Suctioning during normal saline installation on ICU patients

Introduction:

Mechanical ventilation is the process of using a device (ventilator) to support, partially or totally the delivery of gas to the lungs. The desired effect of mechanical ventilation is to maintain adequate levels of Po2 and Pco2 in arterial blood while also unloading the inspiratory muscles (Neil R. Macintyre MD, 2016).  Critically ill patients who need mechanical ventilation require endotracheal suctioning.  Normal saline instillation before endotracheal suctioning was demonstrated to decrease patient oxygenation in most studies (HaticeAyhan, 2015). Consequence, hypoxia is occurred due to NSI during suctioning the patient, which is a common clinical issue for patients receiving mechanical ventilation in the intensive care unit (ICU). (American Association of Critical-Care Nurses, 2015).  From my experience working in ICU most of the patients are on mechanical ventilation which means need to suctioning the patients regularly as need it and most of the health care providers using NSI before suction to make the secretion thinner and easy to remove. However, the installation of normal saline leads to a decrease in oxygen saturation after the suctioning.  While sectioning with installation, normal saline causes decreases oxygen saturation, this has raised the following question: In patients with endotracheal tubes, does suction compared to normal saline, harmful. In order to reveal ambiguity and uncertainty, this paper will discuss and review the literature regarding sectioning instillation normal saline an attempt to answer the question.

Literature Review

Research by Chia-Hui Wang et al. shows that there are adverse events associated with suction during normal saline instillation. Adverse events likely to manifest include blood pressure, reduced oxygenation, high heart rate, and dyspnea. The findings from the research showed that the immediate impact of suction was immediate oxygen saturation within two to five minutes after suction. The secondary effects show that the heart rate and blood pressure were affected after the suctioning. It should be noted from the analysis that NS installation before suctioning did not benefit patients who were under either endotracheal intubation or tracheostomy. NS installation however, reduced oxygen saturation five minutes after suction. Marcus (2018) in his experiment, confirmed that his results regarding effect saline installation on patients before suction were the same when compared with Chia-Hui Wang work. Results from the study showed that it was not safe to use saline installation during endotracheal tube suctioning. The controversies surrounding the use of saline installation during endotracheal tube suctioning has prompted researchers within health care settings to find out the confidence level of nurses with the practice. There are no psychological benefits when saline is installed during suction, according to Marcus (2018). Marcus results indicated a 95 percent confidence interval, an indicator of how the result could benefit the clinic field. To further, Rosanne researched current suctioning practices by registered nurses (RNs) and registered respiratory therapists (RRTs). The experiment took place within 6 ICUs in different hospitals using already provided set of clinical practices. The outcome of the research showed that different hospitals do not follow the same rules while carrying out suctioning. The authors, therefore, recommend a probe on hospitals to find out if suction practice follows the necessary medical guidelines. Unfortunately, the outcome of the study indicates that a high number of those who took part in the research were not aware of the required NSI protocols for ICU treatment.

Ayhan further elaborates on what nurses think about normal saline installation before endotracheal suction and whether their thinking corresponds with nursing practices. The main questions asked were how often the nurses were using NS in suction and their response regarding the practice. Most nurses criticized the practice, and approximately half of the nurses believed that NSI could be harmful. Nurses think that NSI has high chances of negatively affecting patients. Nurses suggest that when in a dilemma on the use of NSI, they always opt to focus on removing secretions, therefore overlooking the negative impacts of NSI. Hoffman et al. 2013, in their article, support the idea that saline instillation is performed on an adult patient at ICU. Respiratory therapists and nurses conduct the practice of using saline with suction without enough knowledge of the required current based research that is supposed to provide guidance. The research intended to determine the benefits and flaws of suctioning on a patient with an overall provision of evidence-based practice recommendation that should go ahead to assist in serving as a guide for practice. The clinical trials carried out during the research were crucial in effectively determining ways in which saline instillation with suctioning, as an artificial airway was harmful. The researchers’ conclusion was to recommend strictly standardized protocol, and clinical guideline follows hospitals that saline instillation with suctioning should not be used on patients. (Camille and caparros, 2019) also support the idea of providing evidence-based practice whose purpose is to serve as a guide for practice. Camille study was as systematic review on the use of saline instillation in suctioning mechanically ventilated adult ICU patients.

