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Endotracheal Suctioning With or Without Instillation of Isotonic Sodium Chloride Solution in Critically Ill Children

	Abstract

Top Abstract Purpose Methods Results Discussion Limitations Conclusions References

 
• Background Instillation of isotonic sodium chloride solution for endotracheal tube suctioning is controversial. Research has focused on the effect of such instillation in adults; no studies in children have been published.

• Objectives (1) To describe differences in oxygen saturation depending on whether or not isotonic sodium chloride solution is instilled during suctioning and (2) to describe the rates of occlusion of endotracheal tubes and nosocomial pneumonia.

• Methods A convenience sample of 24 critically ill patients were enrolled before having suctioning and after informed consent had been given. Ages ranged from 10 weeks to 14 years. Patients were randomized to 1 of 2 groups. In group 1, subjects received between 0.5 and 2.0 mL of isotonic sodium chloride solution, depending on their age, once per suctioning episode. In group 2, subjects received no such solution. A total of 104 suctioning episodes were analyzed. Oxygen saturation was recorded at predetermined intervals before and for 10 minutes after suctioning. Occlusion of endotracheal tubes and rates of nosocomial pneumonia also were compared.

• Results Patients who had isotonic sodium chloride solution instilled experienced significantly greater oxygen desaturation 1 and 2 minutes after suctioning than did patients who did not. No occlusions of endotracheal tubes and no cases of nosocomial pneumonia occurred in either group.

• Conclusions Results of this study support a growing body of evidence that instillation of isotonic sodium chloride solution during endotracheal tube suctioning may not be beneficial and actually may be harmful.

Instillation of isotonic sodium chloride solution during endotracheal suctioning has been a widespread practice in critical care units for years. Clinicians think that the instilled fluid aids in the removal of respiratory secretions. The rationales for use of isotonic sodium chloride solution are to loosen secretions, lubricate the suction catheter, enhance a cough, and dilute secretions.^1–4 Although not clearly stated in the literature, instillation of isotonic sodium chloride solution may have been introduced b efore the time when ventilator circuits were routinely humidified. Some clinicians recall endotracheal tubes composed of "red rubber" material. At that time, suctioning catheters were made of the same material, making the passage of such a catheter difficult because of the friction between the endotracheal tube and the catheter. Isotonic sodium chloride solution was used as a lubricant to move the catheter through the endotracheal tube. Although isotonic sodium chloride solution has commonly been used, a review of the literature reveals a lack of empirical evidence substantiating its benefits.

Demers and Saklad³ suggest that instillation of isotonic sodium chloride solution might not be helpful: "Mucus and water in bulk form are immiscible and occupy separate phases in vitro, even after vigorous shaking. Endotracheal instillation and rapid removal is therefore of dubious value." In a study with radiolabeled isotonic sodium chloride solution, Hanley et al⁵ showed that only 10.7% to 18.7% of the instilled solution could be retrieved by suctioning. The unretrieved fluid could interfere with alveolocapillary oxygen exchange.

The potential adverse effects of instillation of isotonic sodium chloride solution during suctioning include interference with alveolocapillary oxygen exchange resulting in decreased oxygen saturation, decreased mixed venous oxygen saturation, increased frequency of nosocomial pneumonia, and increased intracranial pressure.^1,2,6–8 Several studies have been conducted to evaluate the effect of instillation of sodium chloride solution on oxygen saturation. Bostick and Wendelgass¹ studied the effect of such instillation on 45 adult patients who had cardiac surgery. Patients were randomized to 1 of 3 groups to receive 0, 5, or 10 mL of isotonic sodium chloride solution. Samples of arterial blood were obtained for blood gas analysis 5 minutes before the start of suctioning and 20 minutes after the completion of suctioning. Bostick and Wendelgass found no significant difference in the PaO₂ levels of the 3 groups, but they noted a downward trend of PaO₂ in patients who received a larger amount (10 mL) of solution. Ackerman and Gugerty⁶ studied oxygen saturation in critically ill adult patients, with each patient acting as his or her own control. They found a greater decrease in oxygen saturation and a delayed improvement in oxygen saturation after suctioning when isotonic sodium chloride solution was used. Ackerman⁹ then studied 40 critically ill men, with each patient acting as his own control. Patients were randomized to receive 5 mL of isotonic sodium chloride solution for every other suctioning episode. Oxygen saturation was recorded 1 minute before each episode of suctioning and every minute for 5 minutes after. At minutes 2, 3, 4, and 5 after suctioning, use of the sodium chloride solution had an adverse effect on oxygen saturation.

