Oxygen saturation and secretion weight after endotracheal suctioning

Konstantinos Giakoumidakis, Zoi Kostaki, Evridiki Patelarou, George Baltopoulos and Hero Brokalaki Abstract
Endotracheal suctioning is a common aspect of nursing care to mechanicallyventilated patients. The aim of this study was to investigate the effects of two suctioning techniques on oxygen saturation (SaO^) and the amount of drained secretions. A quasi-experimental study of 103 mechanically-ventilated patients was conducted from two tertiary hospitals in Greece. Two suctioning techniques were applied to each patient: with normal saline instillation and without. Normal saline instillation was associated with increased secretions' weight (p<0.001) and no significant differences in SaOj values compared with no instillation. In examining each suctioning technique separately, the use of normal saline instillation was associated with a decrease in SaO, levels 1 minute (p<0.001) and 15 minutes (p=0.002) after this procedure. In addition, suctioning without normal saline instillation was associated with a decrease in SaO, 1 minute (p<0.001) after the suction. In conclusion, normal saline instillation is related with a negative outcome on patient oxygnation for a prolonged period after the suction and causes the reinoval of a greater amount of secretions than the applied technique with no instillation. Comparing the two techniques, none is superior to the other resulting from the statistically insignificant comparative differences in SaO^ values. Key words: Amount of secretions Normal saline instillation Suctioning large tiuniber of intensive care unit (ICU) patients require mechanical ventilation via an artificial airway on a daily basis (Halpcrn and Pastores, 2010). The artificial airway severely compromises the action of ciliated cells in the airways, the local iniinune system and the cough reflex, resulting in an important difficulty in the destruction and removal of the produced pulmonary secretions
Konstantinos Giakouniidakis is Registered Nurse, Cardiac - Surgery hitensivc Care Unit, Evangelisnios' Ceneral Hospital of Athens, Creece, Zoi Kostaki is C'aptain, 251 Hellenic Airforce (ienenil Hospital o Athens, (reecc, Evridiki I'.itelarou is Registered Nurse, University Hospital of Heraklion, Oete, (Greece, George Baltopoulos IS Professor, Faculty of Nursing, National & K.ipodistrian University of Athens, Greece and Hero Brokalaki is Associate Professor, Faculty of Nursing, National & Kapodistrian University of Athens, ( Greece
.'iavptcd for puhlication: November 2011

Oxygen saturation

(Raymond, 1995; Guglielminotti et al, 1998; Buglass, 1999). Because the presence of an artificial airway impairs the patient's natural ability to mobilize and expectorate secretions, endotracheal suctioning is used to remove secretions and maintain a patent airway for optimal ventilation and oxygnation (Raymond, 1995).

Background
Several techniques have been adopted by health professionals in order to minimize the potential complications and increase the endotracheal suctioning effectiveness. The instillation of normal saline has been considered widespread practice in ICUs for years (Blackwood, 1999; Kinloch, 1999;Akgl and Akyoglou, 2002; Celik and Kanan, 2006). A national survey in the USA revealed that 74% of centers have airway management policies incorporating instillation of isotonic saline (Sole et al, 2003). Clinicians believe that the instilled fluid aids the removal of respiratory secretions and the rationale behind using an isotonic sodium chloride

solution is to loosen secretions, lubricate the suction catheter, enhance coughing and dilute secretions (Ridling et al, 2003). Although the use of isotonic saline before trachal suctioning is common practice, its effectiveness remains controversial (Raymond, 1995). Normal saline instillation appears to enhance secretion clearance through cough stimulation in adults (Gray et al, 1990) and a recent study has correlated saline instillation before endotracheal suctioning with positive outcomes, such as the lower incidence of ventilator-associated pneumonia (Caruso et al, 2009); however, this practice is not supported by the literature (Branson, 2007; Morrow and Argent, 2(K)8).The recent clinical practice guidelines published by the American Association for Respiratory Care (2010) suggest that routine use of normal saline instillation should not be performed. In addition, several investigators have not documented the safety and effectiveness of normal saline instillation prior to endotracheal suctioning and have characterized this technique as harmflil and not iielpflil for critically ill patients. Ackerman (1993) studied the effect of normal saline on oxygen saturation (SaO,) measured by pulse oxymetry in 40 male subjects requiring mechanical ventilation. SaO^ was decreased 2, 3, 4 and 5 minutes after suctioning with installation of normal saline. As a result, the instillation of norm;il saline should be regarded as potentially hazardous and not as routine or standard intervention. In addition, several suidies have correlated the endotracheal instillation of normal sahne with shortness of breath and discomfort, oxygen de-saturation, decreased partial pressure of oxygen in arterial blood (PaO,) and increased incidence of pulmonary infections (Ackerman, 1993; Hagler andTraver, 1994; Kinloch, 1999;Ji et al, 2002; Celik and Kanan, 2006). Concerning the volume ot dniincd secretions, several studies have found statistically significant differences in the mean weights of sputum between different patient suctioning groups (groups without and with saline instillation before suctioning).The main finding was the association between the instillation of normal saline with greater

