Research ArticleClinical Practice Guidelines Show
Respiratory Care February 2022, 67 (2) 258-271; DOI: https://doi.org/10.4187/respcare.09548 AbstractArtificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial airway is a common procedure performed worldwide on a daily basis. As such, it is imperative that clinicians are familiar with the most-effective and efficient methods to perform the procedure. We conducted a systematic review to assist in the development of evidence-based recommendations that pertain to the care of patients with artificial airways. From our systematic review, we developed guidelines and recommendations that addressed questions related to the indications, complications, timing, duration, and methods of artificial airway suctioning. By using a modified version of the RAND/UCLA Appropriateness Method, the following recommendations for suctioning were developed for neonatal, pediatric, and adult patients with an artificial airway: (1) breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, and an acute increase in airway resistance may be an indicator for suctioning in neonates; (2) as-needed only, rather than scheduled, suctioning is sufficient for neonatal and pediatric patients; (3) both closed and open suction systems may be used to safely and effectively remove secretions from the artificial airway of adult patients; (4) preoxygenation should be performed before suctioning in pediatric and adult patients; (5) the use of normal saline solution should generally be avoided during suctioning; (6) during open suctioning, sterile technique should be used; (7) suction catheters should occlude < 70% of the endotracheal tube lumen in neonates and < 50% in pediatric and adult patients, and suction pressure should be kept below –120 mm Hg in neonatal and pediatric patients and –200 mm Hg in adult patients; (8) suction should be applied for a maximum of 15 s per suctioning procedure; (9) deep suctioning should only be used when shallow suctioning is ineffective; (10) routine bronchoscopy for secretion removal is not recommended; and (11) devices used to clear endotracheal tubes may be used when airway resistance is increased due to secretion accumulation IntroductionSecretion management is vital to effective gas exchange, especially in the patient with an artificial airway. It is incumbent on the health-care team to ensure safe and effective secretion removal in patients with artificial airways. Artificial airway suctioning is a common procedure performed daily along the care continuum worldwide. This procedure includes patient preparation, application of suction via the introduced catheter, and post-procedure care.1 Although generally considered safe, the application of artificial airway suctioning through either an endotracheal tube (ETT) or tracheostomy tube is not without potential complications. Transient adverse events such as oxygen desaturation, bleeding, hemodynamic changes, and alterations in heart rate have been reported.2-4 Poor airway suctioning practices may lead to longer-term consequences, such as damage to the airway mucosa5 and hospital-acquired infections.3 A previous clinical practice guideline (CPG) published by the American Association for Respiratory Care (AARC) in 2010 focused on this procedure.1 The 2010 AARC clinical practice guideline generated 10 recommendations for safe endotracheal suctioning of patients on mechanical ventilation and with artificial airways that were informed by a detailed literature review. Methods of suctioning the artificial airway have varied over time, and the scientific evidence that drives current clinical practices has evolved. As such, we conducted a systematic review of the literature to update, when appropriate, recommendations for effective artificial airway secretion clearance. The CPG developed from this systematic review focused on the following questions relevant to artificial airway suctioning of neonatal, pediatric, and adult patients:
