score of 5.72 ranked second among the 10 nursing care domains. The most frequent oral care provided was oral suctioning, normal saline irrigation, and chlorhexidine rinse with 95%, 90%, and 81.3% frequency, respectively.

Conclusions:

Nurses participating in this study considered oral care to be of prime importance. Most of the participants although trained in this area felt the need for continuing training courses.

Intensive care nurses' opinions and practice for oral care of mechanically ventilated patients

Context:

Oral care is an essential aspect of critical care nursing. However, no study has been published on oral care practice of Iranian and Asian nurses. The majority of published studies were conducted in western and European countries.

Aims:

This study aimed to evaluate the nurses’ opinions and practice about oral care in patients under mechanical ventilation.

Settings and Design:

A cross-sectional study was conducted on 130 intensive care nurses from 6 intensive care units in the university hospitals of Iran.

Materials and Methods:

A questionnaire was used to gather the data and charts of 45 patients were evaluated.

Statistical analysis:

Descriptive statistical analysis are presented.

Results:

Oral care obtained the 7^th rank in prority and a mean score of 5.7 on a scale of 1-10. More than 21% of subjects did not perform oral care in their usual duties. High load of writing tasks and personnel shortages were the major barriers to oral care. Only 20% of the patients’ charts contained a report on oral care.

Conclusions:

Nurses did not consider oral care in intensive care patients as a high priority. This result highlights the need to continue education programs on oral care for improving the knowledge and attitude of intensive care nurses with respect to oral care.

Portable suction unit failure in a rural EMS system

INTRODUCTION

Portable suction units used by EMS personnel are utilized infrequently and often are powered by batteries. Lack of use and inspection often results in failure of the device when it is needed. The purpose of this study was to examine the incidence of portable suction unit failure in a rural EMS system and to identify the reasons for failures.

METHODS

A convenience sample was obtained through both random inspections by the staff of a regional EMS council and data from twice monthly checks reported by respective EMS agencies following a standard protocol for each unit. A standard protocol was used, including checking the vacuum level on each suction unit and inspecting the tubing, canister, and battery. Each inspector assessed whether the unit was capable of achieving 300 mmHg of suction within four seconds. Also, the unit was inspected for any signs of misalignment or dry rot of the gasket, kinking of suction hose, damage to the suction canister, weak/dead battery, or defective pump. Findings were recorded.

RESULTS

Over a two-year period, 9,631 suction unit inspections were completed. There were 233 failures (2.4%) noted. The majority (126, 54.1%) were due to battery failure. Seventy-three units failed due to other reasons (not recorded, switch failure, battery not seated). Ten inspections failed due to incorrect assembly. Nineteen inspections failed due to defects with the suction canister. Five inspections failed due to kinked/disconnected suction tubing.

CONCLUSION

Only a relatively small percentage of inspections of suction units revealed failures (4.6% Advanced Life Support, 8.6% Basic Life Support) using the above-stated criteria. However, given the importance of airway management and potential complications associated with airway compromise, including aspiration pneumonia, hypoxia, and hemodynamic instability, this is of concern relative to the morbidity and mortality that could be related to airway failure. Due to the relative infrequency of use and the nature of portable suction units, the potential for lack of maintenance and deficiencies in routine inspection may impact the functional status of these devices in EMS agencies. Clearly, improved documentation of battery installation date, charging in accordance with manufacturer recommendations, and thorough inspection of the portable suction unit in its entirety will ensure readiness of these devices. Additionally, more rigorous documentation and analysis of inspections should be a focus of EMS agencies.

Mouth care for orally intubated patients: a critical ethnographic review of the nursing literature

OBJECTIVES

The aim of this critical ethnographic literature review was to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients.

METHODS

The online databases CINAHL and MEDLINE were searched for nurse-authored English language articles published between 1960 and 2011 in peer-reviewed journals. Articles that did not discuss oral problems or related care for intubated adult patients were excluded. Articles that met the inclusion criteria were chronologically reviewed to trace changes in language and focus over time.