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Endotracheal suctionine is used to maintain mechanicauy-ventilated

patients' airway for optimal uentilation and oxygnation

drained weights of secretion (Bostick and Wendelgass, 1987; Ackerman and Gugerty, 1990; Gray et al, 1990). However, the clinical significance of this finding was unclear because the weight increase could be attributed to retrieval of instilled saline and not mucus. Contrary to these findings, Lerga et al. (1997) did not observe statistically significant association between secretions' weight and normal saline instillation. The primary aim of this study was to investigate the effects of two different suctioning procedures (without normal saline instillation and with normal saline instillation) on a patient's SaO-, level in arterial blood. A secondary aim was to examine the association between the type of suctioning procedure and the amount of drained secretions through the dirterence in secretion weight obtained when suctioning without and with normal saline instillation. The routine use of normal saline during suctioning worldwide despite the controversial data in the literature underlines the necessity and the significance of this study.

Design and settings

The study was quasi-experimental, among mechanically ventilated patients in the ICU of two general, tertiary hospitals in Athens, Greece. Inclusion criteria in the study were: Mechanical ventilation by an endotracheal or tracheostomy tube Existence of at least one of the following indicators of suctioning; sawtooth pattern on the flow-volume loop on the monitor screen of the ventilator and/or the presence of coarse crackles over the trachea, increased peak inspiratory pressure during volumecontrolled mechanical ventilation or decreased tidal volume during pressurecontrolled ventilation, deterioration of SaO, and/or arterial blood gas values, visible secretions in the airway and suspected aspiration of gastric or upperairway secretions (American Association for Respiratory Care, 2010) Existence of an arterial line for receiving arterial blood samples in order to measure patients' arterial blood gasses Continuous haemodynamic monitoring Systematic administration of bronchodilators and/or mucolytic agents, in order to secure more homogeneity of our study population, based on the therapeutic effect of these

medicines on patient oxygnation and airway clearance. In addition, patients with the following conditions were excluded: Age 18 years old or younger Haemodynamic instability Chronic pulmonary or kidney disease Tracheobronchial anomaly or trauma Use of muscle-relaxation medication Application of endotracheal suctioning in the last 90 minutes. In total, the study population consisted of 210 consecutive mechanically-ventilated patients, out of whom 103 met the inclusion criteria and constituted our final study sample. This small proportion (103/210) might be explained by the several inclusion and exclusion criteria that were defined to ensure higher homogeneity of our studied sample. Data collection A short three-unit questionnaire on basic demographic characteristics and clinical patient data was used for data collection purposes. The first unit included information on demographic and clinical characteristics (age, gender, length of ICU stay in days, duration of intubation in days, ventilator modes, type and size of artificial airway. Acute

Methods
Data were collected over three and a half years, from June 2004 to November 2007.

