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Volume 1, 2016, Issue 1, Pages 15-19; Paper doi: 10.15412/J.JCC.02010104; Paper ID: 20008.
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The Impact of Catheter Size on SpO2 Changes in Endotracheal Suctioning
(Research Paper)
  • 1 Research Center for Nursing and Midwifery Care in Family Health, School of Nursing and Midwifery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
  • 2 School of Nursing and Midwifery, Yasuj University of Medical Sciences, Yasuj, Iran
  • 3 School of Nursing and Midwifery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
  • Correspondence should be addressed to Akvan Paimard, School of Nursing and Midwifery, Yasuj University of Medical Sciences, Yasuj, Iran; Tel: ; Fax: ; Email: akvan_paimard9@yahoo.com.

Abstract

Artificial airway results in the weakening of cough reflex, elimination of ciliated cells and finally, accumulation of secretion. Therefore, patients with decreased level of consciousness that have artificial airway need periodic suctioning. One of the main side effects of endotracheal suctioning is the reduction of SpO2. The present study was conducted with the aim of comparing the effect of endotracheal suctioning using open method and two different suctioning catheter sizes on SpO2 of patient hospitalized in intensive care units (ICUs). This quasi-experimental study was conducted on 36 patients, hospitalized in ICU of Shahid Beheshti Hospital in the city of Yasuj, who were selected as sample using purposeful sampling method. Each member of the sample underwent suctioning with catheter No. 12 three times and with catheter No. 14 three times and each suctioning in each patient was selected randomly. Each suctioning was consisted of three catheter insertion episodes. The SpO2 changes were recorded before, during, 5 minutes after and 20 minutes after suctioning. Repeated measures ANOVA was used for comparison of the changes of SpO2 mean. The results showed that SpO2 mean was reduced in the two explored methods in the study, compared to the initial state (P<0.001). SpO2 was reduced with the increase of suction episodes, however, the reductions in the small and big catheter were not significantly different from each other. As SpO2 in patients is reduced during endotracheal suctioning and this reduction is increased in continuous suctioning episodes, it is recommended to reduce the number of suctioning episodes. Also, as there is no significant statistical difference between small and big catheters in terms of SpO2 reduction level, each catheter can be used depending on the condition of patients.

Keywords

Endotracheal Suctioning, Suctioning Catheter, SpO2

1. INTRODUCTION
O

ne of the initial indicators of an acute disease is deterioration of the patient’s respiratory function. Respiratory disturbance is one of the main causes of a critical disease and one of the main reasons for admission in intensive care units (ICUs) (1, 2). One of the common methods in treatment of these patients is using endotracheal tube (ETT) in a short-term way (3). Artificial airway results in the weakening of cough reflex, elimination of ciliated cells and finally, accumulation of secretion disruption in the exit of secretions from the airway and as these patients cannot discharge the secretions, they will need periodic suctioning (4). The basic aim of endotracheal suctioning is removing secretions and preventing the blockage of the airway, preventing atelectasis, favorable ventilation and oxygenation and reduction of the breathing burden (5). Suctioning is done in open and closed ways. In the open method, the patient is disconnected from the device and the suctioning is done but in closed method the patient is connected to the mechanical ventilator and suctioning is done in this way (6). The most common method used for endotracheal suctioning is open method that requires disconnecting the patient from the device during suction this itself results in drop of the pressure of airway and lung volume. Therefore, the main side effect of open suctioning is hypoxemia that can pave the way for change in heart rate, heart rhythm disorders, hemodynamic imbalance, cardiac arrest and death (7). As endotracheal suctioning can result in intracranial hypertension (1, 8), collapsed lung through negative pressure and thus result in reduction of oxygen saturation (9, 10) and there is the possibility of bradycardia and hypotension, and even cardiac arrest in severe cases, due to vagus nerve stimulation or severe hypoxia (5), SaO2 level should be monitored before, during and after suctioning (11). The outer diameter of suctioning catheter is recommended not to be more than half of ETT diameter (12). There are some agreed reports regarding suctioning catheter that point out the suctioning catheter should be small and with an adequate size to facilitate the exit of big secretions. When the catheter is small, air enters the lung through around the catheter during open suctioning which prevents Functional Residual Capacity (FRC) and reduces atelectasis risk (13). However, this choice is not always effective as in an ETT with No. 2.5, the smallest catheter occupies over 75 percent of the tube and patient is at the risk of atelectasis (14). In other observations it has been shown that using a catheter with a bigger size results in more negative pressure in the lung however, it is more effective in removal of secretions (5). In nursing reference books nothing has been pointed out regarding exact catheter size and most of the things mentioned are recommendations. Also, there is no evidence of appropriate selection. Therefore, considering the lack of accurate guidance regarding selection of appropriate suctioning catheter size and its impact on SpO2 level, the present study was conducted with the aim of comparing the effect of two different sizes of suctioning catheter in open endotracheal suctioning on SpO2 level in patients hospitalized in ICUs.

