Journal of Critical Care 30 (2015) 762767

Contents lists available at ScienceDirect

Journal of Critical Care

journal homepage: www.jccjournal.org

Ventilation

Normal saline instillation before endotracheal suctioning: What does

the evidence say? What do the nurses think?: Multimethod study
Hatice Ayhan, RN, PhD a,, Sevinc Tastan, RN a, Emine Iyigun, RN a, Yagmur Akamca, RN b,
Elif Arikan, RN c, Zubeyde Sevim, RN c
a
School of Nursing, Gulhane Military Medical Academy, Ankara, Turkey
b
Erzurum Maresal Cakmak Miltary Hospital, Erzurum, Turkey
c
Haydarpasa Training Hospital,Gulhane Military Medical Academy, Istanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Keywords: Purpose: This study aimed to systematically review studies that investigated the effects of normal saline instilla-
Normal saline instillation tion before endotracheal suctioning and to determine the views of nurses concerning this procedure.
Endotracheal suctioning Methods: This study was carried out in 2 stages as a systematic review and a descriptive study. In the rst stage,
Intensive care nurse the Medline and CINAHL databases were searched. The second stage of the study consisted of a survey of 65
intensive care nurses.
Results: The systematic review identied 7 studies. Nearly all of the studies had a self-controlled clinical trial
design. Normal saline instillation before endotracheal suctioning was demonstrated to decrease patient
oxygenation in most studies (P b .05). However, the impact of normal saline on hemodynamics and the incidence
of ventilator-associated pneumonia remain unclear. Most nurses (87.7%) apply normal saline instillation.
Conclusion: Although the effects of normal saline instillation on hemodynamics and pneumonia incidence remain
controversial, this procedure signicantly decreases the oxygenation. Therefore, the use of this procedure is not
recommended. However, normal saline instillation is used frequently by nurses to manage thick and tenacious
secretions in clinical practice. Additional studies are needed to determine the effectiveness of applications that
may be alternatives to normal saline instillation in the management of these secretions.
2015 Published by Elsevier Inc.

1. Introduction
Intubated patients are unable to cough sufciently to remove
pulmonary secretions. In such cases, the retention of secretions causes
atelectasis and insufcient ventilation. Thus, endotracheal suctioning
is an important nursing practice for intubated patients [1]. Nurses
occasionally encounter thick and tenacious secretions during endotra-
cheal suctioning. To manage these secretions, normal saline instillation
(NSI) is used throughout the world [2-4]. The use of NSI before endotra-
cheal suctioning is intended to lubricate the catheter, liquefy and soften
secretions, and mobilize secretions by stimulating coughing [5,6].
2. Background
Studies designed to determine the impact of NSI before endotracheal
suctioning, which is a practice that is commonly used in intensive care
units, have been performed since the 1970s. Demers and Saklad [7]
indicated that water and mucus do not blend in an in vitro environment.
Hanley et al [8] reported that only 10.7% to 18.7% of a saline solution can
be retrieved with suctioning and that the portion that remains in the
Corresponding author.
E-mail address: hayhan@gata.edu.tr (H. Ayhan).
lungs negatively affects gas exchange. In that respect, the reduction of ox-
ygen saturation after NSI and the increased risk of ventilator-associated
pneumonia (VAP) have been supported by studies [9,10]. In addition,
Hagler and Traver [11] demonstrated in a laboratory environment that
the use of NSI caused bacteria to move toward the lower airway.
The previous systematic reviews stated that NSI disturbs the oxy-
genation of the patient and causes anxiety and pain. However, these re-
views reported that results of studies on this subject were inconsistent
and insufcient due to methodological restrictions [12-14]. The most
recent reviews on this subject stated that the existing studies failed to clear-
ly demonstrate a positive impact of NSI. In contrast, NSI was reported to
have physiological and psychological side effects [1,15,16]. The shared
view of all reviews on this subject is that this procedure cannot be applied
as a routine and standard practice in clinical practice until the physiological
benets of NSI are proven [1,14-16]. In addition, it is recommended that NSI
be used only for patients who are proven to need NSI [16,17]. Robert's
study [18] stated that this recommendation causes hesitation among
health care professionals when NSI is required in intensive care.
Although previous studies failed to clearly demonstrate that NSI is
useful and effective, NSI is widely used by nurses in clinical practice
[3,4,19]. A study performed by Chau et al [20] reported that nurses
continue to use NSI in clinical practice, although compliance with the
current evidence-based guidelines is high. Thus, NSI usage before

