Mechanical Ventilation and Saline Instillation

Mechanical Ventilation
and the Role of Saline
Instillation in Suctioning
Adult Intensive Care
Unit Patients
An Evidence-Based Practice Review
Alyssa Camille S. Caparros, BSN, RN, PCCN, MSN-AGACNP-BC;
Alison Forbes, MSN, ACNP-BC, CCRN

Background: Saline instillation in suctioning mechanically ventilated

patients remains a common practice in the intensive care unit (ICU). Many
respiratory therapists and nurses are using saline with suctioning
without an adequate knowledge of the current evidence-based research
to guide this practice.
Objectives: The purpose of this study was to determine if this routine
method is beneficial or harmful to the patients and provide evidence-based
practice recommendations that will serve as a guide for practice.
Methods: This is a comprehensive review on the use of saline instillation in
suctioning mechanically ventilated adult ICU patients. Database such as
CINAHL, MEDLINE, Cochrane, PsycINFO, and national guidelines are
extracted for the review of literature. The study population consists of
patients 18 years or older, who are intubated or have a tracheostomy in
place, requiring mechanical ventilation, and who are admitted in the ICU.
Results: Although most of the evidence suggests not to use saline when
suctioning, there are various limitations to the studies such as small
sample size, settings, inconsistencies in data collection, or not enough
or outdated research clinical trials, which calls for further studies.
Conclusion: This study does not support the use of saline instillation
when suctioning an artificial airway. Further clinical trials are crucial to
effectively determine if saline instillation use with suctioning an artificial
airway is deemed harmful, which can be strictly enforced as a mandatory

246 Dimensions of Critical Care Nursing Vol. 33 / No. 4 DOI: 10.1097/DCC.0000000000000049

Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.


clinical guideline for all hospitals to include in their standardized protocol
to not use saline instillation with suctioning.
Keywords: Mechanical ventilation, Saline instillation, Suction
[DIMENS CRIT CARE NURS. 2014;33(4):246/253]
Respiratory failure is one of the most frequent causes of
admission or longer stay in acute care settings. It is usually
accompanied by a variety of medical problems, such as stroke
and other neurological conditions, cardiovascular disease,
and respiratory disorders. Patients with acute respiratory
failure require urgent medical attention by the health care
team to prevent further deterioration that can eventually lead
to mortality. With medical advancement, mortality can be
prevented if interventions are quickly and properly provided.
Endotracheal tube (ETT) intubation and tracheostomy tube
(TT) are the most commonly used advanced artificial air-
ways in managing respiratory failure. Intubated or trache-
ostomy patients are placed on a mechanical ventilator. These
patients are critically ill and require close monitoring by
the health care providers and are usually transferred to the
intensive care unit (ICU) for further management. The nurses
who are providing direct care to patients on mechanical
ventilation (MV) carefully assess for signs of respiratory
complications such as ventilator-associated pneumonia (VAP).
Oral suctioning and tracheal suctioning are crucial nursing
interventions to prevent VAP. Hemodynamic changes can
also occur during suctioning of these patients. Nurses pro-
vide judicious patient care, and they monitor for any changes
in the patients status so they can quickly and accurately
respond to any situations that may arise.
BACKGROUND OF MECHANICAL VENTILATION
Artificial Airways
It is important to assess the ability to secure the airway of
the patient in managing acute and life-threatening con-
ditions or injuries. Artificial airways such as endotracheal
tube and TT are placed when there is compromised
ventilation. 1
ENDOTRACHEAL TUBE
Endotracheal tube intubation is performed during emer-
gency situations such as acute respiratory failure or inability
of the patient to maintain a patent airway. Endotracheal
tube intubation requires a cricoid pressure by placing the
thumb and the index fingers on the cricoid cartilage. This
will compress the esophagus to reduce the risk for gas-
tric aspiration during the intubation.1 The ETT is placed
by a qualified provider, and placement is confirmed by a
chest radiograph. The ETT balloon should be inflated that
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Mechanical Ventilation and Saline Instillation
is enough to provide a seal and secure the airway, and the
pressure should not exceed 15 to 25 mm Hg, which can be
measured by using the cuff manometer.1
The internal diameter of the ETT is 8 to 9 mm for men
and 7 to 8 mm for women. The end of the inserted ETT is
positioned at 2 cm above the carina, the site of tracheal
bifurcation.1 Securing the ETT is critical when placement
is verified, to prevent from dislodging or moving.1 Endo-
tracheal tube placement is assessed by the nurses and the
respiratory therapists (RTs) every shift or in accordance to
the hospital protocol.
TRACHEOSTOMY TUBE
A tracheostomy is a surgical opening of the tracheal an-
terior wall through the neck area. This opening is made at
the second or third cartilaginous ring level and is kept patent
by inserting a TT. Indications for placing a permanent TT
are (a) to maintain the airway because the normal mech-
anism to maintain the airway has been compromised, (b)
to facilitate long-term means of ventilatory support for
patients with respiratory failure by MV, (c) elective or emer-
gency surgery for tracheostomy placement for head or neck
trauma, and (d) to minimize the risk of aspiration from
inability to swallow or absence of the laryngeal reflex.2
The type and size of the TTs depend on the patients
needs, reasons for placement, and the size of the patients
trachea. Tracheostomy tubes can be disposable or nondis-
posable. Caring for this patient population is based on
managing the airway while maintaining the safety of the
patients and preventing complications. Patients with a
TT are not able to talk or make any sound because the
TT is placed beneath the vocal cords. A speaker valve can
be used after passing speech therapy evaluation for any
risk of aspiration.2 In acute care setting, most patients with
TTs have disposable inner cannulas, which are changed
every shift and as needed depending on the secretions. For
nondisposable TTs, a tracheostomy kit can be used to clean
the inner tube. Tracheostomy care is done by the nurses or
RTs depending on the hospital policy, and the tracheos-
tomy site should be assessed regularly.
Mechanical Ventilation
Mechanical ventilation is one of the most common inter-
ventions in the ICU. It is a supportive intervention used
until the underlying physical issue has been resolved. Patients
July/August 2014 247
 Mechanical Ventilation and Saline Instillation

