I hereby declare that the present dissertation entitled “Effectiveness of closed endotracheal suctioning as against open endotracheal suctioning upon respiratory outcome in mechanically ventilated adult patients” is the outcome of the original research work undertaken and carried out by me under the guidance of Dr. Latha Venkatesan, M.Sc (N)., M.Phil (N)., Ph.D (N), Principal, Apollo College of Nursing, and Mrs. Jaslina Gnanarani .J, M.Sc (N)., Reader, Medical Surgical Nursing Department, Apollo College of Nursing, Chennai. I also declare that the material of this has not found in any way, the basis for the award of any degree or diploma in this university or any other university.
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One of the main factors influencing the care in ICU especially in developing countries is the cost factor.Unfortunately there are no credible studies looking at the cost effectiveness of the two types of suctioning from the developing countries.In a randomized, controlled study by Lorente etal, VAP incidence and costs of suctioning were assessed in 457 mechanically ventilated patients assigned to the open-suctioning technique or to a closed system which allows partial (suctioning catheter with its protected covering sheath) or complete system change. The closed system was changed not routinely but only when it presented mechanical failure or visible soil (partial change), or when the patient needed reintubation (complete change). No difference was found between groups in the rate and incidence density of VAP or in the distribution of micro-organisms responsible for VAP. Costs of suctioning were similar between open and closed
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causing absorption atelectasis [7–9]. It has recently been suggested that a closed suction system may be effective in preventing suctioning-induced decreases in lung volume and oxygenation. In fact, Pesenti and coworkers  found no reduction in end-expiratory lung volume (EELV) or arterial oxygen saturation in patients with ALI and ARDS after suc- tioning with such a system. Significant drawbacks with closed suction systems include risk for producing high nega- tive pressures and reduced efficacy in removing thick secre- tions from the airways [2,11,12]. Brochard and coworkers  showed that lung volume and arterial oxygenation could be maintained during open suctioning by using constant flow insufflation. This method appears to be effective but necessi- tates use of a special endotracheal tube. Another measure to counteract suctioning-induced hypoxaemia is hyperinflation of the lungs. This is usually performed by administering large breaths using an anaesthetic balloon, without attention to
The conventional way of open system is single-use and requires disconnection of the endotracheal tube from the mechanical ventilator and insertion of a suction catheter of appropriate size for the diameter of the endo- tracheal tube. The closed system employs a multiple-use suction catheter attached to the ventilator circuit, with- out disconnecting it from the patient (during suction- ing) (1). During the last decade, using closed system has become more popular, but the evidence for preference of closed suction system (CSS) over open endotracheal suc- tion (OES) has been overlooked so far (9). Use of OES or CSS depends on the clinical status of the neonates, and skill or preference of nurses (10).
Meera and Samsion (2011) conduucted a evaluative study was done to assess Instillation of isotonic sodium chloride solution for endotracheal tube suctioning is beneficial or not. Research has focused on the effect of such instillation in adults; no studies in children have been published. A convenience sample of 24 critically ill patients was enrolled before having suctioning and after informed consent had been given. Ages ranged from 10 weeks to 14 years. Patients were randomized to 1 of 2 groups. In group 1, subjects received between 0.5 and 2.0 ml of isotonic sodium chloride solution, depending on their age, once per suctioning episode. In group 2, subjects received no such solution. A total of 104 suctioning episodes were analyzed. Oxygen saturation was recorded at predetermined intervals before and for 10 minutes after suctioning. Occlusion of endotracheal tubes and rates of nosocomial pneumonia also were compared. The study result shows that; Patients who had isotonic sodium chloride solution instilled experienced significantly greater oxygen desaturation 1 and 2 minutes after suctioning than did patients who did not. No occlusions of endotracheal tubes and no cases of nosocomial pneumonia occurred in either group. The study concluded that instillation of isotonic sodium chloride solution during endotracheal tube suctioning may not be beneficial and actually may be harmful.
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The major goal of intubation and intratracheal suctioning of infants born through MSAF is to retrieve as much material as possible from the larger-caliber airways below the vocal cords before it can migrate distally. The act of breathing likely promotes distal migration of meconium-stained fluid. Hence, the recom- mendations that intubation and intratracheal suctioning be per- formed as soon as possible after the neonate is delivered. Until there appears support for the proposed mechanism of MAS (as- piration of regurgitated gastric contents), I do not think tracheal cleansing should be delayed. I certainly recognize that some in- fants may gasp in utero and aspirate MSAF. Additionally, the vast majority of meconium-stained neonates (including those born through thick MSAF) will not develop MAS.