http://dx.doi.org/10.1016/j.jcrc.2015.02.019
0883-9441/ 2015 Published by Elsevier Inc.
 H. Ayhan et al. / Journal of Critical Care 30 (2015) 762767
endotracheal suctioning remains a controversial issue. Furthermore,
new studies that investigated the effects of NSI were not included in
previous systematic reviews [21-24]. As the evidence obtained through
scientic methods is converted into practice, clinicians' views and own
experiences are very important. Accordingly, the aim of the present
study is to systematically review studies that investigated the effect of
using NSI before endotracheal suctioning on sputum amount, patient
oxygenation, hemodynamics, and the development of pulmonary infec-
tion. In addition, this study aims to evaluate NSI use for adult patients by
intensive care nurses and assess the views of nurses on this topic.
3. Methods
This multimethod study was carried out in 2 stages as a systematic
review (part I) and a descriptive study (part II).
3.1. Part I
3.1.1. Search strategy
Two databases (Medline and CINAHL) were searched with EndNote
X5 (Thomson Reuters ISI Research Soft, 2011) software using endotra-
cheal suctioning, isotonic sodium chloride, and normal saline as
keywords to obtain potential articles. We identied 62 references and
deleted duplicate articles. We retained 48 articles. This strategy is sum-
marized in the ow diagram (Fig. 1).
3.1.2. Eligibility criteria
We conned our search to English language articles and randomized or
nonrandomized clinical trials that were published since 2002. We planned
to include studies that examined the effects of NSI usage before endotra-
cheal aspiration in adult patients. Studies that did not comply with the sta-
ted criteria were excluded. The reasons for exclusion were recorded (Fig. 1).
3.1.3. Study selection
Eligibility was assessed independently by 2 researchers based on the
title or abstract. The 2 researchers' reviews were compared, and 42
studies that did not comply with the inclusion criteria were excluded.
A total of 6 articles were determined to be appropriate. The full texts
of these articles were obtained.
Medline (n = 20)
CINAHL (n = 42)
62 relevant articles identified
48 abstracts assessed for eligibility
6 articles evaluated for inclusion
7 articles included
Fig. 1. Flow diagram of study selection.
763
The references of the selected articles were screened to identify ad-
ditional relevant articles. One article that fullled the eligibility criteria
was added to this review.
3.1.4. Data collection and synthesis
Two researchers independently reviewed the full text of the studies.
Data were extracted using a standardized form. This data summary form
consisted of the study design, the sample size, the outcome measures,
and main results. These summaries were compared at a later time, and a
consensus was reached among the researchers. Disagreements were
resolved by discussion. A meta-analysis could not be performed due to
heterogeneity in the methodologies of the studies. Thus, the data were
synthesized using a systematic review approach, which is the most
appropriate method for summarizing heterogeneous evidence. A systema-
tic review uses a process to identify comprehensively all studies for a
specic focused question, appraise the methods of the studies, summarize
the results, present key ndings, identify reasons for different results
across studies, and cite limitations of current knowledge [25]. Accordingly,
the data were presented in the framework of the main results.
3.1.5. Quality assessment
Methodological quality of the studies was independently assessed
by 2 reviewers using the EBRO classication of the Dutch Cochrane Cen-
tre and the Dutch Institute for Healthcare Improvement (CBO), member
of the Guidelines International Network [26]. The classication that was
used hereby is shown in Table 1.
3.2. Part II
3.2.1. Setting
This research was performed in 4 intensive care units (ie, anesthesi-
ology and reanimation, neurosurgical, neurology, and the medical in-
tensive care unit) of a training and research hospital in Turkey from
February 1, to 25, 2013.
3.2.2. Participants and study size
Nurses who worked in the intensive care unit for at least 3 months
and volunteered to participate in the research were included the
study. Sixty-ve nurses (90.2%) formed the sample of the study.
Excluded: 14
Duplicates: 14
Excluded: 42
No abstract: 4
No relevant data: 26
Systematic review: 7
Pediatric studies: 4
Commentary: 1
1 article reached from refence list of the other
articles
764 H. Ayhan et al. / Journal of Critical Care 30 (2015) 762767

