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Endotracheal Suctioning of the Adult Intubated Patient -- What Is the Evidence?


This Viewpoint offers a guide to the latest clinical and research articles of value to advanced practice nurses and other clinicians. Pedersen CM, Rosendahl-Nielsen M, Hjermind J, Egerod I Intensive Crit Care Nurs. 2009;25:21-30

Article Summary
Suctioning is the mechanical aspiration of pulmonary secretions from a patient's artificial airway. Intubated patients often have secretions that they are unable to adequately expel by coughing. Intubated patients may be unconscious or so physically impaired that they cannot clear their own respiratory tracts. Endotracheal (ET) suctioning is therefore necessary to reduce the risk for consolidation and atelectasis that may lead to inadequate ventilation and pneumonia. The suction procedure, notwithstanding the skills of the nurse, is associated with several potential complications and risks including bleeding, infection, atelectasis, hypoxemia, cardiovascular instability, elevated intracranial pressure, and lesions to the tracheal mucosa. This article reviewed the available literature regarding suctioning of adult intubated intensive care patients and summarized evidence-based recommendations for best practices for ET suctioning. A literature search was performed in Medline, CINAHL, and the Cochrane Library and a total of 77 papers were included in the final review: 4 studies describing patient experiences of suctioning, 19 literature reviews, 2 meta-analyses, and 52 clinical trials. The literature review demonstrated a paucity of good clinical trials regarding the different aspects of the suctioning procedure. Widely accepted, published recommendations for practice appear to be based on clinical experience, and offer fairly limited documentation concerning their sources. Practice recommendations for the timing of suctioning, catheter size, vacuum pressure, insertion depth, duration of suction, and hyper-oxygenation were found to be based on studies that were relatively old, had small sample sizes, or used animals. The authors concluded that there is room for improvement in the establishment of exact recommendations for clinical practice related to ET suctioning. The major recommendations that may be used to guide nurses to provide safe and consistent pulmonary care in adults, while reducing the risk for complications associated with ET suctioning, include:

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Suction only when necessary; Use a suction catheter that occludes less than half the lumen of the endotracheal tube; Use the lowest possible suction pressure; Insert the catheter no further than carina; Suction no longer than 15 seconds; Apply continuous rather than intermittent suction during the individual suction procedure; Avoid saline lavage; Provide hyperoxygenation before and after the suction procedure; Provide hyperinflation combined with hyperoxygenation on a nonroutine basis; Use either closed or open suction systems; and Always use aseptic technique.

The recommendation for open vs closed endotracheal suctioning is based on evidence from more recent, larger, and more substantial clinical controlled trials. However, most of these trials were conducted with heavily sedated and relaxed patients on volume-controlled ventilation, devices that are now rarely used. Clinical trials based on more contemporary ventilation practices, such as sophisticated ventilation devices and nonsedated patients, are still needed before the superiority of either suction system can be acknowledged.

Viewpoint
A limitation to implementing the recommendations listed in this article is lack of strong evidence on the subject of ET suctioning. The authors attempted to provide the "best current evidence" using the available information. The recommendations are based on their interpretations of the literature (a combination of experience and research), but the authors freely concede the limitations of this body of literature and call for research that will produce more reliable external evidence. This article does contribute to the best evidence nursing literature that nurses depend on when making informed decisions. As there is such a lack of scholarly research in this area, this review is intended by the authors to provide a step in the direction toward safer practice. The authors recommend setting up an expert group that will update these guidelines every couple of years. The authors are also quick to note that whenever nurses use a guideline, they should always consider the recommendation in relation to the needs of the individual patient. The literature review supports the need for further investigations ranging from randomized controlled trials to qualitative studies of factors involving both patients and nurses.

http://www.medscape.com/viewarticle/588777
2-20. ENDOTRACHEAL SUCTIONING a. The procedures for endotracheal (within the trachea) suctioning are similar to those used for naso and oropharyngeal suctioning with two major differences. (1) Endotracheal suctioning, unlike naso- and oropharyngeal suctioning, is done as an aseptic, or sterile, procedure. (2) Suctioning the trachea interferes greatly with oxygenation. A high suction pressure and a lengthy suctioning time will greatly decrease the amount of oxygen in the alveoli. If the patient is old or greatly debilitated, suctioning has the potential to set off cardiac arrhythmias. b. Wash your hands, then assemble and set up the suction equipment. (1) Check the suction and the tubing by aspirating water through the connecting tubing. (2) On the bedside table, place an open package of 4x4 gauze, a sterile suction catheter, a suction set or sterile basin, a container of sterile water or normal saline, and sterile gloves.

