Review
Endotracheal suctioning of the adult intubated patient—What is the evidence?

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Summary

Intubated patients may be unable to adequately cough up secretions. Endotracheal suctioning is therefore important in order to reduce the risk of consolidation and atelectasis that may lead to inadequate ventilation. The suction procedure is associated with complications and risks including bleeding, infection, atelectasis, hypoxemia, cardiovascular instability, elevated intracranial pressure, and may also cause lesions in the tracheal mucosa. The aim of this article was to review the available literature regarding endotracheal suctioning of adult intubated intensive care patients and to provide evidence-based recommendations The major recommendations are suctioning only when necessary, using a suction catheter occluding less than half the lumen of the endotracheal tube, using the lowest possible suction pressure, inserting the catheter no further than carina, suctioning no longer than 15 s, performing continuous rather than intermittent suctioning, avoiding saline lavage, providing hyperoxygenation before and after the suction procedure, providing hyperinflation combined with hyperoxygenation on a non-routine basis, always using aseptic technique, and using either closed or open suction systems.

Introduction

Intubated patients may be unable to adequately cough up secretions. Based on the work by Day et al. (2002), endotracheal suctioning (ET suctioning) is an important activity in reducing the risk of consolidation and atelectasis that may lead to inadequate ventilation. ET suctioning is defined as: “A component of bronchial hygiene therapy and mechanical ventilation and involves the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place” (AARC, 1993 p. 500). The procedure is associated with complications and risks including bleeding, infection, atelectasis, hypoxemia, cardiovascular instability, elevated intracranial pressure, and may also cause lesions in the tracheal mucosa (Branson et al., 1993, Thomson et al., 2000).

Endotracheal suctioning is described by patients as painful and uncomfortable, and may result in a choking sensation initiating a violent cough, and also cause an unpleasant sensation that the lungs are actually being suctioned into the catheter (Gjengedal, 1994, Patak et al., 2004). Despite the discomfort, patients report that the procedure is necessary and subsequently eases their breathing (Bergbom-Engberg, 1989, Jablonski, 1994). The discomfort associated with suctioning does not diminish during a course of mechanical ventilation; on the contrary, it may worsen (Bergbom-Engberg, 1989).

The apparent discomfort and the potential complications of suctioning may intimidate inexperienced nurses. As Day et al. (2002) stated practice is not always based on current research recommendations, which may lead to inconsistent practice among nurses, affecting the patient experience (Sole et al., 2003, Celik and Elbas, 2000).

Due to the frequency and risk associated with endotracheal suctioning, there is a need to examine clinical practice critically, and to identify clinical research to guide practice. The aim of this article was to review the available literature regarding the endotracheal suctioning of adult intubated intensive care patients and to provide evidence-based recommendations.

Section snippets

Design

A search of literature was performed in Medline, Cinahl and Cochrane Library. The following key words were used: intensive care, critical care, suction, endotracheal suctioning. The initial strategy was to use broad terms in order to increase the sensitivity of the search. The search was then limited to adult patients (≥19 years old) including Danish, Swedish, Norwegian and English language articles from 1995 to 2008. References cited in bibliographies of past reports were included. In order to

Suctioning performed routinely or when necessary

Traditionally, endotracheal suctioning was performed routinely every 1–2 h to ensure the removal of secretions, and to prevent pneumonia and endotracheal tube (ET-tube) occlusion (Glass and Grap, 1995). Due to the considerable risk and adverse effects, it is now recommended, that ET suctioning should be performed only when necessary (Young, 1984, Branson et al., 1993, Odell et al., 1993, Glass and Grap, 1995, Day et al., 2002). A prospective randomised study of 383 patients demonstrated that prn

Discussion

The literature review has demonstrated a paucity of good clinical trials covering the many aspects of the suctioning procedure. The widely accepted recommendations appear to be based on clinical experience and fairly limited documentation. When searching for the original sources for recommendations on the timing of suctioning, catheter size, pressure, insertion depth, duration, and oxygenation, most studies are relatively old, based on small sample sizes, or based on animal studies. As a

Contribution/authorship

CMP, MRN, JH contributed in the conception and design of the study; CMP, MRN, JH, IE in drafting the article; and the final approval was made by IE.

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