on MV decrease their work of breathing, relieve respira-
tory distress, rest the fatigued respiratory muscles, improve
ventilation, stabilize the chest wall, and restore the acid-base
balance.3
Patients on Mechanical Ventilation
Patients on MV have the potential to develop hemody-
namic instability. The need for MV is the patients common
feature requiring admission to the ICU.4 Choosing settings
for MV requires balance between oxygen delivery, removal
of carbon dioxide, and prevention of respiratory injury re-
lated to trauma. Inappropriate and inaccurate ventilatory
support strategy can result to increase mortality. Therefore,
many ventilatory techniques have been presented in stan-
dardizing the selection process of the ventilation settings
(Table).5
Suctioning Type and Routine
Many hospitals have implemented standard order sets and
guidelines in managing MV. Respiratory therapists are the
experts in providing respiratory care to patients. They have
the extensive knowledge on many pathophysiologies that
necessitate MV and the pharmacology used in managing
ICU patients who are mechanically ventilated. Respiratory
therapists are competent in controlling MV settings and
are also able to interpret laboratory results and make ap-
propriate adjustments that affect the care of these patients.7
They have the capability to develop and implement guide-
lines that support the application of MV management.
They assess the patients for any deviation and monitor for
signs of respiratory distress and are prepared for any sudden
change in the patients respiratory status and apply appro-
priate and rapid measures in managing potential acute events.
Physicians, nurses, RTs, physical therapists, care assistants,
and other allied health care personnel work as a team in
providing care to these patients.
OPEN SUCTIONING
This requires disconnecting the ETT or TT from the me-
chanical ventilator, which can result in significant loss of
lung volume, and is followed by applying the suction that
can further exacerbate the derecruitment of the lungs.8