Comparison and contrast of Findings

The first step of the research was to determine the effect of saline instillation during endotracheal tube suctioning on oxygen. The outcome of the study by Chia-Hiu Wang used RCTs to evaluate the outcome of NS installation before suctioning in ICU patients. Each person who took part in the experiment was subjected to standardized and meta-analysis in order to effectively find out the pooled effect size of NS installation through the random-effect model. The study also was assessed, two independent reviewers. The reviewers utilized Cochrane collaboration to find out about the bias risk of the study. The study further shifted from quality to risk of bias, followed by checklists and numeric scores. The checklists and numeric scores are carried towards domain-based assessments with considerations of different type of bias. According to (Sterne et al. 2016), one example of checklists is the Cochrane risk of bias of tools for randomized trials. In order to arrive at detailed findings, Chi-Hiu Wang research assessed various domains. One of the domains includes the adequacy of randomization, outcome assessors, concealment allocation, and blinding of patients. On the other, hand the study methodology for research by Markus (2018) used a randomly selected sample of RCT. All the 608 patients who took part in the research were admitted in ICUs, and 402 of the patients were estimated to be under mechanical ventilation. Just like Chia-Hiu Wang, the study by Markus utilized a randomized control trial. In both studies, the randomization is used to eliminate bias and therefore, truly ensure a direct comparison of the different groups that are under trial. The outcome of the trial and methodology indicated a low risk of biases in the study. The reason for low biased risk is that the outcome of the experiment objectively measures the trials. Another reason is that the data collected were directly taken from patients who were in ICU with the help of a trained observer who doubles up as a sample participant. The trial utilized in this research uses a well-pointed participation sample with a clear methodology. A clear methodology boosts the relevance of the experiment as it put the focus on the intended research project. The statistical outcome of the research based on a confidence interval of 95 percent indicates a p value of 0.02. The p value is below 0.05 an indicator the findings of the research to determine the effect of saline instillation during endotracheal tube suction on oxygen is significant.

Clinical practice guidelines are key factors to consider when carrying out suctioning by nurses. The findings from research conducted by (Rosanne Leddy, 2019)shows that not all the individuals who took part in the study were blinded to treatment; it is only the researchers who were blinded during the analysis of the data collected. The outcome of the study, therefore, shows that it reduced the chances of biases from medical professionals and patients. Research, which does not allow for blinding often result in a biased study. There is, however, an exception in the case of randomized controlled trials required in evaluating allied health intervention. In such a scenario, it would be difficult to blind both the participants and therapist since they are tasked with providing intervention for categorizing participants to either of the control groups. According to (Hoffmann, Tammy, et al 2013) utilizing RCTs control for human and environmental bias assist in improving the validity of the research. The validity of the research is improved through the assigning of participants into different groups and interventions. The authors of this study worked towards avoiding biases through the use of the randomly collected sample. The medical professions were allowed to examine the surveys before the organization admins. Ayhan study differed from another researcher since the findings utilized two stages. The two stages of the study are systematic review and descriptive case study. According to (Palinkas et al. 2013), the use of mixed method designs is preferred when implementing research because they provide a good and informed understanding of issues under research. The results of the research showed that 87.7% of nurses applied normal saline instillation. This outcome of the research is generally the same as other researchers’ outcomes. The study did use five studies to assess the impact of NSI before endotracheal suctioning on oxygenation. The five studies provided clear, explicit objectives that utilized inclusion criteria for the overall study to improve the transparency of the research according to (O'Connor, Whitlock and Spring, n.d.). The findings of the study showed that oxygen saturation decreases significantly when saline was used as compared to baseline values obtained before suctioning.

Strengths and limitations of the studies

The meta-analysis used by Chia-Hiu in his study had its limitation. The sample size of patients who took part in the experiment per treatment group was small for some of RCTs selection. The small selected group did have a significant impact on the statistical power of experiment results. Experiments should utilize big trials in order to arrive at statistically significant results. The second limitation of Chia-Hiu Wang study is that some of its primary and secondary outcomes were not consistent but rather varied across the studies. For most of the selected RCTs, randomization and allocation concealment were not correctly reported, therefore resulting in biased selection or confirmation. The final limitation of this study was that the selected RCTs were not able to provide an adequate discussion regarding blinding of patients and its outcome assessors, therefore having a negative final inferences basis of author analysis. Markus (2018), on the other hand, carried out its study within one day. Therefore its limitations varied. The research weakness is drawn from the fact that the project took only one day to complete, making it hard to carry out in-depth analysis and research. Researching only one-day lead to possibilities of methodological limitations (Jorge, Lilian Martins, 2014, pg27) such as limited units of a sample size to carry out an analysis. A study carried out in just one day have high chances of finding it difficult for the outcome of the research to provide a significant relationship with the collected data. Another limitation with Markus research is that he did not mention cases where a patient was dropped during the period of the research. It is, therefore, necessary for the author to mention instances where patients under research dropped out. The importance of mentioning about dropouts during the research is to improve the research clarity of the reader. The final research to determine the role of saline installation in suctioning adults by author is weak since the study is based on systematic reviews. Unlike the first two authors, this research does not support the question of the study. The study utilized a small sample size does making it the study to be invalid. According to (Hoffman, Tammy, et al 2013) studies that utilize small sample size conduct flawed research. During the research, the author’s settings used inconsistent data collection method. It was evident that the data used were not enough, and in some cases, the clinical trials were outdated. Use of outdated research clinical trials to support systematic study is not recommended. The author further failed to mention whether the study witnessed chances of bias riskiness. Chances are as a result of random variation while biased is as a result of systematic variation. Research by (Hoffman, Tammy, et al 2013) bias is a systematic error as a result of the methods used in selecting participants of the intended research study. The outcomes from this research are analyzed, resulting in inaccurate results, thus negatively influencing the final interpretation of results.

