Decreasing the Adverse Effects of Endotracheal Suctioning

During Mechanical Ventilation by Changing Practice

Salvatore Maurizio Maggiore MD PhD, François Lellouche MD, Claudia Pignataro MD,
Emmanuelle Girou PharmD, Bernard Maitre MD, Jean-Christophe M Richard MD PhD,
François Lemaire MD, Christian Brun-Buisson MD, and Laurent Brochard MD

BACKGROUND: Little is known about the incidence of and risk factors for adverse effects from
endotracheal suctioning. We studied the incidence and risk factors, and evaluated the effect of
suctioning practice guidelines. METHODS: During a 3-month period, in 79 mechanically ventilated
subjects, we recorded the adverse effects in 4,506 suctioning procedures. Then practice guidelines
were implemented, and 1 year later, during another 3-month period, in 68 subjects, we recorded the
adverse effects in 4,994 suctioning procedures. RESULTS: In the first period, adverse effects
occurred frequently: oxygen desaturation in 46.8% of subjects and 6.5% of suctionings, hemor-
rhagic secretions in 31.6% of subjects and 4% of suctionings, blood pressure change in 24.1% of
subjects and 1.6% of suctionings, and heart rate change in 10.1% of subjects and 1.1% of suction-
ings. After guidelines implementation, all complications, both separately and all together, were
reduced. The incidence of all complications together decreased from 59.5% to 42.6% of subjects,
and from 12.4% to 4.9% of procedures (both P < .05). PEEP > 5 cm H2O was an independent risk
factor for oxygen desaturation. Receiving > 6 suctionings per day was a risk factor for desaturation
and hemorrhagic secretions. The use of guidelines was independently associated with fewer com-
plications. CONCLUSIONS: Endotracheal suctioning frequently induces adverse effects. Tech-
nique, suctioning frequency, and higher PEEP are risk factors for complications. Their incidence
can be reduced by the implementation of suctioning guidelines. Key words: endotracheal suctioning;
closed suctioning system; practice guidelines; mechanical ventilation; ARDS; PEEP. [Respir Care 2013;
58(10):1588 –1597. © 2013 Daedalus Enterprises]

Introduction Endotracheal suctioning is therefore needed to avoid ac-

cumulation of secretions into the lung, and its associated
The presence of an artificial airway during mechanical complications. Nevertheless, endotracheal suctioning is an
ventilation makes coughing less effective or not possible. invasive procedure, and is not free from hazards and, ex-
ceptionally, from lethal adverse events.1 Numerous side

Dr Maggiore is affiliated with the Department of Anesthesiology and

Intensive Care, Agostino Gemelli Hospital, Catholic University of the
Sacred Heart, Rome, Italy. Drs Lellouche, Pignataro, Richard, Lemaire, Dr Maggiore presented a version of this paper at the International
Brun-Buisson, and Brochard are affiliated with the Medical ICU; Dr Girou Conference of the American Thoracic Society, held May 17–22, 2002, in
is affiliated with the Infection Control Unit; and Dr Maitre is affiliated Atlanta, Georgia.
with the Department of Pulmonology, Henri Mondor University Hospi-
tal, Créteil, France. Dr Lellouche is also affiliated with the Cardiac Sur- The authors have disclosed no conflicts of interest.
gery ICU, Laval University Hospital, Québec City, Canada. Dr Pignataro
is also affiliated with the Department of Anesthesiology and Intensive Correspondence: Salvatore Maurizio Maggiore MD PhD, Department of
Care, Lariboisière Hospital, Paris, France. Drs Richard and Brochard are Anesthesiology and Intensive Care, Agostino Gemelli Hospital, Catholic
also affiliated with the Intensive Care Department, University Hospital, University of the Sacred Heart, Largo Agostino Gemelli 8, 00168 Rome,
University of Geneva, Geneva, Switzerland. Dr Brochard is also affili- Italy. E-mail: smmaggiore@rm.unicatt.it.
ated with the Institut National de la Santé et de la Recherche Médicale
(INSERM) Unit 955, Paris 12 University, Créteil, France. DOI: 10.4187/respcare.02265