RESULTS

A total of 469 articles were identified, and 84 papers met all of the inclusion criteria. These articles presented an increasingly scientific and evaluative nursing discourse. Oral care originally focused on patient comfort within the literature; now it is emphasized as an infection control practice for the prevention of ventilator-associated pneumonia (VAP). Despite concern for its neglected application, the literature does not sufficiently address mouth care's practical accomplishment.

CONCLUSIONS

Mouth care for orally intubated patients is both a science and practice. However, the nursing literature now emphasises a scientific discourse of infection prevention. Inattention to the social and technical complexities of practice may inhibit how nurses learn, discuss and effectively perform this critical aspect of patient care.

The role of the endotracheal tube cuff in microaspiration

The cuff of the endotracheal tube (ETT) is designed to provide a seal within the airway, allowing airflow through the ETT but preventing passage of air or fluids around the ETT. Deliberate or inadvertent movement of the ETT may affect cuff pressure or shift folds in the cuff, mobilizing pooled secretions. When this seal is compromised, microaspirations contaminated with gastric contents or bacterially colonized oral secretions can occur that leave the patient susceptible to a host of problems, such as hypoxia, pneumonitis, and respiratory infections. These complications are costly in terms of morbidity and mortality, as well as hospital expense. We will discuss the role of the ETT cuff in microaspiration and identify potential directions for future research to improve outcomes in mechanically ventilated patients.

Oropharyngeal secretion volume in intubated patients: the importance of oral suctioning

BACKGROUND

Aspiration of secretions that accumulate above the cuff of the endotracheal tube is a risk factor for ventilator-associated pneumonia. Routine suctioning of oropharyngeal secretions may reduce this risk; the recommended frequency for suctioning is unknown.

OBJECTIVES

To quantify the volume of secretions suctioned from the oropharynx of critically ill patients at 2 different intervals to assist in identifying a recommended frequency for oropharyngeal suctioning.

METHODS

A prospective, repeated measure, single-group design was used. Twenty-eight patients who were orally intubated and treated with mechanical ventilation were enrolled; 2 were extubated during data collection, yielding a sample of 26 patients. The patients were suctioned at baseline with a deep suction catheter, and the volume and weight of secretions were recorded. The procedure was repeated at 2-hour and 4-hour intervals.

RESULTS

Most of the patients were male (mean age, 49 years). Three suctioning passes were needed to clear secretions, with a mean time of 48.1 seconds. The mean volume of secretions at the 2-hour interval was 7.5 mL. Five patients required suctioning before the 4-hour interval. For the remaining 21 patients, the volume retrieved was 6.5 mL at the 2-hour interval and 7.5 mL at the 4-hour interval (P = .27). The 5 patients who required extra suctioning had significantly more secretions at the 2-hour interval (11.6 mL vs 6.5 mL; P = .05).

CONCLUSIONS

A minimum frequency of oropharyngeal suctioning every 4 hours is recommended. However, more frequent suctioning may be needed in a subset of patients.

Critical care nurses' knowledge, attitudes and practices of oral care for patients with oral endotracheal intubation: a questionnaire survey

AIM

This study investigated intensive care unit nurses' knowledge, attitudes and practices of oral care for intubated patients together with the associated factors of the same.

BACKGROUND

Effective oral care improves patient comfort and prevents oral infection. Although oral care is a common requirement of nursing practice, providing intubated patients with oral care is a challenging task.

DESIGN

A descriptive, cross-sectional design.

METHODS

This study applied purposive sampling method at 12 adult intensive care units in one medical centre in northern Taiwan. Two hundred and five nurses were recruited. Data were collected by structured questionnaires which consisted of four sections: knowledge, attitudes and practices of oral care for intubated patients and demographic information for the nurses.

RESULTS

The average percentages indicating the intensive care unit nurses' oral care knowledge, attitudes and practices were 58·8, 79·4 and 49·8%, respectively. Higher scores on oral care knowledge were associated with nurses performing oral care more frequently. Nurses learning about oral care from reading related studies and materials of their own accord may increase the frequency with which they provide oral care to intubated patients. The nurses' age and the type of intensive care unit they work in were significant factors related to the frequency of performing practices related to oral care.

