Jump to content

Trach suctioning. Bullet vs. no bullet

Posted

You are reading page 2 of Trach suctioning. Bullet vs. no bullet. If you want to start from the beginning Go to First Page.

Specializes in ICU, medsurg/tele.

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.

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.

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

LuxCalidaNP

Specializes in Family Practice, Urgent Care, Cardiac Ca. Has 3 years experience.

As I recall from Dr. Grap's work on VAP, use of saline pre-suctioning EXPONENTIALLY increases the risk of infection.

KimmbaFNP, MSN, APRN, NP

Specializes in Holistic FNP, AHN. Has 12 years experience.

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.

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.

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?

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 44 years experience.

moved to our pulmonary nursing forum --see posts a the top re vent info.

Thank you. I found most of the answers I was looking for, although not all. The information was most helpful.

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.

That is a broad statement and does not apply to every situation. Education for the appropriateness of the use of saline should be emphasized instead.

Not everyone will have a bottle of Mucomyst or NaHCO3/saline mix sitting around for direct instillation when an ETT or trach plugs nor is it always safe to pull every tube because of a plug nor will the plug always be so serious it requires meds but still needs some help getting out of the airway.

There are also recent studies that have shown saline reduces colonization by making the secretions more readily coughed and suctioned out. However, some of the concerns from older studies siting not using saline are with patients who do not have a cough from either paralysis or sedation to where there is a possiblity of more contamination in the lower airways.

Each patient should have their specific needs evaluated and anticipated. I do agree a mucolytic and hydration should be first considered when secretions are becoming thicker but those may not work instantly. Education should provide when suctioning with saline is appropriate.

Of course the neonatal unit is a very different area with other considerations.

dmc_rrt

Has 5 years experience.

We teach all our long term trach pts to use these, or sterile saline through a syringe, when they need to clear their secretions. Its NBD

Its NBD

That depends. If you are doing it because you've been taught you always do it that way or if you actually know when to use saline and when it should not be used. Some RTs and RNs flood the trach or ETT just because that is what they were taught to do with each suctioning regardless of secretions. They then teach this to the LTC trachs which if they are not able to adequately cough, will return again and again with pulmonary infections.

iwanna

Specializes in behavioral health.

I have had a few trachs due to sub-glottic stenosis. The last one that I had was in 1994, and I used NS bullet for plugs. It really helped to cough up the thick secretion. I used the bullet when needed then followed with the suctioning.

I recently took a class run by the PA dept of health Trach and Vent home program. They have had over a thousand cases across the state over time. So based on their research which is pretty much the latest and greatest..based on the American Thoracic Society recommendations...BEST PRACTICE is not to use the saline any more...not even the drops to clear a plug. They admitted that many in the medical community are still widly using saline to try to breakup a plug or for thick secretions even though the evidence has been around for 10 years. (I for instance work for places where that is the policy.) The instructors felt that part of the reason is our culture IE: "well that was how I was shown to do it so its the right way...we are so resistant to change! Anyway...saline in itself is an irritant to the lungs and the lining of the alveoli. They know that no matter how much you suction after putting saline down the trach that you can never get it all out of those small passages in the lower lobes. And...for those wondering about the drops for the "emergency plug" ...they dont want you to waste your time messing around with that...SO..try to suction once, try to reposition once, then just change the whole trach.

I can provide better references then verbatum i am sure if anyone was interested...i dont have those materials with me ATM.