The

Instillment
of Saline in
Suctioning
Group D

PICOT Question
During endotracheal (ET) or tracheostomy tube suctioning, does the utilization of
saline increase the efficacy of extracting secretions when compared with traditional
dry suctioning in hospitalized patients that have either an endotracheal or
tracheostomy tube?
PICOT:
P Patients with endotracheal or tracheostomy tubes
I Use of saline to increase the efficacy of extracting secretions
C Compared to dry suctioning
O Improved efficacy of extracting secretions
T During patient hospitalization

Significance of the Clinical Question

Background

Artificial and positive pressure ventilation induce increased production of bronchial secretions
Airway suctioning is one of the most common treatments performed to intubated patients and is most
often done by nurses

Some nurses believe that instillation of normal saline before suctioning is effective in lubricating and
removing pulmonary secretions

Other nurses believe that it contributes to more unstable patients, excessive coughing, and
pneumonia
Problem

There are no clear guidelines for nurses regarding suctioning with saline

There are many nurses who use saline before suctioning and many who do not
Purpose

To explore current evidence in order to create an evidence-based recommendation for nurses

regarding suctioning with saline instillation
(Adib, Ghanbari, Alavi, & Leyli, 2014; Caparros & Forbes, 2014)

Summary of Current Practice

National Guidelines from the American Association for Respiratory Care on
ET Suctioning (Caparros & Forbes, 2014):
(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 versus deep suctioning
(e) Use closed suctioning for adult patients with high FIO2 or positive end
expiratory pressure or those at risk for lung derecruitment
(f) Routine use of normal saline instillation (NSI) before ET suctioning
is NOT recommended
(g) Suctioning duration should be limited to less than 15 seconds

Summary of Current Practice

Nursing Practice Issue: Evidence based practice recommendations do
not support the use of saline instillation, but it remains a common
practice in the intensive unit setting (Caparros & Forbes, 2014)
Many nurses use saline when suctioning without knowledge of current
evidence-based research to guide this practice (Caparros & Forbes, 2014)
Normal saline instillation is hypothesized to loosen secretions,
increase secretion removal, and remove tenacious secretions, but
evidence is lacking to support this (Caparros & Forbes, 2014)

Summary of Current Practice

Effects of Saline Use on Patient Care Outcomes:
Potential Benefits Associated with
NSI:
Decreased VAP (Ayhan et al., 2015;
Caruso et al., 2009; Favretto et al., 2012)

Improved secretion removal

through enhancement of
the cough reflex
Breaking up of thick secretions
for easier removal

Adverse Events Associated with

NSI:
Excessive coughing
Decreased SPO2
Bronchospasm
Tachycardia
Pain and dyspnea
Increased intracranial
pressure
(Caparros & Forbes, 2014)

SYNOPSIS OF CURRENT
FINDINGS

FOR NSI

MIXED STANCE

AGAINST NSI

Controlled Clinical Trial with

Randomization (Level II)

Experimental (Level III)

(Giakoumidakis, Kostaki, Patelarou, Baltopoulos, &

Controlled Clinical Trial with

Randomization (Level II)

(Caruso, Denari, Ruiz, Demarzo, & Deheinzelin,

2009)

Brokalaki, 2011)

Systematic Review of
Descriptive Studies (Level V)
(Ayhan, Tastan, Iyigun, Akamca, Arikan, & Sevim, 2015)
(Favretto, Silveira, Canini, Garbin, Martins, Dalri, 2012)

(Akbaryan Deheki, Sanagoo, Amri, Moghaddam, Vakili,

Nasiri, & Jouybari, 2014)
(Adib, Ghanbari, Alavi, & Leyli, 2014)

Experimental (Level III)

(Rafiee, Iranmanesh, Sabzevari, 2011)
(Zahran & El-Razik, 2011)

Qualitative Studies (Level VI)

(Leddy & Wilkinson, 2015)

VAP: Risk reduced in NSI

suctioning

VAP: Risk reduced by

insignificant amount w/ NSI; 5mL
saline did reduce the risk of VAP
better than 10mL

