Saline Instillation-evidence-based practice

In healthcare, stakeholders examine every aspect through evidence-based practice (EBP) with the intent of ensuring optimal and consistent high-quality patient care. EBP plays a significant role both in clinical and in policy making with the objective of creating evidence-based clinical guidelines. Despite the existence of clinical guidelines, discrepancies between best evidence practice and actual practice continue to exist particularly in the intensive care unit (ICU). One shared practice is the syphoning of lung excretions of intubated patients. The objective of suctioning is to help in sustaining airway patency and avert snags associated with secretion withholding (Pozzi et al., 2015). Even though the available literature reveals that there is a significant variation of suction practices regardless of the age, there is a common practice utilized by almost all physicians, which is instillation of normal saline before suctioning. Though suctioning is a widely applied technique, researchers assert that the practice has adverse implications for patients and as such, the PICOT question of this study has consistently questioned its effectiveness: are mucolytic agents, humidification and adequate hydration an alternative aid in mucus and secretion removal to instillation of normal saline.

P– Use of normal saline that can lead to bacterial infections and related adverse implications

I -Use of mucolytic agents, humidification, and hydration

C– Efficacy of saline instillation compared with the response

O– Elimination of bacterial infections and related complications

Literature Review

Clinicians have firmly held on to instillation of saline because they learnt that saline disintegrates secretions and aids in the removal of tenacious discharges. Halma and Krisko-Hagel (2008) conducted a clinical review to summarize present evidence on the efficacy of saline instillation on sputum yielding. Also, the review sort to determine the adverse physiological and psychological implications associated with the practice. The study revealed that there is an increased volume of sputum retrieval though it has no clinical significance. Secondly, the review indicated that previous studies agree that patients who undergo instillation suffer from decreased desaturation and oxygenation that deteriorate after suctioning and as such, the practice impairs the gas exchange evidenced through desaturation. Moreover, the subjects showed increased levels of anxiety, pain, and dyspnoea after suction and linked the problem to decreased pulmonary compliance in particular among the elderly (Halm, & Krisko-Hagel, 2008). Finally, the review combines researchers who agree on increased risks of infection due to bacterial colonies dislodgement. Halma cites an article that reveals dislodgment of colonies up to more than five times. Therefore, collectively, the reports reviewed and summarized by Halm and Krisko-Hagel (2008) provide evidence about the adversarial physiological implications of instillation of normal saline and consequently providing support against routine use of normal saline with suctioning.

Caparros and Forbes, (2015) agree that patients on mechanical ventilations are highly vulnerable to complications such, infections, and hemodynamic adjustments. Without evidence and guidelines to support the routine application of NSI and creation of artificial airways, the risks of possible complications increase particularly to patients who are in unstable medical conditions. Caparros and Forbes (2015) conclude that there is a need for alternative methods of mucus secretion removal because continued uses of NSI can result in complications such as hemodynamic adjustments and VAP.  Leddy and Wilkinson (2015) affirms Caparros and Forbes’s finding by pointing out that besides detrimental effects to patients, there are no clear guidelines stating conditions favouring application of NSI in the retrieval of mucus secretion. Therefore, due to the absence of lucidity concerning preeminent practice will underwrite to inept and conceivably hazardous procedures that threaten the excellence of care and potentially elevate adverse patient consequences.

Even though the application of NSI is widely used, there exist different secretion management methods for mechanically ventilated patients regardless of age. Some of the standard methods include humidification and airway suctioning. Mechanically ventilating patients pose a risk of retaining secretions from numerous of sources (Branson, 2007).  Endotracheal intubation impairs the mucociliary escalator and inclines the patient to the infection that increases the capacity and tenacity of mucus. In addition, relative immobility of mechanically ventilated patients confined to bed can lead to impaired cough, retained secretion, atelectasis, and fluid restriction that can contribute to thickened secretion. Therefore, it is essential for physicians to use evidence based best practices in the management of mucus secretion to prevent patients from adverse complications associated with current practices (Ayhan et al., 2015). One of the most efficient flow control methods is humidification that involves heating and humidifying the inspired gas. There are two approaches in humidification, heated humidification, and moisture exchange humidification (Branson, 2007). Heated humidification includes increasing gas temperatures from the humidifier chamber to the patient. Humidification secretion management method is an evidence-based practice that has minimal side effects as compared to the standard saline instillation that increases risks of infection and oxygen desaturation among patients.

Humidification is an effective evidence based secretion management approach necessary for all healthcare providers, and as such, it is essential for the searcher to transform the findings into practice. First, there is a need to break down the research’s conclusions into simple terms and language for the target group to find it easier to use. Transformation of research findings into practice depends on communication between the researcher and implementers of the conclusions and recommendations (Evans et al., 2014). Thus, I intend to use available communication strategies that include message tailoring to inform and influence my fellow nurses on the need to use alternative secretion management methods particularly humidification. Secondly, in the dissemination of the information, I would target nurses attending to mechanically ventilated patients, make them aware of adverse implications of NSI, introduce them to humidification method, and avail necessary material to support the process. Through effective communication, information dissemination and implementation plan, it is easier to provide the research findings to the decision makers at the facility and translating the evidence to counter opposition.

Project Summary

Due to vicissitudes in respiratory procedures and mucociliary function, intubated patients experience impaired capabilities while clearing airway secretions. Patients often depend on syphoning through their endotracheal tube to retrieve sputum with the intent of preventing ventilator associated infections and occlusion. Specific suggestions for suctioning the endotracheal tube, oxygen desaturation, acute respiratory distress and elevated peak inspiratory pressure. During secretion management, nurses encounter dense and tenacious mucus during the suction process. To manage these exudations, nurses use normal saline instillation (NSI) to lubricate the catheter, deliquesce and soften secretions by stimulating coughing (Spears, Cook & Garcia, 2012). However, use of NSI has attracted criticism from different scholars due to lack of evidence supporting the practice and its adverse physiological and psychological implications. Therefore, utilization of this procedure is not recommended, and as such, I applied a PICOT research model to study the asserted implications and formulate an alternative practice particularly in paediatric intensive care patients. During the study, the intervention is an application of the humidification, enhancing hydration and use of mucolytic agents in mucus suction process among paediatric patients.

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