Committee CompositionA committee was selected by the AARC leadership based on their known experience related to the topic, their interest in participating in the project, and their commitment to the process details. The committee first met face to face, where they were introduced to the process of developing CPG. At that time, the committee selected a chair and wrote a first draft of PICO (patient, intervention, comparison, outcome) questions. Subsequent meetings occurred as needed by conference call. Frequent e-mail communications occurred among the committee members and the AARC staff. The committee members received no remuneration for their participation in the process, although their expenses for the face-to-face meeting were covered by the AARC. Search StrategyA literature search was conducted by using the PubMed, CINAHL via EBSCOhost, and the Scopus.com databases on studies of artificial airway suctioning in neonatal, pediatric, and adult subjects. The search strategies used a combination of controlled vocabulary (ie, Medical Subject Headings and CINAHL headings) and keyword variations that related to artificial airway suctioning indications, complications, techniques, and outcomes. The searches were limited to English language studies on human populations. The searches were also designed to filter out citations indexed as commentaries, editorials, interviews, news, or reviews. No date restrictions were applied to the searches. The complete search strategy executed in each database is available in an online supplement (see the supplementary materials at http://www.rcjournal.com). Duplicate citations were identified and removed by using EndNote X7 citation management software (Clarivate Analytics, Philadelphia, Pennsylvania). Study SelectionAt least two reviewers (TCB, JBS, SLS) independently assessed study eligibility in the Covidence systematic review software (Melbourne, Australia). Inclusion criteria used to assess eligibility were the following: (1) artificial airway (including laryngectomy and tracheal T tubes); (2) tube scraping devices; (3) neonatal, pediatric, and adult populations; and (4) English language. The exclusion criteria used were the following: (1) natural airway suctioning, (2) case study, (3) bench study, (4) not empirical research (eg, theory or opinion articles), (5) non-English language studies, and (6) animal studies. Development of RecommendationsIt is recognized that a process is necessary to combine the best available evidence with the collective experience of the committee members. To achieve this, a modification of the RAND/UCLA appropriateness method was used.6 The literature was collapsed into evidence tables according to the PICO question (Supplementary Table 1 [see the supplementary materials at http://rc.rcjournal.com]). Individual panel members were assigned the task of writing a systematic review of the topic, drafting one or more recommendations, and suggesting the level of evidence supporting the recommendation as follows:
Committee members reviewed the first draft of evidence tables, systematic reviews, recommendations, and evidence levels. Each committee member rated each recommendation by using a Likert scale of 1 to 9, with 1 meaning that expected harms greatly outweigh the expected benefits and 9 meaning that expected benefits greatly outweigh the expected harms. The ratings were returned to the committee chair. The first ratings were done with no interaction among the committee members. A conference call was convened, during which time the individual committee ratings were discussed. Particular attention was given to any outlier scores and the justification. Recommendations and evidence levels were revised with input from the committee members. After discussing each PICO question, committee members again rated each recommendation. The final median and range of committee members’ scores are reported. Strong agreement required that all the committee members rank the recommendation ≥ 7, weak agreement meant that one or more committee members ranked the recommendation < 7, but the median vote was at least 7. For recommendations with weak agreement, the percentage of committee members who rated ≥ 7 was calculated and reported after each weak recommendation. The process flow that the panel used to rate the appropriateness and quality of the literature selected through the search process is illustrated in Figure 1. Drafts of the report were distributed among the committee members in several iterations. When all the committee members were satisfied, the document was submitted for publication. The report was subjected to peer review before final publication. Assessment and RecommendationsThe search strategies retrieved a total of 1,667 articles. After the removal of duplicates, 1,134 articles remained for screening, of which 831 were excluded at the title and abstract level. Of the remaining 303 articles, 219 were excluded after full-text review against the inclusion and exclusion criteria (Fig. 2). Unless otherwise stated, recommendations apply to neonatal, pediatric, and adult patient populations.