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Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS) score, history of chronic obstructive pulmonary disease (COPD), 24-hour fluid balance, presence or absence of respiratory infection, white blood cells count, administration of bronchodilators or/and mucolytic agents).The second unit included information on the applied endotracheal suctioning technique (without normal saline instillation or with instillation of 5 ml normal saline) and the third unit included information on patient oxygnation parameters (SaO,) and weight of drained secretions. SaO, values were recorded before the procedure, as well as 1 and 15 minutes after the endotracheal suctioning, by analysing arterial blood samples on a blood gases machine. The secretions weight was measured accordingly after the application of each suctioning procedure, using a pair of precision scales. Endotracheal suctioning was performed according to standard principles, as described by the Emergency and Intensive Care Nursing Department of the Hellenic Nurses'Association (2006). Patients were hyperoxygenated with 100% oxygen for 1 minute. Then, using a catheter with the maximum size of 14Fr, regarding the size of the artificial airway, patients were suctioned with negative pressure of 150 niniHg and sterile technique for 15 seconds. For the selection of the appropriate suction catheter size, the authors used the following formula: Fr = [Artificial airway size (mm) - 2] X 2 (Hellenic Nurses' Association, 2006; Pedersen et al, 2009). Blood gases were taken 1 and 15 minutes after the procedure, using a disposable 2.5 ml syringe (Three-Piece Luer Lock Syringes, Frank Healthcare Co. Ltd) that had been fiushed with heparin. The authors chose the first minute with the aim of testing the direct outcome of the applied procedures and the fifteenth minute to identify the recovery time of the oxygnation parameter. All blood samples from each patient were analysed on blood gases machines of the same type (ABL 70(1 Series Blood Gas Analyzer, Radiometer). The drained secretions were collected using a specific collector and all samples were weighed on precision scales of the same type. Two methods of suctioning were carried out in each patient, allowing for a 90-minute interval between the two methods. No more secretions and significant haemodynamic and oxygen transport changes were the criteria for stopping suctioning. The first method was suctioning without the use of normal saline (which we referred to (interquartile rangc-lK), while categorical variables are presented as absolute and relative frequencies. The Wilcoxon sigiied-rank test was used to identify differences betweeti groups on weight of secretions. The authors also applied the Wilcoxon signed-rank test to investigate if SaO,, values differentiate immediately before and after (at 1 and 15 minutes) each procedure separately and to comparatively assess the two suctioning procedures. All tests of statistical significance were two-tailed, and p-values of less than 0.05 were considered significant. The statistical analysis was performed using SPSS (v. 14.0). Ethical considerations Permission to condiit t this study was obtained from the ethical committees of the hospitals and an informed consent was obtained from each patients next of kin. The study has been conducted in full accordance with ethical principles, including the World Medical Association (WMA) Declaration of Helsinki (WMA, 2011), and as aforementioned, each suctioning was carried out only after specific indications and according to patient needs.

Table 1. Demographic and clinical sample characteristics of the study population

Hospital A B Gender Male Female Type of artificial airway Endotracheal tube Tracheostomy tube Ventiiation modes CMV SIMV Spontaneous Use of bronchodilators Use of mucolytic agents Age (years) Length of stay (days) Duration of intubation at the time of suctioning (days) Apache Ii Score Glasgow Coma Scaie

38 (36,9) 65 (63,1) 35 (34,0) 68 (66,0) 67 (65,0) 36 (35,0) 49 (47.6) 37 (35.9) 17(16,5) 90 (87.4) 29 (28.2) Mean (SD) 63,0 (21.1) 12,6(16.9) 11.2(15.5) 10.3 (6.9) 6.1 (3.8)

CMV: controlled mechanical ventilatior SD: standard deviation SIMV: synchronized intermittent mandatory ventilation

Results
Sixty-six percent of the sample was female with a mean age of 63 (standard deviation (SD) 21.1) years old.The patients'mean GCS score was estimated at 6.1 (3.8) and the mean APACHE II score was 10.3 (6.9).The mean ICU length of stay and duration of intubation (at the time of suctioning) were 12.6 (16.9) and 11.2 (15.5) days, respectively. In addition, 65% of the patients had an endotracheal tube and the remaining ones (35%) had a tracheostomy tube. Most patients received either synchronized intermittent mandatory ventilation (SIMV) (35.9%), or controlled mechanical ventilation (CMV) (47.6%). A detailed distribution of the study population according to specific demographic and clinical characteristics is depicted in Inhlc I. The iiuiin associations between the type of suctioning procedure and the weight of drained secretions are summarized in 'liihle 2. The weight of secretions was greater after the application of suctioning with normal saline, than without normal saline (p<O.O()l), which

as procedure 1) and the second method was suctioning with instillation of 5 ml normal saline 0.9% (procedure 2). Aspirations were carried out only after specific indications for suctioning, which have been mentioned in the inclusion criteria of this study. The researchers obtained the data based on the medical and nursing patient records, as well as via their personal contact with the patients. The APACHE II and GCS scores ware calculated for each patient using data collected through hospital records. Data analysis The normality assumption for continuous variables was evaluated by using both the Kolmogorov-Smirnov criterion (p>0.05 for all variables) and normal probability plots. Quantitative variables are presented as mean (standard deviation-SD) and median

