Article:

Owen, E. B., Woods, C. R., O’Flynn, J. A., Boone, M. C., Calhoun, A. W., & Montgomery, V. L. (2016). A bedside decision tree for use of saline with endotracheal tube suctioning in children. Critical care nurse, 36(1), 1-10.

Brief Summary

The article sought to determine whether “saline instillation is associated with an increased risk of suctioning-related adverse events in patients 18 years old or younger requiring mechanical ventilation through an endotracheal tube for at least 48 hours when suctioned per protocol using a bedside decision tree” (Owen et al., 2016, p. 1). Intubated patients commonly have impaired ability when clearing airway secretions due to changes mucociliary function and respiratory mechanics (Owen et al., 2016). Such patients require suctioning to remove sputum to prevent ventilator associated infections and occlusion. The suctioning is done via the endotracheal tube after symptoms such as decreased tidal volume, acute respiratory distress, increased respiratory pressure or crackles on the trachea. As hypothesized, instilling saline before suctioning can help prevent encrustation, liquefy mucus and stimulate a strong cough thus making sure that retained pulmonary secretions are removed. Studies conducted with the aim of monitoring the effects and safety of saline instillation has revealed diverse results. Since the “American Thoracic Society” and “American Association for Respiratory Care” have both offered advice that using saline in suctioning for children and adults be avoided, bedside care givers use a decision tree to determine whether to use the saline (Owen et al., 2016).  The researcher thus sought to determine whether the use of saline in children escalation the risk of hostile events related to the suctioning.

Data and Results

The researchers conducted an observational study in “Kosair Children Hospital” in Kentucky. The study concentrated with children who met the inclusion criteria as described above.  A descriptive analysis was done on the data recorded during the observation. A total of 69 patients met the inclusion criteria (Owen et al., 2016). The results showed that there were adverse events in 586 suctioning passes and the events were high (39.3%) in the saline study group than in the dry suctioning study group (19.5%). The observed adverse events and their statistics in both groups are shown below.

Source: Owen et al., 2016, p.5

Article Conclusion

The researchers formulated their conclusion based on the study statistics and other earlier studies. One such study was done by Ridling et al. (2003) and noted a substantial decrease in the Spo₂ at one and two minutes after suctioning. However, there was no difference after ten minutes which suggested a limited effect.  Another study conducted by Caruso et al. (2009) showed that in adults, there are fewer cases of microbiologically proven VAP when saline is instilled well before suctioning. The researchers of this article thus concluded that the use of saline in endotracheal suctioning leads to adverse events. The researchers also suggested that maybe other methods such as physiotherapy and humidified gas can be used before administering saline (Owen et al., 2016).

Since the findings of the study suggest that if the saline branch of the decision tree is selected patients are at an amplified risk of adverse events, then the patient should be reassessed before choosing the saline arm to ensure that all other safe methods and procedures are not appropriate. The data from this study can also be interpreted to mean that saline should only be used as a last option. Further studies should be done to determine if the use of physiotherapy and humidified gas reduces the risk of the identified adverse events.

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