CONCLUSION

Findings show that nurses who have more resources for learning about oral care have greater knowledge about it and provide oral care to intubated patients more frequently.

RELEVANCE TO CLINICAL PRACTICE

Encouraging nurses to learn more about oral care using diverse educational resources will enhance their knowledge and improve their practice. Nursing administrators are encouraged to establish policies and procedures for oral care of intubated patients based on the type of patients cared for, in addition to holding in-service training, with a view to enhancing the quality of oral care for critically ill patients.

Relationship between feeding tube site and respiratory outcomes

BACKGROUND

It is unclear if placing feeding tubes postpylorically to prevent respiratory complications is worth the extra effort. This study sought to determine the extent to which aspiration and pneumonia are associated with feeding site (controlling for the effects of severity of illness, degree of head-of-bed elevation, level of sedation, and use of gastric suction).

METHODS

A retrospective analysis was performed on a large data set gathered prospectively to evaluate aspiration in critically ill, mechanically ventilated patients. Feeding site was designated by attending physicians and confirmed by radiography. Each patient participated in the study for 3 consecutive days, with pneumonia assessed by the simplified Clinical Pulmonary Infection Score on the fourth day. Tracheal secretions were assayed for pepsin in a research laboratory; the presence of pepsin served as a proxy for aspiration. A total of 428 patients were included in the regression analyses performed to address the research objectives.

RESULTS

As compared with the stomach, the percentage of aspiration was 11.6% lower when feeding tubes were in the first portion of the duodenum, 13.2% lower when in the second/third portions of the duodenum, and 18.0% lower when in the fourth portion of the duodenum and beyond (all significant at P < .001). Pneumonia occurred less often when feedings were introduced at or beyond the second portion of the duodenum (P = .020).

CONCLUSIONS

The findings support feeding critically ill patients with numerous risk factors for aspiration in the mid-duodenum and beyond to reduce the risk of aspiration and associated pneumonia.

An exploration of factors affecting Hong Kong ICU nurses in providing oral care

AIM AND OBJECTIVES

This paper aims to explore the factors that affect Hong Kong intensive care unit nurses in providing oral care.

BACKGROUND

The literature shows that evidence-based oral care prevents ventilator-associated pneumonia. Nevertheless, not all intensive care unit nurses provide such care. Although several studies have been undertaken to identify factors that affecting the provision of oral care, none of these studies looked at the situation in Hong Kong.

DESIGN

An exploratory qualitative design was adopted, with audio-taped interviews.

METHODS

A convenience sample of 10 registered nurses with 3-14 years of intensive care unit working experience was recruited from the intensive care unit of one regional hospital in Hong Kong. Transcribed interviews were analysed by means of content analysis.

RESULTS

The participants' descriptions of their oral care practices covered oral health assessment, cleansing the oral cavity and care of the surrounding areas. Findings revealed the following significant factors that influenced intensive care unit nurses in providing oral care: their perceptions of the purpose of oral care; their fears about providing it; the priority of oral care; and inadequate support for oral care.

CONCLUSIONS

The findings indicate that nurses' oral care practices were not evidence based. Factors that affected the provision of oral care were consistent with those found in previous studies.

RELEVANCE TO CLINICAL PRACTICE

Study findings indicate that present oral care training should be revised. The findings also highlight the influence of ward culture on nurses' priorities in providing oral care. Appropriate materials, adequate staffing levels and the establishment of an evidence-based oral care protocol may facilitate the provision of oral care in the intensive care unit.

How I learned my ABCs: Action, back to basics, collaboration, discovery

BACKGROUND

Research is essential to generate the scientific evidence for critical care nursing practice, but it is challenging to conduct research in the busy critical care environment. The challenges are even greater in a setting with limited resources for research and where nurses have not typically conducted independent clinical studies.

OBJECTIVES

To detail a successful research trajectory for studying the ABCs of patient care in the critically ill: airway, breathing, and circulation.