Table 2. Suction technique and secretion weight correiation

Secretions' welgiit (g) Median (IR) Min, Max value Procedure I 1,00 (2,00) 0.00, 8.00 Procedure 2 2.00 (2.00) 0.00, 9.00 p- value (z-score) ^ O.OOIa (-6.6)

a, Wilcoxon signed-rank test IR: Interquartile range

Procedure I: Suctioning without normal saline instillation Procedure 2: Suctioning with a 5 ml nornnal saline Instillation

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was a statistically significant result. The weight Discussion of drained secretions associated with normal The main finding of the study was the saline instillation was almost two times greater statistically significant difference of SaO.., compared to the procedure without normal levels attributed to each suctioning technique saline instillation. Table 3 shows the change in individually, after 1 and 15 minutes, compared SaO., values 1 and 15 minutes after the suction, with values immediately before the procedure. for both endotracheai suctioning procedures, Nevertheless, the comparative differences of compared with the baseline values (before the SaO-, levels were not statistically significant suction). The comparative differences of SaO, neither 1, nor 15 minutes, after the suctioning were not statistically significant either 1 or procedure. Finally, another important finding 15 minutes after the suctioning procedure. of the study was the statistically significant The differences of SaOj (prior to and 1 or association between the increased weights of 15 minutes after the procedure) owing to suctioned secretions and the type of suction. each suctioning are summarized in Table 4. In However, it is worth mentioning that the particular, suctioning without normal saline statistically significant difTerences in both was correlated with a statistically significant SaO-, values and amounts of secretions are decrease in SaO, (p<O.O()l) after 1 minute. insignificant from a clinical point of view, The authors did not find any statistically because the absolute differences are very small significant change of SaOj 15 minutes after and do not significantly affect the patient's the procedure. Suctioning with normal sahne clinical condition. instillation was correlated with a statistically Suctioning is an essential aspect of airway significant decrease in SaO2 1 (p<().001) and management and nursing care in the 15 luiiuites (p=().()02) after the suction. critically ill, which can be done through

various techniques to maximize its safety and effectiveness. However, the many associated risks and complications have created scientific skepticism regarding the clinical benefits. Identifying the oxygnation disorders which accompany endotracheai suctioning without or with normal saline instillation could lead to important conclusions regarding the safety of each suctioning technique. The association between the amount of drained secretions and the suctioning type could inform clinicians about the effectiveness of the two suctioning procedures. Although the authors observed a statistically significant decrease in SaO-, 1 minute after suctioning without normal saline and both 1 and 15 minutes after suctioning with normal saline instillation, no statistically significant differences were found when the changes of SaO-, levels between the two suctioning techniques were compared. The decreased SaO-, levels 1 minute after both suctioning techniques could be explained by the interruption of ventilation during the suctioning and the patients' anxiety about the procedure. In this case, the negative effect of suctioning seems temporary. The decreased SaO^ after 15 minutes in the case of the procedure with normal saline instillation could be explained by the harmful effect of normal saline to the patients oxygnation. In line with the results, Ackerman and Gugerty (1997) found a statistically significant decrease in SaO., immediately after suctioning, regardless of whether a saline bolus was instilled or not. In addition, Ackerman and Mick (1998) reported that in those patients with pulmonary infections, who were receiving instillation of normal saline, SaO-, had not returned to baseline values 10 minutes after suctioning and Ackerman (1993) concluded that the instillation of normal saline in the trachea prior to suctioning had an adverse efTect on SaO-, that worsened over time. In particular, significant changes on SaO, were found 2, 3, 4 and 5 minutes after instillation. Akgul and Akyolcu (2002) found no statistically significant difference in SaO., values comparing the two suctioning procedures (without and with normal saline instillation), which is also in line with the authors' findings. Finally, the study ofJi et al. (2002) showed that the instillation of normal saline was associated with a statistically significant decrease in SaOj after suctioning compared with the baseline (immediately before suctioning) values. In contrast with the authors' results, Ackerman and Gugerty (1997) found a statistically significant difference in

Table 3. The changes of SaO2 values at 1 and 15 minutes after suctioning and baseline
1 min after and baseline dSaO2 (%) Median (IR) Min. Max value Procedure 1 Procedure 2 0.20 (1.00) 0.30 (0.80) - 7.50. 6.40 - 5.00. 4.10 15 min after and baseline Procdure 1 Procedure 2 0.10 (0.90) 0.10 (0.60) -17.10. 5.20 -5.30. 2.80 p-value (z-score) 0.92a(-0.4)