(3) Set up the suction set or sterile basin. Fill the sterile container with the sterile water or normal saline. c. Using aseptic technique, open the catheter package just enough to expose the connecting end and connect the catheter to the suction tubing. Don the sterile gloves. Using aseptic technique, remove the catheter from the package and hold it in your dominant hand. Test the catheter by aspirating some of the sterile solution. d. Pick up a piece of the gauze with your non-dominant hand and grasp the patient's tongue. Gently pull the tongue out of the mouth. This will provide a view of the oropharynx and at the same time raise the epiglottis to permit easier insertion of the catheter into the trachea. As an alternative method, the catheter may be introduced through the nose.

e. As the patient inhales, introduce the catheter (with suction diverted) toward the posterior of the mouth and down the throat into the trachea. The patient will probably cough at this point. If coughing brings up sufficient secretions to clear the air passages, the procedure may be discontinued at this point. If not, relax the tongue a bit and instruct the patient to breathe normally. f. Apply suction and gently rotate the catheter to aspirate secretions. Remember to suction for only 5-10 seconds at a time. Withdraw the catheter and rinse between suctioning by aspirating sterile solution. This will keep the catheter moist and free of secretions that may block the lumen. g. Repeat the procedure until the secretions have been cleared. Remember that frequent catheter introductions irritate the tracheal mucosa, so suction thoroughly to avoid repeated insertions. h. Observe the patient closely for changes in color or respiration, disorientation, or agitation. These could be signs of anoxia. Listen to the patient's breath sounds, which should become quieter as secretions are removed.

http://nursing411.org/Courses/MD0917_Nursing_care_cardio_resp/220_Nursing_Care_related_to_the_cardiorespiratory_system.html

Methods Used to Assess the Quality and Strength of the Evidence


Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence


Grade of Quality of the Evidence Quality of the Evidence

Grade A

Quality High

Description

Well-performed randomized controlled trials or overwhelming evidence of some other sort. Further research is very unlikely to change our confidence in the estimate of the effect.

Moderate Randomized controlled trials that are less consistent, have flaws, or are indirect in some way to the issue being graded, or very strong evidence of some other sort. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low

Observational evidence (from observational studies, case series, or clinical experience), or evidence from controlled trials with serious flaws. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very Low Any estimate of effect is very uncertain.

Adapted from: Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schnemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-926.

Methods Used to Analyze the Evidence


Review

Description of the Methods Used to Analyze the Evidence


The American Association for Respiratory Care (AARC) clinical practice guidelines (CPGs) steering committee has initiated a new process by which the "reference-based" guidelines will be revised and updated by adopting a modification of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system (see "Availability of Companion Documents"). This guideline is the product of this process. Although it is clear that most treatments and interventions in respiratory care are rarely graded A, it is our responsibility to make recommendations based on the best evidence available at the time the CPG is updated. The words "recommended" and "suggested" are used to reflect the strength of the recommendation, as level 1 and level 2, respectively (see "Rating Scheme for the Strength of the Recommendation"). Although grading evidence is complex, the committee has set the goal of recommending what you, the clinician, should do. While the format for most traditional sections of the CPGs remains unchanged, each newly revised CPG includes recommendations with graded evidence. This is the latest in our efforts to improve the value of the AARC CPGs.

Methods Used to Formulate the Recommendations


Not stated

Rating Scheme for the Strength of the Recommendations


Strength of the Recommendations Level Strength 1 2 Description

Stronger Benefits clearly outweigh the risks and burdens (or vice versa) for nearly all patients. Weaker Risks and benefits are more closely balanced or are more uncertain

Adapted from: Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schnemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-926.

Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation


Not stated

Description of Method of Guideline Validation


Not applicable Back to top

Recommendations
Major Recommendations
The levels of evidence (grade A-D) and the strength of the recommendations (level 1-2) are defined at the end of the "Major Recommendations" field. The words "recommended" and "suggested" are used to reflect the strength of the recommendation, as level 1 and level 2, respectively. Patient Preparation It is recommended to use smaller catheters whenever possible, since suction pressure seems to have less influence on lung volume loss than catheter size. (Copnell et al., 2009) For a given diameter of the endotracheal tube (ETT), the level of negative pressure transmitted to the airway is determined by the combination of the catheter size and the suction pressure. The larger the diameter of the catheter size, the less attenuation of the suction pressure through the airways. (Kiraly et al., 2008)

Diameter of the suction catheter should not exceed one half the inner diameter of the artificial airway in adults, providing an internal-to-external diameter ratio of 0.5 in adults (Tiffin, Keim, & Frewen, 1990; Vanner & Bick, 2008) and 0.50.66 in infants and small children. (Singh et al., 1991)

In preparation for the suctioning event, delivery of 100% oxygen in pediatric (Kerem, Yatsiv, & Goitein, 1990) and adult patients (Bourgault et al., 2006) and 10% increase of baseline in neonates (Pritchard, Flenady, & Woodgate, 2001; Gonzlez-Cabello et al., 2005; Pritchard, Flenady, & Woodgate, 2003) for 3060 seconds prior to the suctioning event is suggested, especially in patients who are hypoxemic before suctioning. (Demir & Dramali, 2005; Oh & Seo, 2003) This may be accomplished either:

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By adjusting the fractional inspired oxygen (FiO2) setting on the mechanical ventilator By use of a temporary oxygen-enrichment program available on many microprocessor ventilators (Campbell & Branson, 1992) Manual ventilation of the patient is not recommended, as it has been shown to be ineffective for providing delivered FiO2 of 1.0. (Barnes & McGarry, 1990; Woodgate & Flenady, 2001) Practitioners should ensure that positive end-expiratory pressure (PEEP) is maintained if no other alternative is available to hyper-oxygenate.

The negative pressure of the unit must be checked by occluding the end of the suction tubing before attaching it to the suction catheter, and prior to each suctioning event. Suction pressure should be set as low as possible and yet effectively clear secretions. Experimental data to support an appropriate maximum suction level are lacking. Negative pressure of 80100 mmHg in neonates (Wilinska et al., 2008) and less than 150 mmHg in adults have been recommended. (Plevak & Ward, 1997)

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The closed suctioning technique facilitates continuous mechanical ventilation and oxygenation during the suctioning event. (Johnson et al., 1994; Lee et al., 2001) It may prevent lung derecruitment associated with the use of open-suction system in patients at higher risk of desaturation (e.g., premature newborns). (Woodgate & Flenady, 2001; Lindgren et al., 2007; Kalyn et al., 2003; Tan et al., 2005; Cordero, Sananes, & Ayers, 2000; Choong et al., 2003; Kiraly et al., 2009; Hoellering et al., 2008)

It should be considered in patients requiring high FiO2 and positive end expiratory pressure (PEEP) (e.g., acute lung injury). (Maggiore et al., 2003; Brochard et al., 1991; Lasocki et al., 2006; Tingay et al., 2007; Cereda et al., 2001; Caramez et al., 2006; Fernandez et al., 2004)

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It neither increases nor decreases the risk of ventilator-associated pneumonia. (Subirana, Sola, & Benito, 2007; Topeli et al., 2004; Zeitoun, de Barros, & Diccini, 2003) Daily changes of in-line suction catheters do not decrease the risk of ventilator-associated pneumonia and is not cost-effective. (Kollef et al., 1997; Stoller et al., 2003) A patient should be placed on a pulse oximeter to assess oxygenation during and following the procedure.

