Trach suctioning. Bullet vs. no bullet - page 2

I know in the past NS bullets have been used to help clear thick secretions in trached/ vented pts. I know that EBP says we should NOT do this. I personally will not do it as an RN. If RT wants to do... Read More

  1. Visit  NickB profile page
    2
    The whole purpose of the NS bullet is to clean out the suction tube when you are finished suctioning the patient. The normal saline is not to be instilled into the patient. Think about it, if you were to put 3ml of NS into the patient and then suction their secretions, how could you ever be sure that you extracted all 3ml of NS. There is no way to measure it. Lungs are not where you want to be putting in more liquid. This would greatly increase the chance of infection.
    Up2nogood RN and Simba&NalasMom like this.
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  3. Visit  Simba&NalasMom profile page
    0
    Quote from Jasel
    I'm not familiar with "NS bullets". What are those exactly?? Anyway if the trach is almost plugged or just really thickened up I'll just take the whole thing out and clean it. We only have one trach patient at our facility who has been there for years. She also gets atropine drops SL BID to help clear up secretions which works pretty well from what I've seen.
    Yep, atropine works like a charm.
  4. Visit  Simba&NalasMom profile page
    0
    I haven't had a lot of trach pts, but all the ones I've seen have those mist collars and pretty much wear them at all times when they're in bed. Never seen secretions so thick I couldn't clear them with normal sterile suctioning.
  5. Visit  sunnycalifRN profile page
    0
    Quote from roser13
    What is the contraindication for the bullets? When I worked a trach floor, we didn't suction without them.
    this is from that Medscape article:

    There also exists the potential to contribute to ventilator-associated pneumonia by instilling saline before insertion of a suction catheter. Saline instillation may dislodge bacteria from a colonized ET tube, sending it down into the lower airway.[17,18] The researchers found suctioning alone has the potential to dislodge up to 60,000 viable bacterial colonies and when 5 mL normal saline was instilled, up to 310,000 viable bacterial colonies were dislodged -- a 5-fold increased risk
  6. Visit  ShannonRN2010 profile page
    0
    We were told to use them when we suctioned my dad here at home. I know we did it a lot toward the end, his secretions were so thick and he had pseudomonas.
    Actually they think a mucus plug is probably what killed my dad, not the ALS.
  7. Visit  hiddencatRN profile page
    1
    Quote from sunnycalifRN
    this is from that Medscape article:

    There also exists the potential to contribute to ventilator-associated pneumonia by instilling saline before insertion of a suction catheter. Saline instillation may dislodge bacteria from a colonized ET tube, sending it down into the lower airway.[17,18] The researchers found suctioning alone has the potential to dislodge up to 60,000 viable bacterial colonies and when 5 mL normal saline was instilled, up to 310,000 viable bacterial colonies were dislodged -- a 5-fold increased risk
    Interesting- I would never have thought of dislodging bacteria colonies. Would this apply to nasal suctioning too? We usually use the bullets to do a drop or too in each nare with our RSV kids.
    Sehille4774 likes this.
  8. Visit  ventmommy profile page
    0
    I, and all our nurses per MD orders, use NS bullets to suction my son. You do NOT dump the entire bullet down the trach (I fired a nurse from his case for doing this). It is 3-5 DROPS, bag in 3 breaths, suction, put back on vent. Even with humidity and heated circuits, his secretions are thick enough that this is necessary several times a day. It works wonders without adding another drug to his day.
  9. Visit  collegemomoffour profile page
    2
    I am a private duty vent nurse and I do both types of suctioning. your main concern is to get all of the saline back when you suction. It is not very much to start with and I have never had any problems with using them. My other clients do not use them but instead have RT and use nebs. Hope this helps
    Sehille4774 and roser13 like this.
  10. Visit  LuxCalidaNP profile page
    0
    As I recall from Dr. Grap's work on VAP, use of saline pre-suctioning EXPONENTIALLY increases the risk of infection.
  11. Visit  kcocat profile page
    5
    Ok - I'm an RN AND a Registered Respiratory therapist. Here's the deal with instilling normal saline with suctioning (both ET tube and Trach - doesn't matter)....

    1. A multitude of studies demonstrated that you DO NOT get all the saline back up. They quantified and measured it. May LOOK like you do, but you do not.

    2. A couple of studies also demonstrated that it took a patient 2-4x as long for their PaO2 to return to baseline after suctioning with saline EVEN WHEN preoxygenated. They also had to transiently increase the oxygen to the patient for a much LONGER time period in order to get the PaO2 to return to baseline. In Cardiac patients many needed a higher FiO2 for an hour or more just to keep their PaO2 at the desired baseline after the insult from the saline.

    3. As mentioned by a previous poster, utilization of saline dislodges microbes from the ventilator circuit and ET Tube or trach tube INTO the patient's lungs, increasing your chances of VAP (vent aquired pneumonia).