Table 1 3.2.3. Variables and data collection

Assessment of methodological quality of studies concerning intervention Data were collected using a data collection form that was prepared
Level Explanation by the researchers. This form consisted of 11 questions, 5 of which
A1 Systematic review of at least 2 independently conducted studies of A2 level
were related to dening characteristics of the nurses and 6 of which
A2 Randomized double blind clinical comparing study of good quality and size were related to the use of NSI before endotracheal suctioning.
B Randomized clinical study, with moderate quality and size, or other
comparing research (case-control study, cohort study)
C Case series
3.2.4. Ethical considerations
D Expert opinion
Before the implementation of the study, ethical committee approval
was obtained from the institution where the research was conducted.

Table 2
Characteristics and outcomes of studies

Study, year Design n, population, intervention Outcome Main results

Akgul and Akyolcu Self-controlled 20 patients suctioning Arterial blood gases Blood gas and oxygen saturation levels
[26], 2002 clinical trial without saline vs with SpO2 level Heart rate were similar between groups (P N .05).
5-mL normal saline Signicantly increase heart rate with
saline in the fourth and fth minutes
after suctioning (92 vs 96, P b .05)
In examining each suctioning group
separately according to baseline levels:
signicantly increase pH levels with saline
5 min after suctioning, P b .05
Ji et al [27], 2002 Self-controlled 16 patients suctioning Oxygen saturation The recovery time for oxygen saturation
clinical trial without saline vs with to return to baseline levels after suctioning
2-mL normal saline vs was just after suctioning (P = .54), 45 seconds
with 5-mL normal saline after suctioning (P = .06), and in excess of
5 min (P = .003) with 0-, 2-, and 5-mL saline
instillations, respectively.
Klockare et al [28], 2006 Self-controlled 9 patients inhalation of a Distribution of Compared with direct instillation, nebulized
clinical trial nebulized uid vs instillation radiolabeled saline solution solution is more uniformly distributed between
of 2 mL of saline solution in the respiratory tract and within the lungs, no signicant difference
(lung activity [both sides] %: 51.6 vs 75.9, P N .05).
Most of the instilled uid goes to the posterior
portion of the right lower pulmonary lobe
(lung activity right %: 33.2 vs 66.7, P = .028;
lung activity left %: 17.4 vs 7.4, P N .05).
Caruso et al [21], 2009 Randomized 130 patients suctioning Incidence of VAP The rate of clinically suspected VAP was similar
controlled trial without saline vs 132 Endotracheal tube occlusion between groups (31.8% vs 24.6%, P = .22).
with 8-mL normal saline The incidence of microbiological proven VAP
was signicantly lower in the saline group
(23.5% vs 10.8%, P = .008).
The relative risk reduction of VAP in the saline
group was 54% (95% condence interval, 18%-74%).
The incidence of endotracheal tube occlusion
was similar between groups (3% vs 0.8%, P = .37).
Giakoumidakis Self-controlled 103 patients suctioning Secretions' weight Normal saline instillation was associated with increased
et al [22], 2011 clinical trial without saline vs with Oxygen saturation secretions' weight (g/median: 1.0 vs 2.0, P b .001).
5-mL normal saline No signicant differences in SaO2 values
compared with no instillation (P N .05).
In examining each suctioning group separately according
to baseline levels: normal saline instillation was associated
with a decrease in SaO2 levels 1 min (P b .001) and 15 min
(P = .002) after suctioning. In addition, suctioning without
normal saline was associated with a decrease in SaO2
1 min (P b .001) after the suctioning.
Iranmanesh and Self-controlled 50 patients suctioning Oxygen saturation In suctioning with saline, there was a decrease in oxygen
Raei [23], 2011 clinical trial without saline vs with Heart rate saturation, whereas in another group, except at interval
5-mL normal saline Arrhythmia of 1 min, there was an increase in oxygen saturation.