VAP: No data mentioned

regarding effects on VAP

Secretions: Helps reduce

infectious microorganisms
associated with VAP

Secretions: Increase in amount

and weight with NSI

Secretions: Increased volume of

secretions with NSI

Oxygenation: No data mentioned

regarding effects on oxygenation

Oxygenation: Decreased
oxygenation; lower SpO2 after one
minute and fifteen minutes when
using NSI

Oxygenation: BP, HR, and RR

increased with NSI; decline in
oxygen saturation

MOST PERTINENT STRENGTHS

AND WEAKNESSES

Type of Article
AGAINST NSI
Controlled Clinical Trial with
Randomization (Level II)
(Akbaryan Deheki, Sanagoo, Amri, Moghaddam,
Vakili, Nasiri, & Jouybari, 2014).
(Adib, Ghanbari, Alavi, & Leyli, 2014)

Strengths

FOR NSI
Controlled Clinical Trial with
Randomization (Level II)
(Caruso, Denari, Ruiz, Demarzo, & Deheinzelin,
2009)

Limitations

Use of reliable instruments

Consistency of suctioning
methods
Standardized volume of saline
instilled
Time interval >/= 2 hours used
between methods

Small sample size

Single-center design
Many results were insignificant

Similar participant
characteristics
NSI was the only independent
variable that contributed to
VAP
Long study time

The use of a single-center

design - Oncologic Hospital
Lack of blind study consistency
amongst the respiratory
therapists
Sample size was not
calculated to compare mortality
associated with VAP between
the two groups

Type of Article

Strengths

AGAINST NSI
Experimental (Level III)
(Rafiee, Iranmanesh, Sabzevari, 2011)
(Zahran & El-Razik, 2011)

MIXED STANCE
Experimental (Level III)
(Giakoumidakis, Kostaki, Patelarou, Baltopoulos, &
Brokalaki, 2011)

Limitations

Consistent with other findings

from similar studies
Ethics committee approval
Both sexes were recruited for
the study
Consistent intervention
Consistency of ventilatory
settings

Ethical committee approval

Informed consent
ET suctioning was done
according to standards of the
hospital
Consistent analysis of blood
and sputum samples

Moisturizing the inhaled gas

for diluting secretions to
minimize post-suctioning
complications was not
available to investigate
Not enough participants to be
considered a large study
Low physician response rate
Resistance and static
compliance
Smaller sample size
Quasi-experimental
Conducted in two hospitals
Conflicted findings from the
literature review

Type of Article

Strengths

MIXED STANCE
Systematic Review of
Descriptive Studies (Level
V)

High RN response rate

(90.2%)
Ethics committee approval
Minimal risks
Large group of databases
searched
No conflict of interest

(Ayhan, Tastan, Iyigun, Akamca, Arikan, & Sevim,

2015)
(Favretto, Silveira, Canini, Garbin, Martins, Dalri,
2012).

Limitations
Only female nurses
No pediatric studies were
included
Only English studies were
used
Study took place in a single
location
Evidence of saline still
remains contradictory

Type of Article
AGAINST NSI
Qualitative Studies (Level
VI)
(Leddy & Wilkinson, 2015)

Strengths
Consistent with findings
from other studies
High response rates from
RNs (94%) and RRTs (97%)
Minimal risk study

Limitations
Geographical proximity of
participants
Lacks institution diversity
Not enough participants to
be considered a large study

EVIDENCED BASED NURSING

RECOMMENDATIONS

Type of Article

Findings

AGAINST NSI
Controlled Clinical Trial with
Randomization (Level II)
(Akbaryan Deheki, Sanagoo, Amri, Moghaddam, Vakili,
Nasiri, & Jouybari, 2014).
(Adib, Ghanbari, Alavi, & Leyli, 2014)

FOR NSI
Controlled Clinical Trial with
Randomization (Level II)
(Caruso, Denari, Ruiz, Demarzo, & Deheinzelin, 2009)

Conclusions

NSI increased post-suction BP,

HR, and RR. There was also a
higher mean decrease in
SpaO2
Increase in MAP
Peak airway pressure
decreased after suctioning with
normal saline