METHODS

After initial studies on circulation were conducted, the research was narrowed to focus on airway management. Airway management may be a key factor in preventing ventilator-associated pneumonia because aspiration of colonized oral, gastric, and tracheal secretions is the primary cause of ventilator-associated pneumonia. Multiple descriptive, pilot, and interventional studies have been conducted; findings from each have contributed to future studies.

RESULTS

Other ABCs were critical to this research success: action, back to basics, collaboration, and discovery. It is important for researchers to be self-motivated and to take initiative to develop skills and resources for conducting clinical studies. Several guiding principles help to promote success in research: (1) generate research ideas grounded in observation and clinical practice, (2) collaborate with others, and (3) establish affiliations and partnerships. Discovery occurs in many ways: new findings to guide practice and research, resources to conduct the study, and self-discovery.

CONCLUSIONS

Nursing research is not easy. However, determination and resources help nursing researchers achieve success.

Oral care practices for orally intubated critically ill adults

BACKGROUND

Ventilator-associated pneumonia is a major threat to patients receiving mechanical ventilation in hospitals. Oral care is a nursing intervention that may help prevent ventilator-associated pneumonia.

OBJECTIVES

To describe oral care practices performed by critical care nurses for orally intubated critically ill patients and compare these practices with recommendations for oral care in the 2005 AACN Procedure Manual for Critical Care and the guidelines from the Centers for Disease Control and Prevention.

METHODS

A descriptive, cross-sectional design with a 31-item Web-based survey was used to describe oral care practices reported by 347 randomly selected members of the American Association of Critical-Care Nurses.

RESULTS

Oral care was performed every 2 (50%) or 4 (42%) hours, usually with foam swabs (97%). Oral care was reported as a high priority (47%). Nurses with 7 years or more of critical care experience performed oral care more often (P=.008) than did less experienced nurses. Nurses with a bachelor's degree in nursing used foam swabs (P=.001), suctioned the mouth before the endotracheal tube (P=.02), and suctioned after oral care (P<.001) more often than other nurses. Nurses whose units had an oral care policy (72%) reported that the policy indicated using a toothbrush (63%), using toothpaste (40%), brushing with a foam swab (90%), using chlorhexidine gluconate oral rinse (49%), suctioning the oral cavity (84%), and assessing the oral cavity (73%). Oral care practices and policies differed for all those items.

CONCLUSIONS

Survey results indicate that discrepancies exist between reported practices and policies. Oral care policies appear to be present, but not well used.

Current practice in airway management: A descriptive evaluation

BACKGROUND

Ventilator-associated pneumonia, a common complication of mechanical ventilation, could be reduced if health care workers implemented evidence-based practices that decrease the risk for this complication.

OBJECTIVES

To determine current practice and differences in practices between registered nurses and respiratory therapists in managing patients receiving mechanical ventilation.

METHODS

A descriptive comparative design was used. A convenience sample of 41 registered nurses and 25 respiratory therapists who manage critical care patients treated with mechanical ventilation at Sharp Grossmont Hospital, La Mesa, California, completed a survey on suctioning techniques and airway management practices. Descriptive and inferential statistics were used to analyze the data.

RESULTS

Significant differences existed between nurses and respiratory therapists for hyperoxygenation before suctioning (P =.03). In the 2 groups, nurses used the ventilator for hyper-oxygenation more often, and respiratory therapists used a bag-valve device more often (P =.03). Respiratory therapists instilled saline (P <.001) and rinsed the closed system with saline after suctioning (P =.003) more often than nurses did. Nurses suctioned oral secretions (P <.001) and the nose of orally intubated patients (P =.01), brushed patients' teeth with a toothbrush (P<.001), and used oral swabs to clean the mouth (P <.001) more frequently than respiratory therapists did.

CONCLUSION

Nurses and respiratory therapists differed significantly in the management of patients receiving mechanical ventilation. To reduce the risk of ventilator-associated pneumonia, both nurses and respiratory therapists must be consistent in using best practices when managing patients treated with mechanical ventilation.