0.31a(-1.0)

Median (IR) Min. Max value

A. Wilcoxon signed-rank test. dSaO2: difference n oxygen saturation in arteria blood before and after intervention IR: Interquartile Range. Procedure 1 ; Suctioning without normal saline instillation. ''rocedure 2: Suctioning with a 5 ml normal saline instillation

Table 4. Comparison of SaO2 values 1 and 15 minutes after the endotracheai suctioning and baseline (for each suctioning method separateiy)
SaO2 (%) i-value -score) Procedure I Immediately before I min after 98.70 ( 1.90) 98.20 (2.30) 48.10.100.0 42.60,99.90 Procedure 2 Immediately before I min after 98.70(2.00) 98.10(2.20) 59.60,100.00 60.0.99.90 <0.001 (-4.4) 15 min after 98.50 (2.30) 56.50, 100.0 <0.001 (-5.6) 15 min after 98.30 (2.00) 62.50, 99.90 0.002 (-3.0) 0.497 (-0.7)

Median (IR) Min. Max

Median (IR) Min, Max

IR: Interquartile Range. Procedure 1 : Suctioning without normal saline instillation. Procedure 2; Suctioning with a 5 ml normal saiine instillation. SaOZ: oxygen saturation in arterial blood p-value I : Wilcoxon signed-rank test for the comparison of SO2 values immediately before and I minute after each suctioning procedure p-value 2: Wicoxon signed-rank test for the comparison of SO2 values immediately before and 15 minute after each suctioning procedure

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values between the two methods at 45 seconds and at all times thereafter, and Ackerman and Mick (1998) reported a statistically significant decrease in SaO,, 4, 5 and 1(J minutes after suctioning in patients receiving instillation of a 5 ml bolus of normal saline compared to those who did not. In addition, contrary to the authors' findings, Akgul and Akyolcu (2002) concluded that normal saline instillation was not associated with any significant decrease in SaO, levels 5 minutes after the procedure, a result that is consistent with other studies (Gray et al, 1990; Reynolds et al, 1990). In addition, Ji et al (2002) revealed that the suctioning without normal saline instillation caused decreased SaO., after suctioning, but this change was not statistically significant. Another important finding of this study was the association between the increased suctioned secretions' weight and the type of suction, in particular, endotracheal suctioning with instillation of 5 ml normal saline was characterized by aspiration of greater amounts of secretion than suctioning without normal saline instillation. In line with the authors' results, Bostick and Wendelglass (1987) observed a statistically significant difference in the mean sputum weights between three patient suctioning groups. The investigators concluded that patients in groups with normal saline instillation had significantly greater weights of drained secretion, but the clinical significance of this finding was unclear because the weight increase may have been a result of the retrieval of instilled saline and not mucus. In addition. Gray et al (1990) found a statistically significant difference in drained secretions' weight between the two suctioning methods. In particular, suctioning with normal saline instillation caused a significantly

greater amount of material to be aspired than suctioning without normal saline instillation. Ackerman and Gugerty (1990) also correlated the amount of drained secretions with the applied suctioning technique. They found a statistically significant increase of 1.25 g ill the sputum weights of patients who had received a 5 ml normal saline instillation before suctioning. Lerga et al (1997) studied 25 patients with previous pulmonary disease who underwent cardiac surgery. In contrast with the authors' study results, they revealed that the amount of suctioned secretions was similar using both techniques, with and without normal saline instillation. At this point, it is important to emphasize that it is possible that the instillation of normal saline did affect the final associations, acting as a confounding variable. As a result, it is difficult to assume a causal association between the type of suctioning and the amount of drained secretions. It is also difficult to answer with confidence whether normal saline instillation causes the removal of a greater amount of secretion or the volume of instilled isotonic saline counts with the weight of secretions. Moreover, Demers and Sakland (1973) revealed that the instillation of normal saline is not effective in thinning or liquefying secretions because mucus and water in bulk forms are immiscible and occupy separate phases in vitro, even after rigorous shaking.Therefore, instillation and rapid removal by suctioning is of dubious value. This view is confirmed by Raymond (1995).