2. MATERIALS AND METHODS

This study with quasi-experimental within subject design was conducted with pretest-posttest design with two comparative interventions. The population of the study was consisted of patients hospitalized in the intensive care unit of Shahid Beheshti Hospital in the city of Yasuj. The sampling was done using purposeful sampling method and for a duration of three months (November 2015 to February 2016). The sample size was estimated being 34 individuals in each group based on Cochrane methods, two-sided significance level of α=0.05 and test power of 90 percent. Considering the probability attrition of about 10 percent of the samples, 38 patients were finally selected as the sample. The criteria for inclusion in the study was consisted of being hospitalized in ICUs of the hospital, having oral endotracheal tube, being connected to the ventilator with volume mode, minimum age of 18 years and maximum age of 60, being hemodynamically stable, systolic blood pressure of higher than 90 and lower than 140, a heart rate of lower than 100 and higher than 50 beats per minute and blood oxygen saturation of higher than 90 percent. The criteria for exclusion from the study included removal of ETT for any reason during the study, need for changing the ventilator mode from volume-controlled to pressure-controlled, need for suctioning less than three times, having coagulopathy and thrombocytopenia, not taking narcotic drugs and muscle relaxants, having underlying respiratory diseases, taking positive inotropic agents such as dopamine and paralysis of upper and lower parts of the body. The researcher registered the research in Iranian Registry of Clinical Trials (IRCT: 2015100724410N1). Then he obtained an introduction letter from Shahid Sadoughi University of Medical Sciences and Health Services. Afterwards he visited the hospital and selected the samples that had criteria for inclusion in the study, after explaining the aims and methods of the study and gaining the consent of the hospital authorities. The research process was explained to the patients’ family members and legal guardian and the patients details were entered into the study after gaining their written consent. The sequence of using small (12 French) or big (14 French) suctioning catheter for each patient was selected randomly. Based on an accepted principle the diameter of suctioning catheter should be smaller than half of the internal diameter of the ETT and both catheters had the aforementioned criterion. All the catheters used in this study were made by Sopa Company in Iran. Each patient underwent suctioning three times with the small catheter and three times with the big catheter. For conducting the study, the researcher selected a trained nurse who had skill in suctioning of the airway and gave her the necessary trainings regarding the study and data recording. Then suctioning on the patient was performed by the researchers under a uniform guideline. Suctioning was performed when necessary and suctioning indications included secretions in airway, coughing, increase of airway pressure under the ventilator, O2SAT reduction, and movement of ala of the nose, respiratory struggle and secretion sound in ETT. The monitoring device was Novin S1800 and made by the company Pooyandegan Saadat in Iran and had precision of 1 mmHg and sensitivity of mmHg. The trend setting of the monitoring device for exploring the SpO2 changes. The maximum endotracheal suctioning period was 10 seconds with pressure of minus 120 mmHg. Patients in this study underwent endotracheal suctioning with each catheter size three times. In order to record the data SPo2 measured and recorded 5 minutes before the intervention. The patients underwent 100% oxygen for two minutes before endotracheal suctioning and then they were separated from the ventilator. Then suctioning was done for ten seconds and afterwards, the patients were connected to the ventilator with 100 percent oxygen for 30 seconds. Then the patients were separated from the device for the second time and the third time and underwent endotracheal suctioning. After suctioning, the patients were connected to ventilator and underwent 100 percent oxygen for two minutes. The SpO2 was measured at fifth and twentieth minutes after the end of suctioning. The software SPSS version 19 was used for data analysis. Parametric tests were used, considering the natural dispersion of the findings. Repeated measures ANOVA was used for measuring SpO2 changes in each method and paired t-test was used in each suctioning stage for the comparison of the two explored methods.

3. RESULTS AND DISCUSSION

This study was conducted on 38 patients in coma who were hospitalized in intensive care units. Two patients were excluded from the study due to early removal of ETT and finally, the study was conducted on 36 patients. The mean age of the patients was 39.11 years with the range of 18 to 60 years. 21 (58.3%) patients were male and the rest were female. The ETT used for all the patients was of size 7.5 and the patients’ consciousness level based on Glasgow coma scale was between 4 and 8 and its total mean in the patients was 5.89±1.16. The findings of the study indicated that SpO2 mean during the suctioning with the small catheter changed in different stages (P<0.001) which indicates the reduction of SpO2 during suctioning and in different episodes and it returned to the initial state after 5 minutes the minimum reduction of SpO2 belonged to the third episode (0.991%), the second episode (0.713%) and the first episode (0.333%) of suctioning respectively (Table 1 ).