Decline in the incidence of

microbiological proven VAP by
54%

Increases adverse effects on

post-suction physiologic
parameters
NSI is not recommended
during suctioning

Using 8mL of isotonic saline

solution before endotracheal
suctioning decreases
incidence of VAP

Type of Article

Findings

AGAINST NSI
Experimental (Level III)
(Rafiee, Iranmanesh, Sabzevari, 2011)
(Zahran & El-Razik, 2011)

MIXED STANCE
Experimental (Level III)
(Giakoumidakis, Kostaki, Patelarou,
Baltopoulos, & Brokalaki, 2011)

Conclusions

Decreased oxygenation
saturation
Increased HR
PaCO2 increased
Reduction in PaO2

NSI produced a greater weight

of secretions
SaO2 levels were lower after 1
and 15 minutes after NSI
SaO2 levels were lower for
only 1 minute with dry
suctioning

Can cause decreased

hemoglobin saturation with
oxygen
Education is key
Alternative measures:
hydration, humidification,
mucolytic agents, and
mobilization.
Increased weight is
controversial
Suggest a prolonged, negative
impact on oxygenation
The authors see no statistical
or clinical significance

Type of Article

Findings

MIXED STANCE
Systematic Review of
Descriptive Studies (Level V)
(Ayhan, Tastan, Iyigun, Akamca, Arikan, &
Sevim, 2015)
(Favretto, Silveira, Canini, Garbin, Martins, Dalri,
2012).

Suctioning performed with 5mL

saline aspired twice the
amount of secretions versus
no saline
Less tube obstruction in group
with NS
O2 saturations decrease with
NSI
72.9% of saline in the lungs
87.7% nurses NSI before ETS
42.1% think NSI harmful - do it
anyways
Minimally invasive ETS has
better results
Lower occurrence of VAP with
NSI
NSI: 10.8%
No NSI: 23.5%

Conclusions

NSI before ETS decreases

oxygenation status
Sputum amount,
hemodynamics, and VAP
incidence is controversial
Need for additional
randomized trials to determine
effectiveness of NSI
Nurses continue to use NSI
despite findings

Type of Article

Findings

AGAINST NSI
Qualitative Studies (Level VI)
(Leddy & Wilkinson, 2015)

100% use NSI >/= one time

88.5% of respiratory therapists
used NSI >/= one time
All respondents observed >/= 1
adverse event following NSI
Only 16% of survey
respondents attended a
suctioning training within the
last 12 months

Conclusions

Gap between literature findings

on NSI and hospital protocols
Highlighted the need for
greater nurse education
Indicated that risks may
outweigh benefits

Application and Implementation

Rogers Diffusion of Innovations Theory (Rogers, 2003):

Pre-survey

4 hour training
session

Post-survey

Reassessment

Application and Implementation

Knowledge
Assess the existing level of understanding among nurses regarding saline
use during endotracheal suctioning.

Awareness knowledge - discovering the existence of the new information

(Rogers, 2003)

Brief survey of ICU staff and nurses will be conducted prior to

implementation of a no-saline suctioning policy.
The knowledge phase should be completed immediately following the
release of the protocol.

Application and Implementation

Persuasion & Decision
An individual must be aware of the need for the innovation, and he/she
must acknowledge that the proposed innovation is feasible (Rogers, 2003).
ICU nurses and staff must be able to anticipate that implementation of
a no-saline suctioning will have a positive effect on patient outcomes.
Acknowledging that they will have adequate time and assistance to
perform the interventions, if necessary
Weighting advantages and disadvantages and deciding whether to adopt
or reject the innovation (Rogers, 2003)

Application and Implementation

Implementation
Staff education
ICU staff and nurses will receive training in order to effectively
implement the new practice.
Nurses will attend a pre-scheduled education day lasting no longer
than 4 hours, in addition to their scheduled shifts.
Informal training sessions will be conducted, as needed, if there are
staff members who are unable to attend the formal session, or for
those who require additional guidance.
Employing the innovation