and the amount of suctioned pulmonary secretions in intensive care patients in Greece. However, this study had some limitations. Firstly, although the small sample size of 103 patients seems appropriate when compared with similar studies undertaken previously (Ackerman and Gugerty, 1990; Ackerman, 1993; Akgul and Akyolcu, 2002; Ji et al, 2002; Ridhng et al, 2003), this threatens the vaHdity of the study and impedes the ability to generalize the findings to critically ill and mechanically-ventilated patients treated in a wide range of ICUs. Secondly, the quasi-experimental design of this study and the lack of randomization affect its external and internal validity. Finally, this study was conducted in two general ICUs of two hospitals which mean that there might be differences regarding the applied therapeutic protocols and the medical, nursing and physiotherapy care planning, which could affect the homogeneity of the provided care. The limitations in the study in conjunction with the conflicting findings from the literature review indicate the need for further research, with experimental design and randomization, larger sample size and more sample homogeneity.

Conciusion
The results of the authors' study showed that endotracheal suctioning is associated with oxygnation disorders, either without or with normal saline instillation prior to suctioning. The significant decrease in SaO,, values 1 minute after the applied procedure (either without or with normal saline instillation) indicates the direct negative outcome caused by the interruption of mechanical ventilation in conjunction with the application of an unpleasant procedure which temporarily impedes the patient's oxygnation and ventilation. In addition, the significant decrease of SaO, values 15 minutes after the suctioning with normal saline instillation indicates the prolonged negative impact of normal saline instillation given the late return of SaO, values at baseline. Nevertheless, neither the procedure without normal saline, nor the procedure with normal saline was superior, as was indicated by the comparisons of SaO, levels. In particular, the authors found no statistically or clinically significant differences in SaO^ levels between the two suctioning techniques. Also, the instillation of normal saline to the trachea seems to cause the removal of a greater amount of pulmonary secretion than the applied technique without normal saline instillation. However, the value of this

Limitations
To the best of the authors' knowledge, this study was the first to examine the effect of endotracheal suctioning type (without or with normal saline instillation) on oxygen saturation

KEY POINTS
I Endotracheal suctioning is a worldwide practice in intensive care units, which aims to remove secretions and maintain a patent artificial airway I Although the instillation of normal saline during suctioning is a common technique, its effectiveness and safety remain questionable i The endotracheal suctioning is associated with oxygnation disorders i Neither suctioning without normal saline, nor suctioning with normal saline instillation, is superior to the other regarding patient SaO^ levels I Although the instillation of normal saline is associated with greater drained secretions weight, the value of this finding is controversial because the increased weight could result from aspirated normal saline I Nurses should avoid the instillation of normal saline in their suctioning protocols

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Ikf
finding is controversial because the increased weight of patients' secretions could result from the aspirated normal saline. In any case, although this study detected associations which reach statistical significance, their clinical insignificance cannot be ignored, based on the extremely small differences regarding the SaO, values and the weight of drained secretions. From the literature review the authors conclude that, during the last 20 years, the assessment of the clinical benefits in conjunction with the complications of endotracheal suctioning, which is among the most common nursing interventions to improve the respiratory function of mechanically-ventilated ICU patients, is a point of great interest. Endotracheal suctioning is often accompanied by the instillation of isotonic saline to the trachea in order to ease flow and the removal of secretions from the airway. Nevertheless, the authors observe that this technique remains controversial and causes scientific skepticism concerning its safety and effectiveness. The instillation of normal saline solution during endotracheal suctioning may not be beneficial and may actually be harmful. Although the instillation of isotonic saline solution is a common practice in critical care settings worldwide, its negative effect on patient oxygnation and its debatable benefit on the amount of drained secretions should encourage nurses to avoid the application of this technic]ue in their suctioning protocols.This should not be a routine method for the removal of pulmonary secretions by an artificial airway
Conflict of interest: none Ackerman MH (1993) The effect of saline lavage prior to suctioning. AmJ Cril dm 2(4): 326-30 Ackcrjiian MH. Gugerty B (1990) The effect of normal saline bolus instillation in artificial airways. TIte Journal
../.SOHJV8(2): 14-7

