Descriptive bias are needed to confirm or

Descriptive study to assess clinical indicators for endotracheal suctioning in 42 conveniently selected adult patients receiving mechanical ventilation.. The most frequently identified cues were the crackles over the trachea (88%), saw tooth waveform (33%), coughing (29%), and visible secretions (5%).

This study concluded that patient on mechanical ventilator should be routinely assessed for coarse crackles over the trachea which is the most common indicator for endotracheal suctioning.26Systematic review and meta-analysis of randomized controlled trials that compared impact of closed versus open endotracheal suctioning systems for mechanically ventilated adults. The random effects model was used select to sixteen trials with 1,929 participants were included. The result implied that when compared with open endotracheal suctioning system; closed endotracheal suctioning system was associated with a reduced incidence of ventilator associated pneumonia and was not associated with reduction of mortality or reduced length of mechanical ventilation. The study concluded that based on current, limited evidence, it is unlikely that, closed endotracheal suctioning system is inferior to open endotracheal suctioning system regarding ventilator associated pneumonia prevention; however, further trials at low risk of bias are needed to confirm or refute this finding.27Single-blinded clinical trial was carried out to compare the effects of shallow and deep endotracheal tube suctioning on respiratory rate, arterial blood oxygen saturation and number of suctioning in intensive care units.

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Convenience sampling was performed for enrolling 37 patients in the study. The results of this research showed that in order for effective airway clearance in the shallow suctioning group, in 56.8% of the subjects (21 people), one time suctioning and in 43.2% subjects (16 people), two times suctioning was required. However, in the deep suctioning group, in 81.1% of the participants (30 people), one time suctioning and in 18.9% (7 people), two times suctioning was required.

The study results concluded that the number of suction needed to effectively clear airway in the shallow suctioning group is significantly higher than in the deep suctioning group .28The comprehensive review study to determine the role of saline instillation in suctioning adult intensive care unit patients: an evidence-based practice review. The study population was randomly selected consisting of patients 18 years or older, who are intubated requiring mechanical ventilation, and are admitted in the ICU. Most of the findings suggested not to use saline when suctioning. This study does not support the use of saline instillation when suctioning an artificial airway.29This clinical trial was conducted on 40 patients in ICU, aiming to compare the effects of the open and closed system suctioning methods on blood pressure, mean arterial pressure, heart rate, and percentage of arterial oxygen saturation, time, and costs in patients under mechanical ventilation. Total coverage sampling was used to select the participants.

Significant changes were observed in heart rate (P = 0.025) and percentage of arterial oxygen saturation (P < 0.001).

The mean lengths of time in open and closed suctioning methods were 5.59 ± 0.211 and 4.34 ± 0.039 seconds, respectively (P < 0.001). Therefore, this study concludes that closed method can replace open suction method in caring of severely critically ill patients.

30Comparative study was conducted regarding clinical experience and incidence of ventilator- associated pneumonia by the use of closed suction system versus open suction-system. In this study the adult patients on mechanical ventilation were consecutively selected. Air entry and de-saturation events during suction were monitored. The result shows that no differences in airway colonization at admission between the groups were detected. The closed suction systems group had a higher Simplified Acute Physiology Score (SAPS) III and also a non-significant increase in ventilator associated pneumonia incidence. This study concluded that a high frequency of circuit contamination in the closed suction systems group paralleled with experienced secretions clearance problems seem unfavorable and in concordance with previous studies.31In a quantitative cross-sectional survey, to compare critical care nurses’ knowledge and adherence within different groups.

The principles of inductive content analysis were used on 101 critical care nurses to analyze the barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. The mean score in the knowledge test was 59.9%. More experienced nurses performed significantly better than their less-experienced colleagues (p = 0.029). The overall, self-reported adherence was 84.0%. This study concluded that main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge and guidance.

32 A prospective observational study nested within a crossover trial to identify changes in heart rate, mean arterial pressure, and oxygen saturation after open and closed endotracheal suctioning randomly in four intensive care unit. In total, 197 complete endotracheal suctioning procedures (103 OSS and 94 CSS) were monitored. Changes in heart rate and mean arterial pressure were comparable after using closed system suction and open system suction, whereas in Spo2, slightly better values were monitored 3 and 5 minutes after open system suction, these differences being rather small (0.3%-0.7%) and clinically not relevant. This study concludes that as changes in heart rate, mean arterial pressure, and Spo2 were comparable and mild during and after closed system suction and open system suction, hence both systems can be considered equally safe.