To further study the effects of instillation of isotonic sodium chloride solution on oxygen saturation, Acker-man and Mick¹⁰ evaluated the effect of such instillation in critically ill adult patients with pulmonary infections. Twenty-nine critically ill adults were randomized into 2 groups. One group received 5 mL of isotonic sodium chloride solution before suctioning; the other group did not. Those randomized to receive the solution had a decreased oxygen saturation at 4, 5, and 10 minutes after suctioning. In 2 additional studies^4,11 in which adult patients in an intensive care unit (ICU) were randomized to receive or not receive isotonic sodium chloride solution during endotracheal tube suctioning, researchers found no difference in oxygen saturation between the 2 groups.

Although instillation of isotonic sodium chloride solution during endotracheal tube suctioning has been used for years, evidence consistently shows that such instillation is detrimental in adults, most often resulting in decreased oxygen saturation. The effects of its use in children, however, have not been well studied.

 

Kinloch⁷ evaluated the effect of instillation of isotonic sodium chloride solution on mixed venous oxygen saturation in adult patients in a cardiac ICU who were randomized to receive or not receive 5 mL of solution before suctioning. Mixed venous oxygen saturation was recorded via continuous mixed venous oxygen catheters placed in the pulmonary artery. Values were recorded before, during, and after the completion of suctioning. Kinloch found a 3.78-minute delay in the recovery of mixed venous oxygen saturation to baseline levels in those patients who had isotonic sodium chloride solution instilled versus patients who did not.

To evaluate the risk of nosocomial pneumonia, Hagler and Traver⁸ examined the effectiveness of instilling isotonic sodium chloride solution in dislodging bacteria from a colonized endotracheal tube. Specifically, they evaluated 10 endotracheal tubes from critically ill adults who had been intubated for at least 48 hours. All endotracheal tubes were treated the same way. First a 14F suction catheter was inserted into the endotracheal tube until 5 cm protruded beyond the length of the tube. This 5-cm length was cut off with sterile scissors and allowed to drop into a sterile cup. Then 5 mL of sterile isotonic sodium chloride solution was run through the endotracheal tube, and the fluid was collected in a sterile cup. The materials dislodged by both procedures (insertion of a catheter and instillation of fluid) were cultured for quantitative analysis. Lavage with 5 mL of isotonic sodium chloride solution dislodged up to 310 000 (mean 79 672) viable bacterial colonies from the lining of the artificial airway, whereas the insertion of the catheter without lavage dislodged up to 60 000 (mean 10 460). Hagler and Traver concluded that this dislodgment of bacteria by instillation of isotonic sodium chloride solution might lead to contamination of the lower part of the airway and possibly nosocomial pneumonia.

Although evidence and the inclination to eliminate or minimize the use of isotonic sodium chloride solution during endotracheal suctioning are growing, in many pediatric ICUs, instillation of such solution is still part of routine practice. Some pediatric clinicians are concerned that most studies have been done in adults and that the results may not apply to children because of the small size of the endotracheal tubes used in children. The main concern is the risk of endotracheal tube occlusion if such solution is not instilled. No studies in children have been published; however, 2 studies in neonates were done.