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 DECREASING THE ADVERSE EFFECTS OF ENDOTRACHEAL SUCTIONING

effects of endotracheal suctioning have been reported.2-11

Some old studies on selected patient populations sug- QUICK LOOK
gested a high frequency of specific adverse events, such as Current knowledge
oxygen desaturation and arrhythmia.1,12 Leur and co-
workers13 reported a relatively low incidence of some en- Endotracheal suctioning is associated with various com-
dotracheal suctioning adverse events in a selected popu- plications, ranging from discomfort to hemodynamic
lation of surgical patients without ARDS and with a short collapse, but the incidence and severity of these com-
duration of mechanical ventilation. Thus, the incidence plications has not been systematically studied. The use-
and risk factors of adverse effects of endotracheal suction- fulness of adherence to suctioning guidelines has also
ing in a general medical population of critically ill patients not been addressed.
are uncertain.
What this paper contributes to our knowledge
Adverse effects of suctioning, particularly oxygen de-
SEE THE RELATED EDITORIAL ON PAGE 1707 saturation and hemorrhagic secretions, were frequent
and were reduced by the implementation of practice
In 2010 the American Association for Respiratory Care guidelines. Factors that increased the risk of suctioning-
published updated clinical practice guidelines for endo- related complications included more frequent suction-
tracheal suctioning,9 with the aim of optimizing the pro- ing, requirement for a PEEP of ⬎ 5 cm H2O, and the
cedure and reducing the hazards. Specific suctioning strat- presence of ARDS.
egies are not systematically used in ICUs,14 and their
usefulness has not been well assessed. Moreover, the op-
timal approach to reduce endotracheal-suctioning-related
complications has not been fully clarified.15,16 Therefore Study Design and Data Collection
we carried out a clinical investigation to evaluate the in-
cidence of endotracheal-suctioning-associated adverse Endotracheal-suctioning-related adverse events were
events in mechanically ventilated patients, and to deter- collected daily during the 2 3-month periods. During the
mine whether the implementation of practice guidelines first period, endotracheal suctioning was performed ac-
could decrease the rate. Suctioning-induced adverse events cording to the usual practice at that time: suctioning pro-
before and after the implementation of practice guidelines cedures were mainly performed routinely every 2 hours or
were compared using the same methodology. Practice more often if secretions were visible in the endotracheal/
guidelines for endotracheal suctioning were drafted inde- tracheostomy tube; subjects were disconnected from the
pendently from those of the American Association for ventilator; the duration of the procedure, the vacuum pres-
Respiratory Care,9 and before their release. sure (frequently ⬎ 400 cm H2O), size of the suction cath-
eter, and depth of suctioning were not standardized; saline
Methods was instilled in case of dry, tenacious secretions; no spe-
cial precaution was used in subjects with ARDS; in gen-
Study Location and Subject Population eral, closed suction systems were not used.
In the 1-year interval between the 2 study periods, clin-
The study was conducted in the 26-bed medical ICU of ical practice guidelines for endotracheal suctioning were
Henri Mondor University Hospital, Créteil, France. The developed during the first month based on the available
institutional ethics committee approved the study and evidence, and subsequently implemented. The rationale
waived the requirement for informed consent. All consec- and the feasibility of each guideline were discussed in
utive patients needing mechanical ventilation and depth with physicians and nurses until a consensus was
ⱖ 18 years old were included during two 3-month periods, reached and, finally, guidelines were described in a written
from February to April 2000 (period 1) and from April to protocol. To facilitate implementation, repeated meetings
June 2001 (period 2). According to clinical requirements, were organized to educate and to instruct the whole per-
subjects received sedation by continuous infusion, follow- sonnel about this protocol. Repeated informal follow-up
ing our local protocol, which was the same in the 2 study training was also performed, and a medical referent was
periods. They were mechanically ventilated with volume always available for any questions and technical needs.
controlled continuous mandatory ventilation or pressure In the second period, endotracheal suctioning was per-
support mode. Heat and moisture exchangers were gener- formed according to practice guidelines. No major change
ally used. In all subjects, pulse oximetry, electrocardiog- took place in the unit in between these 2 periods regarding
raphy, and arterial blood pressure were continuously mon- airway and ventilator management. During the 2 study
itored, according to routine practice. periods, nurses were instructed to detect and report daily