33 In this randomized crossover study examining that the end-expiratory lung volume recovers more slowly after closed endotracheal suctioning than after open suctioning in 20 patients post cardiac surgery. Closed suctioning and open suctioning was performed in random order, 30 minutes apart. The result showed that reductions in lung impedance during suctioning were less for closed suctioning than for open suctioning. However, at all points post suctioning, end-expiratory lung impedance recovered more slowly after closed suctioning than after open suctioning. Therefore, the use of closed suctioning cannot be assumed to be protective of lung volumes post suctioning. Consideration should be given to restoring end-expiratory lung impedance after either suction method via a recruitment maneuver.

34In a systematic review, to evaluate endotracheal suction in intubated critically ill adult patients undergoing mechanical ventilation. 17 Randomized controlled trial was included. The results of the studies allowed the grouping of evidence into six categories of intervention related to endotracheal suction: research-based endotracheal suction compared to normal endotracheal suction, in one study; routine endotracheal suction compared to minimally-invasive endotracheal suction, in two studies; open system endotracheal suctioning compared to closed system endotracheal suctioning, in eight studies; change of closed system at 24 compared to 48 hours, in two studies; daily change of the closed system compared to non-routine change, in one study; and saline instillation compared to non-saline instillation, in three studies. The study concludes that interventions were undertaken analyzing outcomes referent to hemodynamic alterations, alterations in blood gases, microbial colonization and nosocomial infection, quantity of secretion suctioned, pulmonary alterations, memory of the experience of endotracheal suction on the part of the patient, and discomfort related to the suction.35Non-participant structured observational study which aimed at the development of standard practice guidelines for open and closed system suctioning. 48 nurses employed in the cardiovascular surgery intensive care unit of a state hospital were included in this study by total coverage sampling.

The findings implied that there was a significant difference between the mean scores of the answers for the use of open and closed system suctioning before and after training. In addition, all steps of both suctioning procedures were carried out correctly during the third observation. The study concluded that compliance of the nurses to the standard practice guidelines for open and closed suctioning and their knowledge levels on the subject were increased after training, while the implementation of standards was satisfactory.36Action research study to evaluate effect of simulation-based interprofessional educational module on adult suctioning to provide multi professional groups of students the opportunity to collaborate in applying basic suctioning skills within complex patient care situations. Total coverage sampling was used to assess 48 nurses.

The result showed that four major themes emerged: instructors’ role expectations, prior student learning, student collaboration, and instructor communication. This study concludes that development of the educational module using action research allowed for further development of a pedagogical approach to inter professional education to increase its effectiveness.37Descriptive cross sectional study to assess the level of knowledge on endotracheal suctioning among staff nurses and student nurses in Narayana Medical College and hospital.

Convenient sampling technique was followed to included 30 samples. The study finding reflects that with regard to level of knowledge of endotracheal suctioning among staff nurses 1(7%) had inadequate knowledge, 11(73%) had Moderate knowledge, and 3(20%) had adequate knowledge. Among nursing students 3(20%) had inadequate knowledge, and 12(80%) had moderate knowledge. The present study concluded that comparing the level of knowledge between staff nurses and nursing students, Staff nurses have adequate level of knowledge than nursing students regarding endotracheal suctioning.

38This study aimed to systematically review studies that investigated the effects of normal saline instillation before endotracheal suctioning and to determine the views of nurses concerning this procedure. This study was carried out in 2 stages as a systematic review and a descriptive study. In the first stage, the Medline and CINAHL databases were searched. The second stage of the study consisted of a survey of 65 conveniently selected intensive care nurses.

Normal saline instillation before endotracheal suctioning was demonstrated to decrease patient oxygenation in most studies (P 80% practice score was achieved. Findings of the study revealed that the mean post- implementation knowledge score and practice score of nursing personnel regarding endotracheal suctioning was significantly higher than the mean pre implementation knowledge and practice score (p


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