Suctioning Techniques and Airway Management Practices: Pilot Study and Instrument Evaluation

The authors compare institutional policies and procedures related to closed suctioning and airway management, and describe and compare practices of registered nurses and respiratory therapists concerning closed-system suctioning and airway management of intubated patients. Included is a look at the use of oral care and instillation of isotonic sodium chloride solution.This pilot study was done to gather preliminary data and refine instruments and procedures for a large multisite study of Suctioning Techniques and Airway Management Practices (STAMP). The purposes of the STAMP study are to compare institutional policies and procedures related to closed suctioning and airway management, and to describe and compare practices of registered nurses and respiratory therapists concerning closed-system suctioning and airway management of intubated patients.Ventilator-associated pneumonia (VAP) is a common infection in critical care units. Numerous risk factors for this infection have been identified. It commonly occurs as a result of aspiration of bacteria that colonize the oropharynx.1 Dental plaque, invasive devices, and respiratory care equipment can lead to oropharyngeal colonization, microaspiration of secretions, and VAP.1–3 Duration of intubation and mechanical ventilation are risks for VAP.4,5 Thus, suctioning and airway management practices have a potential effect on this type of pneumonia.6A recent survey7 showed that 80% of respondents in the mid-Atlantic area most often use closed-system suctioning devices for suctioning patients’ airways. The devices are designed to prevent suction-induced hypoxemia, especially in patients who require high levels of positive end-expiratory pressure to maintain oxygenation. Institutions that use closed-system suctioning report no change, or a decrease, in VAP when the devices are used.8–14 However, practices have changed with the advent of these devices. The devices are designed to suction only the lower part of the airway. Oral suctioning is no longer an integral part of the endotracheal suctioning procedure, and some equipment is used for both closed-system and oral suctioning. The changes in practice may result in less use of oral suctioning and in cross-contamination of equipment.Because microaspiration of secretions is a risk factor for VAP, assessment of practices related to oral suctioning, oral care, and management of endotracheal tubes is important. Published guidelines provide little information related to use of closed-system suctioning and airway management, and the guidelines may not reflect current practices.1,15 Knowledge of practice may assist in determining interventions to improve patients’ outcomes. Comparing practices of nurses and respiratory therapists may also help ascertain differences in practices and aid in establishing collaborative policies and procedures.A descriptive, comparative survey design was used for the pilot study. Ethical approval was obtained from the universities and at each site. All data were coded to maintain confidentiality.Four sites in the southeastern United States were recruited to participate by convenience sampling. The settings were adult critical care units at the sites that used closed-system suctioning devices on more than 50% of the patients who required mechanical ventilation. Coordinators at each site facilitated study approval, completed the institutional survey, and distributed and collected surveys to critical care nurses and respiratory therapists who regularly used closed-system suctioning devices to suction the airways of adult patients.The following two instruments were used to collect data: (1) STAMP: Institutional Policies and Data, and (2) STAMP: Individual Survey. Before administration of the instruments, content validity for both instruments was established by a panel of 3 persons with nursing, respiratory care, and/or survey method expertise. The first tool consisted of 45 questions related to suctioning and airway management practices, products for suctioning and oral care, and VAP data. The individual survey consisted of 42 items: 9 demographic questions and 33 questions related to practices.The 4 institutions ranged in size from 100 to 900 beds. The individual survey was completed by 132 staff members: 95 nurses (72%) and 37 respiratory therapists (28%). One third of the surveys distributed were completed. Most respondents were women (75%), had 6 or more years of experience in the care of intubated patients (62%), and had a baccalaureate degree or higher (55%). Except for highest degree, demographic data of respondents were similar to characteristics of all staff employed in the critical care units. We think that more persons with baccalaureate degrees or higher completed the survey.Table 1 gives policies and procedures related to suctioning and airway management. All sites designated nurses to manage oral care; respiratory therapists were responsible for managing endotracheal tubes and the closed-system suctioning devices. Of the 4 