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 DECREASING THE ADVERSE EFFECTS OF ENDOTRACHEAL SUCTIONING

on standardized data collection sheets all adverse events • Depth of Endotracheal Suctioning. To minimize muco-
for each suctioning procedure. During and just after the sal trauma, shallow suction (limited to the artificial air-
intervention period (period 2), adherence to practice guide- way and the trachea) was performed, instead of deep
lines was also assessed by respiratory therapists and phy- suctioning.13 In practice, approximately 8 –10 cm of the
sicians not involved in suctioning procedures. They ran- suction catheter was left outside the endotracheal tube.
domly observed suctioning procedures and, for each With a tracheostomy the suction catheter was introduced
procedure, reported if guidelines were followed. A total of up to approximately half its length. In any case, insertion
600 observations were performed during night and day. was stopped if an obstacle was met, and the suction
Nurses were not informed of the observers’ task. catheter was withdrawn approximately 1 cm. Suction-
Adherence to the study protocol was assessed daily by ing was then started while gradually withdrawing the
investigators and respiratory therapists. This was done by catheter.
comparing the number of suctioning procedures reported
• Instillation of saline was avoided.21-23 In case of dry,
on the subject’s daily clinical chart and the number of
tenacious secretions, the heat and moisture exchanger
procedures reported on the specific daily sheet used for
was replaced by a heated humidifier. Selective suction-
the study. In addition, in an attempt to validate the reli-
ing under direct visualization by fiberoptic bronchos-
ability of detecting and reporting adverse effects of endo-
copy was performed if a mucus plug was suspected.
tracheal suctioning following the given instructions, one
of the investigators repeatedly observed suctioning pro- • Size of the Suction Catheter. This had to be adapted to
cedures and reported if these instructions were followed. the size of the endotracheal tube, so that the diameter of
Reliability in reporting adverse events of suctioning was the suction catheter was ⬍ 50% the inner diameter of the
calculated as: artificial airway.10,11,17,24,25 In practice, 16 French suc-
tion catheters were used with artificial airways with an
Number of correctly reported events/number of observations inner diameter ⱖ 9 mm, 14 French suction catheters
⫻ 100 were used with 8.0-mm or 8.5-mm endotracheal tubes,
A total of 540 observations were performed: 270 in each and 12 French catheters with 7.0-mm or 7.5-mm endo-
period. tracheal tubes.
• The duration of endotracheal suctioning was limited to
Clinical Practice Guidelines for Endotracheal ⬍ 10 –15 seconds.17,26,27 If needed, the suctioning pro-
Suctioning cedure was repeated after a time period sufficient for
restoring baseline ventilation and oxygen saturation.
The guidelines for endotracheal suctioning were as • The suction pressure had to be set between 200 and
follows: 250 mm Hg.17,25,27,28
• In subjects with ARDS, to minimize suctioning-induced
• Frequency of Endotracheal Suctioning. The suctioning
lung derecruitment, a closed suction system was used,
procedures had to be performed according to the sub-
and ventilator auto-triggering was allowed during the
ject’s needs, and not routinely.17 The need for endotra-
procedure.5,6 Closed suctioning systems were changed
cheal suctioning was evaluated based on oscillations on
in case of mechanical failure or visible soiling only: not
the expiratory part of the flow-time curve18 and tracheal
routinely.23,29-31 Recruitment maneuvers were used in
or bronchial respiratory sounds.19,20 Ventilator alarms
case of persisting hypoxemia after suctioning.4,32
(increased peak airway pressure during volume controlled
continuous mandatory ventilation, or decreased tidal vol-
A sterile technique was employed at all times. The sub-
ume during pressure-targeted ventilation modes), pres-
ject’s appearance (eg, sweating, skin color, agitation), vital
ence of secretions in the endotracheal tube or oxygen
signs (oxygen saturation, heart rate, cardiac rhythm, arte-
desaturation, after excluding other possible causes, were
rial blood pressure), and ventilatory parameters (breathing
also considered as later indicators of the need for suc-
frequency, tidal volume, peak inspiratory pressure) were
tioning. In paralyzed subjects, endotracheal suctioning
monitored during the whole suctioning procedure.17,27
was performed every 4 hours, even if the aforemen-
tioned signs were absent.
Adverse Effects of Endotracheal Suctioning
• Disconnection from the ventilator had to be avoided.
The suction catheter was introduced through the swivel
adapter of the catheter mount, or a closed system was Adverse effects of endotracheal suctioning were defined
used.6 a priori, as follows:

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 DECREASING THE ADVERSE EFFECTS OF ENDOTRACHEAL SUCTIONING

• Oxygen desaturation: an SpO2 decrease of ⬎ 5% Table 1. Subjects, Outcomes, and Number of Suctioning Procedures