Application and Implementation

Confirmation
Collecting and analyzing information to determine if the change should
be continued, expanded, revised, or discontinued (Rogers, 2003)

Agency seeks to confirm the decision made to adopt or reject the

innovation
Nursing audit
Collection of objective data regarding patient outcomes at 1
month and 6 months post-implementation

Cost Analysis
Banner University Medical Center:
Evidence-based Recommendation
Banner ICU RN: $34.94/hr
Banner Respiratory
(Glassdoor, 2016)
Training Hours: 4 hour training
Therapist: $22.00/hr (Glassdoor, 2016)
Training Hours: 4 hour training
session for endotracheal suctioning
session for endotracheal
Total Cost: $139.76 per trained nurse
suctioning
Total Cost: $88.00 per trained
a week
No overtime because less than or
respiratory therapist a week
equal to 40 hours
(12 hrs X 3 days = 36 hrs + 4 hrs = 40 hrs)
(U.S. Department of Labor, n.d.)

Cost Analysis
Hospital-acquired Infections in the
United States
Estimated $9.8 billion a year

(Waknine, 2013)

Ventilator-associated Pneumonia:
second most common reason
(31.6%)

(Waknine, 2013)

Risk of Not Using NSI:

Secondary Infection: VAP
ICU cost per day:
$4,000-$6,000

(Winters, 2013)

Average Additional Days: 7-9

days

(Medscape, 2016)

Ventilator-associated
Pneumonia: average $40,144
per case

(Medscape, 2016)

Cost Analysis
Additional Costs of NSI:
Normal Saline Syringes
Cost per 1 Syringe: $1.23

(Moore Medical LLC, 2016)

Frequency of Use: 57 of 65
nurses report using NSI when
suctioning

(Ayhan, Tastan, Iyigun, Akamca, Arikan, &

Sevim, 2015)

United States ICUs:

Mechanically ventilated patients
range from 20.7%-38.9%

(Wunsch, Wagner, Herlim, Chong, Kramer, &

Halpern, 2013)

Risks of NSI that Can be Cost

Producing: (American Association for Respiratory
Care, 2010)

Bronchospasm:
Albuterol: $40.82/90mL
(Vallerand, Sanoski, & Deglin, 2013)

Dislodgement of bacteria in
lower airways
Causes VAP: $40,144
(American Association for Respiratory Care, 2010)

Pain, anxiety, dyspnea

Lorazepam: $39.80/30 mL
(Vallerand, Sanoski, & Deglin, 2013)

Risk vs. Benefit

Risks
Normal Saline Instillation
Decreased oxygen saturation
(Akbaryan et al., 2014; Ayhan et al., 2015; Giakoumidakis et al., 2011; Rafiee
et al., 2011; Zahran & El-Razik 2011)

Slightly higher BP, RR, and HR post suction

(Akbaryan et al., 2014)

Significant increase in MAP

(Adib et al., 2014)

Excessive coughing
Increased hypoxia
Bronchospasm
Dislodgement of the bacterial biofilm that colonizes the
ETT into the lower airway
Pain, anxiety, dyspnea

(American Association for Respiratory Care, 2010)

Dry Suctioning
Not associated with a decreased
incidence of VAP
(Caruso et al., 2009; Favretto et al., 2012)

*Hospital has to pay for costs associated

with VAP

Risk vs. Benefit

Risks Associated with Both Dry Suctioning and NSI

Decrease in lung compliance and functional residual capacity

Atelectasis
Increases risk for hypoxia
Tissue trauma to the tracheal and/or bronchial mucosa
Bronchoconstriction/bronchospasm
Increased microbial colonization of lower airway
Changes in cerebral blood flow and increased intracranial pressure
Hypertension/hypotension
Cardiac dysrhythmias
(American Association for Respiratory Care, 2010)

Mixed Findings for Both Dry Suctioning and NSI

PaCO2 increases significantly with normal saline instillation.
Increased pH with dry suctioning
(Zahran, 2011)

Risk vs. Benefit

Benefits
Normal Saline Instillation
Increased weight of secretions
(Ayhan et al., 2015; Giakoumidakis, 2011)

