Endotracheal and Upper Airway Suctioning: Changes in Newborns’ Physiological Parameters

Lopes Barbosa et al’s quantitative study of the physiological effects of endotracheal tube (ETT) suctioning of neonates in the Neonatal Intensive Care Unit (NICU) concludes that the procedure does affect certain physiological observations.  This study does not make a substantial contribution to nursing practice because its focus is narrow and it largely confirms common nursing practice in this setting. The study would benefit from inclusion of a qualitative component addressing the clinical indications for ETT suctioning and accounting for the changes in physiology as desired by the procedure. As designed, the study is structurally sound in both scope and ethics for nursing research.

Andréa Lopes Barbosa, RN, M.Sc, et al’s quantitative study of the physiological effects of endotracheal suctioning of upper airways in newborn patients in the NICU concluded that the nursing procedure of airway suctioning was painful and had some effect on several physiological observations. The study included 104 newborns, 97 of whom were preterm and all were intubated and under some sort of oxygen therapy including oxyhood’s, mechanical ventilation, and CPAP, for greater than six hours. The purpose of the study was to quantify the effects of suctioning intubated neonates by evaluating heart rate (HR), pulse, respiratory rate (RR), and oxygen saturation (SpO2) over a time series including before the intervention, during, and five minutes after. The authors excluded candidates who were born to drug-addicted mothers, had a fever, or Persistent Pulmonary Hypertension (PPH) (Lopes Barbosa et al. 2011, 1371). These exclusions were valid as the study was strictly quantitative specifically studying the effect of suctioning on newborns. Without these exclusions the conclusions of the study would be easier to invalidate. 

The quantitative study concluded that there were changes in both heart rate, respiratory rate, and pulse immediately before, during, and five minutes after the suction procedure. The authors conclude that nursing practice should, “Intervene using non-pharmacological techniques to reduce changes in RR, HR, pulse, and SpO2 while performing this procedure [upper airway suctioning]” (Lopes Barbosa et al., 2011, 1375). This conclusion is based on a quantitate review of the data. There are no specific recommendations on any changes in nursing practice based on this study. It is not stated whether the ETT suction was clinically indicated or performed as part of a standard schedule. Although there were observed changes, without some qualitative evaluation, its impossible to determine whether they are clinically significant. In some cases the SpO2 increased after the nursing intervention suggesting that the removal of obstruction was necessary. Incorporating a qualitative component in this study’s design would have more benefit to informing nursing practice. As it stands it confirms the underlying nursing practice of not performing unnecessary procedures that are not clinically indicated. 

It’s mentioned that ICU’s perform this procedure on a schedule without an evidence-based clinical evaluation for the need of the procedure. Further, the study cites standards from the American Association for Respiratory Care including that this procedure should be performed when clinical indicated as evidenced by secretions, agitation, and decline in SpO2 (Lopes Barbosa et al., 2011, 1371). This statement is more important than the rest of the study. It is stated in the study that unnecessary procedures should be avoided in the ICU. However, as the study is laid out it doesn’t make a convincing argument that it studied an actual problem or drew any significant conclusions. It is common sense that a critical care nurse should avoid all unnecessary procedures on delicate patients. If this study concluded that there was severe problems with ETT suctioning in the NICU then nursing practice should be augmented to account for such a determination that is not present here.   

This study appears to be in compliance with all applicable ethical considerations consistent with a quantitative study using human subjects. In this case, consent for candidate participation was obtained from the patients’ legal guardians. Rigorous parameters were established governing what types of patients were to be included and excluded in the study. Of greatest concern is that participation in the study would not affect the patient outcome in these cases. The data collected was merely notation of already observed variables at different times. The fact that this data was collected had no influence on the treatment of the patient and therefore there were no concerns that this study would adversely effect the patients. Finally, the study design was presented to the ethics committee and gained the committee’s approval. All research involving human subjects must go through this process to ensure that the rights of study participants are respected and this was done in this study. 

The slight changes in SpO2 observed are reasonable consequences for both the indication of the procedure and the effect of the procedure regardless of the clinical indications. Without a qualitative element, the study confirms that: ETT suction affects SpO2, but does not evaluate the significance of this observation. The observed changes in these physiological parameters were of a very small margin and more consistent with the inherent agitation consistent with the procedure itself including the necessary occlusion of the ETT during suction. This study’s influence on nursing practice would be greatly enhanced if the same study was performed using mixed methods. This would give more clinical significance to the findings and be more informative to nursing practice.

Reference

Lopes Barbosa, A. L., Vera Lucia Moreira Leitao Cardosc, M., Bezerra Bras, T., & Gracinda Silvan Scochi, C. (2011). Endotracheal and upper airways suctioning: changes newborns’ physiological parameters.  Revista Latino-Americana De Enfermagem (RLAE), 19(6), 1369-1376. doi:http://dx.doi.org.library.gcu.edu:2048/ S0104-11692011000600013