Indications for and Complications of Artificial Airway SuctioningRetained tracheobronchial secretions are common in patients with an artificial airway. It is important for the caregiver to recognize when suctioning is warranted as well as the potential complications and hazards. A review of the literature yielded 27 relevant studies.2,4,7-31 Indications.Five
studies7-11 focused on the indications for ETT suctioning. One study in the neonatal population found a statistically significant increase in airway resistance (Raw) (P < .01) and, therefore, recommended monitoring Raw to determine the need for
suctioning.7 One study in pediatric patients showed that ETT suctioning in subjects with respiratory crackles noted in the operating room and postanesthesia care unit resulted in improved In the adult population, Guglielminotti et al9 found that a sawtooth pattern on the ventilator flow waveform, visible secretions in the ETT, and respiratory sounds heard when auscultating over the trachea were good indicators of the need for suctioning (P < .001). Results from Sole et al10 corroborated these indicators, with the exception of visible secretions (P = .5). The volume of secretions (≥ 0.5 mL) retrieved during suctioning was associated with several of the previous listed indicators but was not statistically significant (P = .17), although there was significant improvement in all indicators after suctioning (P < .001). Lucchini et al11 found that the use of an acoustic secretion detector served as a better indication of secretions in the airway and the need for artificial airway suctioning than the indicators in the previous studies and resulted in significantly fewer suctioning adverse events (P < .001). Complications.Twenty-two studies2,4,12-31 focused on
the complications associated with artificial airway suctioning. In the adult patient population, Beuret et al12 showed that the ability of the ETT cuff to seal the airway was not significantly affected by suctioning (P = .06). In neonatal subjects, Durand et al13 showed that ETT
suctioning significantly affected heart rate, mean arterial pressure, intracranial pressure (ICP), and cerebral perfusion pressure (P < .05). In a study by Fanconi et al,14 ICP was significantly lower (P < .001) when neuromuscular blockers were given before suctioning. All other physiologic responses were not significantly affected by suctioning. Simbruner et al15 reported that transcutaneous In the pediatric population, Morrow et al18
found that changes in lung compliance, expired tidal volume, breathing frequency, and minute ventilation were significantly different after than before artificial airway suctioning (P < .05). Scoble et al19 found that reusing a suction catheter for 24 h did not affect the incidence of pneumonia compared with when using a new catheter with each artificial airway suctioning event
(P > .05). Boothroyd et al20 found that using graduated suction catheters and controlled vacuum pressures resulted in a significantly lower incidence of right upper lobe collapse compared with standard practice (P < .05). Fisher et al21 found that ICP increases in
children with brain injury were due to tracheal stimulation from artificial airway suctioning rather than increased In an adult population, Jongerden et
al22 found significant increases in heart rate and mean arterial pressure (P < .01) but not A study conducted by Guglielminotti et al28 showed that artificial airway
suctioning caused a significant increase in Raw (P < .01) and intrinsic PEEP (P < .05). A study by Van de Leur et al29 found that artificial airway suctioning when using saline solution lavage compared with minimally invasive suction with no lavage produced significant increases in oxygen desaturation (P = .001), cardiac arrhythmias (P =
.002), systolic blood pressure (P = .003), blood in respiratory secretions (P = .001), and subject recollection of the suctioning event (P = .001). In a separate study, Van de Leur et al30 found these same adverse effects, excluding subject recollection, but found no significant difference (P > .05) in duration of intubation, mortality, ICU LOS, or
infection when using invasive compared with minimally invasive artificial airway suctioning techniques. Seymour et al4 reported that minute ventilation, mean arterial pressure, heart rate, and rapid shallow breathing index were significantly increased after ETT suctioning (P < .05). Recovery time ranged from 1 to 7 min. Walsh et
