Effects of Standardizing Procedures on Adverse Effects of Endotracheal Suctioning
Abstract & Commentary
By David J. Pierson, MD, Editor
SYNOPSIS: This study shows that adverse effects of endotracheal suctioning, particularly oxygen desaturation and hemorrhagic secretions, are frequent in mechanically ventilated patients, and can be reduced by the implementation of practice guidelines.
SOURCE: Maggiore SM, et al. Decreasing adverse effects of endotracheal suctioning during mechanical ventilation by changing practice. Respir Care 2013; Mar 6. [Epub ahead of print].
Maggiore and colleagues studied the incidence of adverse effects of endotracheal suctioning in a 26-bed French medical ICU, and assessed the impact on this incidence of implementing a new set of institutional guidelines related to suctioning practices. They used a before-and-after study design, first prospectively documenting a priori defined suctioning-related events and complications on 79 intubated, ventilated patients (4506 suctioning procedures) during a 3-month period when there were no specific suctioning guidelines in the unit, and then repeating the observations 1 year later, after guideline implementation, in 68 patients (4994 procedures). The suctioning guidelines used were similar to those of the American Association for Respiratory Care (AARC),1 but were developed independently, shortly before the latter were published.
Suctioning-associated adverse events were frequent prior to guideline implementation, occurring at least once in 60% of the patients. Most frequent among these were oxygen desaturation (SpO2 decrease of ≥ 5%; occurring during 6.5% of all suctioning procedures and in 47% of patients) and hemorrhagic secretions (in 4% of procedures and 32% of patients). Severe hypertension (systolic BP > 200 mmHg) occurred in 14 patients (18%), hypotension (BP < 80 mmHg) in seven (9%), tachycardia (rate > 150/min) in five (6%), and bradycardia (rate < 50/min) in four (5%); one patient experienced transient, spontaneously resolving ventricular tachycardia during suctioning.
During the second observation period, after implementation of the suctioning guidelines, adverse events were less frequent (in 5% vs 12% of all procedures, P < 0.05) and occurred in only 43% of the patients. Each adverse event the investigators evaluated was significantly reduced during the post-guideline period. Considering both periods together, receiving positive end-expiratory pressure > 5 cm H2O was an independent risk factor for desaturation, and being suctioned > 6 times/day was associated with both desaturation and hemorrhagic secretions. The authors conclude that endotracheal suctioning frequently induces adverse events, and that carrying out the procedure according to current guidelines reduces their incidence.
Endotracheal suctioning in critically ill patients receiving mechanical ventilation can induce potentially life-threatening adverse events such as desaturation, bleeding into the airways, hemodynamic instability, and arrhythmias. This study corroborates this long-recognized fact, and more importantly, reminds us that the incidence and severity of suctioning-related adverse events can be reduced if current best practices are followed during the procedure.
Prior to implementation of the practice guideline in the authors’ ICU, intubated patients were suctioned routinely at least every 2 hours, and disconnected from the ventilator circuit for the procedure (closed suction systems generally not being used). Saline was frequently instilled; high suction pressures (400 cm H2O or more) were often used; and the duration of suctioning, the size of the catheter, and its depth of insertion were not standardized. The new suctioning protocol, essentially congruent with the AARC guidelines,1 was implemented between the study’s two observation periods using multi-modality educational procedures targeted at all ICU staff.
Along with other items, the new guideline included the following changes:
- Avoidance of circuit breaks, generally via use
of closed-system catheter sets;
- Sterile technique at all times;
- No routine suctioning: as-needed only (except
for paralyzed patients);
- Avoidance of saline instillation;
- Use of catheter of appropriate size for internal
diameter of artificial airway;
- Limiting duration of suction application and suction pressure used; and,
- Avoiding passing the catheter too far down
Endotracheal suctioning is a necessary part of the respiratory care of critically ill patients. Although no mortality or lasting morbidity were observed in the study by Maggiore et al, that such outcomes can be associated with suctioning procedures is without question to anyone who has worked long-term in the ICU. Although the strength of the evidence supporting each of the above protocol elements varies, the measures listed constitute current best practice based on what is known. Their use in all intubated patients can be expected to reduce the incidence and severity of suctioning-associated adverse events to the lowest levels currently attainable.
- AARC Clinical Practice Guidelines. Respir Care 2010;55:758-764.