• Hemorrhagic secretions: blood visible in suctioned se- Before After

cretions Guidelines Guidelines P
n ⫽ 79 n ⫽ 68
• Severe hypertension: an increase in systolic blood pres-
Age, y 57.7 ⫾ 17 60.2 ⫾ 15.5 .36
sure to ⬎ 200 mm Hg SAPS II at admission 46.1 ⫾ 16.5 50.5 ⫾ 20.3 .16
• Severe hypotension: a drop in systolic blood pressure to Admission type, %
⬍ 80 mm Hg Medical 74.7 79.4
Surgical 8.9 5.9 .74
• Severe tachycardia: an increase in heart rate to Emergency surgery 16.5 14.7
⬎ 150 beats/min Diagnoses, %
Respiratory failure 29.1 29.4 .97
• Severe bradycardia: a decrease in heart rate to ⬍ 50 beats/ Sepsis or septic shock 27.8 17.6 .14
min ARDS 13.9 23.5 .13
Heart failure 15.2 5.9 .07
• Arrhythmia: any new appearance of sustained supra-
Cardiac arrest 5.1 8.8 .37
ventricular or ventricular arrhythmia
Hemorrhagic shock 1.3 7.4 .06
Cerebrovascular disease 2.5 5.9 .31
Statistical Analysis Pulmonary embolism 1.3 1.5 .91
Neurological disease 3.8 0 .10
Results are reported as mean ⫾ SD, except when oth- Duration of mechanical ventilation, d 10.9 ⫾ 12.2 14.5 ⫾ 19.5 .18
erwise indicated. Incidence density, expressed per 100 ven- ICU stay, d 17.3 ⫾ 15.4 23.3 ⫾ 32.2 .14
tilator days, was calculated according to the formula: ICU survival, % 65 49 .051
Suctioning procedures, no. 4,506 4,994 .23
Suctioning procedures/subject/d 6.6 ⫾ 2.2 6.7 ⫾ 2.8 .91
(Number of events/study days) ⫻ 100 Subjects with ⬎ 6 suctionings/d, % 65.8 51.5 .08
Ventilator days, no. 604 621 .34
Dichotomous variables were compared with use of the Ventilator days/subject 7.7 ⫾ 7.8 9.1 ⫾ 10.8 .34
chi-square test, and continuous variables with the Student ⫾ values are mean ⫾ SD.
t test. After assessing normality, the continuous variables SAPS ⫽ Simplified Acute Physiology Score
were dichotomized using adequate cut-points. Logistic
regression analysis was performed, incorporating all fac-
tors with P ⬍ .10 in the univariate analysis. A P ⱕ .05 equately reported in 95.2% of cases, varying from 94.8%
in a 2-tailed test was used to indicate significance. in period 1 to 95.6% in period 2. As shown in Table 1, the
All analyses were performed using statistics software general characteristics of the subjects, number of collected
(StatView 5, SAS Institute, Cary, North Carolina). suctioning procedures, and outcomes were not statistically
different between the 2 periods.
Results
Adverse Effects of Endotracheal Suctioning Before
We included 147 subjects, and 9,500 suctioning proce- Guidelines Implementation
dures were recorded during a total of 1,225 ventilator days.
During the pre-intervention 3-month period (period 1), In period 1, 47 subjects (59.5%) experienced at least
4,506 suctioning procedures in 79 subjects were collected one complication from endotracheal suctioning: oxygen
during 604 ventilator days. After guidelines implementa- desaturation occurred in 37 subjects, hemorrhagic secre-
tion (period 2), 4,994 suctioning procedures, in 68 sub- tions in 25, hypertension in 14, hypotension in 7, tachy-
jects, were collected during 621 ventilator days. cardia in 5, and bradycardia in 4 (Fig. 1). One subject
Nurse reliability in detecting and reporting suctioning experienced transient ventricular tachycardia, which re-
adverse effects was 94% overall, varying from 91% in solved spontaneously after suctioning. Adverse effects
period 1 to 96% in period 2. The most common errors in occurred in 559 procedures (Fig. 2) and 173 ventilator
reporting adverse events concerned severe hypotension days (Fig. 3), which calculated to a rate of endotracheal-
(20%) and oxygen desaturation (17%). The comparison suctioning-associated adverse effects of 92.5 per 100 ven-
between the number of suctioning procedures reported on tilator days. Oxygen desaturation (incidence density of
the subject’s daily chart and the number of procedures 48.3 per 100 ventilator days) and hemorrhagic secretions
reported on the specific daily sheet used for the study (incidence density of 30 per 100 ventilator days) were the
showed that endotracheal suctioning procedures were ad- most frequent adverse effects.

