The present essay is related to the case study of a conflict between two nurses that happened because of the installation of saline into a 75-year-old patient during the process of suctioning. The aim of the installation was to loosen his thick secretions. The problem is that the instillation of saline into the patients endotracheal tube caused the severe cough. The essay discusses whether the installation of saline while suctioning is acceptable, analyzes evidence related to best practices, and develops a PICO question for the installation of saline during endotracheal suctioning.
Strategies to Search for Evidence Related to Best Practices for Suctioning
For the search for evidence related to best practices to be successful, it is necessary to determine the keywords related to the problem and use these words to find relevant articles in databases. Stillwell et al. (2010) argue that developing a PICO question is an indispensable part of the search because it helps identify the keywords and determine the level of evidence needed. Stillwell et al. (2010) also emphasize that for the search to be successful, it is important to choose a relevant database, such as the Cochrane Database of Systematic Reviews or Cumulative Index to Nursing and Allied Health Literature.
The topic of evidence related to the best practices for suctioning will be discussed in detail later. At this point, it should be noted that an experienced nurse from the case study was wrong to instill saline during endotracheal suctioning. The clinical practice guideline developed by the American Association for Respiratory Care (2010) clearly states that “routine use of normal saline instillation prior to endotracheal suction should not be performed” (p. 758). One might think that normal saline instillation could loosen secretions and, hence, facilitate the suction procedure. Nonetheless, the evidence to support this suggestion is insufficient (American Association for Respiratory Care, 2010). What is more, the studies conducted by Kinloch (1999) and Kacmarek and Bassi (2019) reveal that instillation of saline before endotracheal suctioning worsens oxygenation status, cardiovascular compromise, and increased airway pressure. The cough, redness, and overall distress of the 75-year-old patient clearly illustrate that saline instillation was acceptable.
Evidence Related to Best Practices
As it has been noted in the preceding paragraph, saline installation is not an efficient and safe technique that could be used during endotracheal suctioning. To suck thick secretions, best practices suggest increasing pressure instead of instilling saline. The evidence also shows that suctioning should last no more than 15 seconds. In case a patient requires re-suctioning, the time between procedures should be no less than 10-15 seconds. If suctioning is performed on a mechanically ventilated patient, it is recommended to use oxygen insufflation. This technique helps to maintain the normal rate of oxygenation.
Another takeaway from the analysis of the evidence related to best practices shows that the practice of disconnection of the intubated patients from ventilators during suction has become outdated. Nowadays, this practice has become substituted with closed suctioning, during which a catheter is connected to the ventilator. Close suctioning has fewer adverse reactions in contrast to the open one. Finally, the best practices include the application of a shallow suctioning method instead of a deep one. In shallow suctioning, the catheter is attached to the endotracheal tubes end, whereas in deep suctioning, the catheter enters the trachea and increases the risk of hurting it.
The PICO question could be seen as a framework for formulating a research question. The abbreviation PICO stands for Population, Intervention, Comparison, and Outcomes. In our case, P is patients with endotracheal tubes; I is the installation of saline as a way of facilitation secretions extraction; C is dry suctioning, and O is increased efficacy of secretions extraction. Therefore, the PICO question sounds as follows: Does the installation of saline during suctioning secretions from patients with endotracheal tube increases the effectiveness of secretions extraction compared to dry suctioning?
PICO could be applied in case of uncertainties or divergence of nurses opinions. In the presented case study, the problem at the workplace appeared because the experienced nurse instilled saline in the intubated patient to loosen his thick secretions. In her opinion, the patients distress caused by a severe cough was not a sign that this procedure is inappropriate. This way, in this particular case of the elderly, intubated man with thick secretions, the PICO question on the efficacy of saline instillation could be applied as a way to check whether this practice is safe and should be employed further. The analysis of the evidence related to best practices provides an answer to the PICO question and shows that the instillation of saline is an ineffective and harmful technique with numerous side effects. Another example that is not based on the case study is when a patient or a nurse doubts whether to perform the operation. PICO helps to compare the outcomes of the operation and a non-invasive method of treatment and show which treatment method is more effective.
American Association for Respiratory Care (2010). Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care, 55(6), 758-764.
Kacmarek, R. M., & Bassi, G. L. (2019). Endotracheal tube management during mechanical ventilation: less is more!. Intensive care medicine, 45(11), 1632-1634.
Kinloch, D. (1999). Instillation of normal saline during endotracheal suctioning: effects on mixed venous oxygen saturation. American Journal of Critical Care, 8(4), 231-240.
Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice, step by step: searching for the evidence. The American Journal of Nursing, 110(5), 41-47.