Endotracheal suctioning in children
Endotracheal suctioning in children
Endotracheal suctioning in children
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
<strong>Endotracheal</strong><br />
Suction<strong>in</strong>g <strong>in</strong> Children:<br />
What is evidence<br />
based<br />
Irene Harth<br />
Universitätsmediz<strong>in</strong> Ma<strong>in</strong>z<br />
Zentrum für K<strong>in</strong>der- und Jugendmediz<strong>in</strong>, PICU
Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
<strong>Endotracheal</strong> Suction<strong>in</strong>g<br />
• Essential <strong>in</strong> the care of ventilated patients<br />
• Intubation reduces natural functionalities<br />
• Ma<strong>in</strong>tenance of open airways<br />
• Removal of secretions<br />
• Secure proper ventilation and<br />
oxygenation<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Complications<br />
• Hypoxia<br />
• Bronchospasm<br />
• Hypertension<br />
• Bradycardia & Hypotension<br />
• ICP<br />
• Infection<br />
• Mucosal trauma<br />
• Atelectasis, Pneumothorax<br />
• Distress<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Cl<strong>in</strong>ical Recommendations<br />
• Preoxigenation<br />
• Catheter selection / depth of <strong>in</strong>sertion<br />
• Vacuum pressure / frequency / duration<br />
• Technique (open, <strong>in</strong>l<strong>in</strong>e, sal<strong>in</strong>e lavage)<br />
• Hygiene<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Recommendations – Preoxigenation<br />
Optimal degree and duration unknown<br />
• 10 % FiO 2 / 2 m<strong>in</strong> Skov L et al. 1992, Gonzales et al. 2005<br />
• 10 – 20 % FiO 2 / 1 m<strong>in</strong> Hodge D et al. 1991<br />
• 100 % O 2 / >30 sec Branson RD et al. 1993<br />
Due to known risks of hyperoxia return to<br />
pre<strong>suction<strong>in</strong>g</strong> levels as soon as SaO 2 has<br />
stabilised!<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Recommendations – Suction<strong>in</strong>g Catheter<br />
Catheter Size Selection<br />
• big enough, to effectively remove thick<br />
secretions but<br />
• not so big, that tube is occluded Morrow et al. 2004<br />
• best results - 0,7: 1 S<strong>in</strong>gh NC et al. 1991<br />
• Insertion with help of graduation<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Recommendations – Hygiene<br />
Open <strong>suction<strong>in</strong>g</strong>: standard precautions for<br />
<strong>in</strong>fection prevention, no strict sterility Siegel JD 2002<br />
• Dis<strong>in</strong>fection of hands before/after procedure<br />
• Gloves, clean or sterile<br />
• Mouth/eye protection, gown<br />
Re-us<strong>in</strong>g suction catheter does not affect the<br />
<strong>in</strong>cidence of nosocomial pneumonia Scoble et al. 2001<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Recommendations – Vacuum Pressure<br />
Lack of high level evidence for an optimal,<br />
safe and effective suction level<br />
• 360mmHg effective (<strong>in</strong> vitro) Morrow et al. 2007<br />
• Mucosal damage at 100 mmHg Kuzenski et al. 1978<br />
__________________________________<br />
1 bar = 750,06 mmHg<br />
0,2 bar = 150,01 mmHg<br />
0,48 bar = 360 mmHg<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Recommendations – Duration<br />
Open <strong>suction<strong>in</strong>g</strong>:<br />
• whole procedure 10 – 15 sec Branson et al. 1993<br />
• actual <strong>suction<strong>in</strong>g</strong> time < 5 sec Runton et al. 1992<br />
Closed <strong>suction<strong>in</strong>g</strong>:<br />
• 2 sec cycles activation of suction<br />
• provide adequate MV<br />
• no limitation <strong>in</strong> time<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Closed System Suction<strong>in</strong>g<br />
Advantages<br />
• Reduced loss <strong>in</strong> lung volume<br />
• M<strong>in</strong>imized hypoxia, esp. <strong>in</strong> Neonatology<br />
• Reduced hemodynamic <strong>in</strong>stability<br />
Woodgate 2003, Kalyn et al. 2003, Choong et al. 2003<br />
• Reduced cross contam<strong>in</strong>ation Siegel JD 2002<br />
• better tolerability by patients Cordero et al. 2000<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Closed Suction<strong>in</strong>g Systems<br />
Nurs<strong>in</strong>g Perceptions<br />
• easier to perform<br />
• less time-consum<strong>in</strong>g<br />
• ma<strong>in</strong>ta<strong>in</strong>s better physiologic stability<br />
Cordero et al. 2000<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Sal<strong>in</strong>e <strong>in</strong>stillation<br />
• sal<strong>in</strong>e as secretion harmful Demers et al. 1973<br />
• transport of contam<strong>in</strong>ated material<br />
<strong>in</strong> lower respiratory tract (VAP) Freytag et al. 2003<br />
• Patient distress - adverse effects on<br />
oxygenation <strong>in</strong> adult and paediatric studies<br />
• significantly greater oxygen desaturation <strong>in</strong> NICU<br />
Ridl<strong>in</strong>g D. et al. 2003<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Recommendations<br />
“It is proposed that after years of<br />
<strong>in</strong>consistent practice <strong>in</strong> try<strong>in</strong>g to remove thick<br />
and tenacious secretions, it is time to focus<br />
on ways to prevent thick and tenacious<br />
secretions”<br />
Dr. Bronagh Blackwood<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Recommendations – Sal<strong>in</strong>e<br />
• Adequate hydration<br />
• Humidification of ventilation circuit<br />
• Nebulizer<br />
• Mucolytica<br />
• NEVER use sal<strong>in</strong>e for <strong>suction<strong>in</strong>g</strong><br />
rout<strong>in</strong>ely<br />
Ridl<strong>in</strong>g et al. 2003<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Conclusion<br />
Preoxigenation<br />
Optimal degree and duration unknown<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Conclusion<br />
Vacuum Pressure<br />
High enough to remove secretions<br />
But not so high that it causes mucosal<br />
damage<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Conclusion<br />
Selection of Suction<strong>in</strong>g Catheter<br />
Catheter should be large enough to<br />
effectively remove thick secretions but<br />
not so large that ETT is occluded<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Conclusion<br />
Frequency of Suction<strong>in</strong>g<br />
• Suction<strong>in</strong>g on cl<strong>in</strong>ical <strong>in</strong>dication<br />
• No rout<strong>in</strong>e <strong>suction<strong>in</strong>g</strong><br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Conclusion<br />
Hygiene<br />
• Standard precautions for <strong>in</strong>fection control<br />
• no strict sterility necessary<br />
• Instillation of sal<strong>in</strong>e solution <strong>in</strong>creases risk of<br />
nosocomial pneumonia (VAP) and<br />
• has adverse effects on oxigenation<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Conclusion<br />
Suction<strong>in</strong>g Systems<br />
In PIC & NIC closed <strong>suction<strong>in</strong>g</strong><br />
systems are preferable to<br />
the open technique<br />
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Zentrum für K<strong>in</strong>der- u. Jugendmediz<strong>in</strong><br />
Thank you very much for your<br />
attention<br />
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