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 DECREASING THE ADVERSE EFFECTS OF ENDOTRACHEAL SUCTIONING

Fig. 1. Mean percentages of subjects who suffered adverse effects from endotracheal suctioning. The sum of proportions for specific
complications is greater than the percentage for all complications, because several complications could occur with a single procedure.
* P ⬍ .05. † P ⫽ 004.

Fig. 2. Mean percentages of suctioning procedures that had complications. The sum of proportions for specific complications is greater
than the percentage for all complications, because several complications could occur during a single procedure. * P ⬍ .001. † P ⫽ .006

Effect of Practice Guidelines on Endotracheal- adverse effects of 39 per 100 ventilator days (P ⬍ .001).
Suctioning-Associated Adverse Effects This reduction concerned all adverse effects, with a de-
crease of 40% for oxygen desaturation (incidence density
Adherence to practice guidelines was 95.9%. The ef- of 31.1 per 100 ventilator days) (P ⬍ .001), 83% for
fects of guidelines implementation are shown in Figures 1, hemorrhagic secretions (5.5 per 100 ventilator days) (P ⬍
2, and 3. Compared to period 1, the proportion of subjects .001), 78% for hypertension (1.8 per 100 ventilator days)
experiencing any complication from endotracheal suction- (P ⬍ .001), 94% for hypotension (0.3 per 100 ventilator
ing was significantly reduced after guidelines implemen- days) (P ⬍ .001), 75% for tachycardia (1.8 per 100 ven-
tation (P ⫽ .04). Particularly, fewer subjects presented tilator days) (P ⬍ .001), and 67% for bradycardia (0.6
hemorrhagic secretions (P ⫽ .004), hypotension (P ⫽ .04), per 100 ventilator days) (P ⫽ .006). The proportion of
and, after adjusting for the duration of mechanical venti- days of mechanical ventilation with complicated suction-
lation, oxygen desaturation (P ⫽ .02). No subject pre- ing procedures was also significantly reduced in period 2
sented any form of arrhythmia during period 2. The rate of (P ⬍ .001). Oxygen desaturation and hemorrhagic se-
complicated suctioning procedures was reduced by 61% in cretions remained the most frequent adverse effects. In
period 2, with a rate of endotracheal-suctioning-associated period 2 the proportion of subjects with frequent suction-

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 DECREASING THE ADVERSE EFFECTS OF ENDOTRACHEAL SUCTIONING

Fig. 3. Mean percentages of ventilator days on which suctioning procedures had complications. The sum of proportions for specific
complications is greater than the percentage for all complications, because several complications could occur during a single procedure.
* P ⬍ .001. † P ⫽ .01 ‡ P ⫽ .05.

ing procedures (⬎ 6/d) was lower, albeit not significantly, suctioning-induced blood pressure changes was the occur-
than in period 1 (see Table 1). rence of oxygen desaturation.

Risk Factors for Endotracheal-Suctioning-Associated Discussion

Adverse Effects The main results of this study are that:
For the analysis, hypertension and hypotension were • Endotracheal suctioning was frequently complicated,
grouped together into a “blood pressure changes” cate- mainly by oxygen desaturation and hemorrhagic secretions.
gory, and tachycardia and bradycardia were grouped into • The implementation of practice guidelines reduced the
a “heart rate changes” category. The results of the uni- incidence of all adverse effects.
variate analysis for individual and grouped adverse effects
are shown in Table 2. General characteristics were not • Frequent suctioning, PEEP ⬎ 5 cm H2O, and ARDS
different between subjects with or without endotracheal- were risk factors for the main adverse events (oxygen
suctioning-associated adverse effects. For all adverse desaturation and hemorrhagic secretions).
events, frequency of suctioning was significantly higher in • Oxygen desaturation was a risk factor for hemodynamic
subjects with adverse effects than those without. Subjects alterations during endotracheal suctioning.
exhibiting oxygen desaturation during endotracheal suc-
tioning had a higher frequency of ARDS, were ventilated The first step of our education initiative to reduce ad-
with a PEEP higher than 5 cm H2O, and had an FIO2 verse effects from endotracheal suctioning was to assess
greater than 0.6 more frequently than subjects who did their incidence during current practice. In this study a large
not present oxygen desaturation. Anticoagulation for at proportion of mechanically ventilated subjects experienced
least 3 days was more frequent in subjects with hemor- adverse events when endotracheal suctioning was not pro-
rhagic secretions than in those who did not present such tocolized. Previous small clinical studies have reported
complication. several complications of endotracheal suctioning.1,3,5,6,12
The results of the multivariate regression analysis are In a population of mostly surgical patients with a relatively
shown in Table 3. Only PEEP ⬎ 5 cm H2O and ⬎ 6/d short duration of mechanical ventilation (4 –5 d) and with-
suctioning procedures were independently associated with out ARDS, Leur et al found that complications of routine
an increased risk of oxygen desaturation during suction- endotracheal suctioning occurred in 38.6% of procedures.13
ing. By contrast, not having ARDS and being in period 2 When a less invasive suctioning technique was adopted
were independent protective factors for desaturation. Fre- (using a modified suction catheter), complications were
quency of suctioning (⬎ 6/d), but not anticoagulation, was reduced to 28.6%. In the first period of our study (routine
independently associated with an increased risk of hem- suctioning), we found a smaller incidence of hypertension
orrhagic secretions, while period 2 was a protective factor and arrhythmia, but a larger incidence of oxygen desatu-
for this complication. The only independent risk factor for ration than previously reported.13 Differences in the defi-