This difference was statistically signicant (changes in
mean oxygen saturation: 1 min, 0.7 vs 1.37,
P = .008; 2 min, 0.12 vs 0.28, P = .031; 5 min
after suctioning, +0.26 vs 0.20, P = .008
Heart rate was similar between groups after suctioning (P N .05).
In both group, there was not found dangerous arrhythmia (P N .05).
Zahran and Abd Self-controlled 26 patients suctioning Hemodynamic response Heart rate, systolic blood pressure, diastolic blood pressure,
El-Razik [24], 2011 clinical trial without saline vs with Incidence of cough and respiratory rate were similar between groups (P N .05).
5-mL normal saline Arterial blood gases Cough response was similar between groups after suctioning (P N .05).
In examining each suctioning group separately according
to baseline levels: pH value increases immediately and
5 min after suctioning without saline and decreases
immediately and 5 min after suctioning with saline
(P = .04, .045, and .025, respectively). PaCO2 increases
signicantly immediately after suctioning with saline,
and PaO2 and SaO2 reduce signicantly 5 min after
suctioning with saline (P = .04, .045, and .025, respectively).
 H. Ayhan et al. / Journal of Critical Care 30 (2015) 762767
3.2.5. Data analysis
To analyze the data, the SPSS (Chicago, IL) 15.0 software package
was used. The data were presented as the number (n), percentages
(%), or median (interquartile range).
4. Results
4.1. Results of the systematic review
4.1.1. Study characteristics
A detailed description of each of the 7 included studies is provided in
Table 2. According to this table, 1 of the studies was a randomized
controlled study, but no double blinding for which the methodological
quality was level B. The remaining studies were self-controlled clinical
trials, and similarly, the methodological quality of those studies was
fair (level B) [26]. A total of 486 intensive care patients from samples
ranging from 9 to 262 patients were included in these studies.
4.1.2. Main results
The results of the studies included in this systematic review were
analyzed with respect to the following categories: impact on sputum
amount, impact on oxygenation, impact on hemodynamics, impact on
pulmonary infection, and distribution of saline in the lungs.
4.1.2.1. Impact on sputum amount. The amount of sputum extracted with
endotracheal suctioning and tube congestion was assessed in 2 studies
[21,22]. In the study performed by Giakoumidakis et al [22], it was de-
monstrated that the weight of the secretion extracted when endotracheal
suctioning was performed with 5 mL of saline was twice the amount that
was aspired with no saline (P b .001). In the study performed by Caruso
et al [21], the difference was not found to be statistically signicant (P N
.05), although less obstruction in the tube was observed in the group in
which NSI was applied.
4.1.2.2. Impact on oxygenation. The impact of NSI before endotracheal
suctioning on oxygenation (ie, pH, PaO2, PaCO2, SaO2, and SpO2) were
assessed in 5 studies [22-24,27,28]. Most of the studies determined
that oxygen saturation decreased signicantly after endotracheal
suctioning with saline when compared to the baseline values obtained
before suctioning (P b .05). After endotracheal suctioning without sa-
line, the oxygen saturation returned to baseline values within a maxi-
mum of 1 minute [22-24,28]. In the study performed by Akgl and
Akyolcu [27], the pH increased signicantly 5 minutes after suctioning
with NSI. In the study performed by Zahran and Abd El-Razik [24], the
PaCO2 increased signicantly and the PaO2 decreased signicantly after
suctioning with NSI. With respect to the cough response, no difference
was identied between the groups.
4.1.2.3. Impact on hemodynamics. The hemodynamic impact of NSI
before endotracheal suctioning was assessed in 3 studies [23,24,27]. In
the study performed by Akgl and Akyolcu [27], the heart rate was de-
monstrated to increase signicantly after suctioning with NSI (P b .05).
In the remaining studies, no difference in hemodynamics was observed