al31 found the following changes after open ETT suctioning preceded by hyperinflation with 100% oxygen was performed: Based on the available evidence, breath sounds, visible secretions in the artificial airway, and sawtooth pattern on the ventilator flow waveform are the best indicators of the need for artificial airway suctioning in the adult and pediatric population (evidence level B, all the committee members rated the appropriateness score at 8). An acute increase in Raw may be an indicator for the need for artificial airway suctioning in neonates (evidence level B, median appropriateness score 7, range 7–8). Physiologic responses to artificial airway suctioning such as increased heart rate, mean arterial pressure, ICP, cardiac arrythmias, and oxygen desaturation are among the potential complications in all patient populations. Significant decreases in lung volume were noted post-suctioning as well as decreases in cerebral blood flow velocity in neonates. Mitigation strategies such as adequate sedation, preoxygenation, and suctioning only when indicated may reduce the incidence and severity of these complications (evidence level B; median appropriateness score 7.6, range 7– 9). Routine Versus As-Needed Only Artificial Airway SuctioningThe frequency at which to perform artificial airway suctioning remains controversial. A review of the literature yielded 2 studies32,33 related to frequency of suctioning: one study each in neonatal and pediatric patient populations. In a randomized, controlled trial of 180 very low birthweight neonates randomized to artificial airway suctioning every 4 h or every 8 h, plus as needed, Cordero et al32 found no difference in mechanical ventilation days, hospital LOS, bloodstream infections, ventilator-associated pneumonia (VAP), or adverse events between the groups. In a randomized controlled trial of 90 pediatric subjects randomized to artificial airway suctioning either every 2 h or as-needed only, Lema-Zuluaga et al33 showed no difference in VAP, mechanical ventilation days, ICU LOS, or mortality between the 2 groups. No studies were found that addressed suctioning frequency in the adult patient population. Based on the evidence presented in these studies, as-needed suctioning is just as effective as routine suctioning and does not increase morbidity or mortality in neonatal and pediatric populations. The current evidence supports the previous recommendation advanced in the 2010 AARC CPG1 to perform airway suctioning of the artificial airway only as needed (evidence level B, all the committee members rated the appropriateness score at 8). Open Versus Closed System Artificial Airway SuctioningSince the development of closed suction system devices in the early 1990s, researchers have sought to compare the resultant clinical outcomes with those of the traditional open suction system. This systematic review included 28 studies22,27,34-59 focused on relevant clinical outcomes that compared closed suction system with the open suction system. The majority of the studies22,27,36,39-46,48,49,51,52 included physiologic outcomes and the development of hospital-acquired infections. Two studies34,35 that compared the closed suction system with the open suction system focused on secretion management. Witmer et al34 studied adult subjects who were intubated. They compared the quantity of secretions removed during artificial airway suctioning and found that secretions removed via closed suction system (median 1.7 g) and the quantity removed via the open suction system (median 1.9 g) (P = .88) were not statistically different.34 Lasocki et al35 studied the effects of the closed suction system and the open suction system on secretion removal in 9 adult subjects who were intubated. They discovered that the mean aspirate mass was larger with the open suction system (mean 3.2 g) than with the closed suction system (mean 0.6 g) (P = .03).35 The small sample size of this latter study raises concern about the generalizability of this finding. Several
studies22,27,36,39-46,48,49,51,52 evaluated changes in physiologic parameters in response to the closed suction system and the open suction system.
Studies that enrolled adult subjects focused on parameters such as heart rate, breathing frequency, Several pediatric and neonatal studies focused on physiologic parameters as well.45-52 Changes after suctioning with the closed suction system or the open suction system were similar to those found in the adult studies and likely transient. Evans et al48 found a lower incidence of physiologic disturbances (heart rate, Most of the outcome-oriented studies that compared open with closed suctioning focused on rates of bacterial colonization and VAP/ventilator associated events (VAE). The majority of these studies were in adult subjects, although a few studies included neonatal and pediatric subjects.37,42,50,53-59 Cordero et al53 compared infection rates with the use of the closed suction system and the open suction system in neonates. They found that the difference in rates of airway colonization and nosocomial pneumonia were not statistically different between the 2 methods.53 Morrow et al50 performed an 8-month study that compared various outcomes of the closed suction system versus the open suction system in pediatric subjects who were intubated and who received mechanical ventilation for > 24 h. The rate of VAP was not statistically different between the 2 methods (P = .6).50 Almost all of the studies that focused on adults who were intubated37,42,53-59 found no statistically significant differences in VAP/ventilator associated event rates, colonization rates, transmission