TABLE Modes of Ventilation

Controlled mandatory
ventilation
Synchronized intermittent
mandatory ventilation
Assist control ventilation
Pressure support ventilation
Positive end-expiratory pressure
Modes of Ventilation
This delivers preset tidal volumes and
respiratory rate in patients with
no spontaneous breathing.1
This allows the mechanical ventilator to
detect the patients own breathing and
allows for spontaneous breathing
between the ventilator breaths. This
mode also provides a ventilator assist
to the patients own breath and can
be used to facilitate weaning.1
The patient receives a set of tidal volume
at a set rate. The patient can add
spontaneous breaths but only gets a
set tidal volume with each spontaneous
breath.1
This is used to assist with spontaneous
breaths. The patient initiates a breath,
and the mechanical ventilator is triggered
to deliver a pressure support to that
breath to a preset pressure to support the
patients breathing. This mode requires
the patient to have spontaneous breathing.1
This is not an actual ventilation mode but
serves as an important ventilation concept.
Patients airway is being kept open
above atmospheric pressure at the end
of expiration.6
CLOSED SUCTIONING
Disconnecting the ETT or TT from the mechanical venti-
lator is not required, allowing for a continued tidal volume
delivery and minimize lung volume loss. Closed suctioning
is recommended in patients with acute lung injury or acute
respiratory distress syndrome because they can have al-
veolar derecruitment that can be seen during suctioning
the patients.8
Suctioning is important in maintaining patency and
managing tracheal secretions. Tracheal suctioning can be
distressing for the patients and can cause hemodynamic
changes such as hypoxemia, arrhythmias, atelectasis, tra-
cheal mucosal injury, bleeding, and infection.2
Mechanical Ventilation and Hospital-Acquired
Infection
Ventilator-associated pneumonia is the most common hospital-
associated infection in mechanically ventilated patients. In-
cidence currently ranges from 2 to 22 episodes per 1000
ventilator days. Ventilator-associated pneumonia mean inci-
dence is 2.8 in the United States.9 Ventilator-associated
pneumonia is defined as a type of hospital-acquired pneu-
monia that occurs in patients that are on MV support at
the time of the diagnosis of pneumonia or within 48 hours
of having been placed on MV.10
Ventilator-associated pneumonia pathogenesis involves
aspiration of the bacterial organisms from the oropharynx
into the lungs and subsequently causes failure of the defense

248 Dimensions of Critical Care Nursing Vol. 33 / No. 4

Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.