sites, 3 designated both nurses and respiratory therapists as responsible for endotracheal suctioning, oral/nasal suctioning, and management of the suctioning equipment. Oral suctioning was performed with a tonsil-type (Yankauer) device. A common suction tubing and canister were used for both closed-system suctioning and oral suctioning. No standards existed for replacing the oral suctioning device and suctioning equipment.Staff members were asked how often they performed activities related to closed-system suctioning and airway management. Table 2 summarizes the percentages of nurses and respiratory therapists who stated that they perform such activities 60% or more of the time. Chi-square analysis indicated significant differences (P≤.05) between nurses and respiratory therapists for several items. Respiratory therapists use hyperoxygenation, instill isotonic sodium chloride solution, and rinse the closed-system suctioning device more often than nurses do; nurses suction the mouth more often after closed-system suctioning than respiratory therapists do.A comparison of responses from nurses and respiratory therapists on other airway management practices is reported in Table 3. Nurses routinely suction oral secretions (every 4–12 hours), brush patients’ teeth, and use oral swabs for mouth care more often than do respiratory therapists (P≤.05). However, brushing of patients’ teeth was reported by only 58% of nurses and 16% of respiratory therapists. The majority of staff stated that they rinse the tonsil suctioning device with tap water (71%), and store it in its original package that is taped to the wall, shelf, or ventilator (60%). The tonsil suctioning devices are replaced every 24 hours (44%) or as needed (39%). Respiratory therapists manage endotracheal tube cuffs at all sites; most (78%) reported that they measure cuff pressures every 8 hours. Endotracheal tubes are repositioned as needed (51%). Suctioning above the cuff or the endotracheal tube before the tube is repositioned is done about half of the time. Only 54% of nurses were knowledgeable of management of the cuffs of endotracheal tubes.Many suctioning and airway management procedures were not included in written policies at the 4 institutions. In a recent study,7 many nurses stated that their institutions did not have policies for closed-system suctioning. Staff reported a variety of practices and did not always follow institutional recommendations.Nearly 80% of staff (Table 3) stated that closed-system suctioning was the same as or better than traditional open suctioning. This finding is higher than reported in the literature. Blackwood16 and Blackwood and Webb17 reported that removal of secretions was ineffective 45% of the time when closed-system suctioning was used and attributed the finding to thick secretions. These 2 studies16,17 were done in Ireland, and the wording of the questions differed from the wording of our questions.The 4 institutions did not address hyperoxygenation and hyperinflation techniques in their policies on closed-system suctioning. Research studies12,18–20 indicate that closed-system suctioning prevents suction-induced hypoxemia; however, some patients still require hyperoxygenation before and during suctioning. About half of the respondents stated that they hyperoxygenate the patient via the ventilator before suctioning the majority of the time. This finding is similar to that reported by Paul-Allen and Ostrow (41%).7 Less than 20% of staff reported using hyper-ventilation; it is not known if this step is needed with closed-system suctioning. Paul-Allen and Ostrow reported that 35% of nurses used hyperinflation with closed-system suctioning and that the techniques for hyperinflation varied and could lead to adverse effects such as barotrauma.7A total of 5% to 10% of staff stated that they disconnect the closed-system suctioning device and use traditional open suctioning the majority of time that patients need suctioning. This percentage is much lower than the 61% reported in a previous study.7 However, this practice is not advocated because it disrupts the closed system, which potentially increases the risk for infection.Most institutions reported that instillation of isotonic sodium chloride solution is included in their policies as a treatment for thick secretions. Many staff (more respiratory therapists than nurses) reported that they instill isotonic sodium chloride solution the majority of time that they suction patients’ airways. Recent studies indicated that adverse effects are associated with instillation of isotonic sodium chloride solution, and the nursing literature strongly advocates that instillation of isotonic sodium chloride solution be avoided, citing no benefits to its use.21–26 Despite these published reports, staff continue to instill isotonic sodium chloride solution. Other researchers have reported similar findings.16,27,28Institutions did not include oral care management in their policies and procedures. Oral care is often considered basic nursing care and may be taken for granted. More nurses than respiratory therapists perform