rates, or rates of hospital-acquired infection. One study56 did find a difference in colonization rate between the closed suction system (67%) and the open suction system (39%) (P < .02) but that did not translate into an increased number of infections. One study looked at the rates of mucus plugging between the 2 suction methods. Åkerman et al37 found more occurrences of ETT occlusion with the closed suction system but not at a statistically significant level. Of the 28 included studies for this research question, 5 studied the impact of the closed suction system and the open suction system on outcomes related to mortality, hospital and ICU LOS, and time spent on mechanical ventilation.37,42,50,55,58 Four of the studies included adult subjects who were intubated.37,42,55,58 None of these studies showed a statistical difference between the closed suction system and the open suction system on mortality, hospital LOS, ICU LOS, or duration of mechanical ventilation. Morrow et al,50 as previously discussed, found the same results: no statistical difference in mortality, hospital LOS, ICU LOS, or duration of mechanical ventilation. Based on the quantity and quality of the included evidence, either the closed suction system or the open suction system can be used safely and effectively to remove secretions from the adult patient with an artificial airway. Although the differences in outcomes between the closed suction system and the open suction system in pediatric and neonatal patients are minimal, using a closed suction system with this population is logical. The clinician is urged to use appropriate infection control measures and safety precautions to avoid unnecessary adverse reactions, such as physiologic changes and damage to the airway mucosa (evidence level B, median appropriateness score 8.3, range 7–9). Preprocedure Oxygenation and Hyperoxygenation for Artificial Airway SuctioningArtificial airway suctioning may cause a clinically important decrease in oxygenation in some patients. A review of the available literature on hyperoxygenation before suctioning yielded 6
studies39,60-64 with 3 of these being published in the
1990s.60-62 In a randomized crossover trial with 25 pediatric subjects on mechanical ventilation, Kerem et al60 found that preoxygenation with 100% oxygen prevented hypoxemia during suctioning, whereas
hyperinflation by using baseline Although the evidence supports preoxygenation, it seems that 100% oxygen is not required for all patients. The 2010 AARC
CPG1 recommended using 100% oxygen to preoxygenate adult and pediatric patients before suctioning either by manually adjusting the oxygen or by using the temporary preoxygenation program on the ventilator. Manual ventilation to provide preoxygenation was not recommended. There is currently available evidence that these recommendations are appropriate, although preoxygenation with an
Normal Saline Solution Lavage for Artificial Airway SuctioningThere has been considerable research on the effects of using normal saline solution during artificial airway suctioning. The theoretical advantages of using normal saline solution are loosening secretions and increasing the volume of secretions removed during
suctioning.1 A review of the literature yielded 8 studies that focused on the impact of normal saline solution use during artificial airway suctioning on oxygenation.65-72 Results of 7 of these studies
suggest that normal saline solution may negatively affect oxygenation. These studies were small, but indicated that measures such as McKinley et al74 performed a randomized trial to evaluate the hours of intubation and invasive mechanical ventilation in pediatric subjects. They found that using no saline solution was as effective as using quarter-normal or normal saline solution.74 In a prospective observational study, Owen et al71 noted more adverse events in pediatric subjects who received normal saline solution during suctioning events. A randomized clinical trial by Caruso et al75 noted a decrease in microbiologically proven VAP with the use of normal saline solution during artificial airway suctioning. Although this finding is interesting, it has not been corroborated in another study to this point. The 2010 AARC CPG1 recommended against the routine use of normal saline solution. Since that guideline, no new evidence convincingly impacts that recommendation. Normal saline solution instillation, if ever performed, should be done so sparingly and with consideration of the potential for adverse events, such as a decrease in oxygen saturation, excessive coughing, bronchospasm, tachycardia, dyspnea, an increase in ICP, and the dislodgement of bacterial biofilm on the inside of the artificial airway. Based on the currently available evidence, it seems that the routine use of normal saline solution is unnecessary during artificial airway suctioning (evidence level B, median appropriateness score 9, range 8–9). Clean Versus Sterile Artificial Airway Suctioning ProcedureAs previously discussed, both the open suction system and closed