Our study has several limitations. First, it was conducted in an in vitro model that was designed to replicate the human tracheal environment. However, the results may not be applicable to the in vivo setting where other factors may impact the ETT surface such as frequent suctioning, nebulizer therapy or host factors. Second, the concomitant use of Ag and TiO 2 would seem to be marginally effective against VAP if it does not inhibit a common cause of VAP (ie, S. aureus). Third, minimizing the particulate surface that facilitates bacterial binding could be effective by reducing the surface area for bacterial adherence and growth. Fourth, the coating, peeled off under mechanical stress, could be dislodged by a suction catheter and produce potentially harmful Ag particles in the human airway and lung parenchyma. Nevertheless, titanium dioxide is known to be safe in humans and is used in such products as cosmetics, toothpaste, and sun screen. Hence, the combination of Ag and TiO 2 needs to be evaluated in a clinical setting. Lastly, this study did not directly evaluate the attractive feature of TiO 2 photocatalysis. The potency of TiO 2 either individually or in combination with Ag needs to
The results of this study are consistent with above studies. However, these studies have not evaluated mean arterial pressure. While this study found a significant increase in mean arterial pressure immediately after suctioning. In this case, suction as an invasive procedure leads to physiologic responses; the body response to suction as a stimulator has been higher in the phase immediately after the suction. This caused significant changes. The increase was light; therefore, the increase seems insignificant clinically. On the other hand, increase in cough reflex as a result of normal saline can lead to increase in mean atrial pressure 16 .
microorganisms endogenously (contaminated liquid injected into a naso-gastric tube), or endogenously (duodeno-gastric reflux).And, subsequent sustained micro aspiration of this contaminated secretions from oropharynx or stomach, pooled above around the endotracheal tube's cuff ultimately leads to infection of the lower respiratory tract (15). There is evidence suggesting that a gastric pH of 3.5 plays a role in prevention of
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A study was conducted to compare the effectiveness and complications of deep versus shallow suctioning on tracheostomy patient. The methods of suctioning vary according to institutional practice and the individual clinician performing the task. The depth of suctioning was one of these variables. The sample consist of 60 patients which equally divided in to two groups, that is 33 patients were subjected to deep suctioning and 33 patients were subjected to shallow suctioning. The catheter passed to the tip of the tracheostomy tube or beyond the tip into the trachea to facilitate removal of secretions. However, there was an increased level of trauma to the lower airways may result from the suction catheter being passed into the airway beyond the tip of the tracheostomy tube (6.43±1.17), when compared to shallow suctioning (5.83±0.99), the obtained ‘T’ value was 3.29 which was significant at p≤0.05 level. (Spence K, 2002)
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Garcia et al. (2009) determined the effect of a comprehensive oral and dental care protocol on the rate of VAP by pre-post interventional study. Adults’ receiving mechanical ventilation more than 48 hours in Brookdale University Hospital was studied in a two consecutive 24-month periods. Pre-interventional group (n = 779) had no oral assessments, no subglottic suctioning, no tooth brushing, and suctioning of secretions in oral cavity as needed. The interventional group (n = 759) was treated with a protocol which included oral assessment, deep suctioning every 6 hours, oral tissue cleansing every 4 hours or as needed and tooth brushing twice daily. VAP rate was determined using Clinical Pulmonary Infection Score (CPIS) (CPIS > 6). The rate of VAP was found to be 12% per 1000 ventilator days before the intervention and decreased to 8.0% per 1000 ventilator days during the intervention ( p = 0.06). Researcher concluded that the implementation of comprehensive oral care protocol and staff compliance significantly reduced the VAP rate and its associated costs.
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The patient’s chest radiograph was reviewed and chest auscultation was performed prior to CPT to identify areas of particular involvement. Depending on the location of coarse crepitations, presence of secretions and the newborn tolerance, appropriate drainage positions were applied with avoidance of head down position and excessive neck flexion/extension. According to Crane  each postural drainage position was applied for 3-5 min. with Lung squeeze technique (LST) and vibration, followed by about 2 min. suctioning or until clear return of the fluid to the tube, according to the patient’s tolerance. Every newborn was put in 3-4 positions according to coarse crepitations.
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The present study showed that the cost of the closed system suction in ICU was higher for patients with a du- ration of ICU stay for less than 48 hours; however, the cost would be decreased significantly for patients with a duration of ICU stay of more than 48 hours. The costs would also be lower for patients who need ETT suction- ing for more than 14 times a day. In some studies, it was reported that the costs of the closed suction was more than the open method (13, 30). However, the findings of the present study were consistent with studies by Dodek et al. and Lorente et al. who reported that the costs of the closed suction system are lower than the open one, espe- cially in patients with hospitalization for more than four days (14, 17). The lower costs of the closed suction system could be attributed to the possibility for longer use of the suction set and needing to fewer staff for suctioning pro- cedure (14, 17).
