Instillation of Saline into Bronchioles when Suctioning

[EricTAMUCC-BSN, BSN, RN]

"Ackerman4 responded to that challenge and studied the effect of instillation of normal saline on oxygen saturation measured by pulse oximetry in 40 male subjects requiring mechanical ventilation. Oxygen saturation was decreased at 2, 3, 4, and 5 minutes after suctioning with instillation of normal saline. Ackerman recommended that instillation of normal saline not be a "routine or standard" intervention and that it should be regarded as potentially hazardous.

Instillation of normal saline before suctioning not only is associated with a decrease in oxygen saturation but also may increase the risk of infection.

For example, pathogens that cause pneumonia, such as Staphylococcus aureus, can be cultured from disposable vials of saline after the vials are opened and used.5 However, disposable vials are not the only source of potential contamination. Hagler and Traver6 obtained endotracheal tubes that had been removed from 10 patients after a minimum of 48 hours of intubation and evaluated dislodgment of bacteria caused by insertion of a suction catheter with or without instillation of normal saline before insertion of the catheter. The number of bacteria dislodged increased 5-fold with instillation of normal saline.

Thus, the results indicated that artificial airways are colonized with bacteria and that instillation of normal saline dislodges these bacteria and carries the organisms to the lower parts of the airway. Hagler and Traver recommended that the practice of instilling normal saline before suctioning be abandoned.

Nurses, however, do not appear to be following this recommendation. Swartz et al7 recently surveyed pediatric nurses practicing in pediatric ICUs in 92 hospitals and found that all but 1 respondent used instillation of normal saline before suctioning. In addition, nurses are not the only professionals who do suctioning. In most institutions, respiratory therapists also perform this procedure. We know of no study that examined the practice of all professionals who routinely do suctioning."

-http://www.aacn.org/AACN/jrnlajcc.nsf/GetArticle/ArticleThree74?OpenDocument

[VizslaMom]

I absolutely do NOT practice this. I've seen RT's and other RN's doing it, but I will not. I believe that it does increase the risk of infection...and we see enough Vent-Associated Pneumonias without having to add to it needlessly IMO.

[zambezi, BSN, RN]

I voted no because that is what I do 97% of the time...however, there is that occassional person that I will use saline with suctioning because of thick, tenuous, chunky secretions that just won't come out. ick. I know you know what I am talking about. :uhoh21:

[BBFRN, BSN, PhD]

I've used them for mucous plugs...only the single use pink squeezer kind.

[elnski]

In my area of practice, wc is in the non-invasive unit, the use of saline being instilled into the bronchus is discouraged.. We either give saline nebs regularly for thick secretions, or give humidified O2. Humidified O2 could either be cold (such as via an inspiron) or warm (thru a fisher paykel via a trachy).. usually, the thick secretions are sorted out this way (& of course w/ the help of a good physio)

It is not advisable to instill n/s esp if the cough reflex is depressed for obvious reasons..

But in the case of bronchoscopy, ive seen pts become brighter afterwards and saturating brilliantly..perhaps bec of the bronchial washing w/ saline...of course, its a diffrent case..

[begalli]

Extremely rarely I'll use a couple ml's of ns to help in collecting a culture if the patient has little or really thick secretions. I only use single bullets however and again, very rarely.

I'm shocked to see that a few of our highly experienced RT's still use it frequently. I ask that they don't use it on my patients though if they're nice enough to offer to suction.

[Katmae RN]

I find squeezing saline down someone's trach or et tube is cruel. The patient coughs and gags even worse than just suctioning. It must be awful! I know when i swallow something and it goes down "the wrong pipe" it is very uncomfortable and scary. There are other methods to thin secretions like warm humdified trach collar, albuterol tx's mucomyst etc.Also a simple trach cleaning to clear it of a plug. I think its barbaric to use saline.

[fergus51]

Everyone does it where I work now. And they instill a lot.