Cardiovascular Changes During Open Suctioning Technique for Patients under Intermittent Positive Pressure Ventilation

Ahmed Abbas Kadhim
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Keywords : Cardiovascular Changes,Open Suctioning Technique ,Pressure Ventilation
Medical Journal of Babylon  11:2 , 2014 doi:1812-156X-11-2
Published :15 July 2014

Abstract

A descriptive study was conducted on purposive sample of 50 patients (32 males and 18 females) were between 21 - 70 years of age from October 2011 to April 2012 in the respiratory care unit at Al - Kadhimia Teaching Hospitals and Al- Shaheed Ghazi Teaching Hospital in Baghdad city to identify the cardiovascular changes during open suctioning technique for patients under intermittent positive pressure ventilation. Check-list type was developed and the data were collected by interview method, review of patients records and observation the patients monitors. The criteria for diagnosis of cases depended on the medical decision by the physician. The results showed that during endotracheal suctioning (ETS) the mean values of heart rate (HR) and blood pressure (BP)were increased from the baseline while the oxygen saturation (SPO2) as indicated by pulse oximeter was decreased. The changes in the variables of the study in regarded to the males were 26%, 12%, and -18 changes from baseline respectively while in females the changes from baseline were 21% ,2% , and -18%.The males were more affected than females in regard to HR and BP while in SPO2, the results stayed the same in both sex. After 2-3 minutes of ending the suctioning procedure all the values gradually returned to baseline over the next 7 minutes. During ETS the mean value of HR increased from a baseline in relation to duration (1- 10, 11-15 and >15 seconds) of ETS .17%, 20% and 33% changes from baseline respectively. Also, in BP the changes from baseline were 3%, 11% and 9% while the mean value of the SPO2 as indicated by pulse oximeter was decreased from a baseline. -10%,-17%, and -20% changes from baseline respectively. The total mean value was increased in HR (24%) and BP (8%) while decreased in SPO2 (18%). ETS resulted in an increase in HR and BP while the SPO2 decreased when there an increase in the duration of suctioning. The results also, showed that 68% of the patients were on appropriate size of the ETT in relation to outer diameter (OD) of the suction catheter while, 32% weren’t. 35% (12 out of 34 ) of the patients who were on appropriate size lasted more than 15 second of suctioning duration while there was 81% (13 out of 16) in the same duration were on inappropriate size. The present study recommended that duration of 10-15 seconds is advocated as the longer the duration of each suctioning event the greater the risk of increasing HR and BP, and decreasing of SPO2. Selection of appropriately sized suction catheter for a given tube inner lumen diameter is also important to avoid complications during the suctioning procedure. Further studies are recommended to perform on comparison of closed endotracheal suction versus open endotracheal suction on mechanically ventilated patients.

Introduction

Mechanical ventilators are being used for some patient in intensive care units (ICUs) due to various physiological and clinical causes. Keeping endotracheal tube (ETT) clean and open is necessary in order to improve the patient oxygenation [1]. Endotracheal suctioning (ETS) is common invasive nursing procedure performed in the routine management of the critically ill patients with artificial airways.Hemodynamic parameters changes during and after the procedure. If appropariate strategies do not be applied during the ETS, Hemodynamic changes can be significant and life threateing in critically ill patients [2] .The most frequent procedure for suctioning consists of disconnection from mechanical ventilation, followed by insertion of a suction catheter into the trachea while negative pressure is generated. Disconnection itself results in an airway pressure drop and loss of lung volume, but a further volume decrease is observed during suctioning due to the generation of negative pressure in the airway [ 3] .The procedure includes patient preparation, the suctioning event, and follow-up care [4,5] . Appropriate management of the patient with an artificial airway can have an impact on reducing complications, length of stay and mortality and morbidity. It has a number of potential risks that may lead to complications including hypoxia, cardiac dysrhythmias ,mucosal damage and causes stress to patients, which may alter their haemodynamic status. Correct technique and preparation by the clinician can assist in reducing the risks of adverse events and reduce the level of discomfort for the patient. Although considered a routine procedure, suctioning should be carried out on the basis of clinical need and may vary among different diagnostic groups [6] .The first reports on the serious side-effects of ETS came from thoracic surgeons, probably because they were the first to use positive pressure ventilation, suction and oxygen saturation monitoring on a routine basis during anesthesia. In 1948 in the Journal of Thoracic Surgery, Kergin et al [7] presented a number of patients undergoing thoracotomy and stated that the sudden profound fall in arterial oxygen saturation associated with bronchial suction is probably due not only to sucking out oxygen, but also to a temporary increase in the atelectasis by negative intra-bronchial pressure. Our anesthetists now watch the oximeter and apply positive pressure as indicated. In the beginning of the described cardiac and student deaths during tracheal suctioning was thought to be caused by respiratory tract reflexes. As better was of monitoring oxygen saturation (SPO2), blood pressure (BP) variation and lung volumes were developed the circulatory and respiratory side-effects of suctioning could be observed. It became obvious that the suctioning induced lung collapse was the primary reason for these cardio-pulmonary effects [7]. Although the need for intensive care has often been defined by the need for ventilation, and there are literally thousands of publications on techniques, principles, complications, and challenges of ventilation, there is a surprising lack of evidence for best practice regarding a fundamental technique in ventilation: suctioning of the airway. Since tracheostomy or endotracheal intubation (ETI) was first undertaken, potential obstruction of the (ETT) by mucus has been a consistent and life-threatening problem [8]. The primary purpose of ETS is to remove secretions and prevent airway obstruction, thereby aiming to prevent atelectasis whilst optimising oxygenation and ventilation and decreasing the work of breathing. A number of studies suggest that lung compliance drops following suctioning. Animal studies have shown a drop in static lung compliance following suctioning [9].The present study aimed to identify the cardiovascular changes during open suctioning (OS) technique for patients under intermittent positive pressure ventilation (IPPV).