In a prospective study of 25 neonates,¹² infants who had instillation of isotonic sodium chloride solution for suctioning were compared with infants who did not. In that study,¹² the phases of suctioning were standardized to include a prebaseline phase in which an arterial blood gas analysis was done, and the fraction of inspired oxygen and ventilatory rate were increased on the basis of each neonate’s needs and were not standardized across the study group. Hyperventilation and hyperoxygenation were accomplished with mechanical ventilation, thus the patients were not treated with ventilation via a manual resuscitation bag by a staff member. Each patient had suctioning done 3 times, with a 15-second rest period between each episode of suctioning. During the rest period, the infants received mechanical ventilation. All patients were treated the same, except that patients in 1 group received an instillation of isotonic sodium chloride solution during the first episode of suctioning. Infants weighing less than 1500 g received 0.25 mL of solution, and infants greater than 1500 g received 0.5 mL. Samples for arterial blood gas analysis were collected 10 minutes after the conclusion of suctioning. The authors¹² found no significant difference in oxygenation, heart rate, or blood pressure from before to after suctioning.

Reduction in oxygen saturation after suctioning was compared between children who had isotonic sodium chloride solution instilled and those who did not. Rates of occlusion of endotracheal tubes and pneumonia were also compared between the 2 groups.

 

In another study in neonates,¹³ oxygenation and pulmonary mechanics were studied in 18 infants. Patients acted as their own controls, and suctioning was done alternately with and without instillation of isotonic sodium chloride solution. The investigators monitored compliance as well as oxygen saturation at baseline and 10, 20, and 30 minutes after suctioning. They found no overall difference in compliance but significantly lower oxygen saturation from baseline in the infants who had fluid instilled. They also reported that recovery of oxygen saturation was delayed in patients who had had fluid instilled.

In 2 literature reviews,^14,15 authors concluded that isotonic sodium chloride solution should not be instilled as part of routine endotracheal care in adults. Further, an official position statement about the care of children with tracheostomies was submitted by the American Thoracic Society.¹⁶ In that comprehensive review and delineation of all aspects of care of tracheostomies in children, the guidelines state that isotonic sodium chloride solution should not be instilled routinely. Despite the growing evidence supporting the elimination of routine use of isotonic sodium chloride solution, a survey¹⁷ of 187 critical care nurses and respiratory therapists indicated that such solution is instilled up to 71% of the time. In our clinical experience with pediatric ICU nurses, many of the nurses continue to question the applicability to children of findings from studies in adults and neonates. For these reasons, we conducted this study.

	Purpose

Top Abstract Purpose Methods Results Discussion Limitations Conclusions References

 
The primary purpose of this study was to compare the effects on oxygen saturation, as measured by pulse oximetry, of endotracheal tube suctioning with and without instillation of isotonic sodium chloride solution. The secondary purpose was to determine the number of times the endotracheal tube became occluded and the number of cases of nosocomial pneumonia.

	Methods

Top Abstract Purpose Methods Results Discussion Limitations Conclusions References

 
Setting
The study was done in a 17-bed multispecialty pediatric intensive care unit for patients from newborn to 21 years old at Children’s Hospital and Regional Medical Center in Seattle (a 208-bed tertiary care hospital).

Design
A prospective randomized study design was used. Randomization was accomplished by using sequentially sealed envelopes prepared by someone not involved with the study. Subjects were randomized to 1 of 2 study groups. Subjects remained in their study group during the entire intubation period.

In group 1, subjects had isotonic sodium chloride solution instilled during every suctioning episode. A suctioning episode was defined as the period from the start of removing the subject from mechanical ventilation, including the time performing the procedure until suctioning was accomplished as evidenced by a "clear tube," up to the time of return to mechanical ventilation. The amount of solution instilled depended on the age of the subject. Subjects less than 1 year old received 0.25 to 0.5 mL, subjects 1 to 8 years old received 0.5 mL, and older subjects received 1 to 2 mL. Subjects’ ages were used rather than the size of the endotracheal tube because consent was obtained and children were randomized before having suctioning, and in most instances preoperatively before the size of the endotracheal tube was known. In group 2, the subjects had no solution instilled for the entire time they were intubated.

In both groups, oxygen saturation was measured before suctioning and at 1, 2, and 10 minutes after the end of suctioning. Oxygen saturation measurements were displayed by the bedside monitor every second and were averaged every 5 seconds from the bedside display. Data were collected from the display at the exact times described. The observer or investigator did no averaging of recordings over time.