Table 1. Comparison of the mean of SpO2 changes during different stages of suctioning with the small catheter*

*The values over the breaking line are related to the absolute value of the change difference mean and the values below the breaking line are related to the p-value based on the Post-hoc test using LSD method.

Similar results occurred during suctioning with the big catheter and SpO2 mean during suctioning with the big catheter was significantly different from that of the initial state (p<0.001) (Table 2 ).

Table 2. Comparison of the mean of SpO2 changes during different stages of suctioning with the big catheter*

*The values over the breaking line are related to the absolute value of the change difference mean and the values below the breaking line are related to the p-value based on the Post-hoc test using LSD method.

In suctioning with catheter 14 too, the lowest level of SpO2 belonged to the third suctioning episode. The results of Table 3 indicated that SpO2 means in different suctioning stages using the small and the big catheter were not significantly different.

Table 3. Comparison of the mean of SpO2 changes during suctioning in the two size of catheter*

*: paired T test, denotes statistical significance (P < 0.05)

The present study was conducted with the aim of exploring SpO2 changes in different suctioning stages using catheter sizes 12 and 14 in anesthetized patients. The results of this study indicated that SpO2 mean changes in different times of suctioning. The comparison of these changes while using small and big catheters indicated that there is no statistically significant difference between the two methods. The trend of changes indicated that the first suctioning episode results in reduction of SpO2 to a lesser extent and the third episode resulted in the highest level of reduction in SpO2. Therefore, it is recommended to limit the endotracheal suctioning to the minimum number of required suctioning episodes. The results of the study by Gholamzadeh et al indicated that SpO2 was reduced during suctioning, compared with before the suctioning (p<0.05) and the highest level of changes of arterial blood oxygenation was in 3 minutes after suctioning, compared with during suctioning (p<0.05) and these results are consistent with the present study. It is recommended to hyperventilate the patient or give him/her 100% oxygen for about two minutes before suctioning (1). The results of the present study are consistent with results of the study by Jongerden regarding the significant reduction of SpO2 during open suctioning. The results of their study indicated that SpO2 is significantly reduced during suctioning (p<0.001). The compensations of this reduction of blood oxygen were different 2 minutes after suctioning and 5 minutes after suctioning. In addition, the result of their study indicated the return of oxygen saturation to the initial level that is consistent with the results of the present study and points out the reduction of suctioning duration (15). The results of the study by Carmez indicated that SpO2 changes in different times during open and closed suctioning are not statistically significant and this result is not consistent with the results of the present study. As the present study only employed open suctioning nothing can be said about the difference and its significance with closed suctioning but it is recommended to conduct a separate study on this subject and explore the differences between the two suctioning methods. Also, in their study they found no significant SpO2 reduction in different suctioning times and this result is not consistent with the result of the study by (16). It seems that the difference is due to the use of catheter size 12 and also the duration of suctioning in each stage can impact the results (17). The result of the study by Walsh et al indicated that SpO2 level was reduced during suctioning, compared with before it but the reduction was not statistically significant (P<0.005). It seems that due to the lack of mentioning catheter size and suctioning duration an appropriate assessment of the relationship of the results of their study with those of the present study cannot be done (18). The basic aim of endotracheal suctioning is removing secretions and preventing the blockage of the airway, preventing atelectasis, favorable ventilation and oxygenation and reduction of the breathing burden, all of which are the ways of increasing SpO2. The results of the present study indicated that during endotracheal suctioning patients experience the reduction of SpO2 level and this reduction is high during suctioning but is returned to the initial state after a short period of time and this process requires using oxygen for the patient before and after any time of suctioning. Reduction of the SpO2 levels increased after repeated suctioning episodes.

4. CONCLUSION
ACKNOWLEDGMENT

This study was the result of a thesis presented to Shahid Sadoughi University of Medical Sciences and Health Services. The authors express their sincere gratitude to the deputy of research of the aforementioned university and all individuals who cooperated and participated in the study.

AUTHORS CONTRIBUTION

Dr. Javadi designed the study and supervised data collection. Mr. Paimard processed the data, prepared draft of manuscript and supervised revision. Mrs. Maghsoudi collected data and prepared draft of manuscript. . Mrs. Mirzaei collected data and prepared draft of manuscript.

CONFLICT OF INTEREST

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

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Paper Title: The Impact of Catheter Size on SpO2 Changes in Endotracheal Suctioning
Paper Details: Volume 1, Issue 1, Pages: 15-19
Paper doi:10.15412/J.JCC.02010104
Journal of Client Care
Journal home page: http://journals.lexispublisher.com/jcc
Copyright © 2017 Mostafa Javadi et al. This is an open access paper distributed under the Creative Commons Attribution License.
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