between the groups [23,24].
4.1.2.4. Impact on pulmonary infection. One study reviewed the impact of
NSI before endotracheal suctioning on the development of VAP and
atelectasis [21]. That study determined that the microbiologically
conrmed VAP rate was 10.8% in the group in which 8 mL of normal
saline was instilled. The VAP rate was 23.5% in the group without saline,
representing a signicant difference (P b .05). In addition, no difference
in the atelectasis rate was observed between groups, although this rate
was higher in the group without saline [21].
4.1.2.5. Distribution of saline in the lungs. One study assessed the distribu-
tion of instilled saline in the lungs [29]. In that study, a radiolabeled
765
saline solution was applied with a nebulizer or via direct instillation.
Although 72.9% of the instilled saline reached the lungs, this rate was de-
termined to be lower with nebulization (55.6%); however, this difference
was not statistically signicant. In addition, 63% of the instilled saline
reached the lower lobe of the right lung, but the uid applied with nebu-
lization was distributed equally both within the lungs and between the
lungs [29].
4.2. Views of nurses
4.2.1. Characteristics of the participants
All of the nurses included in our study were female, with a median
age of 27.0 years (22-38 years). Most of the nurses (87.7%) had a
bachelor's degree, and the average intensive care experience was 3
years (Table 3).
4.2.2. Main results
When the NSI practices of the nurses before suctioning were
reviewed (Table 4), it was determined that most of the nurses (87.7%)
apply NSI before endotracheal suctioning. All of the nurses who apply
NSI stated that they do so to liquefy the secretions and make them
easy to remove. Most of the nurses (77.1%) stated that they apply NSI
based on the condition of the secretions. On average, most of the nurses
instill 1 to 4 mL of normal saline into the airway before endotracheal
suctioning. Approximately one third of the nurses (26.3%) who apply
NSI stated that they also apply steam inhalation to the patients, 18% of
the nurses stated that they apply a mucolytic or nebulizer medication,
and 15% of the nurses stated that they change the patient's position.
A review of the views of the nurses who apply NSI regarding whether
this practice is harmful (Table 5) determined that nearly half of the
nurses (42.1%) who instill normal saline before suctioning continue
this practice, although they believe that it might be harmful. According
to the nurses, the damage that this practice might cause is increased
lung infection risk (91.6%) and decreased oxygen saturation (34.8%).
Half of the 8 nurses who do not apply NSI (12.3%) stated that they
avoid this practice because they do not think that it is useful; the other
half stated that they avoid this practice because they think it is harmful.
5. Discussion
The basic aim of endotracheal suctioning is to open and maintain the
airway. In most regions of the world, this practice is the responsibility of
nurses [3]. Most nurses commonly use NSI before endotracheal
suctioning [3,4]. For that reason, it is important to assess the evidence
and determine the views of intensive care nurses on this practice.
The percentage of nurses who state that they instill normal saline in
the airway (87.7%) was found to be quite high among the intensive care
nurses in our study. However, most of the nurses stated that they do not
perform this practice routinely. In similar studies, NSI was reported to
be applied by most health care professionals for patients with thick
Table 3
Characteristics of the intensive care nurses (n = 65)
n %
Age/median (IR) 27.0 (10)
Intensive care unit
Anesthesiology and reanimation 16 24.6
Medical 19 29.2
Neurology 14 21.5
Neurosurgery 16 24.6
Level of education
Associate degree 3 4.6
Bachelor's degree 57 87.7
Master of science in nursing 5 7.7
Job experiences/year/median (IR) 5 (10.5)
intensive care experience/year/median (IR) 3 (6.25)
IR indicates interquartile range.
766 H. Ayhan et al. / Journal of Critical Care 30 (2015) 762767