Materials and methods

A descriptive study was conducted on purposive sample of 50 patients (32 males and 18 females) were between 21 - 70 years of age from October 2011 to April 2012 in the respiratory care unit at Al - Kadhimia Teaching Hospitals and Al- Shaheed Ghazi Teaching Hospital in Baghdad city to identify the cardiovascular changes during open suctioning (OS) technique for patients under intermittent positive pressure ventilation (IPPV). Check-list type was developed and the data were collected by interview method, review of patients records and observation the patients monitors .The criteria for diagnosis of cases depended on the medical decision by the physician. The simple way to calculate the patients mean arterial pressure is to use the following formula: MAP = [(2 x diastolic) + systolic] divided by 3 [10].


Results

The results as showed in table (1) that 64 % of the patients were males and 36% were females and they were between 21 - 70 years of age. 48% of the patents were between 21-30 years of age.The results as showed in table (2) that during endotracheal suctioning (ETS) the mean values of heart rate (HR) and blood pressure (BP) were increased from the baseline while the oxygen saturation (SPO2) as indicated by pulse oximeter was decreased. In males, 26%, 12% and -18% changes from baseline respectively. In females, the changes from baseline were 21%, 2% and -18%. The males were more affected than females in regard to HR and BP while in SPO2, the results stayed the same in both sex. After 2-3 minutes of ending the suctioning procedure all the values gradually returned to baseline over the next 7 minutes.The results as showed in table ( 3) that during endotracheal suctioning the mean value of HR increased from a baseline in relation to duration ( 1- 10, 11-15 and >15 seconds) of endotracheal suctioning . 17%, 20% and 33% changes from baseline respectively. Also, in BP the changes from baseline were 3%, 11%, and 9%.While the mean value of the oxygen saturation (SPO2) as indicated by pulse oximeter was decreased. -10%,-17% and -20% changes from baseline respectively. The total mean value was increased in HR (24%) and BP (8%) while decreased in SPO2 (- 18). After 2-3 minutes of ending the suctioning procedure all the values gradually returned to baseline over the next 7 minutes. The results as showed in table (4) that 68% of the patients were on appropriate size of the ETT in relation to outer diameter (OD) of the suction catheter while, 32% weren’t. 35% of the patients who were on appropriate size lasted more than 15 seconds of suctioning duration while there was 81% in the same duration were on inappropriate size.