Associated with a significant decrease in ventilator

associated pneumonia

Dry Suctioning
Oxygen desaturation and increased
heart rate is less marked
(Rafiee et al., 2011)

(Ayhan et al., 2015; Caruso et al., 2009; Favretto et al., 2012)

Benefits Associated with Both Dry Suctioning and NSI

The removal of pulmonary secretions
Keeps the artificial airway patent
(American Association for Respiratory Care, 2010)

Evaluation/SMART Outcomes
Hospital Outcomes
Teach ICU nursing staff about evidence-based endotracheal suctioning by having the nurses attend an
education session of 4 hours and then evaluating the knowledge gained through a survey within a month of
the instructional program.
Evaluate efficacy of implementation of endotracheal suctioning by auditing the NSI use by ICU nursing staff for 1
month and then 6 months after the education session.
The hospital will initiate a formal protocol outlining the use of evidence-based endotracheal suctioning within 6-7
months.

Patient Outcomes
Patients will have a improved hemodynamic parameters in the form of higher oxygen saturation immediately
after the endotracheal suctioning once the nurses attend the endotracheal educational program and employ
evidence-based nursing techniques.

Summary
Question: Do we as nurses use saline during ET/tracheostomy suctioning or do we use dry suctioning to more effectively
extract secretions?
ET suctioning is a common nursing practice, yet there are no definitive guidelines stating whether or not nurses should
be suctioning with saline.
The result? Some nurses use saline instillation when suctioning their patients and some do not (Adib, Ghanbari, Alavi, & Leyli, 2014;
Caparros & Forbes, 2014).
Some studies are against the use of saline instillation as it can decrease the patients oxygen saturation and can also
cause an increase in HR, BP, and RR (Akbaryan et al., 2014).
However, there are also recent studies that indicate saline use before suctioning is beneficial in that it decreases the
incidence of VAP (Ayhan et al., 2015; Caruso et al., 2009; Favretto et al., 2012).
Therein lies the problem; there is a lack of definitive evidence for the use of NSI before suctioning.
Despite there being mixed findings in relation to this issue, The American Association for Respiratory Care on ET
Suctioning (2014) has outlined best practice for ET suctioning which concludes that:
The majority of studies used to update current guidelines state NSI is not likely beneficial and may be harmful or even
detrimental to the patients
NSI with suctioning is not recommended to be routinely performed

Summary Continued
This recommendation can be applied to a specific hospital facility using Rogers diffusion of innovations theory whereby

Knowledge will be assessed and instilled to the nursing staff

Through persuasion and decision making, they can decide whether or not they will adopt or reject the
intervention

Staff education can help implement the intervention

And data can be collected to confirm the efficacy of the intervention

This application process should take approximately 6-7mo from start to finish
In terms of cost, given that NSI is not recommended based on current evidence and can even be harmful to patients,
any additional costs associated with the implementation of the new protocol are worthwhile for the hospital to
acquire as the adverse events associated with NSI could instill an even greater cost burden to the facility.
The risks associated with continuing to use saline during suctioning include adverse effects associated with
oxygenation, respiration rate, ventilation, and alterations in hemodynamic parameters post suctioning. In
using dry suctioning, the patient benefits from a less marked change in oxygen desaturation and less of an
increase in HR (Akbaryan et al., 2014; American Association for Respiratory Care, 2010; Ayhan et al., 2015; Giakoumidakis et al., 2011; Rafiee et al.,
2011; Zahran & El-Razik 2011).

SUMMARY
Overall, in spite of what nurses believe to be the most effective form of suctioning,
in keeping with current best practice, nurses SHOULD NOT instill the use of saline
before suctioning to improve the efficacy of extracting secretions. Further clinical
trials are crucial to effectively determine if saline instillation use with suctioning an
artificial airway is deemed harmful, so that it can then be strictly enforced as a
mandatory clinical guideline for all hospitals to include in their standardized
protocol (Caparros & Forbes, 2014).