suction system procedures can be used safely and effectively to remove secretions from an artificial airway. When performing an open artificial airway suctioning procedure, the clinician must maintain an environment that protects both the patient and the clinician from pathogens. However, questions arise with regard to whether the procedure should be a clean procedure, one that is free from visually obvious contamination, or a sterile procedure, one that is free from bacteria or microorganisms. Some clinicians argue that the sterility of the clinician is irrelevant because the open suction catheter will pass through a non-sterile field, and subsequent passes of the catheter will no longer be sterile.76 This systematic review of the literature found no studies focused on patient outcomes when comparing the clean versus sterile open suctioning procedure. Past CPG1 have evaluated this research question. The Centers for Disease Control and Prevention 2003 Guidelines for Preventing Health-Care Associated Pneumonia77 recognized that tracheal suctioning does increase the opportunity for cross-contamination and that the risk of cross-contamination can be reduced by using an aseptic (sterile) technique. However, the committee was unable to make a recommendation for using a sterile rather than a clean technique when performing endotracheal suctioning. The 2010 AARC CPG1 was also unable to make a recommendation, although it did state that the clinician is encouraged to use the sterile technique throughout the suctioning procedure. There is a gap in the literature with regard to clinically relevant outcome differences between clean and sterile technique for artificial airway suctioning. However, it is potentially unethical to recommend that further research be conducted to address this gap because the potential for harm with a less-than-sterile environment is a distinct possibility. Therefore, based on committee experience, it is recommended that the clinician use a sterile procedure, when possible, for open suctioning events to protect the patient from potential cross-contamination (evidence level C, all the committee members rated the appropriateness score at 7). At a minimum, in addition to performing hand hygiene on entering and leaving a patient’s room or area, the clinician should perform hand hygiene immediately before performing open suctioning to minimize the risk of introducing any new pathogens into the artificial airway. Suction Catheter Size and Applied Vacuum PressureResearch
that evaluated the safety and effectiveness of various catheter sizes and applied vacuum pressures is scarce. In a within-subjects repeated-measures study, Javadi et al78 evaluated the impact of different sizes of suction catheters on various outcomes such as heart rate, blood pressure,
Yousefi et al79 conducted a randomized trial that evaluated the impact of 2 levels of applied vacuum pressure (–100 and –200 mm Hg) on physiologic indices in adult subjects. They noted that
Based on the available evidence, it seems that various suction catheter sizes and vacuum pressures can cause physiologic alterations. That said, the optimal suction catheter outer diameter size to artificial airway inner diameter size ratio is not known at this time. The optimal applied vacuum pressure that is both safe and effective at clearing secretions is also not known. The 2010 AARC CPG1 recommended that suction catheters should occlude < 50% of the ETT lumen in pediatric and adult patients, and < 70% in neonates. No new evidence convincingly refutes this recommendation (evidence level C, all the committee members rated the appropriateness score at 7). There was no formal recommendation on applied vacuum pressure in the previous guideline due to the overall lack of data to support a recommendation.1 There is minimal evidence that suction pressures should be kept below –200 mm Hg in adults and between –80 and –100 mm Hg in neonates (evidence level C, all the committee members rated the appropriateness score at 7). Efforts to set the suction pressure as low as possible to effectively clear secretions should be made (evidence level C, all committee members rated the appropriateness score at 9). Duration of the Artificial Airway Suctioning ProcedureLimiting the duration of each session is an intuitive strategy to mitigate the potential complications and/or hazards of artificial airway suctioning. This limitation could apply to either the amount of time the suction catheter is introduced into the artificial airway or the amount of time that suction is applied. Unfortunately, this review of the literature did not find studies that compared patient outcomes with varying lengths of time the catheter is introduced into the airway and/or suction is applied. Most sources, predominantly previous CPG,1 editorials,76,81 and textbook chapters,82 recommend limiting the duration of the procedure to ≤15 s. The committee’s experience is commensurate with these sources, and the committee recommends keeping each suctioning event as brief as possible and no longer than 15 s (evidence level C, all the committee members rated the appropriateness score at 7). Shallow Versus Deep Artificial Airway Suctioning ProcedureResearch that evaluated the safety and effectiveness of shallow versus deep artificial airway suctioning techniques is limited. Two
