To suction the ETT, or not?

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I am increasingly irritated in my current position regarding the management of ventilator patients. I am working in a small rual hospital, 6 bed ICU and have been told repeatedly by the respiratory personnel here it is no longer accepted practice to suction the ETT, much less to break the circuit to do so. The nursing staff here do not suction, they call respiratory for any respiratory issues.

I have kept current since leaving the city and the large ICU's. I worked over 20 years trauma and burn ICU, and feel I have adequate assessment skills to make the judgement if my patient needs suctioning or not. This I do not simply do on a wim! I know the indications and the risks of ETT suctioning, but I do not think it is appropriate to simply leave all those wonderful secretions, mucous plugs, pulmonary edema, ect in there.

I am big on turning, repostioning, mouth care, HOB elevation ect. Once in a blue moon we have a patient deteriorate into full blown ARDS. (Don't want to go into what that becomes here). I have done an extensive literary search, see nothing that states ETT suctioning is not done--I have concluded if there are secretions, they get suctioned being carefull to assess patient, ect. Also stated if needed it is "okay" to break the circuit. What is your experience lately?

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What is their rationale for not suctioning in general other than not wanting to break the circuit? Or do you mean that at your facility, suctioning is seen as an RT responsibility rather than a nursing one? Either way, it sounds odd to me. You need to maintain a patent airway and part of that is getting the crud out of there. What about inline suctioning? Is that done at your facility?

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Specializes in Neuro Critical Care.

We do not break circuit to suction at my hospital but it is absolutely necessary. I always consider suctioning to be as important as cough/deep breath in a non-intubated patient. I have no idea what their rationale is but I would ask them where they get their info.

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The most recent rationale was that "current research states that one should not suction and the circuit should not be broken". I am not a nurse that will call respiratory when my patient needs suctioning, so if it offends, that is not my purpose.

Closed suctioning devises are on all vent patients here, so why not use them? I do when the situation merits suctioning. If I need to break the circuit, I also do that--they do not.

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Specializes in Critical Care Nursing.

having recently developed a guideline on this we recommended

you should only suction when it is required BUT the research is limited on how easy it is to ID when this is appropriate

I used a closed suction system and therefore did not open the circuit.

patients with lung disease should not have their circuit opened because of alveolar derecruitment.

guideline is available at ICCMU website (search for ICCMU)

username: iccmu

password: Icu41585

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................I am not a nurse that will call respiratory when my patient needs suctioning, so if it offends, that is not my purpose..........

>

No offense taken here, if you doing it yourself saves me time, great, I've got puh-lenty of other stuff to do. But remember, it's RT's Pt. as well, many nurses don't see it that way but it does'nt change the fact. Just because I'm not the primary caregiver, doesn't mean I'm not responsible for the Pt. I came from a large teaching hospital outside NYC, to a small rural hospital. I basically went from a vent jock, to more of a physician extender / educator role.

I understand not breaking the vent circuit, but how does suctioning with an inline closed suction system open the circuit? Do you mean lavaging everytime you suction? (that should almost never be done) The latest I'm reading says disconnecting the circuit should be done only when absolutely necessary. (CPR) It's my understanding thats why nebulizers arent given in-line anymore, MDI's instead. In the past 6-7 years I've seen opening the circuit go from an almost hourly event, to being taboo.

Having that secure airway is great, but it also means the Pt cannot maintain their physiologic PEEP. A circuit disconnect can cause atelectasis possibly resulting in PN or ARDS in some people. When you mentioned ARDS you said "Don't want to go into what that becomes here", what do you mean by that?

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HME's Vs. heated humidifiers have become a hot topic in my hospital because of this argument. Some of us feel that as soon as the Pt is on the vent, they should be put on a heated humidifier. Some of my......Ahem......less motivated colleagues feel an HME will suffice until "they've been tubed for a few days". Of course by then the risk of VAP has increased tremendously, and breaking the circuit will only increase it even more.

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Specializes in ICU.

Is it not possible to be using inlines? Thats the only way I suction routinely, unless i need a sterile sample, then I take them off, bag, and sterile suction. If the pt is too unstable, the RT puts a new inline on for me. I dont understand why you shouldnt suction if you think the pt needs it. I wonder where the RT got that info from. Seems like poor practise to me. They would get a big pneumonia if they didnt already have it im sure, but even letting small secretions sit down there. What about a patient with a bad pneumonia. Sometimes they need suction q1h. Then what do they want you to do??

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This particular patient had a very big pneumonia and pulmonary edema. She was a postoperative abdomen and did not do well. I haven't seen any current literature that supports the stance of the Respiratory Dept here, so I will continue.

Thanks for the input, I enjoyed the guideline you suggested, chani :bow:. PageRespiratory, there was no hummidification or HME--I did get hummidification in place--the ETT was nearly occluded with dried, thick secretions. I could barely insert the closed system suction catheter down the ETT--did end up breaking the circuit and doing the evil deed. I first got her 4 days postop, she was circling the drain--went into multisystem failure and the family withdrew support the next day.

I suppose most of this is stepping on toes--I suctioned beaucoo, with plugs ect. Pt was on 10 of PEEP, PIP were in the 50's , tidal volumes were under 300 and sats were staying in the 86% range, she was on ASV. So, the course for this patient was not good--WBC maxed out at 49! lots going on with her. I can understand "derecruitment" with elevated PEEPs and worry about ALI, but this patient needed suctioning. Thanks again for your input

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Specializes in Critical Care Nursing.

taa much cactusflower

I hope my comments wasn't misconstrued but I definately didnot mean that patients shouldn't be suctioned at all.

As for most, if not all, patient procedures, the patient should only get it when they need it NOT as a matter of routine. the known adverse effects of suction alone should be good enough reasons.

The problem, is of course that it can be difficult to identify when the patient needs it. A sawtooth pattern on the vent can be an indication as is noise BUT not foolproof. These are the best evidence we could find BUT is low level evidence

]Leur, J. P., Zwaveling, J. H., Bert, G. L. and Schans, C. P. (2003) Endotracheal suctioning versus minimally

]invasive airway suctioning in intubated patients: a prospective randomised controlled trial. ]Intensive

]Care Med, ]29], 426-432.

]Maggiore, S. M., Lellouche, F., Pigeot, J., Taille, S., Deye, N., Durrmeyer, X., Richard, J.-C., Mancebo, J.,

]Lemaire, F. and Brochard, L. (2003) Prevention of endotracheal suctioning-induced alveolar

]derecruitment in acute lung injury. ]Am J Respir Crit Care Med, ]167], 1215-1224.

I avoid opening the circuit for a number of reasons including lung pathology point of view and infection control.

BUT there won't be much gas exchange if the lungs full of sputum and the return from a closed suction system can be limited. HOWEVER perhaps the problem is not the closed suction system BUT that the secretions need to be mobilised from the peripheries better with appropriate humidification and patient movement.

So therefore we need to make individual patient decisions and apply CPG judiciously.

What we need are good multi-centre RCTs to identify

-when patients need suctioning AND

- needs of patients with different lung pathology

cheers

chani

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I'd be asking for hard copies of this claimed research.

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Specializes in Critical Care Nursing.

you are correct in asking to look at this research for yourself. Indeed the levels of evidence are not high and there were signficant biases in the research methods. Therefore to make changes to current practice based on these takes a lot of discussion and debate.

Please have a look at the CPG in the previous replies. You will find the reviews of relevant articles as well as the systematic review which was the basis of the recommendations.

But since there should be a good reason to do something as well as a good reason NOT to do something we erred on the side of caution since there was at least some evidence suctioning is harmful especially to vulnerable groups of patients.

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