Procedure The suctioning event consists of the placement of a suction catheter through the artificial airway into the trachea and the application of negative pressure as the catheter is being withdrawn. Each pass of the suction catheter into the artificial airway is considered a suctioning event. (Gardner & Shirland, 2009)

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Shallow suctioning is recommended to prevent trauma to the tracheal mucosa. Deep suctioning has not shown superior benefit over shallow suction (Spence, Gillies, & Waterworth, 2003) and may be associated with more adverse events. (Boothroyd et al., 1996; Ahn & Hwang, 2003; Youngmee &

Yonghoon, 2003)

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The duration of each suctioning event should be no more than 15 seconds. (Kerem, Yatsiv, & Goitein, 1990; Pederson et al., 2009; Morrow & Argent, 2008) Sterile technique is encouraged during open suctioning technique. (Koeppel, 2006) Normal saline instillation. Instillation refers to the administration of aliquots of saline directly into the trachea via an artificial airway. It is hypothesized that normal saline instillation may loosen secretions, increase the amount of secretions removed, and aid in the removal of tenacious secretions. However, there is insufficient evidence to support this hypothesis. Normal saline instillation appears to enhance secretion clearance through cough stimulation in adults, (Gray, MacIntyre, & Kronenberger, 1990) and a recent report suggests that normal saline instillation prior to suctioning is associated with decreased incidence of ventilator-associated pneumonia in ventilated adult patients. (Caruso et al., 2009) The great majority of the references used to update this guideline indicate that normal saline instillation is unlikely to be beneficial, and may in fact be harmful. (Woodgate & Flenady, 2001; Morrow & Argent, 2008; Branson, 2007; Celik & Kanan, 2006; Ridling, Martin, & Bratton, 2003) Therefore, it should not be routinely performed prior to performing endotracheal suctioning.

Follow-Up Care Following the suctioning event:

Hyper-oxygenation for at least 1 min by following the same technique(s) used to pre-oxygenate the patient may be used, especially in patients who are hypoxemic before and/or during suctioning. (Pritchard, Flenady, & Woodgate, 2001)

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Hyperventilation should not be routinely used. Lung-recruitment maneuvers may be attempted in patients with clear evidence of derecruitment. (Maggiore et al., 2003; Morrow, Futter, & Argent, 2007; Dyhr, Bonde, & Larsson, 2003) The patient should be monitored for adverse reactions.

Setting Endotracheal suctioning may be performed by properly trained persons in a wide variety of settings that include (but are not limited to):

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Hospital Extended care facility Home Out-patient clinic Physician's office Transport vehicle The need to maintain the patency and integrity of the artificial airway The need to remove accumulated pulmonary secretions as evidenced by one of: Sawtooth pattern on the flow-volume loop on the monitor screen of the ventilator and/or the presence of coarse crackles over the trachea are strong indicators of retained pulmonary secretions. (Guglielminotti et al., 2000; Wood, 1998)

Indications

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Increased peak inspiratory pressure during volume-controlled mechanical ventilation or decreased tidal volume during pressure-controlled ventilation (Morrow, Futter, & Argent, 2004) Deterioration of oxygen saturation and/or arterial blood gas values (Morrow, Futter, & Argent, 2004) Visible secretions in the airway (Morrow, Futter, & Argent, 2004) Patient's inability to generate an effective spontaneous cough Acute respiratory distress (Morrow, Futter, & Argent, 2004) Suspected aspiration of gastric or upper-airway secretions The need to obtain a sputum specimen to rule out or identify pneumonia or other pulmonary infection or for sputum cytology

Contraindications Endotracheal suctioning is a necessary procedure for patients with artificial airways. Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical condition as result of the procedure. When indicated, there is no absolute contraindication to endotracheal suctioning, because the decision to withhold suctioning in order to avoid a possible adverse reaction may, in fact, be lethal.