Discussions

Reducing risks associated with mechanical ventilation in critically ill patients is a vast, complex, and interdisciplinary process. Although our understanding of the uses, complications, and outcomes associated with mechanical ventilation changes almost every day, the importance of this understanding for bedside clinicians is paramount [11]. Endotracheal suctioning (ETS) is a routine RCU procedure, although it has significant side effects [12]. The results as showed in table (2) that during ETS the males were more affected than females in regard to HR and BP while in SPO2 the results stayed the same in both sex. The total mean value of heart rate increased from a baseline of 107 beats/ minute to 135 beats/ minute with a range of 100 to 170 beats/ minute. A 26% change from baseline. This results declared that the open- system ETS in mechanically ventilated patients had an effects on increase HR because of deprivation the patients from oxygen and increase respiratory effort while after 2-3 minutes of ending the suctioning procedure all the values dropping toward the baseline over the next 7 minutes as a result of remove of chest secretion [13]. In BP the females were less affected than males. Also there was no significant change from baseline in regard to females BP deterioration. This may be indicates that the female hormone has an effect against the increase of BP during ETS. The total mean value of BP increased from a baseline of 99 to 107 mm Hg during suctioning. An 8% mm Hg change from baseline. It is well known that direct stimulation of the airway causes various cardiovascular and respiratory reflexes, such as increase BP, increase HR, and cough. These responses may also be marked during ETS [14]. Increase BP occurs, most likely due to the intense pain of tracheal suction causing sympathetic stimulation and voluntary muscle contraction. This is seen at all ages despite moderate sedation and systemic analgesics. Patient assessment post suction should include an evaluation of the effects on the patients pre suction signs and symptoms as well as the development of hypertension [15]. This result in agree with similar study which showed that elevated mean arterial blood pressure had been observed during open tracheal suctioning (OS) in intubated patient [16] and could result from hypoxemia, airway manipulation and tracheal stimulation [17]. During ETS, the total value of SPO2 as indicated by pulse oximeter decreased from a baseline of 97% to 80 % with a range of 42 to 90. A – 18 % change from baseline. The effects of OS on oxygenation were similar to data reported in other studies. They also found a greater SPO2 reduction during OS than during closed tracheal suctioning (CS) [17, 18].One study had shown that heart rate and mean arterial pressure increased significantly but returned to baseline 5 minutes after suctioning [11].Secretions were cleared from these patients’ airways in order to maintain airway patency, to prevent atelectasis secondary to blockage of smaller airways, and to ensure that adequate gas exchange (particularly oxygenation) occurs [19]. Suctioning has also been associated with many deleterious effects including decreased arterial oxygen tension, which may be more pronounced in cardiac surgical patients and in patients with hypoxemic respiratory failure requiring high levels of positive end-expiratory pressure, in patients with cardiac arrhythmias and in cardiac arrest in patients with acute spinal cord injury [20]. The results as showed in table (3) that ETS resulted in an increase in HR and BP while the SPO2 decreased when there an increase in the duration of suctioning .The patient should be monitored for adverse reactions and be placed on a pulse oximeter to assess oxygenation during and following the procedure [4]. It may be difficult to determine exactly which complications can be attributed to the duration of suctioning [21]. The procedure has many complications and many patients find the experience painful and anxiety inducing major complications includes hypoxia which may be related to an interruption in inspired oxygen flow and partial airway obstruction as the catheter passes into the ETT. The maximum duration of suctioning is inadequately documented. The procedure may suck oxygen/ gas out of the bronchial tree and contribute to alveolar collapse. One study had shown that simple measures may reduce this such as suction should not be applied for more than ten seconds (certainly in less than 10 seconds) [22, 23]. In a comparative study of complications associated with suctioning, a maximum of 10 seconds was recommended for the suctioning itself and 15 seconds for the entire procedure [3, 24, 25]. Studies in adult patients had shown that the duration of less than 15 seconds reduced the drop in partial pressure of oxygen (PaO2) and functional residual capacity (FRC) [17, 26, 27]. Also based on clinical experience, in adult patients, it was recommended that the suctioning procedure should last no longer than 15 seconds [4, 27]. There was variation in the recommended amount of time taken to perform ETS. As in most research [25], the present study recommended that duration of 10-15 seconds is advocated as the longer the duration of each suctioning event the greater the risk of increasing HR and BP, and decreasing of SPO2. The results as showed in table (4) that 68% of the patients were on appropriate size of the ETT in relation to outer diameter (OD) of the suction catheter while, 32% weren’t. 35% (12 out of 34 ) of the patients who were on appropriate size lasted more than 15 seconds of suctioning duration while there was 81% (13 out of 16) in the same duration were on inappropriate size. Selection of appropriately sized suction catheter for a given tube inner lumen diameter is also important to avoid complications during the suctioning procedure .The OD of the suction catheter should be clearly labeled and never exceeds half the inner diameter of the tracheal tube or its connector [15,28 ]. Further studies are recommended to perform on comparison of closed endotracheal suction versus open endotracheal suction on mechanically ventilated patients.

Conclusions

N/A

References

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