oral care, an expected f inding because oral hygiene is taught as an important component of basic nursing care. Most staff reported using swabs for mouth care rather than brushing patients’ teeth. Brushing patients’ teeth is important because oral hygiene may play a role in oral colonization.29 The protocols for practice for airway management of the American Association of Critical-Care Nurses recommend providing oral care “several times a day” by swabbing, brushing teeth, and suctioning oral secretions.30 The purpose is to prevent plaque and periodontal disease. Munro and Grap31 found that plaque increased over a 7-day period after intubation and proposed a link between plaque formation and VAP. A recent study32 indicated that VAP can be reduced by oral decontamination with topical prophylaxis.Because microaspiration of secretions is an etiological factor for VAP, oral suctioning and practices for management of the cuffs of endotracheal tubes are important. Only a few publications33,34 recommend that oral suctioning be done after endotracheal suctioning with closed-system suctioning devices. Oral suctioning is considered “ongoing monitoring” rather than an integral part of suctioning procedures.30 Texts on respiratory therapy do not address oral suctioning in conjunction with closed-system suctioning.35,36 If staff do not suction patients’ mouths routinely, secretions accumulate and microaspiration may be more likely to occur.In a recent study, Rello et al37 noted a decrease in VAP when the pressure in the cuff of the endotracheal tube was maintained at more than 20 cm H2O. Only 32% of respiratory therapists stated that they keep the pressure at this level. Most staff reported using the minimal leak technique for cuff inflation. Institutional policies stated that cuff pressure should be measured every 4 hours; however, most respiratory therapists stated that they measure the pressure every 8 hours. Crimlisk et al38 reported a similar frequency of measuring cuff pressures. More frequent monitoring may assist in detecting leaks in the cuffs. Only half of the respondents suction above the endotracheal tube cuff before they reposition the tube, a practice that may contribute to microaspiration.1 The majority of nurses were unaware of management practices for endotracheal tube cuffs.Suctioning equipment is not addressed in institutional policies (eg, changing of Yankauer devices and suction tubing). Most staff reported changing these devices “as needed.” A recent study39 indicated that these devices harbor potentially pathogenic bacteria within 24 hours of use. Hospital policies recommended rinsing tonsil-type suction devices with sterile isotonic sodium chloride solution, a practice supported by recommendations of the Centers for Disease Control and Prevention.1 However, the majority of staff members stated that they rinse the devices with tap water. Tap water has been associated with outbreaks of bacteria; therefore, its use may warrant further investigation.Our findings represent the practices of only about one third of the nurses and respiratory therapists who work at 4 institutions in the southeastern United States. We do not know if these practices are consistent with those of staff at other sites. The next phase of the study will be to replicate the study with a larger sample of sites and staff members to determine if these findings occur in other sites throughout the United States.We reviewed the STAMP: Institutional Policies and Data tool and obtained feedback about it from the site coordinators. The content experts reviewed the preliminary findings, made suggestions for minor changes to the tool, and reaffirmed content validity. Readability of the tool is 11th grade level.The STAMP: Individual Survey instrument was evaluated for test-retest reliability. The instrument was given to 10 staff volunteers (whose identities were coded) during the designated data collection period and then 2 to 3 weeks later. Test-retest reliability was .82. It was not appropriate to compute a Cronbach α because of the diverse questions and response options. Upon completion of the pilot study, we reviewed the findings and computed a content validity index. We asked the content experts to rate the relevance of items to the study purposes by using a 4-point scale (1 = not relevant; 4 = very relevant).40 We kept all items that were rated 3 or 4 and modified a few of the answer options, resulting in a 32-item survey with a 10th grade level readability.Preliminary findings indicate variation in practice patterns. Consistent performance of practices such as suctioning patients’ mouths, oral care practices, and maintaining the pressure in the cuff of the endotracheal tube at a set level need to be evaluated for effectiveness in reducing VAP. Nurses and respiratory therapists need to collaborate on practices to ensure consistency across disciplines.We thank Suzanne Burns, RN, MSN, ACNP, RRT, and Patricia Carroll, RN, MS, RRT, for their assistance with this project. This study was funded in part by a grant from the American Association of Critical-Care Nurses.