    Historically it was believed that the saline loosened secretions, or that it changed the surface tension of them so that the vacuum pulled the secretions up along with the saline that was sitting on top (which is all it does - do you really think it gets in there, blends around, and thins secretions in a matter of seconds? No - it just sits on top or does down the CLEAR airways, path of least resistance). It was also surmised that acting as an irritant it helped initiate a cough, which would then bring up more secretions. (this last point is the only one with any potential validity, however, you still have the downside of adversely impacting your patient's PaO2 and sending microbes down their tube)

    IF your patient is properly hydrated and their airway adequately humidified, the secretions should come up just fine. If they're still rattling around with rhonchi, etc. than likely they're too low to be suctioned up at that point and you need to wait for the cilia to help mobilize them further up the bronchial tree, or do something to make that happen (such as some form of CPT).

    Utilization of NS would be considered poor practice anywhere I've worked since at least 1996, (Large teaching hospitals/trauma centers) and this position is supported by many studies and EBM. Most progressive centers at least frown on the practice if they don't outright prohibit it.

    For the person who asked about instilling it into the nares of RSV kids - your nasopharynx isn't sterile and has a lot of buggies in there already, so the saline just shifts the microbes around a bit at most. If you did so much they aspirated, then yes, you'd have a problem. The belief with RSV (or other snotty little ones for the matter) is that a few drops will change the surface tension of the secretions so that when the saline is sucked up they go along with it - the same idea originally used for ET Tube & trach suctioning, but which has been shown to not be of benefit with an artificial airway.

    When I was a clinical educator I had all the articles/studies on this. However, I'm now in a FNP program & don't have all that readily at hand. However, I would expect that the education coordinator, clinical specialist, etc. for respiratory care or one of the ICU's would have it for those who work at large teaching hospitals.
    damrcngrl95, Sehille4774, chare, and 2 others like this.
  12. Visit  steelydanfan profile page
    3
    Quote from kcocat
    Ok - I'm an RN AND a Registered Respiratory therapist. Here's the deal with instilling normal saline with suctioning (both ET tube and Trach - doesn't matter)....

    1. A multitude of studies demonstrated that you DO NOT get all the saline back up. They quantified and measured it. May LOOK like you do, but you do not.

    2. A couple of studies also demonstrated that it took a patient 2-4x as long for their PaO2 to return to baseline after suctioning with saline EVEN WHEN preoxygenated. They also had to transiently increase the oxygen to the patient for a much LONGER time period in order to get the PaO2 to return to baseline. In Cardiac patients many needed a higher FiO2 for an hour or more just to keep their PaO2 at the desired baseline after the insult from the saline.

    3. As mentioned by a previous poster, utilization of saline dislodges microbes from the ventilator circuit and ET Tube or trach tube INTO the patient's lungs, increasing your chances of VAP (vent aquired pneumonia).

    Historically it was believed that the saline loosened secretions, or that it changed the surface tension of them so that the vacuum pulled the secretions up along with the saline that was sitting on top (which is all it does - do you really think it gets in there, blends around, and thins secretions in a matter of seconds? No - it just sits on top or does down the CLEAR airways, path of least resistance). It was also surmised that acting as an irritant it helped initiate a cough, which would then bring up more secretions. (this last point is the only one with any potential validity, however, you still have the downside of adversely impacting your patient's PaO2 and sending microbes down their tube)

    IF your patient is properly hydrated and their airway adequately humidified, the secretions should come up just fine. If they're still rattling around with rhonchi, etc. than likely they're too low to be suctioned up at that point and you need to wait for the cilia to help mobilize them further up the bronchial tree, or do something to make that happen (such as some form of CPT).

    Utilization of NS would be considered poor practice anywhere I've worked since at least 1996, (Large teaching hospitals/trauma centers) and this position is supported by many studies and EBM. Most progressive centers at least frown on the practice if they don't outright prohibit it.

    For the person who asked about instilling it into the nares of RSV kids - your nasopharynx isn't sterile and has a lot of buggies in there already, so the saline just shifts the microbes around a bit at most. If you did so much they aspirated, then yes, you'd have a problem. The belief with RSV (or other snotty little ones for the matter) is that a few drops will change the surface tension of the secretions so that when the saline is sucked up they go along with it - the same idea originally used for ET Tube & trach suctioning, but which has been shown to not be of benefit with an artificial airway.

    When I was a clinical educator I had all the articles/studies on this. However, I'm now in a FNP program & don't have all that readily at hand. However, I would expect that the education coordinator, clinical specialist, etc. for respiratory care or one of the ICU's would have it for those who work at large teaching hospitals.
    Thank you for distilling all the known research in such a brief form. This practice is a HUGE NONO, and has been since at least 2002.

    Unless cleaning out a closed ETT suction line, saline bullets have NO business near a ventilator or trach set up.
  13. Visit  debrah7344 profile page
    0
    I am applying for a job in Home Health with Maxim Healthcare. I need to pass an exam on trached or vented patients. Does anyone have any suggestions on how to prepare for this exam?
  14. Visit  NRSKarenRN profile page
    0
    moved to our pulmonary nursing forum --see posts a the top re vent info.


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