system of the patients in clearing the bacteria, which leads
to the development of a lung infection such as VAP.11
Mechanical ventilation for airway support can be a
source of infection. It is an important part in intensive
care provision for patients who are acutely and critically
ill. Although it is beneficial to patients, it can impair the
clearance of mucociliary process, causing retention of se-
cretions, occlusion of the airway, atelectasis, and pneu-
monia.12 Aspiration of orapharyngeal secretions that are
contaminated can lead to the development of VAP. These
secretions pool above the TT cuff and eventually enter
into the lower respiratory tract through the leaking around
the cuff of the TT.9
Ventilator-associated pneumonia can worsen gas ex-
change, increase the load of secretions, and can potentially
lead to deterioration of the function of other body organs
such as the heart. Complications can delay the weaning
process, prolong hospital stay, and increase mortality, which
can result in higher costs of health care. Ventilator-associated
pneumonia is associated with increase in morbidity, MV
duration, and length and cost of stay in the hospital. Most
hospitals have developed clinical preventive care strategies
called the care bundles, which showed effective reduc-
tion rate in VAP. Many preventive measures such as oral
care routine with an antiseptic solution and elevation of
the head of the bed are being implemented to prevent VAP.
Chlorhexidine oral decontamination is also a widely re-
searched strategy that can help in preventing VAP.9,13
Ventilator-associated pneumonia prevention is a pri-
ority to improve patient care and safety. There is a high
morbidity and mortality rate that is associated with VAP
and in an effort to address this issue, the Centers for
Disease Control and Prevention has developed a guideline
for preventing VAP. Ventilator-associated pneumonia
bundles were implemented to help reduce the incidence
of VAP.14
DIAGNOSIS OF VAP
Ventilator-associated pneumonia is suspected clinically
based on the presence of elevated temperature more than
38.3o C, white blood count more than 10000/mm3 or
less than 4000/mm3, purulent secretions, new or persistent
pulmonary infiltrate in the chest radiograph, and positive
sputum culture and gram stain.10
RESPIRATORY CULTURES
There are many bacterial pathogens that can cause respi-
ratory infections. The major potential respiratory bacterial
organisms include Pseudomonas aeruginosa, Staphylococcus
aureus, Acinetobacter species, and enteric species.11 A speci-
men sample from the lower respiratory tract is obtained
when VAP is suspected. This involves a specimen collec-
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Mechanical Ventilation and Saline Instillation
tion through suctioning the ETT or TT by using a sterile
suction catheter. The specimen is withdrawn and sent to
the laboratory for quantitative bacteriology. The presence
of more than 10000 colony-forming units per milliliter of
target pulmonary respiratory pathogens in minibron-
choalveolar lavage fluid or a positive culture is considered
to be a positive finding for the diagnosis of VAP.11 As soon
as the sputum culture identifies a pathogen and not colo-
nization, specific antibiotic treatment should be initiated.15
CHEST RADIOGRAPH
The presence of pulmonary infiltrates that are not symmet-
rical on a chest radiograph that is consistent with VAP
may be sometimes caused by other noninfectious condi-
tions. However, some chest radiograph findings such as
fast cavitation of pulmonary infiltrate that is progressive,
air space process that is joining a fissure, bronchogram that
is a single air are associated with 96% specific for VAP diag-
nosis and can be used reliably.10
EVIDENCE PRACTICE REVIEW
The purpose of this study was to determine if the routine
method of saline instillation prior to suctioning the mechan-
ically ventilated patients is beneficial or harmful to patients.
In addition, our goal was to provide evidence-based practice
recommendations that will serve as a guide for nursing and
respiratory care practice.
A comprehensive review on the use of saline instil-
lation in suctioning mechanically ventilated adult ICU pa-
tients was conducted using databases such as CINAHL,
MEDLINE, Cochrane, PsycINFO, and national guidelines
for the review of literature. Materials reviewed included
only studies of patients 18 years or older, who are intubated
or have a tracheostomy in place, requiring MV, and who
are admitted in the ICU.
FINDINGS AND RESULTS
Extensive efforts are underway to reduce VAP, which sig-
nificantly increases the total number of ventilator-dependent
days, overall mortality, and medical costs. Evidence-based
research studies were analyzed on aspects of caring for the
mechanically ventilated patients, including the use of saline
installation in general and specialty ICU populations in
international settings. Recently, Mei-Yu et al16 conducted
an evidence-based research study approach to examine
the relationship of saline instillation and VAP in the ICU.
Ventilator-associated pneumonia incidence rates were com-
pared between patients receiving normal saline instillation
(NSI) and patients who did not receive NSI with ETT suc-
tioning. Data on NSI use were gathered for 6 months and
July/August 2014 249
 Mechanical Ventilation and Saline Instillation
followed by data collection without using NSI. It was found
that the VAP incidence rate on NSI use with suctioning is