(Rosanne Leddy, 2019) findings did follow the set objectives of the research, but they were still faced with weaknesses. The methodology used by the researchers were weak because the research failed to provide the criteria that were used at arriving at the sample. The findings of the randomized trials were by the prediction that the health professional did not have the correct knowledge to support clinically approved suctioning practices. Other limitations faced during the study by (Rosanne Leddy, 2019) relates to the geographical proximity of participants in the research. The participants were working within 50 km from Mississauga Hospital. There are high chances that the participants of the research had received their education where the study took place. There were 80 participants on the research, which did not include a large study; therefore it can be said that the research was limited. The statistical power is weak when an insufficient number of participants are used in research. (Camille and caparros, 2019) study on evidence-based practice review had a different set of limitations that did not originate from the actual experiment. It is therefore recommended that further detailed research be conducted without relying on reviews that lack evidence. Ayhan study did face some limitations; the final investigation of the study on paediatric patients was not included in the assessment. Another challenge with the study is that it was conducted within one place, therefore, limiting varied views from different personnel. Thus, the obtained results regarding the views of nurses may not be generalizable. Generalizability of clinical investigations can only be possible when research is conducted within both the clinic and the population setting (Kukull, 2012). The study by Ayhan do not represent the population, but only the sample was carried out within a clinical set up, therefore, the research do not qualify for generalization.

The rationale for decision making based on a review of evidence

The decision on whether to allow or eliminate normal saline instillation before suctioning is based on both researched and reviewed evidence. A systematic review by Ayhan to find out about what nurses think of saline instillation showed that most nurses did not like the idea and believed that NSI was harmful to patients. The negative impacts that follow NSI also form the basis for our decision-making rationale. The study by Camille can be used to provide a rationale regarding the benefits and harm of NSI on ICU patients. The evidence provided in the research is strong and therefore, can be used in decision-making. The reason for choosing this study for decision-making is that it performs systematic review while answering the PICO question. The result, therefore, makes it possible to use the systematic review to formulate evidence-based nursing practice. The role of the review is accomplished through the inclusion of high-quality evidence in developing best practice guidelines hence bettering direct nursing practice by research done by (Wilma and Portia, 2016). The negative impacts that have been faced after analysis of ICU patients can form a basis where nurses should be made to follow a specific set out protocols on how to administer NSI.

Conclusion

In conclusion, suctioning with NSI is an essential aspect of ETT or tracheostomy suctioning policy in order to ensure patient safety. Besides, more studies are needed to elucidate the uncertainty with this practice. The routine clinical practice of NSI with suctioning an artificial airway is being done daily without having a clear evidence-based clinical guideline to support its practice Education should be provided to every health care provider regarding the effects of using NSI when suctioning and how it can cause further harm to the patients. However, the developer of this policy should be required to look at further recent articles discussing this point specifically. From the findings carried out throughout different researches, there is evidence to show that NSI hurts patients, therefore, making the process to face controversies and criticism. It is also true to say that nurses believe that NSI negatively affects patients, and they do not have standard protocols that they should follow when administering NSI.

 

 

 

 

 

 

 

Reference list

Camille, A. and Caparros, s. (2019). Mechanical Ventilation and the Role of Saline Instillation in Suctioning Adult Intensive Care Unit Patients: An Evidence-Based Practice Review. [online] Nursingcenter.com. Available at: https://www.nursingcenter.com/journalarticle?Article_ID=2485481&Journal_ID=54014&Issue_ID=2485022 [Accessed 16 May 2019].

HaticeAyhan,RN,PhD a,⁎, SevincTastan,RN a, EmineIyigun,RN a, YagmurAkamca,RN b, ElifArikan,RN c, ZubeydeSevim,RNc Normal saline instillation before endotracheal suctioning: “What does the evidence  say ? What do the nurses think?”: Multimethod study

Jorge .F, Lilian Martins F (2014) How sample size influences research outcomes. 19(4): 27–29. doi: 10.1590/2176-9451.19.4.027-029.ebo

Kukull WA1, Ganguli M. (2012) Generalizability: the trees, the forest, and the low-hanging fruit. DOI: 10.1212/WNL.0b013e318258f812

Rosanne Leddy, J. (2019). Endotracheal suctioning practices of nurses and respiratory therapists: How well do they align with clinical practice guidelines?. [online] PubMed Central (PMC). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530836/ [Accessed 16 May 2019].