Endotracheal Suctioning in PICU - Dissertation Example

 Endotracheal Suctioning in PICU Introduction Children with life-threatening complications like acute respiratory distress syndrome or ARDS are admitted and managed in high dependency care units, also known as pediatric intensive care units or PICUs where they may be intubated and put on mechanical ventilation. All over the world, ARDS is a significant cause of morbidity and mortality in children (Feng and Steele, 2009). In the United States alone, approximately, 1-4 percent of patients admitted to PICUs have an established diagnosis of ARDS of which 72 percent need mechanical ventilation (Feng and Steele, 2009). The mortality rate of this condition is as high as 22 percent (Feng and Steele, 2009). The prognosis of children with severe ARDS on mechnical ventilation depends on the skills and expertise of the team of health professionals attending to the patient. Nurses play a major role in the management of children on mechanical ventilation. They not only monitor the course of patient and inform the intensivist about detrimental changes in the vital signs, they also conduct various procedures on the patient which enhance the care value provided in the PICU. One such procedure is endotracheal suctioning. In this exercise on critical thinking and analysis, the role of nurses pertaining to endotracheal tube suctioning in a child with ARDS and on mechnical ventilation has been critically evaluated to gain insight into the recommendations for practice of endotracheal suctioning through evidence-based research and reflection. Two issues about endotracheal suctioning which are discussed in this analysis are the timing of suctioning and the need to instill saline into the endotracheal tube prior to suctioning. Case scenario 5 year old Peter was admitted to the Pediatric Intensive Care Unit or PICU with a diagnosis of moderate ARDS. In the PICU, he was put on mechanical ventilation in view of poor respiratory effort and respiratory failure. Other aspects of critical care like intravenous line access, antibiotics, routine laboratory investigations, fluids and nutrition and hemodynamic monitoring were taken care of. The patient was kept in PICU for 8 days during which time he received mechanical ventilation for 4 days and after monitoring his clinical picture for another four days, he was shifted to the ward and then was discharged home after 3 days. The clinical disease and pathophysiology Parenchymal lung injury which is diffuse resulting in severe respiratory distress and hypoxemic respiratory failure is known as acute respiratory distress syndrome or ARDS. The pulmonary edema is non-cardiogenic in origin. The diagnosis is mainly made on clinical grounds. The American-European Consensus Conference has set forth the following criteria to make a clinical diagnosis of ARDS (Conrad, 2005): acute onset, bilateral infiltrates, pulmonary artery wedge pressure less than 19 mm Hg (or no clinical signs of congestive heart failure) and PaO2/FIO2 ratio less than 200 (ARDS) or less than 300 (acute lung injury) (Conrad, 2005). ARDS is predisposed by many conditions like infecions, aspiration of either gastric contents or water, inhalation of toxic or hot fumes, overdose of drugs like heroin, systemic inflammatory response syndrome and idiopathic. The hallmark pathology in this condition is diffuse alveolar damage. There is also damage to the lung capillary endothelium (Harman, & Walia, 2006). This leads to loss of integrity of the alveolar-capillary barrier. There is transudation of protein-rich fluid across the barrier resulting in pulmonary edema. Intrapulmonary shunting occurs leading to hypoxemia (Feng and Steele, 2009). The pathogenesis of ARDS can be described in 3 phases: 1. Exudative phase: This is the initial phase in which there is injury to the endothelium and epithelium leading to inflammation and fluid exudation. 2. Fibroproliferative phase: In this phase which follows the initial phase, there is influx and proliferation of fibroblasts and other cellular elements. The patient may recover or worsen in this stage. In sepsis, the main focus of injury is in the vascular endothelium. In aspiration of gastric contents, the focus of injury is in the alveolar epithelium (Harman, & Walia, 2006). Neutrophils play an important role in the pathogenesis of ARDS (Harman, & Walia, 2006). The neutrophils trigger release of cytokines, such as tumor necrosis factor (TNF), leukotrienes and macrophage inhibitory factor. Platelet sequestration and activation is also noted (Harman, & Walia, 2006). 