Demographic data, including age, weight, and endotracheal tube size, were collected along with Pediatric Risk of Mortality III scores.¹⁸ The Pediatric Risk of Mortality III score is a validated tool used by many pediatric ICUs to predict the risk of mortality on the basis of 17 physiological parameters subdivided into 26 groups. Factors such as metabolic status, condition on admission to the ICU, and worst vital signs are collected and entered into a national database. The score is completed within 24 hours of admission, with scores ranging from 0 to 30. The score has no absolute upper limit because of the complexity of the scoring system, but higher scores are associated with a greater risk of mortality.

The number of times the endotracheal tube became occluded was also counted; occlusion was defined as partial or complete blockage of the endotracheal tube necessitating removal of the tube. All data were collected by a registered nurse who was not involved in the suctioning procedure. National Nosocomial Infections Surveillance System definitions for hospital-acquired pneumonia were used to define nosocomial pneumonia.^19,20 Data were collected and characterized by a nurse from the infection control department who was not associated with the study.

Significantly greater reductions in oxygen saturation, lasting up to 2 minutes after suctioning, were found in children who had isotonic sodium chloride solution instilled than in children who did not. Neither group had any tube occlusions or cases of pneumonia.

 

Instrumentation
Oxygen saturation was recorded by using peripheral oxygen probes manufactured by Nellcor (Pleasanton, Calif) and Spacelabs (Bellevue, Wash) modular physiological monitors. Suction was applied by using Ohmeda (Columbia, Md) suction regulators attached to an existing, central vacuum system. Mechanical ventilation was provided by Servo 300 ventilators (Siemens-Elma, Solna, Sweden).

Sample
A convenience sample of 24 critically ill, endotracheally intubated children were enrolled before initiation of suctioning and after consent had been obtained. Because of logistical difficulties in obtaining consent before children received suctioning, children with medical diagnoses or who had unplanned admissions were difficult to enroll. For this reason, most subjects had consent obtained before elective congenital cardiac surgery. All children were transorally intubated and received mechanical ventilation via a Servo 300 ventilator. All circuits were humidified and heated to 36°C. Eligible patients included intubated patients aged newborn to 18 years who had planned admissions to the pediatric ICU. Subjects could not have had suctioning before consent had been obtained and they had been entered into the study. Children who were excluded from the study included those receiving high-frequency oscillatory ventilation; children with hypoplastic left heart syndrome or who had undergone a stage I Norwood procedure; children with pulmonary hypertension, pulmonary hemorrhage, tracheal reconstruction, or an endotracheal tube other than a standard type, such as a reinforced/coiled or right-angled endotracheal tube; children being managed with an in-line suction catheter; and children who received suctioning before consent had been obtained and randomization had been done. Data were collected on all suctioning episodes for the first 24 hours and then once per day thereafter on the first suctioning episode of the day after 7 AM until extubated.

Procedure
The study was approved by the institutional review board at Children’s Hospital and Regional Medical Center in Seattle. Before the study was initiated, pediatric ICU registered nurses and respiratory therapists received information on the procedures, which included a review of the existing policy for endotracheal tube suctioning. Informed consent was obtained before children were enrolled. No set intervals for suctioning were established; rather suctioning was done only when necessary, as determined by the pediatric ICU nurse or respiratory therapist according to existing ICU policy. Triggers for assessing patients for suctioning included oxygen desaturation, coarse breath sounds, coughing or gagging, visible secretions in the endotracheal tube, and/or agitation.

For all subjects, suctioning was done by 2 staff members of the pediatric ICU. Before suctioning, mechanical ventilation was stopped and ventilation was provided by using an anesthesia bag and 100% oxygen at the same positive inspiratory pressure and positive end-expiratory pressure as those used for mechanical ventilation. The size of the catheter was approximately half the diameter of the endotracheal tube. Actual catheter sizes were from 6F to 14F. Catheter depth was measured, and the catheter was inserted no more than 1 cm beyond the end of the endotracheal tube. Suction was set at 80 mm Hg for infants up to 1 year old and 100 mm Hg for all others. Subjects received suctioning until the tube was clear. Then ventilation and oxygenation by manual means were continued until the patient was comfortable (approximately 30 seconds) before mechanical ventilation was resumed.