isotonic sodium chloride solution on endotracheal suctioning in critically ill patients. Dimciis Cril Care Ncs25(l): 11-4 Deniers RR. Saklad M (1973) Minimizing the harmful effects of mechanical a.spiration. Heart Lmn; 2(4): 542-5 Gray JE, Maclntyre NR. Kronenberger'WG (1990) The effects of bolus normal-saline instillation in conjunction with endotracheal suctioning. Respir Care 35(8): 785-90 CUglielminotti J. Desmont.s JM. Dureuil B (1998) Eflects of trachal suctioning on respiratory resistances in mechanically ventilated patients. Ciie.n 113(5): 1335-8 Hagler DA. Traver GA (1994) Endotracheal saline and suction catheters: sources of lower airway contamination. AmJ Cril Care 3(6): 444-7 Halpern NA. Pastores SM (2010) Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mi.\. and costs. Cril GircAicrf 38(1): 65-71 Hellenic Nunes' Association (2008) Guidehne: Open suctioning method on padent with endotrachcMl tube. http://tinyurl.com/d38fzy6 (Accwsed 16 November 2011) Ji YR. Kim HS. Park JH (2002) Instillation of normal saline before suctioning in patients with pneumonia. Yoiisei MedJ 43(5): 607-12 Kinloch D (1999) Instillation of normal saline during endotracheal suctioning: effects on mixed venous oxygen saturation. .>l/ii / Cril Care 8(4): 23140 Lerga C, Zapata MA. Herce A, Martinez A, Margall

MA. Asiain MC (1997) |Eiidotracheal suctioning of secretions: effects of instillation of normal serum]. liiijerm liilemifa 8(3): 129-37 Morrow HM. Argent AC (2008) A comprehensive review of pdiatrie endotracheal suctioning: Effects, indications, ancl clinical practice. Pediair Cril Care Med 9(5): 465-77 Pedersen CM, Rosendahl-Nielsen M, Hjermind j , Egerod I (2009) Endotracheal suctioning of the .idult intubated patientwhat is the evidence? httetnive Crii Care Nurs 25(1): 21-30 Epub 2008 Raymond SJ (1995) Normal saline instillation before suctioning: helpful or harmful? A review of the literature. Am / Cril Care 4(4): 267-71 Reynolds P. Hoffman LA. Schlichtig R. Davies PA. Zullo TG (1990) Effects of normal saline instillation on secretion volume, dynamic ctimpliance. and oxygen saturation. .4i Rev Respir Dis 141(3): A.S74 Ridling DA. M.irtin LI). Bnitton SL (200.1) Endotracheal suctioning with or without instillation of isotonic sodium chloride ilution in critically ill children. AmJ Cm Care 12(3): 212-9 Sole ML. BycrsJF, Ludy JE. Zhang Y, Banta CM, Brummel K (2003) A multisite survey of suctioning techniques and airway management practices. Am / Oi( Cure 12(3): 22IKO World Medical Association (2011) WMA Declaration of Helsinki - Ethical Principles for Medical Research Iin\il\iiig Hiunan Subjects, http://tinyurl.com/ cf6rwcin (Accessed 14 November 2011)

A NEW WAY TO HELP PREVENT INVASIVE PNEUMOCOCCAL DISEASE IN ADUUS. -

Ackerman MH. Mick DJ (1998) Instillation of normal saline before suctioning in patients with pulmonary infections: a prospective randomized controlled trial. .4m I Cril Care 7(4): 261-6 Akgiil "S, Akyolcu N (2002) Effects of normal saline on endotTacheal suctioning. J C/I'H Nuri 11(6): 82630 American Association for Respiratory Care (2010) AARC Clinical Practice Cuidelines. Endotracheal suctioning of" mechanically ventilated patients with artificial airways 2010. Rcspir Cm 55(6): 75H-64 Blackwood B (1999) Normal saline instillation with endotracheal suctioning: primum non nocere (first do no harm). I Ad,> Niirs 29(4): 928-34 Bostick J. Wendelgass ST (1987) Normal saline instillation as part of the suctioning procedure: effects on PaO2 and amount of secretions. Hear! Lung 16(.S): 532-7 Branson RD (2007) Secretion management in the mechanically ventilated patient. Respir Care 52(10): 1328-42 Bugla.ss E (1999) Tracheostomy care: trachal suctioning and humidification. BrJ Nim 8(8): .S()0-4 Caruso P. Denari S, Ruiz SA. Demarzo SE. Deheinzelin D (2009) Saline instillation before trachea! suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Mcd 37{\): 32-8 Celik SA. Kalian N (2006) A current conflict: use of

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liritish Jourii.il ofNursing. 2(11(1. Vol 2(1. No 21

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Copyright of British Journal of Nursing (BJN) is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Copyright of British Journal of Nursing (BJN) is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Copyright of British Journal of Nursing (BJN) is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.