Result and discussion
Hemodynamic status and suctioning
Endotracheal suctioning for removing secretions, and thereby keeping the airway
open and saving the lives of patients is necessary. However, failure to meet the standards
in the implementation of these procedures can have numerous effects. Possible
complications of endotracheal suctioning include hypoxia, bronchospasm, atelectasis,
tracheal tissue injury, pneumonia associated with ventilator, increased intracranial
pressure, hemodynamic instability and cardiac dysrhythmia (37).
There was a study conducted in anesthetic intensive care unit at Tanta University
Hospital. This study made a comparison between Deep endotracheal suction group and
shallow endotracheal suction group and their effect on hemodynamic parameters. The
results showed that changes of pulse, systolic and diastolic blood pressure, PaCO2, PaO2
and HCO3 were similar in both shallow and deep endotracheal tube suctioning methods.
However, significant differences were observed between deep and shallow suction groups
regarding O2 saturation and respiratory rate( 38).
In another study that included 19 sedated and intubated children, 0–18 years old. They
were enrolled in an ongoing prospective observational study. We extracted systemic
oxygen saturation, cerebral regional oxygen saturation, somatic regional (renal) oxygen
saturation, heart rate, and systolic blood pressure and diastolic blood pressure for 5
26
minutes before and 5 minutes after each event and used these data for analysis. The result
was closed and open endotracheal tube suctioning in sedated children is associated with
transient but clinically insignificant changes in heart rate, blood pressure, cerebral
regional oxygen saturation, systemic oxygen saturation, and somatic regional (renal)
oxygen saturation. Saline instillation during endotracheal tube suctioning had no adverse
effects on systemic or cerebral oxygenation(39).
Also, some studies conducted a study in the effects of deep and superficial
endotracheal suctioning on hemodynamic parameters and pain level in mechanically
ventilated. However, there was a prospective, randomized, controlled experimental study
was conducted on 37 patients who underwent superficial and deep endotracheal
suctioning. The arterial blood pressure, heart rate, body temperature, respiratory rate,
oxygen saturation levels and pain status of the patient were compared before and after
endotracheal suctioning at 1 min, 5 min and 30 min.the result of study showed that
superficial endotracheal suctioning caused fewer changes in hemodynamic parameters
and pain levels of patients compared to deep endotracheal suctioning (40).
Through observational study, 191 patients admitted to the neurological intensive care
unit of a tertiary hospital requiring mechanical ventilation were included. The study stated
that Endotracheal suctioning (ES) provokes a cumulative hemodynamic response by
activation of sympathetic and parasympathetic circuits in the central nervous system. The
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main findings of this study are that hemodynamic changes can be quantified during
endotracheal suctioning and that a less pronounced increase in heart rate is associated
with delayed arousal and worse functional outcome(41).
The autonomic response reflects a complex interaction between the brain and
cardiovascular system. Besides the cardiovascular intrinsic system and the endocrine
system, the autonomic nervous system (ANS) regulates heart rate and blood pressure. The
ANS in turn is controlled by the sympathetic and parasympathetic system. Well-known
brain-heart interactions during brain injury include acute myocardial injury, ECG
changes, and arrhythmias which are commonly observed in subarachnoid hemorrhages
patients( 42).
Moreover, some studies conducted a study about the effect of pressure level during
suctioning. Where, it compared the effect of two levels of negative pressure (100 mmHg
and 200 mmHg) in open endotracheal tube suction on the physiological indices among
patients in the ICUs.
The study revealed that with regard to the detrimental effect of endotracheal tube
suctioning on arterial oxygen saturation and heart rate , suctioning with negative pressure
of 200 mmHg is considered to be a low-risk procedure compared to suctioning with
negative pressure of 100 mmHg, if standard procedures in open suction system are
followed(43).