statistically significant. Not using NSI was found to decrease
VAP incidence rate significantly.16
This concept is consistent with and supported by ear-
lier work by Hagler and Traver,17 who found that a 5-mL
NSI dislodged up to 310000 of viable colonies of bacteria.
The potential risk for infection that is caused by dislodging
the bacteria into the lower respiratory tract is added evi-
dence that the routine use of NSI when suctioning should
not be performed.17
Conversely, Caruso and colleagues18 conducted a ran-
domized clinical trial in a closed medical surgical ICU in a
tertiary oncology hospital. Patients were divided into 2 groups.
The first group used suctioning without saline (control group),
and the second group used 8 mL of isotonic solution in-
stilled prior to each tracheal suctioning (saline group). In this
study, the instillation of an isotonic saline prior to tracheal
suctioning reduced the occurrence of microbiologically proven
VAP. The rates of ETT occlusion and atelectasis were similar
between the 2 groups.18
This study prompted debate as Kleinpell19 provided a
commentary about Caruso and colleagues study findings,
noting that evidence from a vast number of research studies
showed that the routine use of NSI prior to suctioning is not
a recommended practice for mechanically ventilated patients.
The findings from Caruso and colleagues are significantly
different from the results of other studies and must be cau-
tiously interpreted because of a number of limitations, such
as the use of an oncology patient population that are dif-
ferent from the general ICU patients with regard to the
occurrence of VAP, pretreatment of antibiotics, immuno-
suppression, and mortality. Kleinpell calls for further re-
search before this practice can be recommended for routine
use in ICU patients.
Normal saline instillation in preparation to suctioning
the airway is commonly used to help remove thick respi-
ratory secretion; however, Christensen et al20 report that
the use of saline can damage the antimicrobial properties
of the respiratory secretions. Their findings suggest that nasal
and tracheal secretions and saliva have natural antimicrobial
properties that can be damaged by instilling concentrations
of sodium and chloride in the normal saline.20
Maggiore and colleagues21 discuss the risk for alteration
in hemodynamics during suctioning with NSI that may result
in complications, mainly oxygen desaturation and bloody
secretions. Normal saline instillation can be used in open
or closed suctioning and has been used by the health care
professionals who believed it would increase the yield of the
sputum by diluting and loosening the secretions, stimulate
the cough, and lubricate the suction catheter. However,
studies are conflicting about the safety and efficacy of
using NSI contrary to these common beliefs.22,23
250 Dimensions of Critical Care Nursing Vol. 33 / No. 4
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
It is believed that it can result to hypoxemia, broncho-
spasm, cardiac and respiratory arrest, infection, and no
improvement in oxygenation or secretion yield.23 A recent
systematic review23 aimed to investigate the safety and ef-
ficacy of NSI technique prior to airway suctioning. It was
found out that there is no evidence that NSI is harmful
to the patients based on hemodynamic changes, gas ex-
change, increased dyspnea, or respiratory distress. Although
there was some weak research result linking the use of
NSI and VAP, further methodological research studies are
warranted.23
Rauen and colleagues24 found in most experimental
studies that SPO2 was significantly decreased with NSI, or
there is no difference in SPO2 with NSI and no saline use.
One interesting finding that they found in their systematic
review was that there were some indications of a reduction
in SPO2 after NSI prior to suctioning, and the return to
baseline SPO2 levels did not occur until at least 3 to 5 minutes
after the suctioning was completed.24
Secretion Production
In regard to secretions, although there is a claimed benefit
of NSI in the improved secretion removal, Rauen et al
report that there are no adequately reported research studies
to support this practice. This is partly due to the problems
that are associated with the methodological process with the
measuring of the secretion amounts in clinical research
studies, which calls for further studies to find out the best
way to quantify the amount of secretion removal when
using NSI prior to suctioning.24
These recent studies contradict earlier work, in 1990
when Gray et al25 reported that NSI resulted in an en-
hanced clearance of secretions by stimulating the cough,
and the effects on hemodynamics, respiratory mechanisms,
exchange of gas, and patient comfort were not significantly
different compared to suctioning without NSI. Similar re-
sult was reported in a small group of intubated adult pa-
tients when NSI was done during chest physiotherapy and
resulted in an increased sputum weight and no adverse ef-
fects on SPO2.26
A recent study from the British Journal of Nursing
also reports that NSI with suctioning mechanically venti-
lated patients appears to remove a greater amount of re-
spiratory secretions compared to not using NSI. However,
the study cautions that this finding is considered contro-
versial because the increase in weight of the suctioned se-
cretions can be attributed to the NSI.27
Dyspnea
One study in 200128 compared the level of dyspnea with
and without using a 5-mL NSI before ET suctioning using