Table 4 gas exchange in the lungs. In this systematic review, oxygen saturation
Normal saline instillation practices of nurses after NSI was determined to be lower than the values observed before
n % suctioning in most studies that report the impact of NSI on oxygenation
Apply normal saline instillation
[22-24,28]. In all studies except for the study performed by Akgl and
Yes 57 87.7 Akyolcu [27], this difference was demonstrated to be statistically signi-
No 8 12.3 cant [22-24,28]. These results are also consistent with previous studies
Reasons of apply normal saline (n = 57)a [32,33]. Therefore, although nurses believe that secretions are thinned
Liquefy the secretions 57 100
with NSI and are easily removed, a large portion of the normal saline ap-
Stimulate to cough 5 8.8
Increase the oxygen saturation 5 8.8 plied to the airway remains in the right lung. This situation negatively
Relieve the patient 4 7.0 affects the patient's oxygenation.
Routine clinical application 1 1.8 The impact of NSI on hemodynamics is an important parameter. In
Frequency of apply normal saline (n = 57) this systematic review, some studies demonstrated that the heart rate
According to the condition of the secretions 44 77.1
increases after suctioning with NSI [27] and that the application of saline
Once in every suctioning 4 7.01
Several times at each suctioning 1 1.75 does not signicantly increase the heart rate [23,24]. Similar studies in
Once a day 4 7.01 the literature indicated that NSI either affects hemodynamics [32,33]
Several times per day 4 7.01 or does not cause a signicant change [6]. Therefore, the hemodynamic
Amount of normal saline
impact of NSI remains controversial.
1-4 mL 40 70.2
5-9 mL 10 17.6 Data concerning the long-term outcomes of NSI before endotracheal
10 mL and higher 7 12.3 suctioning are also needed. An in vitro study reported that NSI might
a
n was multiple.
cause bacteria to proceed to the base of the lung and, therefore, cause
lower respiratory system contamination and VAP [11]. In opposition
to this report, the study performed by Caruso et al [21] demonstrated
and tenacious secretions, similar to the results of our study. Some studies that the incidence of VAP decreased signicantly in the group in
suggested that NSI is used on patients who are proven to need NSI [16]. which NSI was applied. The proposed mechanism of this impact was
However, it remains unclear how the nurses evaluate pulmonary secre- that NSI increases the amount of secretions by stimulating coughing
tions as thick and tenacious. In addition, the amount of normal saline to and, therefore, decreasing the biolm layer in the endotracheal tube.
be applied when NSI is necessary is unclear in the literature. In Reeve's [34] commentary on this study, it was stated that these
In our study, most nurses stated that they apply 1 to 4 mL of normal mechanisms, which were reported to cause a decrease in VAP, were
saline to the airway. Although most of the nurses applied less than 5 mL not measured in the study performed by Caruso et al [21]; therefore,
of normal saline in the study performed by Day et al [4], similar to the this impact could not be determined completely. It was proposed that
result of our study, the study performed by Ozden et al [30] reported the effect of this mechanism should be investigated in future studies
that approximately half of the nurses apply 5 mL of normal saline and [34]. This criticism and recommendation were also stated in the study
23.7% apply 10 mL or more of normal saline. In our study, 12.2% of performed by Caruso et al [21]. In our study, nearly half of the nurses be-
nurses apply 10 mL or more of normal saline. With suctioning, it is lieved that NSI might be harmful. With similar studies [30,35] in our
intended that most of the existing secretions are cleared. In the study, nurses believe that NSI might have negative impact, such as
systematic review, the study performed by Giakoumidakis et al [22] lung infection, decreased oxygen saturation, and disturbances in the pa-
demonstrated that the amount of secretions doubled with NSI. How- tient. It is remarkable that although nurses believe that normal saline
ever, in that study, which was performed with a small sample, it was may have adverse effects, they use it widely. This situation suggests
stated that this increase might occur due to aspiration of the applied sa- that nurses have difculties when dealing with endotracheal secretions
line [22]. In addition, in the study performed by Klockare et al [29], it and that they focus primarily on removing the secretions without con-
was revealed that most of the NSI accumulates in the lower lobe of sidering the negative effects of NSI.
the right lung. Because the right main bronchus is more vertical and However, nearly half of the nurses in our study also use different
shorter and wider than the left main bronchus, this bronchus extends methods, such as humidication and mucolytic and nebulizer medica-
as a continuation of the trachea [31]. Thus, it is possible that the liquid, tions, for managing secretions. These methods were also recommended
which is instilled via the impact of gravity, sinks down to the base of in previous reviews [14,15]. However, it is recommended that these
the right lung. Demers and Saklad [7] stated that mucus and water methods be used to prevent the development of mucus plaques, not in
never blend when saline is added to secretions and that a similar out- the management of thick and tenacious secretions, as reported by the
come will occur in the lungs of the patient. nurses participating in our study. In the pilot study that was performed
Some of the saline has been observed to reside in the lungs. It is by Klockare et al [29] with a limited sample number, it was demonstrated
thought that the normal saline that accumulates in the base of the that saline is distributed equally within the lungs when it is applied with
lung will decrease both the diameter of the airway and the amount of nebulization. However, this result was not statistically signicant.
Nevertheless, that study provided important data concerning the activity
of saline within the lungs after application with nebulization. Accordingly,
studies are needed to determine whether applications such as nebuliza-
tion prevent thick and tenacious secretion formation and to guide nurses
Table 5
in the prevention of endotracheal secretions.
Views of the nurses who apply normal saline regarding harmful effects (n = 57)