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 DECREASING THE ADVERSE EFFECTS OF ENDOTRACHEAL SUCTIONING

Table 2. Univariate Analysis of Complications of Endotracheal Suctioning

Subjects Subjects
With Adverse Without Adverse P
Events Events

Oxygen desaturation (n ⫽ 60) (n ⫽ 87)

Age, mean ⫾ SD 59.6 ⫾ 16.5 58.3 ⫾ 16.3 .65
SAPS II, mean ⫾ SD 46.3 ⫾ 16.1 49.4 ⫾ 19.9 .32
ICU survival, % 58.3 56.3 .81
ARDS, % 25 13.8 .08
PEEP ⬎ 5 cm H2O, % 58.3 33.3 .003
FIO2 ⬎ 0.6, % 66.7 41.4 .003
⬎ 6 suctionings/d, % 81.7 43.7 ⬍ .001
Period 1/2* 37/23 42/45 .02
Hemorrhagic secretions (n ⫽ 33) (n ⫽ 114)
Age, mean ⫾ SD 56.3 ⫾ 16.7 59.6 ⫾ 16.2 .32
SAPS II, mean ⫾ SD 44.3 ⫾ 13.9 49.3 ⫾ 19.4 .17
ICU survival, % 60.6 56.1 .65
Anticoagulation ⬎ 3 days, % 36.4 21.9 .09
⬎ 6 suctionings/d, % 84.9 51.8 ⬍ .001
Period 1/2 25/8 54/60 .004
Blood pressure changes† (n ⫽ 26) (n ⫽ 121)
Age, mean ⫾ SD 56.1 ⫾ 16.4 59.4 ⫾ 16.3 .35
SAPS II, mean ⫾ SD 45 ⫾ 16.1 48.8 ⫾ 18.9 .35
ICU survival, % 73.1 53.7 .07
Oxygen desaturation, % 73.1 33.9 ⬍ .001
⬎ 6 suctionings/d, % 80.8 54.5 .01
Period 1/2 19/7 60/61 .03
Heart rate changes‡ (n ⫽ 13) (n ⫽ 134)
Age, mean ⫾ SD 60.6 ⫾ 16.6 58.7 ⫾ 16.4 .69
SAPS II, mean ⫾ SD 49.1 ⫾ 19.5 48.1 ⫾ 18.4 .85
ICU survival, % 46.2 58.2 .40
Oxygen desaturation, % 76.9 37.3 .006
Hemodynamic changes, % 38.5 15.7 .04
⬎ 6 suctionings/d, % 92.3 56 .01
Period 1/2 8/5 71/63 .55

* After adjustment for the duration of mechanical ventilation.