methodologically similar articles83,84 were published that compared the effects of shallow and deep ETT suctioning on physiologic indices. Abbasinia et al83 evaluated the 2 techniques on changes to
breathing frequency and In a parallel randomized controlled trial, Shamali et al85 compared what they called routine ETT suctioning with a minimally invasive ETT suctioning technique. The routine ETT suctioning technique consisted of manual hyperinflation and preoxygenation for 1 min, and instillation of 8 mL of sterile saline
solution.85 The suction catheter was advanced down the ETT until resistance was met and withdrawn 1 cm; suctioning was then performed by using a vacuum pressure of –100 to –200 mm Hg for a maximum of 10 s.85 The minimally invasive ETT suctioning technique consisted of preoxygenation by the
mechanical ventilator for 1 min. The suction catheter was advanced to the distal end of the ETT; suctioning was then performed by using a vacuum pressure of –80 to –120 mm Hg for a maximum of 10 s.85 The study investigators noted that the minimally invasive ETT suctioning group had statistically fewer alterations in systolic blood pressure, diastolic blood pressure, mean arterial pressure, and
Based on the available evidence, it seems that both shallow and deep suctioning techniques cause similar alterations in physiologic indices. Although deep suctioning may result in less-frequent suctioning events, it may be associated with airway trauma. The 2010 AARC CPG1 recommended the shallow suction technique, citing no definitive benefit of deep suctioning. Since that guideline, no new evidence convincingly impacts this recommendation. It seems that the shallow suctioning technique should be used routinely to avoid potential airway trauma (evidence level B, median appropriateness score 7.7, range 7 - 8). Deep suctioning should generally be used only when shallow suctioning is ineffective with consideration of the potential for airway trauma and the negative impact on physiologic indices (evidence level B, median appropriateness score 7.2, range 7–8). Bronchoscopy Versus Artificial Airway SuctioningBronchoscopy has historically been used for diagnostic purposes or to obtain secretions from specific areas of the lung but not for routine use to clear secretions. A review of the literature yielded 1 study related to routine bronchoscopy use.87 Qiao et al87 conducted a trial in which 73 adult subjects with a COPD exacerbation were randomized to either routine artificial airway suctioning by using bronchoscopy in conjunction with conventional artificial airway suctioning or conventional artificial airway suctioning alone. The investigators found that there were significantly better outcomes in terms of appearance of the pulmonary infection control window, days of invasive mechanical ventilation, total days of mechanical ventilation, hospital LOS, weaning success, incidence of VAP, and mortality with routine bronchoscopy use in conjunction with conventional artificial airway suctioning. The 2010 AARC CPG1 did not address bronchoscopy use for routine secretion removal because only 1 study87 relevant to this topic has been published to date and that study had limited scope, this committee felt that the routine use of bronchoscopy for secretion removal cannot be recommended (evidence level C, all the committee members rated the appropriateness score at 9). Artificial Airway (Tube) Scraping DevicesVarious devices have been developed for the purpose of clearing ETTs of secretions and biofilm that might increase Raw and peak inspiratory pressure, and ultimately result in complete airway obstruction. These devices are used in addition to standard suction catheters to maintain the inner diameter of ETTs. A review of the literature resulted in 4 studies88-91 that assessed changes in Raw when these devices were used in adult subjects. In separate studies of subjects who required mechanical ventilation, Conti et al88 and Scott et al89 noted significant reductions in Raw after the use of experimental obstruction removal devices. In a laboratory study, Adi et al90 found that a device designed to clear ETTs of secretions was able to restore inspiratory Raw of ETTs removed from subjects to levels comparable with that of unused ETTs. In another ex vivo study, by Waters et al,91 an ETT cleaning device was effective at reducing luminal biofilm secretions and improving pressure drop (an indicator of Raw) in size 7.5 mm and 8.0 mm ETTs. Of note, the device was not effective at clearing secretions to the level of unused ETTs. Two randomized controlled trials92,93 found these devices to be effective at reducing mucus accumulation, overall ETT occlusion, maximal ETT occlusion, and biofilm thickness when compared with standard blind suctioning