Suctioning an adult ICU patient: Clinical practice - Pre-oxygenation

Recommendations for practice

Section

Recommendation

Grade

13

If a patient has high oxygen and positive end expiratory pressure (PEEP) requirements and/or is known to de-saturate to clinically significant levels, pre-oxygenation should be considered.

B

14

If pre-oxygenating, use the ventilator capability to deliver 100% oxygen.

B

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations

Pre-oxygenation prior to suctioning has been a standard of care that is not supported by evidence. Moreover, it may be harmful to patients. This practice was based on the assumption that the delivery of an increased fraction of inspired oxygen via the mechanical ventilator or manual resuscitator would prevent instances of hypoxia during suctioning of intubated and mechanically ventilated patients. While routine pre-oxygenation has often been recommended as a precautionary measure to prevent possible instances of desaturation, it cannot be assumed that the administration of high concentrations of oxygen for this use is without risks. It has been demonstrated that high concentrations of oxygen, even for a few minutes, can lead to the development of absorption atelectasis in healthy individuals (22). This effect and subsequent loss of lung volume may be particularly deleterious for the critically ill patient and those with acute lung injury.

Two systematic reviews and one literature review have not shown any new evidence to support the use of pre-oxygenation as a routine practice (9, 11, 13). In a prospective observational study, physiologic disturbances caused by open and closed suctioning were compared, demonstrating a slightly higher SpO2 compared to baseline with pre-oxygenation, however, these changes were not clinically significant (14). Methodological quality and poor study design contributed to weak associations and as there is no new evidence to routinely perform pre-oxygenation during suctioning. 

The routine use of pre-oxygenation should be avoided in patients who do not require it. Preoxygenation is recommended where clinically relevant in patients who are already hypoxic or for patients with compromised cerebral circulation. In all patients, if desaturation occurs, an increase in FiO2 to 1.0 +/- lung recruitment strategies should be considered. Most ventilators include a facility whereby 100% oxygen can be delivered for a preset period, and less haemodynamic effects have been reported with this method.

Grading of recommendation taxonomy

Grade of recommendation

Description

A

Body of evidence can be trusted to guide evidence

B

Body of evidence can be trusted to guide practice in most situations

C

Body of evidence provides some support for recommendation/s but care should be taken in its application

D

Body of evidence is weak and recommendation must be applied with caution

Consensus

Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (9)

References

  1. Rolls K, Smith K, Jones P, Tuipulotu M, Butcher R, A/Prof Kent B, et al. Suctioning an Adult with a Tracheal Tube. Penrith: Intensive Care Coordination and Monitoring Unit (ICCMU) and NSW Health, 2007.
  2. Bouza E, Perez MJ, Munoz P, Rincon V, Barrio JM, Hortal J. Continuous aspiration of subglottic secretions (CASS) in the prevention of ventilator -associated pneumonia in the postoperative period of major heart surgery. Chest. 2008;134(5):938-46.
  3. Lacherade J-C, De Jonghe B, Guezennec P, Debbat K, Hayon J, Monsel A. Intermittent subglottic secretion drainage and ventilator-associated pneumonia: A multicentre trial. American Journal of Respiratory and Critical Care Medicine. 2010;182:910-7.
  4. Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention. Journal of Critical Care. 2008;23:126-37.
  5. Muscedere J, Rewa O, Mckechnie K, Jiang X, Laporta D, Heyland D. Subglottic secretion drainage for the prevention of ventilator associated pneumonia: a systematic review and meta-analysis. Critical Care Medicine. 2011;39(8):1985-91.6. Day T, Farnell S, Wilson-Barnett J. Suctioning: a review of current research recommendations. Intensive and Critical Care Nursing. 2002;18(2):79-89.
  6. AACN. AACN Practice Alert Ventilator Associated Pneumonia. 2008.
  7. Jelic S, Cunningham JA, Factor P. Clinical Review: Airway hygiene in the Intensive Care Unit. Critical Care. 2008;12(2):209.
  8. (AARC) AAfRC. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways. Respiratory Care. 2010;Jun; 55(6):758-64.
  9. NHMRC. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. 2009. p. 1-23.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.