† The blood pressure changes category includes hypertension and hypotension.
‡ The heart rate changes category includes tachycardia and bradycardia.
SAPS II ⫽ Simplified Acute Physiology Score II
Period 1 ⫽ before implementation of guidelines
Period 2 ⫽ after implementation of guidelines

nition of complications, in suctioning techniques, and in Acute Physiology Score II and greater incidence of ARDS.
patient population likely explain these discrepancies. In- This can probably explain the somewhat longer duration
stead of relative changes, we used absolute cutoff values of mechanical ventilation and ICU stay, and the trend
for blood pressure and heart rate modifications, to facili- toward lower ICU survival in period 2 (see Table 1).
tate the task of reporting adverse effects for nurses. As a Our data suggest the usefulness of practice guidelines to
consequence, we could have underestimated these compli- reduce the hazards of endotracheal suctioning.9,11,23 In par-
cations. Not surprisingly, we found a greater incidence of ticular, our results support the clinical value of the recently
oxygen desaturation than in Leur’s study, in which pa- updated clinical practice guidelines of the American As-
tients with severe acute respiratory failure were excluded.13 sociation for Respiratory Care.9 Our guidelines, indepen-
Our subjects were sicker, and approximately 20% of dently developed on the basis of available evidence, are in
them had ARDS (see Table 1). In particular, their illness fact very similar, although there may be some differences,
severity was slightly greater, although not significantly, mainly related to the control of the depth of suctioning.
in period 2, as suggested by the slightly higher Simplified Our method consisted of leaving approximately 8 –10 cm

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 DECREASING THE ADVERSE EFFECTS OF ENDOTRACHEAL SUCTIONING

Table 3. Multivariate Logistic Regression Analysis also influence the occurrence of lung derecruitment and
hypoxia.10,11,25-27 Accordingly, the partial prevention of
Odds
Ratio
95% CI P derecruitment obtained by avoiding ventilator disconnec-
tion or using a closed system in ARDS patients,5,6,11
Oxygen desaturation (n ⫽ 60) while limiting the duration of procedure, the level of the
PEEP ⬎ 5 cm H2O 2.96 1.26–6.95 .01
negative suctioning pressure, and the size of the suction
⬎ 6 suctionings/d 6 2.54–14.23 ⬍ .001
catheter, can explain the observed decrease in oxygen sat-
FIO2 ⬎ 0.6 2.25 0.99–5.07 .052
No ARDS 0.31 0.1–0.9 .03
uration after guidelines implementation. The presence of
Period 2 0.4 0.17–0.93 .03 blood in suctioned secretions is likely explained by air-
Hemorrhagic secretions (n ⫽ 33) way mucosal trauma caused by repeated introductions of
Anticoagulation ⬎ 3 days 1.45 0.58–3.64 .43 the suction catheter and application of negative pres-
⬎ 6 suctionings/d 4.25 1.45–12.44 .008 sure. In agreement with a previous study,13 the reduced
Period 2 0.31 0.13–0.78 .01 depth of suctioning and the limitation of negative pressure
Blood pressure changes (n ⫽ 26)* provided by our protocol can account for the large de-
Oxygen desaturation 4 1.46–11 .007 crease in the rate of hemorrhagic secretions in period 2.
⬎ 6 suctionings/d 1.88 0.6–5.86 .28 A further limitation of the suction pressure might have
Period 2 0.44 0.16–1.17 .09
been associated with a further reduction of oxygen de-
* The blood pressure changes category includes hypertension and hypotension. saturation and hemorrhagic secretions, but this might
Period 2 ⫽ After implementation of guidelines have also reduced the efficacy of suctioning in clearing
secretions. Blood pressure and heart rate modifications
can result from abrupt changes of intrathoracic pres-
sure, the release of endogenous catecholamines sec-
of the suction catheter outside the endotracheal tube, or, ondary to suctioning-induced stress, hypoxemia, and vagal
in the extreme case of a too deep insertion of the suction stimulation.1,13,33
catheter inside the trachea so that an obstacle was met, To our knowledge this is the first study assessing risk
of withdrawing the suction catheter before applying the factors for adverse effects of endotracheal suctioning. This
negative pressure. This method may be imprecise for de- may be useful in identifying patients at increased risk for
termining suction depth, and it does not precisely reflect suctioning-related complications. We found that subjects
the recent clinical practice guidelines of the American with ARDS, and subjects ventilated with high PEEP, were
Association for Respiratory Care.9 The use of suction cath- at an increased risk of oxygen desaturation (see Table 3).
eters with length marks would be the best solution to We have previously shown in ARDS subjects that lung
perform shallow suctioning. Unfortunately, we did not derecruitment observed after ventilator disconnection was
have these catheters available in our ICU, as is still the correlated with the level of applied PEEP.6 Here we could
case in many ICUs. Our protocol, including the tech- quantify the degree of hypoxemic risk conferred by PEEP
nique of suctioning, was designed to make the individual ⬎ 5 cm H2O (a 196% increase in risk). In addition, we
tasks as easy as possible with the available means. Nev- showed that frequent suctioning procedures (⬎ 6/d) sub-
ertheless, we observed a quite striking decrease in the rate stantially increase the risk of oxygen desaturation and hem-
of hemorrhagic secretions in period 2, suggesting that a orrhagic secretions (see Table 3). No risk factor was found
lower rate of mucosal trauma should have occurred after for heart rate changes, likely because of their low inci-
the implementation of guidelines, and supporting the idea dence, whereas oxygen desaturation was the only identi-
that the depth of suctioning was indeed reduced in pe- fied prognostic factor for arterial blood pressure altera-
riod 2. The bleeding rate could have been even lower tions (see Table 3). This confirms previous data suggesting
with a more precise control of the depth of suctioning. that hypoxemia plays a key role for the occurrence of this
Our study design did not permit us to determine the weight complication.33
of each recommendation on the global impact of guide- The 2 suctioning procedures were applied sequentially,
lines implementation on adverse effects of endotracheal in 2 different periods, and not randomized. Although ran-
suctioning. domization might have allowed a more rigorous study
Endotracheal-suctioning-induced oxygen desaturation design, the contemporaneous use of 2 different suctioning
results from lung derecruitment secondary to both the loss procedures would have been a source of confusion for the
of positive airway pressure due to ventilator disconnection nursing staff, potentially leading to major protocol devia-
and the application of negative pressure, particularly in tions. In addition, the study was designed as an education
patients with ARDS.3,5,6,11 The duration of the suctioning initiative, and the study protocol was designed to make
procedure, the level of the applied negative pressure, the the individual tasks as easy as possible. The high adher-
size of the suction catheter, and instillation of saline may ence obtained with this approach may have compensated