alone. However, these studies did not show improvement in outcomes such as mechanical ventilation days, days in ICU, or days of intubation.92,93 Evidence supports the use of devices used to clear ETTs when an increase in Raw and peak inspiratory pressure due to secretion accumulation is suspected (evidence level B, median appropriateness score 8.5, range 8–9). It is not known if these devices should be used intermittently or as part of routine airway management. SummaryThe results of this systematic review are summarized in Table 1. Although several references were included in this systematic review, the quality of the evidence was low. This was also true for all PICO questions, which necessitated that all recommendations be made based on low-level evidence and/or expert opinion. It is imperative to emphasize that, whereas recommendations made in this CPG were based on an exhaustive review of the literature, anecdotal evidence and the clinical experience of the committee members also played a role in the final recommendations. The numerous variables associated with artificial airway suctioning (type of artificial airway, heterogeneous patient population, clinical setting, and available resources), inconsistent experimental designs of the studies reviewed, and overall low quality of the available evidence to date make it difficult to isolate a definitive set of recommendations at this time based exclusively on the literature. The recommendations made by the committee members are intended to support clinicians in their efforts to provide a safe and effective artificial airway suctioning practice. Many of the recommendations informed by this literature review were in agreement with recommendations from the 2010 AARC CPG.1 Table 1. Summary of Recommendations for Each PICO Question The major limitation of this CPG is the overall lack of high-quality evidence to drive clinical recommendations. That said, it should be noted that other review articles agree with our recommendations on the timing and frequency of artificial airway suctioning, use of closed suction systems, preoxygenation before suctioning, avoidance of normal saline solution instillation during the suctioning procedure, use of the sterile procedure for open suction events, suction catheter size and vacuum pressure settings, duration of suction procedure,2 use of a shallow suctioning technique, and the use of tube scraping devices to remove accumulated biofilm and secretions in the artificial airway to reduce Raw and peak inspiratory pressure.82,94-104 A review by Dodek et al105reached the same conclusion as we did on the use of closed suction systems over open suction systems but did so based solely on economic reasons. Day et al98 recommended a deep suctioning technique, despite citing the evidence of greater alterations in vital signs with this method. Artificial airway suctioning remains an integral component of proper artificial airway management. The suctioning procedure is associated with well-known risks and complications that must be weighed against the potential benefit for the patient. Although this systematic review yielded more evidence than the 2010 AARC CPG1 on artificial airway suctioning to support recommendations, the strength of the evidence remains weak and did not warrant major changes to the previous recommendations. More robust, well-designed research studies are needed in this area of respiratory care to provide caregivers with information to assist in safe, appropriate suctioning of the artificial airway. Footnotes
References
What are potential complications associated with suctioning?Complications. Suctioning can stimulate the vagal nerve, predisposing the patient to bradycardia and hypoxia.. Hypoxia can be profound from occlusion, interruption of oxygen supply, and prolonged suctioning.. Mucosal trauma, physical injuries, and bleeding can result from blunt or penetrating trauma.. What is the most common complication of suctioning?Bradycardia. A slow heart rate, known as bradycardia, is one of the most common suctioning complications, likely because suctioning stimulates the vagus nerve. This increases the risk of fainting and loss of consciousness. In patients in cardiac distress, it can elevate the risk of severe cardiovascular complications.
What is the most severe complication of suctioning?Suctioning may result in serious complications, such as hypoxemia, arrhythmias, hypertension or hypotension, increased ICP, bronchospasms, trauma to the mucosa, pain, and anxiety. Evidence shows that ICP can take up to 10 minutes to return to baseline levels after suctioning.
Which of the following is a complication to suctioning the patient airway?In some patients, suctioning may also stimulate the vagus nerve, triggering hypoxia and bradycardia. Suctioning itself can also cause hypoxia. The suction tube can be a form of airway obstruction.
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What is a potential complication of safety concern when suctioning a patient?
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