a crossover, quasi-experimental study design. Using the
vertical visual analogue scale, patients (17 alert adults who
are mechanically ventilated) were asked to rank their dys-
pnea level. Saline was randomly instilled before 1 of 2 suc-
tioning. This study showed no beneficial effects of using
saline. However, it demonstrated that NSI precipitated a
significant increase in the level of dyspnea up to 10 minutes
after suctioning in patients older than 60 years.28
Vital Signs
Maggiore and colleagues found that ET suctioning can
cause decrease in SPO2 by 5%, trauma or bleeding with
blood visible in suctioning secretions, increased blood pres-
sure to 200 mm Hg or decreased blood pressure to 80 mm Hg,
increased heart rate (HR) to 150 beats/min or decreased HR
to 50 beats/min, and arrhythmias such as supraventicular
or ventricular tachycardias.21
Iranmanesh and Rafiei29 studied the effect of NSI on the
SPO2, HR, and cardiac rhythm of multiple trauma patients.
A crossover design was conducted with 50 multiple trauma
patients who were admitted to ICU and were mechanically
ventilated for more than 24 hours. Subjects were selected
randomly to suctioning with or without the use of NSI.
Results indicated that NSI when suctioning can cause po-
tential adverse effects on SPO2, but results in no effect on
the HR or cardiac rhythm. Educational programs should
be provided to the nurses and RTs to help improve their
knowledge on the disadvantages of using NSI when suc-
tioning an artificial airway.29
Current Guidelines
The national guidelines from the American Association for
Respiratory Care30 provide recommendations on ET suc-
tioning. These include (a) suction the ET only when there
are secretions present; (b) preoxygenate the patients with
decreased SPO2 when suctioning; (c) do not disconnect the
patient from the mechanical ventilator when suctioning;
(d) use shallow suctioning than deep suctioning; (e) use closed
suctioning for adult patients with high FIO2 or positive end-
expiratory pressure, or those at risk for lung derecruit-
ment; (f ) routine use of NSI before ET suctioning is not
recommended; and (g) suctioning duration should be limited
to less than 15 seconds.30 The Agency for Healthcare Re-
search and Quality updates the current guidelines (the pre-
vious version of the American Association for Respiratory
Care clinical practice guidelines)31 to include similar recom-
mendations and interventions such as preoxygenation,
shallow suctioning technique, sterile technique during open
suctioning, using lung recruitment maneuvers, suction du-
ration of less than 15 seconds, and monitoring of the pa-
tient.31 It is also noted that deep suctioning and NSI prior
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Mechanical Ventilation and Saline Instillation
to ET suctioning may be considered but are not recom-
mended. The report cautions that NSI is hypothesized to
loosen secretions, increase the amount of secretion re-
moval, and help in the removal of tenacious secretions.
However, evidence is lacking to support this. The majority
of the studies used to update this current guideline indicate
that NSI is not likely to be beneficial and may be harmful
to the patients. Therefore, NSI with suctioning is not re-
commended to be routinely performed, and the potential
danger of the routine use of NSI may be associated with
adverse events such as excessive coughing, decreased SPO2,
bronchospasm, tachycardia, pain and dyspnea, and increased
intracranial pressure.31
The guidelines on routine practice of suctioning mechan-
ically ventilated patients are not consistent with routine
use of saline instillation, as the efficacy of NSI is not sup-
ported by research-based evidence. This practice may pro-
vide no physiological benefits and may have effects that can
be detrimental.32 However, NSI continues to be used in
practice and requires additional study to establish its safety
and effectiveness. Although the use of NSI is a routine clin-
ical practice in some ICUs, its negative effects and ques-
tionable benefits on the amount of suctioned secretions
should encourage the nurses or RTs to not apply this tech-
nique and reconsider the practice and should not be a
routine method in suctioning patients with an artificial
airway for removal of respiratory secretions.27
Maggiore and colleagues21 follow clinical guidelines
for ETT suctioning, as the use of NSI is avoided. They
recommend a heated humidifier for patients with dry and
tenacious secretions. If mucous plug is suspected, suction-
ing under the direct visualization of fiberoptic bronchos-
copy should be performed.21
Rauen and colleagues24 also support these national
guidelines and report that recent evidence provides a unan-
imous recommendation that NSI should not be a routine
practice with suctioning.
CONCLUSION AND RECOMMENDATIONS
Patients on MV are at high risk for many complications
such as infection (ie, VAP) and hemodynamic changes.
Clinical routine practice of NSI with suctioning an arti-
ficial airway is being done on a daily basis without having
a clear evidence-based clinical guideline to support its prac-
tice. This can cause many potential complications especially
to those patients who are already critical or unstable in
terms of their medical conditions. This study found out that
suctioning an artificial airway with the use NSI can pose
great risks to the patients. It can cause complications such as
VAP and hemodynamic changes that are not favorable to
the patients recovering process. This review does not en-
dorse the use of NSI when suctioning a patient with an
July/August 2014 251
 Mechanical Ventilation and Saline Instillation
artificial airway. Education should be provided to every
health care provider regarding the effects of using NSI when
suctioning and how it can cause further harm to the pa-
tients. It is prudent advice from researchers such as Rauen
and colleagues, who reminds us that there is no credible
and scientific research information that supports this prac-
tice. There are no known studies that have shown that
NSI is beneficial, and in addition to its lack of theoretical
benefits, researchers found it to be detrimental to the
