Doing endotracheal suctioning for a patient on a ventilator in the Medical intensive care unit

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Endotracheal suction (ETS) is performed to maintain patency of the airway and remove secretions in patients with an endotracheal tube (ETT) in situ. It is an important part of airway management in ventilated intensive care unit (ICU) patients. Patients with an ETT may be at increased risk of respiratory infections as they are unable to clear secretions by coughing. Recognised potential complications following ETS include hypoxia, tissue trauma, increased risk of infection, cardiovascular instability, and atelectasis.[1], [2] Care and management of the patient and the ETT has been discussed in the literature since 1945.[3], [4], [5] To ameliorate the risks, the American Association for Respiratory Care developed clinical practice guidelines (CPGs) for ETS, ventilation, and extubation.[6], [7], [8] Current recommendations include suction only when necessary, consider preoxygenation if there is a clinically significant reduction in oxygen saturation with suctioning, using positive end-expiratory pressure or recruitment manoeuvres (applying a transient increase in pulmonary pressure to open collapsed alveoli) when required,[9], [10] and setting the suction pressure as low as possible to effectively clear secretions, less than −150 mmHg is recommended.[6], [11] Patient assessment should include listening for course sounds over the trachea and assessing ventilator waveforms.12

Previous studies have shown that there is variability between clinical practice and adherence to practice guidelines.[13], [14], [15] Less than 10% of nurses use the recommended suction catheter size with suction canister pressure monitored 55% of the time13 and differing practice about the use of 0.9% sodium chloride prior to ETS[13], [14] although this is no longer a recommendation.6

Recent work investigated ETS practice of Australian paediatric nurses16 and physiotherapists17 while an earlier study investigated nurses' adherence to best practice in one Australian ICU.18 There is nothing describing nursing ETS practice in the adult ICU population across New Zealand and Australia. This study aimed to describe current practice and triggers influencing nurses' decisions to perform suction to assess congruence with CPG recommendations.

Methods

This observational study was conducted as part an existing Point Prevalence Program (PPP), using cross-sectional research methodology.19 The PPP is a prospective, binational, single day research initiative to facilitate researchers conducting observational research that will underpin future research. The George Institute for Global Health coordinates the PPP on behalf of the Australian and New Zealand Intensive Care Society Clinical Trials Group. Ethics approval was obtained in New Zealand

Results

In total, 682 patients were enrolled at 51 ICUs across New Zealand and Australia, of whom 230 (34%) were intubated and ventilated on the study day. Three of 230 patients were excluded for missing data. Baseline characteristics of the intubated patients are shown in Table 1. Compared to non-intubated patients, intubated patients were younger (54.8 years [SD = 16.2 years] versus 62.0 years [SD = 16.5 years]), had a higher APACHE II score on ICU admission (20.0 [SD = 8.0] versus 15.9 [SD = 6.9]),

Discussion

This is the first time that nursing practice regarding ETS across New Zealand and Australia has been described. We found that the most frequent triggers for performing ETS were audible or visible secretions, that ETS was performed at extubation, for the majority of patients extubated during the study period, that preoxygenation before ETS was common, that suction canister pressure was higher than recommended in CPGs and that there was inadequate patient assessment before ETS.

These results show

Strengths and limitations

Strengths of this study include the prospective design and a binational approach involving a large number of ICUs across a variety of settings. Data collection was undertaken by experienced research nurses/coordinators all working within the ICU speciality ensuring consistency across the data collection.

Although the study is a snap shot of nursing practice, describing practice only on the study day, this is the first-time ICU nursing practice of ETS has been documented across New Zealand and

Conclusions

This study highlights the need for ongoing education in ICU as practitioner education is influential in changing practice34 and may help reduce the gap between CPG and clinical practice.

We have identified key areas where improvements can be made to ICU nursing practice. These include education about patient assessment prior to performing ETS, improved guidance regarding preoxygenation, and the need for further research about what is the best practice at the time of extubation. Improving

Acknowledgements

The authors would like to thank all the contributing sites (Appendix 1), research nurses, and coordinators, the George Institute for Global Health and the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program.

This study forms part of a PhD program supported by a Clinical Training Fellowship from the Health Research Council of New Zealand and a PhD scholarship from the Green Lane Research and Education Fund.

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