Validity and reliability of an oral care practice survey for the orally intubated adult critically ill patient

BACKGROUND

Oral care is proposed as key to preventing ventilator-associated pneumonia, yet little work has been done to measure reliably current oral care practices nationwide. Five critical care oral care surveys are described in the literature; however, their usefulness is diminished because of insufficient validity or reliability measures and sampling limitations that limit generalizability.

OBJECTIVES

The aim of this study was to present a survey instrument for oral care practices for the orally intubated adult critically ill patient and the attendant psychometric properties.

METHODS

The oral care survey items were designed to elucidate information on the type and frequency of each specific task for oral care (toothbrushes, foam swabs, suctioning, and chlorhexidine gluconate oral rinse). The oral care survey was evaluated for face validity, content validity, and stability reliability psychometric properties.

RESULTS

Face validity was established by an expert panel. Content validity was assessed using content validity index (CVI) and pairwise comparison. The overall CVI score was 97.5% agreement. A pairwise comparison for the three raters was computed. The strongest rating agreements were between Rater 1 and Rater 2 (.86) and Rater 1 and Rater 3 (.83). Given these interrater reliability scores and the overall 97.5% CVI score, minor revisions were made for survey items as recommended by the reviewers' comments. Test-retest reliability (.82-.86) showed a less than 10% difference between all items from Time 1 and Time 2.

IMPLICATIONS

This survey, tested for validity and reliability, can be used in future critical care settings as an audit tool for oral care practices performed by nurses.

Not-so-trivial pursuit: mechanical ventilation risk reduction

As many as half of critically ill patients require mechanical ventilation. In this article, a program of research focused on reduction of risk associated with mechanical ventilation is reviewed. Airway management practices can have profound effects on outcomes in these patients. How patients are suctioned, types of processes used, effects of suctioning in patients with lung injury, and open versus closed suctioning systems all have been examined to determine best practices. Pneumonia is a common complication of mechanical ventilation (ventilator-associated pneumonia), and use of higher backrest elevations reduces risk of pneumonia, although compliance with such recommendations varies. The studies reviewed here describe backrest elevation practices, factors that affect backrest elevation, and the effect of backrest elevation on ventilator-associated pneumonia. Oral care strategies also have been investigated to determine their effect on ventilator-associated pneumonia. Oral care practices are reported to hold a low care priority, vary widely across care providers, and differ in intubated versus nonintubated patients. However, in several studies, oral applications of chlorhexidine have reduced the occurrence of ventilator-associated pneumonia. Although ventilator patients require sedation, sedation is associated with significant risks. The overall goals of sedation are to provide physiological stability, to maintain ventilator synchrony, and to ensure patients' comfort-although methods to evaluate achievement of these goals are limited. Reducing risks associated with mechanical ventilation in critically ill patients is a complex and interdisciplinary process. Our understanding of the risks associated with mechanical ventilation is constantly changing, but care of these patients must be based on the best evidence.

Consensus among physiotherapists in the united kingdom on the use of normal saline instillation prior to endotracheal suction: a Delphi study

PURPOSE

To investigate whether physiotherapists consider normal saline instillation (NSI) useful before endotracheal suctioning and, if so, when.

METHODS

Sixty-eight respiratory physiotherapists recruited from the United Kingdom's Association of Chartered Physiotherapists in Respiratory Care agreed to participate in a Delphi study. Clinicians' opinion of when NSI should be used was established and developed into statements. Level of agreement with each statement was collated through three rounds of a questionnaire. Clinicians' experiences were also reported.

RESULTS

From the 52 responses to the third questionnaire, there was consensus that respiratory physiotherapists in the United Kingdom would use NSI when sputum retention is a problem, particularly when treatment options are limited (96%) and when sputum is obstructing the airway (92%). They agreed that non-bronchoscopic bronchoalveolar lavage can be used to resolve persistent atelectasis (70%). They would not use NSI for a test treatment during initial assessment without evidence of retained secretions (94%), when secretions are copious but can be cleared by alternative physiotherapy techniques (96%), to enhance a cough unless very strong evidence indicates retained secretions (81%), or to compensate for inadequate suction technique (90%).