patients.24
Implementing clinical guidelines is crucial in order to
maintain the safety of all patients. Although most of the
evidence suggests not to use NSI when suctioning, there
are various limitations to the studies done such as small
sample size, settings, inconsistencies in data collection, or
not enough or outdated research clinical trials, which calls
for further research studies. Therefore, extensive clinical
trials are recommended to effectively determine if NSI with
suctioning an artificial airway is indeed harmful, and
adherence to national clinical guidelines should be strictly
enforced nationwide for all hospitals to include in their
standardized protocol to not use NSI with suctioning.
Acknowledgments
I would like to extend my deepest gratitude to all the
people who have helped me with this paper. First, I
would like to thank my professor, Dr Thomas Barkley,
for being a great mentor and an advocate for ACNP
students. Thank you for helping me structure my research
topic and for guiding me with writing this article. I would
like to thank my clinical instructor, Alison Forbes, ACNP,
who served as my advisor, assisting me with the revision
and provided comments on how to better organize my
article. I would also like to thank Kevin Quinonez, RT,
for being an expert with regard to respiratory care and
provided his professional and own personal stance
about the article. Lastly, I would like to express my
warmest appreciation to the editor-in-chief of the
DCCN journal, Kathleen Ahern Gould, PhD, RN, for
the professional feedback and the guidance to make
this article possible.
References
1. Higginson R, Parry A. Emergency airway management: com-
mon ventilation techniques. Br J Nurs. 2013;22(7):366-371.
2. Barnett M. Back to basics: caring for people with a tracheostomy.
Nurs Residential Care. 2012;14(8):390.
3. Kane C, York NL. Understanding the alphabet soup of mechanical
ventilation. Dimens Crit Care Nurs. 2012;31(4):217-222.
4. Kacmarek RM. The mechanical ventilator: past, present, and
future. Respir Care. 2011;56(8):1170-1180.
5. Allerd C, Karbing DS, Thorgaard P, Andreassen S, Kjrgaard S,
Rees SE. Variability of preference toward mechanical ventilator
252 Dimensions of Critical Care Nursing Vol. 33 / No. 4
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
settings: a model-based behavioral analysis. J Crit Care. 2011;
26(6):637.e5-637.e12.
6. Meyer T. Mechanical ventilatory support. In: Barkley TW,
Myers CM, ed. Practice Guidelines for Acute Care Nurse Prac-
titioners. 2nd ed. St Louis, MO: Elsevier Health Sciences; 2008:
335-343.
7. Kacmarek RM. Mechanical ventilation competencies of the
respiratory therapist in 2015 and beyond. Respir Care. 2013;58(6):
1087-1092.
8. Corley A, Spooner AJ, Barnett AG, Caruana LR, Hammond NE,
Fraser JF. End-expiratory lung volume recovers more slowly
after closed endotracheal suctioning than after open suctioning: a
randomized crossover study. J Crit Care. 2012;27(6):742.e1-742.e7.
9. Rouze A, Nseir S. Continuous control of tracheal cuff pressure
for the prevention of ventilator-associated pneumonia in critically
ill patients: where is the evidence?. Curr Opin Crit Care. 2013;
19(5):440-447.
10. Joseph N, Sistla S, Dutta T, Badhe A, Parija SC. Role of clinical
diagnosis of ventilator-associated pneumonia. Am J Infect Control.
2013;41(5):471.
11. Ozcaka OO, Bas$oglu OK, Buduneli NN, Tas$bakan MS, Bacakoglu
FF, Kinane DF. Chlorhexidine decreases the risk of ventilator-
associated pneumonia in intensive care unit patients: a random-
ized clinical trial. J Periodontal Res. 2012;47(5):584-592.
12. Ntoumenopoulos G, Shannon H, Main E. Do commonly used
ventilator settings for mechanically ventilated adults have the
potential to embed secretions or promote clearance?. Respir Care.
2011;56(12):1887-1892.
13. Walsh TS, Morris AC, Simpson AJ. Ventilator associated pneu-
monia: can we ensure that a quality indicator does not become a
game of chance? Br J Anaesth. 2013;111(3):333-337.
14. Kjonegaard R, Fields W, King M. Current practice in airway
management: a descriptive evaluation. Am J Crit Care. 2010;19(2):
168-174.
15. Ahrens TS, Prentice D, Kleinpell RM. Progressive Care Nursing
Certification: Preparation, Review, and Practice Exams. New York,
NY: McGraw-Hill Professional; 2011.
16. Mei-Yu L, Shu-Hua C, Yi-Hui S. Reducing ventilator-associated
pneumonia (VAP) by not using instillation saline before suctioning
[in Chinese]. J Nurs Healthc Res. 2012;8(4):325-331.
17. Hagler D, Traver G. Endotracheal saline and suction catheters:
sources of lower airway contamination. Am J Crit Care. 1994;
3(6):444-447.
18. Caruso P, Denari S, Ruiz S, Demarzo S, Deheinzelin D. Saline
instillation before tracheal suctioning decreases the incidence
of ventilator-associated pneumonia. Crit Care Med. 2009;37(1):
32-38.
19. Kleinpell R. Use of normal saline instillation with suctioning:
the debate continues. Crit Care Alert. 2009;17(1):1-2.
20. Christensen R, Henry E, Eggert L, et al. A low-sodium solution
for airway care: results of a multicenter trial. Respir Care. 2010;
55(12):1680-1685.
21. Maggiore S, Lellouche F, Brochard L, et al. Decreasing the adverse
effects of endotracheal suctioning during mechanical ventilation
by changing practice. Respir Care. 2013;58(10):1588-1597.
22. Briening E. The effects of saline instillation prior to endotra-
cheal suctioning. Online J Knowl Synth Nurs. 1996;3(doc 9, online
#33):1.
23. Paratz J, Stockton K. Efficacy and safety of normal saline instil-
lation: a systematic review. Physiotherapy. 2009;95(4):241-250.
24. Rauen C, Chulay M, Bridges E, Vollman K, Arbour R. Seven
evidence-based practice habits: putting some sacred cows out to
pasture. Crit Care Nurse. 2008;28(2):98-102, 104-110, 112-118.
25. Gray J, MacIntyre N, Kronenberger W. The effects of bolus
normal-saline instillation in conjunction with endotracheal suc-
tioning. Respir Care. 1990;35(8):785-790.
26. Schreuder F, Jones U. The effect of saline instillation on spu-
tum yield and oxygen saturation measurement in adult intu-
bated patients: single subject design. Physiotherapy. 2004;
90(2):109.
 Mechanical Ventilation and Saline Instillation