. The researcher obtained formal permission from Ethical committee of Madurai Medical College, Madurai. The study was conducted for a period of 6 weeks from 20.3.17 to 30.4.17 in Intensive Medical Care Unit, Government Rajaji Hospital, Madurai. Rapport was established with the care givers and with the patients .Oral and written informed consent was obtained from the care givers of the subjects. 60 subjects were selected by Non probability (consecutive sampling) technique and assigned 30 subjects into groups I and 30 subjects into group II. Pre test was done on airway clearance in both the groups using structured observational check list Group endotracheal suctioning without normal saline for group1 and with normal saline to group 11 was done every second hourly and on demand basis by using appropriate suction catheter for ten to fifteen seconds with the negative pressure of 100 mm of hg and pre oxygenating with 100% oxygen .While inserting the blunt end suction catheter, pressure should not be applied by closing the two way and when the resistance of catheter is felt pressure should be released to suck out the secretion and the catheter should be removed in rotatory manner in order to prevent tissue injury. 10 minutes after the last endotracheal suctioning at 7pm (approximately between 7pm to 7.30 pm) post test was done with the same observational check list.
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Methods: Quantitative research approach was used with pre experimental one group pretest posttest design. Purposive sampling technique was used to select 50 intensive care unit staff nurses who meet the inclusion criteria. Pretest was done on the first day followed by structured teaching programme (Day 1) and reinforcement intervention (Day 7) to all the samples and posttest on the 7 th and 14 th day. Result: The findings of the study showed that, there was a significant increase in mean posttest knowledge and practice score of the samples (P < 0.05) regarding endotracheal suctioning among staff nurses in intensive care units of selected hospitals in Kollam after structured teaching programme.
<37 weeks’ gestation) or postterm (>42 weeks’ gestation) was significantly higher in the prospective group compared with the retrospective group (12% vs 2%). The proportion of newborns with 1-minute Apgar scores of <3 and/or 5-minute Apgar scores of <7 were similar between groups. Endotracheal suctioning was performed predominantly in the retrospective group (70% vs 2%) and mask PPV primarily in the prospective group (55% vs 19%), indicating the change in practice. After adjusting for late preterm, postterm, and deliveries with fetal distress, a significantly higher proportion of infants were admitted to the NICU for respiratory issues (distress or failure) in the prospective group compared with TABLE 1 Maternal Characteristics
The student nurses selected for this study were female and all of them were learning Critical care Nursing and had undergone 20 hours of training as part of their curriculum.This finding co- relates with the study conducted by Charlotte Ladd et al.(2013) among undergraduate nursing students. All of the 12 students volunteered and more than half of the student nurses (66.7 %) had previous experience with simulation learning. It proved that student nurses had interest in gaining knowledge and performance skill by Simulation learning. These findings were supported in a study about “Nursing students perception of simulation as a clinical teaching method in the Cape town Metropole, South Africa by Neletal (2015). In terms of knowledge gain, the mean pre simulation knowledge scores of Nursing students on Endotracheal suctioning ranged from 6.17±1.75 and in post simulation 8.08±1.56, suggesting that simulation based learning was effective in increasing the knowledge of student nurses regarding endotracheal suctioning. All the student nurses fell into the category of adequate level of knowledge in the post simulation. The pre simulation and post simulation performance ability on endotracheal suctioning had statistically significant differences. This result is in agreement with a more recent study by Tamsin Pike et al. (2010) reported that educational strategies such as clinical simulation enhances learner’s self- efficacy in terms of knowledge and psychomotor aspects.Regarding the correlation between post simulation knowledge score of student nurses regarding endotracheal suctioning was found to be significantly higher than the pre simulation score, (p< 0.001) and post simulation performance skill was found to be significantly higher than the pre simulation performance skill.
Depth of the endotracheal tube suctioning is one of the issues considered to reduce these side effects. Endotracheal tube suctioning can perform using both shallow and deep methods. In the shallow suctioning, after removing the patient from the ventilator without applying any negative pressure, the suction catheter carried only to the end of the endotracheal tube. Then suctioning performed as the catheter withdrawn. In the deep suctioning method, without the application of any negative pressure, the suction catheter driven forward until resistance met, and then it pulled back one centimeter and suctioning performed, as the catheter is being withdrawn. 16 literature reviews in nursing
Introduction: Endotracheal suctioning (ETS) is essential for patient care in an ICU but may represent a cause of cerebral secondary injury. Ketamine has been historically contraindicated for its use in head injury patients, since an increase of intracranial pressure (ICP) was reported; nevertheless, its use was recently suggested in neurosurgical patients. In this prospective observational study we investigated the effect of ETS on ICP, cerebral perfusion pressure (CPP), jugular oxygen saturation (SjO 2 ) and cerebral blood flow velocity (mVMCA) before and after the