3. Fibrosis: This phase occurs in those who have survived ARDS. There is resolution of inflammation and development of pulmonary fibrosis (Feng and Steele, 2009). Nursing interventions Nurses are the back bone of any intensive care unit. In case of Peter, successful mechanical ventilation was possible because of coordinated care of the nurses. Management of ARDS patient on ventilator needs high vigilance and prompt action based on clinical responses and saturations indicators. On all shifts, nurses who took charge of the patient checked the ventilator system and circuit, soon after they took charge of the patient. They looked for maintainanece of positive pressure, absence of circuit leaks, presence of adequate inspiratory air flow and delivery of the prescribed FiO2. The Peak End-Expiratory Pressure or PEEP was initially set at 7. Gradually, based on clinical improvement, the PEEP was brought down to 4 in less than 48 hours. The FiO2 was initially started at 1 and then was gradually decreased to 0.7 over 24 hours. Then it was decreased to 0.4 in 48 hours time frame from the time of admission. All these decisions were made after consulting and discussing with the pediatric intensivist. Peter was always under the supervision of nurse and was never left unattended. Universal precautions were followed and no piece of equipment was shared between Peter and other patients. The patient received endotracheal suctioning. Treatment in Peter was provided through a multidisciplinary approach which involved intensivists, pediatrician, pediatric pulmonologist, nurses, respiratory therapists, dietician, social worker and physical therapist. All procedures and activities on James were performed only after explaining the child's parents about them. Peter was monitored closely while on mechanical ventilation. The nurse checked him visually every 30 minutes and noted the respiratory rate and effort, pattern of breathing, saturations and evaluated for presence of nausea and vomiting. Hourly, his pulse rate and rhythm, manual blood pressure, perfusion and normal functioning of the humidification system were noted. Second hourly checking of condition of conjunctivae and the skin under and around the mask and rubber securing were noted. The breathing pattern was evaluated every hour. Whenever, chest expansion was not good, nurses performed ET suctioning and rechecked for the position of ET tube and chest expansion. The water level of the humidification unit was checked every hour. Response to treatment was monitored using ABG. The nurses was aware of various complications of mechanical ventilation and kept a high index of suspicion for the complications. As a part of provision of care for Peter, nurses provided many interventions like intravenous line acess, arterial blood sampling, chest physiotherapy, oxygen administration, nebulisation and endotracheal tube suctioning. Of interest is the application of endotracheal tube suctioning in the patient. There were 2 groups of nurses who had different opinions about the attributes of ET suctioning. While one group raised the importance of second hourly ET suctioning, the other group questioned the importance of such a policy in view of the potential complications of ET suctioning. Also, there was conflict of issue pertaining to administration of saline solution prior to every suction procedure. To ascertain the evidence-based recommendation for implementation of ET suctioning, a review of literature was conducted with main focus on pediatric population and based on the evidence available through research, policies for ET suctioning were implemented and practised. Critical analysis ARDS is a condition in which huge quantities of bronchial secretions get accumulated in the lungs in response to inflammation. Cough reflex is essential to remove such secretions accumulating in the trachea. Peter had a weak cough reflex because of the nature of the disease and also due to sedation and paralysis. Hence secretions accumulating in the trachea at the and of ET tube could not be brought out by Peter. Increased accumulation of such secretions caused obstruction to the airflow and ventilation and resulted in decreased chest expansion and fall in oxygen saturations. The only way to bring out these secretions and cause an improvement in ventilations is endotracheal suctioning of these secretions. Endotracheal or ET suctioning is a method to remove debris and secretions which accumulate at the end of the endotracheal tube, affecting the process of ventilation. The purpose of endotracheal suctioning is to keep the airway clear and to optimise respiratory function. The procedure is carried out in patients with artificial airway like tracheostomy and endotracheal tube who are not in a position to cough and clear like Peter. Since the tip of the endotracheal tube halts the mucociliary system, suctioning is the only means of removal of these secretions. Also, ET tube is mostly placed in critically ill children like Peter who have a weak cough reflex and thus are unable to clear bronchial secretions on their own (Ridling, Martin and Bratton, 2003). Patients like Peter who are intubated cannot clear secretions of the respiratory tract effectively because the glottis closure is compromised and there is impairment of the normal mucociliary function. Also instillation of inadequately humidified gas and the very presence of endotracheal tube causes irritation of the airways and increased production of the secretions. Another contributing factor is, children with respiratory tract infections like pneumonia have increased volume of sputum and altered rheology of sputum which impede active clearance of the sputum. Hence, all children with artificial airway require ET suctioning to clear secretions and prevent