27. Giakoumidakis K, Kostaki Z, Patelarou E, Baltopoulos G, ABOUT THE AUTHORS

Brokalaki H. Oxygen saturation and secretion weight after en-
dotracheal suctioning. Br J Nurs. 2011;20(21):1344-1351.
28. ONeal P, Grap M, Thompson C, Dudley W. Level of dyspnoea
experienced in mechanically ventilated adults with and without
saline instillation prior to endotracheal suctioning. Intensive Crit
Care Nurs. 2001;17(6):356-363.
29. Iranmanesh S, Rafiei H. Normal saline instillation with suc-
tioning and its effect on oxygen saturation, heart rate, and
cardiac rhythm. Int J Nurs Educ. 2011;3(1):42-44.
30. American Association for Respiratory Care. AARC clinical
practice guidelines: endotracheal suctioning of mechanically ven-
tilated patients with artificial airways 2010. Respir Care. 2010;
55(6):758-764.
31. Agency for Healthcare Research and Quality. Guideline title:
endotracheal suctioning of mechanically ventilated patients with
artificial airways. 2010. http://www.guideline.gov/content.aspx?
id=23992. Accessed March 27, 2014.
32. Blackwood B. Normal saline instillation with endotracheal suc-
tioning: primum non nocere (first do no harm). J Adv Nurs.
1999;29(4):928-934.
Alyssa Camille S. Caparros, BSN, RN, PCCN, MSN-AGACNP-BC,
received her BS Nursing degree on 2008 from the Philippines. She is
currently working at UCLA Medical Center as a registered nurse. She has
been working as a nurse for 5 years now, moving around different acute
care areas such as medical surgical, telemetry stepdown, and ICU. Her
experience evolve around adult and gerontology care and interest in
cardiopulmonary patients. She is a recent graduate from California
State University Los Angeles with a degree in MSN AGACNP.
Alison Forbes, MSN, ACNP-BC, CCRN, works as clinical faculty at
California State University Los Angeles, and ACNP in Trauma/Acute
Care Surgery at Harbor UCLA Medical Center.
The authors have disclosed that they have no significant relationships with, or
financial interest in, any commercial companies pertaining to this article.
Address correspondence and reprint requests to: Alyssa Camille S. Caparros,
BSN, RN, PCCN, MSN-AGACNP, California State University Los Angeles,
5151 State University Dr, Los Angeles, CA 90032 (Lyscaparros@gmail.com).

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DOI: 10.1097/01.DCC.0000445945.09909.cf

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