CONCLUSION

This study provides clinicians' views about when NSI could be used.

Survey of Cuff Management Practices in Intensive Care Units in Australia and New Zealand

Background Cuff management varies widely in Europe and North America. Little is known about current practice in Australia and New Zealand.

Objective To characterize important aspects of cuff management in intensive care units in Australia and New Zealand to compare with international reports.

Methods A questionnaire was sent to all nurse managers of adult intensive care units in Australia and New Zealand.

Results Survey response was 53% (92/175). After intubation, most units (50/92, 54%) used both minimal occlusive volume technique and cuff pressure measurement; 5 (5.5%) used these methods along with pilot balloon palpation. Twenty units (22%) used cuff pressure measurement exclusively and 16 units (17.5%) used the minimal occlusive volume technique exclusively. Only 1 unit (1%) used the minimal leak technique after intubation. For ongoing management, cuff pressure measurement was the preferred method, used exclusively in 42 units (46%), with the minimal occlusive volume technique used in 40 units (43%; sole method in 6 units [7%]) and palpation in 4 units (4%). In most units (65/92, 71%), cuffs were monitored once per nursing shift. In units using the minimal occlusive volume technique, oropharyngeal suctioning (74%) and semirecumbent positioning (58%) were routinely incorporated; sigh breaths (6%), discontinuation of enteral feeding (10%), and nasogastric tube aspiration (26%) were uncommon. Cuff management protocols (37%) and subglottic suctioning (12%) were used infrequently.

Conclusions Cuff pressure measurement was the preferred method, used exclusively or in combination with other methods. The minimal occlusive volume technique was used more often after intubation than for ongoing management.

Continuous measurement of endotracheal tube cuff pressure: how difficult can it be?

Continuous monitoring and download of endotracheal tube cuff pressure for a 12-hour period were required to collect data for an ongoing program of research related to airway management of the critically ill patient. On the basis of reports from the anesthesia literature, continuous monitoring of cuff pressure via a traditional pressure transducer and monitor was identified as the best method to collect data. Although continuous pressure monitoring of many physiologic variables is routine in critical care settings, application of the technology to measurement of endotracheal tube cuff pressure has not been reported outside the operating room. The research team conducted bench testing and pilot testing in human subjects to establish feasibility, accuracy, and safety of continuous cuff pressure monitoring. Monitoring was feasible with stringent procedures applied to ensure safety. A bias of 0.5 cm H2O between continuous and intermittent measures was obtained in both in vitro and in vivo testing.

Minimal occlusive volume cuff inflation: a survey of current practice

OBJECTIVE

To describe the minimal occlusive volume (MOV) procedure used to monitor cuff inflation and identify practice variation.

RESEARCH METHODOLOGY

Self-administered questionnaire.

SETTING

Adult intensive care unit in an Australian university-affiliated hospital.

RESULTS

Survey response was 71% (80/113). Three methods of MOV were identified. Full cuff deflation, followed by reinflation, removal of 1mL increments of air until a leak was detected, then restoration of cuff seal with 1mL of air was the preferred method (47/80 respondents, 59%) (Method 1). Full cuff deflation followed by incremental addition of air until the MOV was established was used by 25/80 (31%) respondents (Method 2). Two (2.5%) nurses established MOV without full cuff deflation (Method 3), five (6.25%) used more than one method and one (1.25%) nurse did not perform cuff checks. Practice variation was identified for patient positioning, confirmation of cuff seal, and cuff leak management. Consistency of practice was noted in MOV procedure frequency, the number of nurses required, pre-oxygenation and oropharyngeal suctioning prior to cuff deflation.

CONCLUSION

Substantial practice variation for certain aspects of cuff management was noted. Evidence to support the efficacy of MOV procedural elements is required to limit practice variation and reduce risk to patients.