Case Study
You are working on a medical-surgical unit. One of your patients is a 50 year-old
man who was just transferred from the intensive care unit. He has a history of
pneumonia and had a tracheostomy tube placed 2 days ago.
His vital signs are:
BP: 150/94 mmHg
HR: 110 beats/min
RR: 30 breaths/min
Oxygen saturation: 80%
(Assessment Technologies Institute, n.d.)

Practice Questions
Which of the following is your priority intervention for this patient at this time?
A. Prepare to obtain a specimen for arterial blood gases
B. Suction the patients airway
C. Assist the patient to semi-Fowlers position

(Assessment Technologies Institute, n.d.)

Practice Questions
Which of the following is your priority intervention for this patient at this time?
A. Prepare to obtain a specimen for arterial blood gases
Although it is essential to monitor this patients ABG values, this is not your highest priority action at this time.

B. Suction the patients airway

Although the respiratory rate is high, it is not high enough to warrant mechanical ventilation. As is common with new
tracheostomy, secretions have probably accumulated in the patients airway. Removing them is likely to raise his oxygen
saturation and help stabilize other vital signs.

C. Assist the patient to semi-Fowlers position

Management of a patient with a new tracheostomy includes positioning him in semi-Fowlers whenever possible to
facilitate ventilation, but this is not your highest priority action at this time.

(Assessment Technologies Institute, n.d.)

Practice Questions
You gather the equipment youll need to perform tracheal suctioning, explain the
procedure to the patient, and perform hand hygiene. You don clean gloves, a
gown, goggles, and a mask. You open your suction catheter kit. Just before you
suction the patients airway, which of the following actions should you perform?
A. Hyperoxygenate the patient
B. Adjust the suction pressure to 150 mm Hg
C. Inspect the lumen of the tracheostomy tube

(Assessment Technologies Institute, n.d.)

Practice Questions
You gather the equipment youll need to perform tracheal suctioning, explain the
procedure to the patient, and perform hand hygiene. You don clean gloves, a
gown, goggles, and a mask. You open your suction catheter kit. Just before you
suction the patients airway, which of the following actions should you perform?
A. Hyperoxygenate the patient
To help prevent a decline in oxygen saturation during suctioning, increase the supplemental oxygen to 100% or as prescribed
by the provider.

B. Adjust the suction pressure to 150 mm Hg

Suction pressure should not exceed 120 mm Hg

C. Inspect the lumen of the tracheostomy tube

This action should be done prior to tracheostomy care to help determine whether or not the patient needs suctioning.

(Assessment Technologies Institute, n.d.)

Practice Questions
While suctioning the patients tracheostomy, you note that his pulmonary
secretions are quite thick. Which of the following interventions should you decide
to add to the patients nursing care plan to help thin the secretions?
A. Perform chest physiotherapy
B. Instill sterile normal saline solution into the airway
C. Increase fluid intake

(Assessment Technologies Institute, n.d.)

Practice Questions
While suctioning the patients tracheostomy, you note that his pulmonary
secretions are quite thick. Which of the following interventions should you decide
to add to the patients nursing care plan to help thin the secretions?
A. Perform chest physiotherapy
Although chest physiotherapy may help in mobilizing secretions, it will not reduce their viscosity.

B. Instill sterile normal saline solution into the airway

Although instilling normal saline solution to loosen secretions used to be a common practice, recent research has indicated
that this practice may no longer be acceptable. Instilling normal saline while suctioning could disperse micro-organisms in the
lower respiratory tract, thus increasing the patients risk of infection. It can also result in lower oxygenation saturation.

C. Use a humidifier or an HME (heat moisture exchanger)

When you breathe through your mouth and nose, air is naturally warmed, moistened, and cleaned. Air coming in through a
tracheostomy tube does not get moistened and cleaned. When this cool, dry air comes into the tube, it causes the lungs to
make more mucus. Humidification is very important for thinning secretions so they do not block the trach tube.

(Assessment Technologies Institute, n.d.)

Results
After suctioning your patients vital signs are:
BP: 122/90 mmHg
HR: 82 beats/min
RR: 16 breaths/min
Oxygen saturation: 95%

(Assessment Technologies Institute, n.d.)

QUESTIONS?