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Some studies conducted a study about the effects of catheter insertion alone and
catheter insertion with the application of negative pressure on the partial pressure of
arterial oxygen (PaO2) and heart rate prior to and following vagal blockade with atropine.
the result showed no difference in the heart rate following vagal blockade(44).
Another study has examined the autonomic mechanisms underlying changes in heart
rate (HR) and systolic blood pressure (SBP) responses to endotracheal tube (ETT)
suctioning and to compare the open versus closed methods of ETT suctioning on these
measures and on arterial oxygen tension. Although there were no significant effects of
ETT suctioning on the autonomic mechanisms of HR modulation and no significant
differences between the two methods of suctioning, ETT suctioning resulted in an
increase in HR, SBP, and PaO2. However, there was a decrease in the parasympathetic
nervous system indicator of HR variability (HRV) following open suctioning(45).
In regarding the difference between superficial and deep suctioning is not only
hemodynamic status, also the respiratory rate and oxygen saturation have been examined.
The study evaluated respiratory rate (RR), arterial blood oxygen saturation (SpO2) and
number of suctioning in patients hospitalized in the intensive care units of Al-Zahra
Hospital, Isfahan, Iran. Findings showed that Shallow and deep suctioning had a similar
effect on RR and SpO2. However, shallow suctioning caused further manipulation of
patient's trachea than deep suctioning method. Therefore, it seems that deep endotracheal
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tube suctioning method can be used to clean the airway with lesser manipulation of the
trachea(46).
In clinical trial, in patients under mechanical ventilation in the ICU of Al-Zahra
Hospital, Isfahan, Iran. Heart rate (HR) and blood pressure (BP) were measured
immediately before and 1, 2, and 3 min after deep suctioning. HR and BP were
significantly increased after deep suctioning (47)
Pain and suctioning
The presence of pain during tracheal suctioning has been demonstrated in earlier studied.
Some studies evaluated the effectiveness endotracheal suction and the way of suctioning
on pain and agitation in patients under mechanical ventilation. The study reported a
significant pain and agitation in patient underwent deep suctioning (48).
Painful care procedures are the most common cause of stress in patients admitted to
Intensive Care Units (ICUs). Tracheal suctioning is the most painful experience for ICU
patients. The studies showed that endotracheal suctioning has a significant pain in
mechanically ventilated patients(49).
30
In a study conducted in patients underwent deep and superficial endotracheal
suctioning on hemodynamic parameters and pain level in mechanically ventilated
neurosurgical patients. The study reported that patients had pain after exposure to deep
suctioning. Also, There was no statistically significant difference between the effects of
deep and superficial endotracheal suctioning in term of pain (50) .
However, pain behaviors and hemodynamic parameters examined through the effects
of endotracheal suctioning and invasive procedures on hemodynamic parameters and pain
behaviors in adult intensive care patients. The study reported that behavioral Pain Scale
scores increased during the suctioning and invasive procedures compared to pre-
suctioning(51)
Pain assessment and management are an important issue to ensure the comfort of
patients in the intensive care unit, and reducing pain is an important nursing intervention.
Therefore, it is important to evaluate pain correctly. For correct pain management, it is
necessary to correctly determine the presence and severity of pain. So, clinical
prospective study was conducted to determine whether endotracheal suctioning was
painless and whether the Behavioral Pain Scale (BPS) was an accurate assessment tool to
assess pain during endotracheal suctioning. The study showed that Endotracheal
suctioning did not cause pain in conscious patients when the procedure was performed
with the correct catheter in accordance with the guideline (52).
31
Due to the frequency and risks associated with endotracheal suctioning, there is a need
to examine clinical practice critically and identify clinical research to guide practice.
Correct technique and preparation by the clinicians can assist to reduce the risks of
adverse events and the level of discomfort for the patients. So clinical trials conducted to
investigate the effects of routine versus the minimally invasive endotracheal tube
suctioning procedure on suction-related pain, airway clearance and airway trauma in
patients who were intubated. The results of study mentioned a significant pain after
routine suctioning (53).