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Running head: TRACHEOSTOMY SUCTIONING WITH SALINE INSTILLATION

Tracheostomy Suctioning with Saline Instillation


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Running head: TRACHEOSTOMY SUCTIONING WITH SALINE INSTILLATION

Tracheostomy Suctioning with Saline Instillation


Evidenced based care requires proof that the care and treatment provided to patients help to
optimize their healthcare outcomes. An example of a critical care ritual that persists despite the
lack of demonstrated benefit is the Normal Saline (NS) instillation before endotracheal
suctioning. Historically, NS has been vastly used to increase sputum yield by lubricating the
suction catheter, loosening and diluting thick secretions, secretion mobilization and enhancing
cough stimulation. Since long ago, Clinicians have been taught that the use of NS helps to
increase secretion clearance. However, various research institutes including Joanna Briggs
Institute argue against NS use claiming that the procedure possesses potential deleterious effects.
The research further states that the procedure is unsubstantiated and thus suggests that its routine
administration should be discontinued. Taking into account the scant evidence of its benefits as
well as its potentially injurious effects, I agree with the practitioners who think that the routine
use of saline should be discontinued (Reeve 2007).
Research suggests that the use of NS demonstrates a detrimental effect on global tissue
oxygenation. The research conducted based its emphasis on patient records from various
databases including those from Cochrane Library, Medline, TRIP as well as Joanna Briggs
Institute. The research included measurement of the nadir, arterial blood gas analysis, and the
recovery time of oxygen saturation. 56% of the results indicated a significant decrease in
oxygenation as well as desaturation that worsened over time after the suctioning. The patients
also proved to take double time to recover compared to when NS was not used. The continued
desaturation is evidence enough that normal saline impairs gas exchange. Kinloch, a member of

Running head: TRACHEOSTOMY SUCTIONING WITH SALINE INSTILLATION

the research team, discovered that patients who were suctioned 5 minutes after instillation
demonstrated a decrease in mixed venous oxygen (by 6 points).
Moreover, the use of normal saline was discovered to increase the heart rate by 4-5 times after
suctioning. In proving the above fact, medical researchers conducted three studies to determine
the hemodynamic effects of NS. The results were increased heart rate, increased intracranial
pressure and increased mean of the arterial pressure. However, there were no effects on the blood
pressure whatsoever (Halm).
Additionally, evidence obtained from the research points out that NS increases the dislodgement
of bacteria from the endotracheal tubes thus potentially increasing nosocomial infection risk.
According to Hagler and Traver, the dislodgement of the bacterial colonies stimulates a growth
in the sputum cultures. The use of normal saline demonstrates a dislodgement of up to five times
the bacterial colonies as compared to when NS is not used. However, According to the research,
the use of the normal saline has a potential significance to lower airway contamination. Random
researches carried out suggest incidences of ventilator-associated pneumonia in cases where NS
is practiced ( Halm).
Jablonski, a member of the research teams, discovered that the patients reported cases of
increased pain, dread, as well as anxiety. One adult patient interviewed during the research
compared the experience with that of a drowning person. The patient added the use of the NS
caused excruciating pain that should rate at 10/10 (Puchalski 2007).
The common rationale for the use of normal saline instillation is to liquefy thick secretions
before suctioning. Mucus, even with vigorous shaking, is immiscible with saline. Therefore,

Running head: TRACHEOSTOMY SUCTIONING WITH SALINE INSTILLATION

there exists no evidence to support the intention of thinning the mucus to ease removal of the
secretions. Furthermore, the practice does not improve pulmonary function thus supporting the
fact that saline has no known benefits (Farman 2010).
I believe that there exist some cases where NS is acceptable. First is the case where other
methods for clearing secretions have failed. The research conducted in New Zealand points out
that 58 % of the clinicians who practice NS do it out of no choice. The surveys further show that
the practice is only done on a routine basis and only when there exist no other methods of getting
rid of the mucus secretions. Second NS can be vital in passing the suction catheter during a
suspected obstruction of an endotracheal tube with thickly encrusted secretions. Third and last is
to clear the suction catheter after each pass and when finished suctioning. The NS is important in
reducing the risk of infections in the airway (Reeve 2007).
In conclusion, the majority of the evidence provided by literature strongly suggests a change in
this practice. The studies conducted have illustrated negative effects of NS on heart rate, the
level of dyspnea as well as oxygenation. Additionally, the fact that there exists no research-based
evidence to support the beneficial impacts of the practice highly suggests that the practice should
be discontinued. According to my opinion, the practice should be permanently discontinued
except in the cases where it is extremely necessary (when other methods have failed; and should
be used only to elicit a cough to the patients with intact cough reflexes).I would also recommend
the practitioners to focus on ways to prevent the development of the thick secretions. The
potential detrimental effects of NS have been vividly established. Therefore, if the procedures
utilization is to be continued, further studies establishing the efficacy of NS on sputum removal
are extremely necessary.

Running head: TRACHEOSTOMY SUCTIONING WITH SALINE INSTILLATION

References:
Puchalski, M. (2007, March 14). Should Normal Saline be Used When Suctioning the
Endotracheal Tube of the Neonate? Retrieved October 28, 2015, from
http://www.medscape.com/viewarticle/552862
Halm, M. (n.d.). Advertisement Instilling Normal Saline with Suctioning: Beneficial Technique
or Potentially Harmful Sacred Cow? Retrieved October 28, 2015, from
http://ajcc.aacnjournals.org/content/17/5/469.full
Reeve, J. (2007). The use of normal saline instillation in the intensive care unit by
physiotherapists: A survey of practice in New Zealand. Retrieved October 28, 2015, from
http://physiotherapy.org.nz/assets/Professional-dev/Journal/2007-November/2007Novreport3.pdf
Farman, C. (2010, August 9). Saline Instillation: Helpful or Harmful? Retrieved October 28,
2015, from http://respiratory-care-sleep-medicine.advanceweb.com/Features/Articles/SalineInstillation-Helpful-or-Harmful.aspx

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