Hazards/Complications

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Decrease in dynamic lung compliance (Main et al., 2004) and functional residual capacity (Heinze et al., 2008) Atelectasis (Lasocki et al., 2006; Subirana, Sola, & Benito, 2007) Hypoxia/hypoxemia (Sabirana, Sola, & Benito, 2007; Jongerden et al., 2007) Tissue trauma to the tracheal and/or bronchial mucosa (Runton, 1992) Bronchoconstriction/bronchospasm (Guglielminotti, Desmonts & Dureuil, 1998; Heinze et al., 2008) Increased microbial colonization of lower airway (Tiffin, Keim, & Frewen, 1990; Freytag et al., 2003) Changes in cerebral blood flow (Skov et al., 1992; Shah et al., 1992) and increased intracranial pressure (Kerr et al., 1997; Kerr et al., 1998; Rudy et al., 1991) Hypertension (Evans, 1992) Hypotension (Woodgate & Flenady, 2001) Cardiac dysrhythmias (Woodgate & Flenady, 2001) Routine use of normal saline instillation may be associated with the following adverse events: Excessive coughing (Gray, MacIntyre, & Kronenberger, 1990) Decreased oxygen saturation (Ridling, Martin, & Bratton, 2003; Ackerman & Gugerty, 1990; Reynolds, Hoffman, & Schlicting, 1990; Kinloch, 1999; Akgul & Akyolcu, 2002; Ji, Kim, & Park, 2002) Bronchospasm Dislodgement of the bacterial biofilm that colonizes the ETT into the lower airway (Caruso et al., 2009; Ackerman, 1993; Hagler & Traver, 1994; Estes & Meduri, 1995) Pain, anxiety, dyspnea (Jablonski, 1994; O'Neal et al., 2001) Tachycardia (Ridling, Martin, & Bratton, 2003) Increased intracranial pressure (Evans, 1992; Chulay, 1994)

Limitations of Method Endotracheal suctioning is not a benign procedure, and operators should remain sensitive to possible hazards and complications and take all necessary precautions to ensure patient safety. Secretions in peripheral airways are not and should not be directly removed by endotracheal suctioning. Assessment of Need Qualified personnel should assess the need for endotracheal suctioning as a routine part of the patient/ventilator system assessment as detailed in section titled "Indications" above. Assessment of Outcomes

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Improvement in appearance of ventilator graphics and breath sounds (Wood, 1998; Morrow, Futter, & Argent, 2004) Decreased peak inspiratory pressure with narrowing of peak inspiratory pressure-plateau pressure; decreased airway resistance or increased dynamic compliance; increased tidal volume delivery during pressure-limited ventilation

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Improvement in arterial blood gas values or saturation, as reflected by pulse oximetry (SpO2) Removal of pulmonary secretions Necessary equipment: Vacuum source Calibrated, adjustable regulator Collection bottle and connecting tubing Disposable gloves

Resources

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Sterile (open suction) Clean (closed suction) Sterile suction catheter For selective main-bronchus suctioning, a curved-tip catheter may be helpful. (Kubota et al., 1990) The information related to the effectiveness of head turning for selective suctioning is inconclusive. Sterile water and cup (open suction) Goggles, mask, and other appropriate equipment for standard precautions (Siegal et al., 2007) Oxygen source with a calibrated metering device Pulse oximeter Manual resuscitation bag equipped with an oxygen-enrichment device for emergency backup use

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Stethoscope Optional equipment Electrocardiograph Sterile sputum trap for culture specimen Personnel. Licensed or credentialed respiratory therapists or individuals with similar credentials (e.g., MD, RN) who have the necessary training and demonstrated skills to correctly assess need for suctioning, perform the procedure, and adequately evaluate the patient after the procedure.

Monitoring The following should be monitored prior to, during, and after the procedure:

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Breath sounds Oxygen saturation Skin color Pulse oximeter Respiratory rate and pattern Hemodynamic parameters Pulse rate Blood pressure, if indicated and available Electrocardiogram, if indicated and available Sputum characteristics Color Volume Consistency Odor Cough characteristics Intracranial pressure, if indicated and available Ventilator parameters Peak inspiratory pressure and plateau pressure Tidal volume Pressure, flow, and volume graphics, if available FIO2

Frequency Although the internal lumen of an ETT decreases substantially after a few days of intubation, due to formation of biofilm, (Shah & Kollef, 2004) suctioning should be performed only when clinically indicated in order to maintain the patency of the artificial airway used. (Van de Leur et al., 2003; Cordero, Sananes, & Ayers, 2001; Wilson et al., 1991) Special consideration should be given to the potential complications associated with the procedure. Infection Control

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Centers for Disease Control guidelines for standard precautions should be followed. (Siegal et al., 2007) If manual ventilation is used, care must be taken not to contaminate the airway. Sterile technique is encouraged during the entire suctioning event. All equipment and supplies should be appropriately disposed of or disinfected.