References
Adib, M., Ghanbari, A., Alavi, C. E., & Leyli, E. K. (2014). Effect of endotracheal suctioning with and without normal saline on
hemodynamic and respiratory parameters in patients undergoing mechanical ventilation in ICUs of hospitals supervised by Guilan University of
Medical Sciences . Biomedical and Pharmacology Journal, 7(2), 515-523. doi: 10.13005/bpj/519
Akbaryan Deheki, N., Sanagoo, A., Amri, P., Moghaddam, S., Vakili, M. A., Nasiri, H., & Jouybari, L. M. (2014). Comparing the
effect of using normal saline, N-acetyl cysteine and not using them in endotracheal tube suction on physiologic parameters and
the amount of secretions in intubated patients under mechanical ventilation. Iran J Crit Care Nurs., 6(4), 152-159.
American Association for Respiratory Care (2010). AARC Clinical Practice Guidelines: Endotracheal suctioning of mechanically
ventilated patients
with artificial airways 2010. Respiratory Care, 55(6): 75864.
Assessment Technologies Institute. (n.d.). Airway management. Retrieved from
http://www.atitesting.com/ati_next_gen/skillsmodules/content/airway-management/casestudies.html

References Continued
Ayhan, H., Tastan, S., Iyigun, E., Akamca, Y., Arikan, E., & Sevim, Z. (2015). Normal saline instillation before endotracheal
suctioning: what does the evidence say? what do the nurses think?: Multimethod study. Journal of Critical Care, 30(4),
762-767. doi:10.1016/j.jcrc.2015.02.019 [doi]
Caparros, A. C. S., & Forbes, A. (2014). Mechanical ventilation and the role of saline instillation in suctioning adult intensive care unit
patients: An evidence-based practice review. Dimensions of Critical Care Nursing, 33(4), 246-253.
Caruso, P., Denari, S., Ruiz, S. A., Demarzo, S. E., & Deheinzelin, D. (2009). Saline instillation before tracheal suctioning decreases the
incidence of ventilator-associated pneumonia. Critical Care Medicine, 37(1), 32-38. doi:10.1097/CCM.0b013e3181930026 [doi]
Favretto, D. O., Silveira, R., Canini, S., Garbin, M., Martins, F., Dalri, M. (2012). Endotracheal suction in intubated critically ill adult
patients undergoing mechanical ventilation: a systematic review. Latin American Journal of Nursing, (20)5, 997-1007. Retrieved from:
http://www.scielo.br/scielo.php?pid=s0104-11692012000500023&script=sci_arttext
Giakoumidakis, K., Kostaki, Z., Patelarou, E., Baltopoulos, G., & Brokalaki, H. (2011).Oxygen saturation and secretion weight after
endotracheal suctioning. British Journal Of Nursing, 20(21), 1344-1351.

References Continued
Glassdoor (2016). Banner health. Retrieved from
https://www.glassdoor.com/Salary/Banner-Health-Tucson-Salaries-EI_IE11958.0,13_IL.14,20_IM869.htm
Leddy, R., & Wilkinson, J. M. (2015). Endotracheal suctioning practices of nurses and respiratory therapists: how well do they align
with clinical practice guidelines? Canadian Respiratory Journal of Respiratory Therapy, 51(3), 60-64.
Medscape (2016). Ventilator-assisted pneumonia overview of nosocomial pneumonias. Retrieved from
http://emedicine.medscape.com/article/304836-overview
Moore Medical LLC (2016). Retrieved from
https://www.mooremedical.com/Index.cfm?Ntk=all&No=0&Search=Search&Ns=Searchorder
%7C0%7C&Ntx=mode+matchpartialmax&Ntt=normal+saline##
Rafiee, H., Iranmanesh, S., Sabzevari, S. (2011). Comparison of the endotracheal tube suctioning with and without normal saline
solution on heart rate and oxygen saturation. Iranian Journal of Critical Care Nursing, 4(3), 117-120. Retrieved from
http://www.inhc.ir/browse.php?a_code=A-10-20-2&slc_lang=en&sid=1

References Continued
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