obstruction of airway (Morrow and Argent, 2008). The components of suction apparatus used for Peter are the vaccum generator, collection device and tubing (Higgins, 2005). In Peter, appropriate sized suction catheters were employed for suctioning. The nurse performing suctioning wore sterile gloves, apron and protected her eyes from any splashings. A small bowl or gallipot was used to clean the catheter in between suctions. During suctioning, the catheter was not allowed to go beyond carina. In Peter, the time of insertion of catheter in the endotracheal tube was less than 10 seconds as indicated in the literature (Higgins, 2005). The procedure was repeated if necessary. Throughout the procedure, hemodynamic stability of Peter was monitored. Nurses performing endotracheal suctioning in Peter were well trained and educated and they undertook this procedure as per the policies, guidelines and norms of the organisation they were working for (Higgins, 2005). The dillemma faced by nurses treating Peter was the controversy related to the benefits of ET suctioning as against the side effects associated with it which has been discussed in literature (Wood, 1998). Nurses are accountable for all aspects of their practice and they need to refer to evidence based practice while determining the indications and frequency of ET suctioning (Wood, 1998). Initially, suctioning in Peter was scheduled to be done once in 2 hours. But sometimes, due to poor chest expansion, increased work of breathing and deteriorationg saturations, endotracheal suctioning had to erformed even during unscheduled timings. Hence some nurses thought that performing endotracheal suctioning only when there is evidence of tracheal obstruction in the form of decreased chest expansion was suitable for this patient. While performing ET suctioning, a common practice is to instill saline prior to suctioning. This is because it has been thought that the instilled saline solution loosens the secretions and dilutes them, thus making suctioning easy. It has also been thought that saline lubricates the suction catheter and it enhances cough in the patient. In Peter, the secretions were thick and and required frequent suctioning. Thus some of the nurses considered administering saline into the andotracheal tube prior to suctioning so that the secretions could be loosened up. However, recent research has thrown light about the lack of rationale and evidence-base in the practice of instillation of saline prior to suctioning. Infact, may studies have condemned the practice and highlighted the potential dangers in routine instillation of saline prior to ET suctioning (Ridling, et al, 2003). According to the survey in 1996, 74 percent of the critical care units used saline instillation prior to suctioning as a policy. However, a report from nurses states that 64 percent of the nurses donot routinely employ this policy (cited in Puchalski, 2007). Thus it is clear that there are no standard policies and recommendations for the use of saline instillation prior to endotracheal suctioning. Any intervtion is administered with the purpose of improvement of clinical condition of the patient. Thus saline instillation prior to ET suctioning is done with expectations of improvement in pulmonary functioning. However, various studies have proved the other way round. In Peter too, administration of saline prior to suctioning caused a fall in the saturations to as low as 78 percent each time it was done. It took atleast 10 minutes for the saturations to recover to 94 percent and for this to happen FiO2 had to be increased to 100 percent. Frequent endotracheal suctioning with saline administration was done on the first two days. It was indeed difficult to wean Peter from high ventilator settings and hence the intensivist ordered for suctioning only when there is evidence of endotracheal obstruction. The intensivist also ordered to stop the practice of instilling saline prior to suctioning. Following such a change in the practice of endotracheal suctioning, Peter was weaned from ventilator easily. According to Demers and Saklad (1973), saline and mucus are immiscible and thus it is impossible for saline to loosen accumulated mucus secretions. Thus, there is no point in administering saline in Peter to loosen the thick accumulated secretions. Some studies have proved the potential adverse effects of saline instillation prior to suctioning like interference with oxygen exchange at the alveolocapillary level, decrease in the saturation of the mixed venous oxygenation, increase in the intracranial pressure and increased frequency of nosocomial pneumonia (Ridling, et al, 2003). Also, only 10.7- 18.7 percent of the instilled saline can be retrieved by suctioning and the unretrived fluid is probably the cause for decrease in alveolocapillary oxygen exchange (Hanley et al; cited in Ridling, et al, 2003). While most of the studies pertaining to the benefits of saline instillation prior to ET suctioning have been conducted in critically ill adult patients, Ridling et al (2003) evaluated the benefits of such a practice in critically ill children. The researchers conducted a prospective randomised