n %

Normal saline instillation has harmful effects 5.1. Limitations

Yes 24 42.1
No 33 58.9
The present study has some limitations. One of these limitations is
Possible harmful effects (n = 24)a
Risk of pneumonia 22 91.6 the fact that only English publications were included in the systematic
Decreased oxygen saturation 8 34.8 review. Another limitation is that studies that investigated pediatric pa-
Anxiety 3 12.5 tients were not included in the assessment. In addition, this study was
Increased blood pressure 1 4.1 conducted in a single center. Thus, the obtained results regarding the
a
n was multiple. views of nurses may not be generalizable.
 H. Ayhan et al. / Journal of Critical Care 30 (2015) 762767
6. Conclusion
There is sufcient evidence to conclude that NSI before endotracheal
suctioning, which is used to soften and easily remove secretions,
signicantly decreases the patient's oxygenation. However, the impact
of NSI on the sputum amount, hemodynamics, and VAP incidence
remains controversial. When considered together, there is no strong
evidence that NSI is a useful procedure. The existing evidence suggests
that practitioners should not use this procedure. However, in clinical
practice, although nurses believe that there may be adverse effects,
they continue to widely use NSI in the management of thick and tena-
cious secretions. So, additional randomized clinical trials are needed to
determine the effectiveness of applications that may be alternatives to
normal saline instillation in the management of these secretions.
Funding and nancial disclosures
No funding was obtained for this study.
Conicts of interest
The authors declare that they have no conicts of interest.
Acknowledgments
The authors thank the intensive care nurses who participated in the
study.
References
[1] Pedersen CM, Rosendahl-Nielsen M, Hjermind J, Egerod I. Endotracheal suctioning of
the adult intubated patientwhat is the evidence? Intensive Crit Care Nurs 2009;
25(1):2130.
[2] Kuriakose A. Using the synergy model as best practice in endotracheal
tubesuctioning of critically ill patients. Dimens Crit Care Nurs 2008;27(1):105.
[3] Sole ML, Byers JF, Ludy JE, Zhang Y, Banta CM, Brummel K. A multisite survey of
suctioning techniques and airway management practices. Am J Crit Care 2003;12:
22030.
[4] Day T, Farnell ST, Haynes S, Wainwright S, Wilson-Barnett J. Tracheal suctioning: an
exploration of nurses' knowledge and competence in acute and high dependency
ward areas. J Adv Nurs 2002;39(1):3545.
[5] Bostick J, Wendelgass ST. Normal saline instillation as part of the suctioning proce-
dure: effects of Pao2 and amount of secretions. Heart Lung 1987;16:5327.
[6] Gray JE, MacIntyre NR, Kronenberger WG. The effects of bolus normal saline instilla-
tion in conjunction with endotracheal suctioning. Respir Care 1990;35:78590.
[7] Demers RR, Saklad M. Minimising the harmful effect of mechanical aspiration:
aspects of respiratory care. Heart Lung 1973;2:5425.
[8] Hanley M, Rudd T, Butler J. What happens to intratracheal saline instillations? Am
Rev Respir Dis 1978;117:1248.
[9] Ackerman MH. The use of bolus normal saline instillation in articial airways: is it
useful or necessary? Heart Lung 1985;14:5056.
767
[10] Ackerman MH, Gugerty B. The effect of normal saline bolus instillation in articial
airways. J Soc Otorhinolaryngol Head Neck Nurs 1990:147.
[11] Hagler DA, Traver GA. Endotracheal saline and suction catheters: sources of lower
airway contamination. Am J Crit Care 1994;3:4447.
[12] Raymond S. Normal saline instillation before suctioning: helpful or harmful? A
review of the literature. Am J Crit Care 1995;4:26771.
[13] Ackerman MH, Ecklund MM, Abu-Jumah M. A review of normal saline instillation:
implications for practice. Dimens Crit Care Nurs 1996;15:318.
[14] Blackwood B. Normal saline instillation with endotracheal suctioning: primum no
nocere (rst do no harm). J Adv Nurs 1999;29(4):92833.
[15] Halm MA, Krisko-Hagel K. Instilling normal saline with suctioning: benecial tech-
nique or potentially harmful sacred cow? Am J Crit Care 2008;17(5):46972.
[16] elik SA, Kanan N. A current conict: use of isotonic sodium chloride solution on en-
dotracheal suctioning in critically ill patients. Dimens Crit Care Nurs 2006;25(1):
114.
[17] Druding MC. Re-examining the practice of normal saline instillation prior to
suctioning. Medsurg Nurs 1997;6(4):20912.
[18] Roberts FE. Consensus among physiotherapists in the united kingdom on the use of
normal saline instillation prior to endotracheal suction: a Delphi study. Physiother
Can 2009;61:10715.
[19] elik SS, Elba NO. The standard of suction for patients undergoing endotracheal
intubation. Intensive Crit Care Nurs 2000;16:1918.
[20] Chau J, Thompson DR, Chan D, Chung L, Au W, Tam S, et al. An evaluation of the
implementation of a best practice guideline on tracheal suctioning in intensive
care units. Int J Evid Based Healthc 2007;5(3):3549.
[21] Caruso P, Denari S, Ruiz SAL, Demarzo SE, Deheinzelin D. Saline instillation before
tracheal suctioning decreases the incidence of ventilator-associated pneumonia.
Crit Care Med 2009;37:328.
[22] Giakoumidakis K, Kostaki Z, Patelarou E, Baltopoulos G, Brokalaki H. Oxygen satura-
tion and secretion weight after endotracheal suctioning. Br J Nurs 2011;20(21):
134451.
[23] Iranmanesh S, Raei H. Normal saline instillation with suctioning and its effect on
oxygen saturation, heart rate, and cardiac rhythm. Int J Nurs Educ 2011;3(1):424.
[24] Zahran EM, Abd El-Razik AA. Tracheal suctioning with versus without saline instilla-
tion. J Am Sci 2011;7(8):2332.
[25] Garg AX, Hackam D, Tonelli M. Systematic review and meta-analysis: when one
study is just not enough. Clin J Am Soc Nephrol 2008;3(1):25360.
[26] Institute for quality and healthcare. Indeling van methodologische kwaliteit van
individuele studies. Available from: http://www.cbo.nl/product/richtlijnen/
handleiding_ebro/article20060207153532/view.
[27] Akgl S, Akyolcu N. Effects of normal saline on endotracheal suctioning. J Clin Nurs
2002;11:82630.
[28] Ji Y, Kim H, Jeong-Hwan P. Instillation of normal saline before suctioning in patients
with pneumonia. Yonsei Med J 2002;43:60712.
[29] Klockare M, Dufva A, Danielsson A-M, Hatherly R, Larsson S, Jacobsson H, et al. Com-
parison between direct humidication and nebulization of the respiratory tract at
mechanical ventilation: distribution of saline solution studied by gamma camera. J
Clin Nurs 2006;15:3017.
[30] Ozden D, Ta Z, Yldz M. The determination of the reason and extent of use of iso-
tonic sodium chloride solution in open and closed system suctioning method
among nurses. HEMAR-G 2009;3:1829.
[31] Seidel HM, Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Chest and Lungs.
Mosby's guide to physical examination. Missouri: Mosby Elseiver; 2011; 146.
[32] Ackerman M. The effect of saline lavage prior to suctioning. Am J Crit Care 1993;
2(4):32630.
[33] Ackerman M, Mick D. Instillation of normal saline before suctioning in patients with
pulmonary infection: a prospective randomized controlled trial. Am J Crit Care 1998;
7(4):2616.
[34] Reeve JC. Instillation of normal saline before suctioning reduces the incidence of
pneumonia in intubated and ventilated adults. Aust J Physiother 2009;55:136.
[35] Schwenker D, Ferrin M, Gift A. A survey of endotracheal suctioning with instillation
of normal saline. Am J Crit Care 1998;7:25560.
2015 Elsevier