An observational study on the open-system endotracheal suctioning practices of critical care nurses

AIM AND OBJECTIVES

The purpose of this study was to investigate open system endotracheal suctioning (ETS) practices of critical care nurses. Specific objectives were to examine nurses' practices prior to, during and post-ETS and to compare nurses' ETS practices with current research recommendations.

BACKGROUND

ETS is a potentially harmful procedure that, if performed inappropriately or incorrectly, might result in life-threatening complications for patients. The literature suggests that critical care nurses vary in their suctioning practices; however, the evidence is predominantly based on retrospective studies that fail to address how ETS is practiced on a daily basis.

DESIGN AND METHOD

In March 2005, a structured observational study was conducted using a piloted 20-item observational schedule on two adult intensive-care units to determine how critical care nurses (n = 45) perform ETS in their daily practice and to establish whether the current best practice recommendations for ETS are being adhered to.

RESULTS

The findings indicate that participants varied in their ETS practices; did not adhere to best practice suctioning recommendations; and consequently provided lower-quality ETS treatment than expected. Significant discrepancies were observed in the participants' respiratory assessment techniques, hyperoxygenation and infection control practices, patient reassurance and the level of negative pressure used to clear secretions.

CONCLUSION

The findings suggest that critical care nurses do not adhere to best practice recommendations when performing ETS. The results of this study offer an Irish/European perspective on critical care nurses' daily suctioning practices.

RELEVANCE TO CLINICAL PRACTICE

As a matter of urgency, institutional policies and guidelines, which are based on current best practice recommendations, need to be developed and/or reviewed and teaching interventions developed to improve nurses' ETS practices, particularly in regard to auscultation skills, hyperoxygenation practices, suctioning pressures and infection control measures.

Policies for endotracheal suctioning of patients receiving mechanical ventilation: a systematic review of randomized controlled trials

OBJECTIVE

The Dutch Working Party on Infection Prevention (Werkgroep Infectiepreventie [WIP]) aimed to determine whether certain policies on endotracheal suctioning are better than others in terms of prevention of ventilator-associated pneumonia (VAP) in patients receiving mechanical ventilation in the intensive care unit.

METHODS

Publications were retrieved by a systematic search of Medline and the Cochrane Library for literature published before February 2006. Additionally, the reference lists of all identified trials were examined. All randomized trials, quasi-randomized trials, and systematic reviews or meta-analyses of randomized or quasi-randomized trials that compared different policies on endotracheal suctioning for patients receiving mechanical ventilation in the intensive care unit were selected. Two reviewers independently assessed trial quality and extracted data. Disagreements were resolved by discussion with a third reviewer. Data from the original publications were used to calculate the relative risk of VAP. Data for VAP were combined in the analysis where appropriate, by use of a random-effects model.

RESULTS

Ten trials were included in the review. The quality of the trials and the way they were reported were generally unsatisfactory. Eight low-quality trials indicate that use of closed instead of open suction systems has no effect on the incidence of VAP. Two moderate-quality trials indicate that changing in-line suction catheters less frequently than every 24 hours does not increase the incidence of VAP.

CONCLUSION

The WIP recommends that there be no preferential use of either open or closed endotracheal suction systems to reduce the rate of VAP, but it elucidates that the quality of the evidence is low. Considerations other than prevention of VAP should determine the choice of the suction system. When closed systems are used, the WIP recommends changing the in-line suction catheters every 48 hours. In case of mechanical failure or soiling of the suction system, they may be changed more frequently.

Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU

The health care culture must change. Florence Nightingale wrote [8] "deep-rooted and universal is the conviction that to give a medicine is to be doing something, or rather everything and to give air, warmth, cleanliness etc. is to do nothing." Hygiene care practices and mobility activities are fundamental and independent care components in the nursing profession. When implemented using available evidence, they can significantly improve patient outcomes. It is time to claim and demonstrate the importance of consistent delivery of the fundamentals of basic nursing care. Interventional patient hygiene is an effective framework to ensure the the basics of nursing care are consistently applied to improve patient outcomes.