The detrimental effects of instillation of isotonic sodium chloride solution during suctioning in children are similar to those found in adults. Results of this study do not support a proposed beneficial effect of instillation of isotonic sodium chloride solution, namely, maintaining patency of endotracheal tubes.

 

Statistics
Each suctioning event was considered an independent event, and all suctioning episodes for a given patient were included. Baseline oxygen saturations were significantly lower in the group that had isotonic sodium chloride solution instilled because more subjects in that group than in the other group had cyanotic heart disease. Therefore, the percent change from baseline was determined at 1, 2, and 10 minutes after suctioning. A t test was used to compare continuous data from groups 1 and 2. A statistical software package (SPSS 7.5 for Windows, SPSS Inc, Chicago, Ill) was used. Statistical significance was defined as P less than .05.

	Results

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Sample
Of the 24 subjects enrolled, 10 were in group 1 (fluid instilled) and accounted for 52 suctioning episodes. In this group, 9 patients had congenital heart disease and 1 patient had asthma. All children with congenital heart disease were recovering from cardiac surgery. Cardiac procedures included repair of the atrioventricular canal, bidirectional Glenn operation, central shunt, Fontan procedure, change in a pulmonary artery conduit, Ross procedure, establishment of a right ventricle–pulmonary artery conduit, and repair of a ventricular septal defect. Group 2 (no fluid instilled) consisted of 14 patients and accounted for 52 suctioning episodes. All patients in group 2 had congenital heart disease and were recovering from cardiac surgery. Cardiac procedures included repair of the atrioventricular canal, bidirectional Glenn operation, Fontan procedure, repair of tetralogy of Fallot, closure of an atrial septal defect, establishment of a right ventricle–pulmonary artery conduit, reconstruction of the pulmonary artery, reimplantation of a coronary artery, Ross procedure, and repair of a ventricular septal defect. All subjects in both groups completed the study. The number of subjects was not matched because of the randomization design, and the total final sample size was less then originally planned; however, the suctioning episodes were matched between the 2 groups (Table 1).

	Discussion

Top Abstract Purpose Methods Results Discussion Limitations Conclusions References

 
These results show for the first time in children the deleterious effects of instillation of isotonic sodium chloride solution during suctioning, supporting a growing body of evidence that suggests that such instillation may not be beneficial. More importantly, our findings support previous research that suggests that this practice may actually be harmful to patients. Many adult ICUs have abandoned the use of fluid instillation as a routine practice. Many pediatric practitioners are concerned that the results of studies in adults do not apply to children because of the smaller size of the endotracheal tubes used in children. Our study included use of small endotracheal tubes. Despite the growing body of evidence, practitioners continue to be concerned about the potential inability to remove thick secretions without instillation of isotonic sodium chloride solution. Adequate humidification of the ventilator circuit is an essential measure to prevent the development of thick, tenacious secretions, and boluses of isotonic sodium chloride solution should not be instilled into the endotracheal tube to loosen secretions.

	Limitations

Top Abstract Purpose Methods Results Discussion Limitations Conclusions References

 
Most children in this study had congenital cardiac disease, so the findings may not be applicable to children with other critical illnesses. Obtaining consent to study patients before they had suctioning in unplanned emergency admissions was logistically difficult and was considered burdensome to the families of the patients. Additionally, as with many studies of children, the study is limited by the variety of ages and endotracheal tube sizes. Although the suctioning procedure was preestablished in the ICU and by the standard of care, the number of care providers performing the procedure was not limited. The numbers of endotracheal tube occlusions and occurrences of nosocomial pneumonias were evaluated, but the number of patients enrolled was insufficient to achieve statistical significance.

	Conclusions

Top Abstract Purpose Methods Results Discussion Limitations Conclusions References

 
Instillation of isotonic sodium chloride solution had an adverse effect on oxygen saturation at 1 and 2 minutes after suctioning. This adverse effect was not present 10 minutes after suctioning. No endotracheal tubes were occluded, an important finding for pediatric clinicians, who may be concerned that not instilling fluid during suctioning will increase the risk of tube occlusion.

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Commentary by Mary Jo Grap (see shaded boxes).

	REFERENCES

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