Recommendations The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) (Guyatt et al., 2008; Jaeschke et al., 2008) criteria:

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It is recommended that endotracheal suctioning should be performed only when secretions are present, and not routinely. (1C) It is suggested that pre-oxygenation be considered if the patient has a clinically important reduction in oxygen saturation with suctioning. (2B) Performing suctioning without disconnecting the patient from the ventilator is suggested. (2B) Use of shallow suction is suggested instead of deep suction, based on evidence from infant and pediatric studies. (2B) It is suggested that routine use of normal saline instillation prior to endotracheal suction should not be performed. (2C) The use of closed suction is suggested for adults with high FIO2, or PEEP, or at risk for lung derecruitment (2B),

and for neonates (2C).

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Endotracheal suctioning without disconnection (closed system) is suggested in neonates. (2B) Avoidance of disconnection and use of lung-recruitment maneuvers are suggested if suctioning-induced lung derecruitment occurs in patients with acute lung injury. (2B) It is suggested that a suction catheter is used that occludes less than 50% of the lumen of the ETT in children and adults, and less than 70% in infants. (2C) It is suggested that the duration of the suctioning event be limited to less than 15 seconds. (2C)

Definitions: Strength of the Recommendations and Grade of Quality of the Evidence Strength of the Recommendations

Level 1 2

Strength

Description

Stronger Benefits clearly outweigh the risks and burdens (or vice versa) for nearly all patients. Weaker Risks and benefits are more closely balanced or are more uncertain

Quality of the Evidence

Grade A

Quality High

Description

Well-performed randomized controlled trials or overwhelming evidence of some other sort. Further research is very unlikely to change our confidence in the estimate of the effect.

Moderate Randomized controlled trials that are less consistent, have flaws, or are indirect in some way to the issue being graded, or very strong evidence of some other sort. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low

Observational evidence (from observational studies, case series, or clinical experience), or evidence from controlled trials with serious flaws. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very Low Any estimate of effect is very uncertain.

Adapted from: Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso- Coello P, Schnemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-926.

Clinical Algorithm(s)
None provided Back to top

Evidence Supporting the Recommendations


References Supporting the Recommendations
References open in a new window.

Type of Evidence Supporting the Recommendations


The type of supporting evidence is identified and graded for many recommendations (see "Major Recommendations"). Back to top

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
Appropriate and effective application of endotracheal suctioning of mechanically ventilated adults and children with artificial airways

Potential Harms

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Decrease in dynamic lung compliance and functional residual capacity Atelectasis Hypoxia/hypoxemia Tissue trauma to the tracheal and/or bronchial mucosa Bronchoconstriction/bronchospasm Increased microbial colonization of lower airway Changes in cerebral blood flow and increased intracranial pressure Hypertension Hypotension Cardiac dysrhythmias Routine use of normal saline instillation may be associated with the following adverse events: Excessive coughing Decreased oxygen saturation Bronchospasm Dislodgement of the bacterial biofilm that colonizes the endotracheal tube (ETT) into the lower airway Pain, anxiety, dyspnea Tachycardia Increased intracranial pressure Back to top

Contraindications
Contraindications
Endotracheal suctioning is a necessary procedure for patients with artificial airways. Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical condition as result of the procedure. When indicated, there is no absolute contraindication to endotracheal suctioning, because the decision to withhold suctioning in order to avoid a possible adverse reaction may, in fact, be lethal. Back to top

Implementation of the Guideline


Description of Implementation Strategy
An implementation strategy was not provided. Back to top

Institute of Medicine (IOM) National Healthcare Quality Report Categories


IOM Care Need
Getting Better Living with Illness

IOM Domain
Effectiveness Safety

http://www.guideline.gov/content.aspx?id=23992