study to evaluate the benefits of saline instillation in critically ill children. They found that practice of saline instillation is not only useless but also harmful as even in children in causes fall in saturations and decrease in oxygen exchange at alveolo-capillary level. In Peter too, administation of saline caused a drop in saturations. Ji, Kim and Park (2002) studied the effects of saline instillation on the return of oxygen saturation to baseline level. The researchers found that suctioning of the endotracheal tube without saline instillation resulted in return of oxygen saturation to baseline levels immediately after suctioning, while administration of 2 ml of saline caused delay in the bounce back of oxygen saturations to normal by 45 seconds. When 5 ml of saline was instilled, the delay was 5 minutes. One of the major complications of endotracheal suctioning even without saline instillation is hypoxia which is related to interruption in the flow of inspired air. Suctioning also causes sucking of oxygen and gas in the airway resulting in alveolar collapse (Higgins, 2005). Hence suctioning must always be associated with instillation of increased concentration of oxygen. In Peter too each time suctioning was performed, he received 100 percent FiO2. Another measure to decrease hypoxia is by reducing the time taken to perform suctioning. Ideally the procedure must be done in 10 seconds (Higgins, 2005). In Peter, the nurses took 8- 10 seconds to complete the wole procedure of suctioning. Suctioning can also cause trauma to the airway mucosa. This can be prevented by using 'atraumatic' catheters which have more than one eye for suctioning (Higgins, 2005). Also, maintaining a low suction vacuum pressure at 60- 150mmHg prevents suction-related injury to the bronchial mucosa (Higgins, 2005). In Peter, atraumatic cathethers were used and a vacuum pressure of 10mmHg was employed to remove the secretions. Another concern with suctioning is the introduction of infection. Currently, the use of closed system suctions has reduced the incidence of suction-related infection. In Peter too, closed system of suctioning was used and nurses too aseptic precautions to prevent infections. Other complications include hypoxia and vagal stimulation related hemodynamic instability and rise in intracranial pressure causing reduction in cerebrual venous return (Higgins, 2005). The decision to perform suctioning must be based on the clinical assessment about the chest excursion, respiratory characteristics, auscultation and palpation, rather than at present timings (Higgins, 2005). According to Morrow and Argent (2008), suctioning in patients with pulmonary hemorrhage and pulmonary edema must be performed only when absolutely necessary, because these conditions can be aggravated during suctioning. There are even reports of suctioning-induced pneumothorax in neonates due to perforation of the bronchus by the catheter (Morrow and Argent, 2008). In small children atelectasis can develop due to the negative pressure of suctioning. In animal models, studies have demonstrated loss of ciliary function consequent to repeated suctioning (Morrow and Argent, 2008). Some of the cardiovascular complications associated with ET suctioning are bradycardia, cardiac arrhthmias and rise in systemic blood pressure (Simbrune, Coradello, Fover, et al, 1981). In Peter, no such complications were noted during suctioning. The rise in intracranial pressure has been demonstrated on neonates, preterm infants, children and adult traumatic brain-injured patients (Morrow and Argent, 2008). In neonates, suctioning causes decrease incerebral blood volume in relation to changes in the tension of carbondioxide, leading to decreased oxygen availability. Research has shown that hypoxia induced during suctioning can result in intraventricular hemorrhage and hypoxic-ischemic encephalopathy (Kohlhauser, Bernert and Hermon, 2000). One important side effect which has not been brought to light by many researchers is the pain caused by suctioning (Morrow and Argent, 2008). Peter was on sedatives and pain killers because of mechanical ventilations and thus pain was taken care of. According to the recommendations established by Edmunds and Sudder (2009) based on literature review, ET suctioning must be resorted to only when the procedure is absolutely essential. The catheter introduced for the purpose of suctioning must occlude less than 50 percent of the ET tube. Lowest possible suction pressure must be employed and the catheter must not be inserted beyond the carina to prevent tracheal injury. The time taken for suctioning must not be beyond 15 seconds. Continuous suction pressure is better than intermittent suction pressure. Also, saline lavage must be avoided. In patients with tendency of dropping of saturations during suctioning, hyperinflation with hyperoxygenation must be provided prior to suctioning. This should be done on individual basis and must not be a routine norm. Aseptic technique is a must to prevent nosocomial infections (Edmunds and Sudder, 2009). Review of outcome Peter was admitted to the PICU with a diagnosis of ARDS secondary to viral infection. He was