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 DECREASING THE ADVERSE EFFECTS OF ENDOTRACHEAL SUCTIONING

at least in part for the less rigorous study design. We did 11. Maggiore SM, Volpe C. Endotracheal suctioning in hypoxemic pa-
not compare directly the efficacy of the 2 suctioning pro- tients. Réanimation 2011;20(1):12-18.
12. Adlkofer RM, Powaser MM. The effect of endotracheal suctioning
cedures, which would require a different study design. All
on arterial blood gases in patients after cardiac surgery. Heart Lung
our recommendations were based on the literature, how- 1978;7(6):1011-1014.
ever, and on our own experiments.6 13. Leur JP, Zwaveling JH, Loef BG, Schans CP. Endotracheal suction-
ing versus minimally invasive airway suctioning in intubated pa-
Conclusions tients: a prospective randomised controlled trial. Intensive Care Med
2003;29(3):426-432.
The adverse effects of endotracheal suctioning, partic- 14. Sole ML, Byers JF, Ludy JE, Zhang Y, Banta CM, Brummel K. A
multisite survey of suctioning techniques and airway management
ularly oxygen desaturation and hemorrhagic secretions,
practices. Am J Crit Care 2003;12(3):220-230.
are frequent and can be reduced by the implementation of 15. Subirana M, Sola I, Benito S. Closed tracheal suction systems versus
practice guidelines. Several factors can be used to identify open tracheal suction systems for mechanically ventilated adult pa-
patients at higher risk of airway-suctioning-related com- tients. Cochrane Database Syst Rev 2007;(4):CD004581.
plications so that we can pay more attention to high-risk 16. Grivans C, Lindgren S, Aneman A, Stenqvist O, Lundin S. A Scan-
patients and target future intervention studies toward those dinavian survey of drug administration through inhalation, suction-
patients most likely to benefit. ing and recruitment maneuvers in mechanically ventilated patients.
Acta Anaesthesiol Scand 2009;53(6):710-716.
17. American Association for Respiratory Care. Clinical Practice Guide-
ACKNOWLEDGMENTS line. Endotracheal suctioning of mechanically ventilated adults and
children with artificial airways. Respir Care 1993;38(5):500-504.
We thank Graça Salgueiro and Véronique Morisset (nurses) and Sylvie
18. Jubran A, Tobin MJ. Use of flow-volume curves in detecting secre-
Lely and Nicole Jackson (respiratory therapists) for their constant sup-
tions in ventilator-dependent patients. Am J Respir Crit Care Med
port, and Jérôme Pigeot and Solenne Taillé (biomedical engineers) for
technical assistance. 1994;150(3):766-769.
19. Guglielminotti J, Alzieu M, Maury E, Guidet B, Offenstadt G. Bed-
side detection of retained tracheobronchial secretions in patients re-
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