initiated on mechanical ventilation and was treated through multidisciplinary approach. Initially endotracheal suctioning was performed every two hours and also during chest excursions and normal saline was instilled prior to ET suctioning. However since it was difficult to wean him from high ventilator settings, the strategy for ET suctioning was changed and Peter was suctioned only duing chest excursions and fall in saturations. Also, saline instillation procedure was stopped. This startegy caused an imporvement in the condition of the patient and he could be weaned easily. The nursing interventions were guided by evidence-based recommendations and policies. Peter recovered in a week's time and was discharged home without any complications. While reflecting on this incident, it can be said that the nurses applied practice based on evidence and contributed to the outcome of the patient. They have acted in the best interests of the patient and have thus helped the patient recover. Implications for practice Though ET suctioning is a necessary procedure to maintain airways in a child on artificial respiratory support, it is not a benign procedure and hence application of this intervention must be administered by weighing the benefits and complications associated with it and by following proper guidelines and policies which are based on evidence available from literature review (Morrow and Argent, 2008). The effects of ET suctioning with or wothout saline instillation on the outcomes of pediatric population, length of stay in the hospital and intensive care unit and mortlity and morbidity are not yet ascertained and thus more studies are warranted with these perspectives to recommend more appropriate guidelines for ET suctioning. Conclusion Through critical analysis and thinking, it is possible to research and reflect which enhances knowlege and provides ample information for evidence based practice. In this essay, critical analysis and thinking of endotracheal suctioning in a patient on mechanical ventilation for ARDS was done. Endotracheal suctioning is an important intervention to prevent blockage of the airways due to accumulation of secretions and debris just beneath the ET tube. However, it is associated with risks of infection, decreased oxygenation, pain, raised pulmonary hypertension, raised intracranial pressures and atelectasis. Also, there is no evidence to establish improved outcomes with frequent suctioning. Another important evidence-based practice established in this critical analysis is instillation of saline solution prior to ET suctioning. The recommendations are not to administer saline as it interferes with oxygeneation at alveolar memebrane level and offers no benefit for loosening secretions. References Conrad, S.A. (2005). Respiratory Distress Syndrome, Adult. Emedicine from WebMD. Retrieved on 31st October, 2009 from http://www.emedicine.com/emerg/topic503.htm Demers, R.R., and Saklad, M. (1973). Minimizing the harmful effects of mechanical aspiration: aspects of respiratory care. Heart Lung, 2, 542–545 Edmunds, M.W., and Sudder, L. (2009). Bringing Evidence to the Process of Endotracheal Suctioning. Medscape Pediatrics. Retrieved on 31st October, 2009 from http://www.medscape.com/viewarticle/588777 Feng, A.K., and Steele, D. (2009). Pediatrics, Respiratory Distress Syndrome. Emedicine from WebMD. Retrieved on 31st October, 2009 from http://emedicine.medscape.com/article/803573-overview Harman, E.M. & Walia, R. (2006). Acute Respiratory Distress Syndrome. Emedicine from WebMD. Retrieved on 31st October, 2009 from http://www.emedicine.com/med/TOPIC70.HTM Higgins, D. (2005). Tracheal Suction. Nursingtimes.net. Retrieved on 31st October, 2009 from http://www.nursingtimes.net/nursing-practice-clinical-research/tracheal-suction/203988.article Ji, Y.R., Kim, H.S., and Park, J.H. (2002). Instillation of Normal Saline before Suctioning in Patients with Pneumonia. Yonsei Med J., 43(5), 607-612. Kohlhauser, C., Bernert, G., Hermon, M, et al (2000). Effects of endotracheal suctioning in high-frequency oscillatory and conventionally ventilated low birth weight neonates on cerebral hemodynamics observed by Near Infrared Spectroscopy (NIRS). Pediatr Pulmonol, 29, 270-275. Morrow, B.M. and Argent, A.C. (2008). A Comprehensive Review of Pediatric Endotracheal Suctioning: Effects, Indications, and Clinical Practice. Medscape Pediatrics. Retrieved on 31st October, 2009 from http://www.medscape.com/viewarticle/580965 Puchalski, M.L. (2007). Should Normal Saline be Used When Suctioning the Endotracheal Tube of the Neonate? Medscape Pediatrics. Retrieved on 31st October, 2009 from http://www.medscape.com/viewarticle/552862 Ridling., D.A., Martin, L.D., Bratton, S.L. (2003). Endotracheal suctioning with or without instillation of isotonic sodium chloride solution in critically ill children. Am J Crit Care. , 12(3), 212-9 Simbruner, G., Coradello, H., Foder Havelec L, et al (1981). Effect of tracheal suction on oxygenation, circulation, and lung mechanics in newborn infants. Arch Dis Child, 56, 326-330. Wood, C.J. (1998). Endotracheal suctioning: a literature review. Intensive Crit Care Nurs., 14(3), 124-36. Read More