Methods of neonatal endotracheal suctioning.

The purpose of this study was to describe how neonatal endotracheal suctioning (ETS) is performed in two local Level III neonatal intensive care units. The following suctioning components were examined: (a) numbers of catheter insertions, (b) head rotation, (c) depth of catheter insertion, (d) irrigant administration, (e) negative pressure application, and (f) oxygen delivery. Informed consent was obtained from the 50 nurses and from parents of infants observed during the suctioning procedure. Data collection included a questionnaire about the nurses' background and direct observation of the suctioning procedure. The nurses had an average of 10 years experience, with 7.2 years in neonatal Nursing;. The nurses' background and experience were similar at both institutions. The mean gestational age of the infants was 29 weeks; the mean postnatal age was 21.5 days; and the mean postnatal weight was 1,437 grams. There was a mean of 3.7 catheter insertions per procedure (range = one to five), with a total of 186 catheter insertions during the 50 procedures. Deep and shallow suction groups were created based on mean catheter-insertion depth per procedure. Shallow suctioning ws performed during 9 procedures, and deep suctioning was performed in the remaining 41 procedures. Overall, in 79% of the 186 catheter insertions, the suction catheter was inserted further the 0.5 cm beyond the tip of the endotracheal tube (ETT). Sixty-eight percent of the infants experienced head rotation as part of the suction procedure. Normal saline was used as an irrigant in all but 2 procedures. Irrigant was administered before 51% of the catheter insertions. The mean negative pressure setting of the suction apparatus was 97 mm Hg. Thirty-nine procedures utilized manual ventilation with a two-person suctioning method. Eleven procedures used the ventilator with a one-person suctioning method. Only 20% of the nurses reported changing the inspired oxygen before suctioning. Deep suctioning and head rotation were prevalent in this study despite complications documented with this practice. Shallow suctioning without a change in head position should be routine practice, unless clinical evidence is present to justify deep suctioning. Although hyperoxygenation has been shown to decrease the amount of hypoxemia during suctioning, it was used minimally.

METHODS OF NEONATAL ENDOTRACHEAL SUCTIONING by Diane Michelle Opp A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The university of Utah December 1993 copyright C Diane Michelle Opp 1993 All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPRO V AL of a thesis submitted by Diane Michelle Opp This thesis has been read by each member of the following supervisory committee and by majority vote has been found to be satisfactory. Chair: Karin T. Kirc off David P. Carlton usa J. Squir THE UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of the University of Utah: I have read the thesis of Diane Michelle Opp in its final form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; (3) the final manuscript is satisfactory to the supervisory committee and is ready for submission to The Graduate School. Date iarin T. Kirchhoff. Chair, Supervisory Committee Approved for the Major Department Linda K. Amos ChairlDean Approved for the Graduate Council Ann W. Hart Dean of The Graduate School ABSTRACT The purpose of this study was to describe how neonatal endotracheal suctioning (ETS) is performed in two local Level III neonatal intensive care units. The following suctioning components were examined: (a) number of catheter insertions, (b) head rotation, (c) depth of catheter insertion, (d) irrigant administration, (e) negative pressure application, and (f) oxygen delivery. Informed consent was obtained from the 50 nurses and from parents of infants observed during the suctioning procedure. Data collection included a questionnaire about the nurses' experience and professional activities and direct observation of the neonatal nurses suctioning neonates. The nurses had an average of 10 years experience, with 7.2 years in neonatal nursing. The nurses' background and experience were similar at both institutions. The mean gestational age of the infants was 29 weeks; the mean postnatal age was 21.5 days; and the mean postnatal weight was 1,437 grams. There was a mean of 3.7 catheter insertions per procedure (range = one to five), with a total of 186 catheter insertions during the 50 procedures. Deep and shallow suctioning groups were created based on mean catheter-insertion depth per procedure. Shallow suctioning was performed during 9 procedures, and deep suctioning was performed in the remaining 41 procedures. Overall, in 79% of the 186 catheter insertions, the suction catheter was inserted further than 0.5 cm beyond the tip of the endotracheal tube (ETT). sixty-eight percent of the infants experienced head rotation as a part of the suctioning procedure. Normal saline was used as an irrigant in all but 2 procedures. Irrigant was administered before 51% of the catheter insertions. The mean negative pressure setting of the suction apparatus was 97 rom Hg. Thirty-nine procedures utilized manual ventilation with a two-person suctioning method. Eleven procedures used the ventilator with a one-person suctioning method. only 20% of the nurses reported changing the inspired oxygen before suctioning. Deep suctioning and head rotation were prevalent in this study despite complications documented with this practice. Shallow suctioning without a change in head position should be routine practice, unless clinical evidence is present to justify deep suctioning. Although hyperoxygenation has been shown to decrease the amount of hypoxemia during suctioning, it was used minimally. v TABLE OF CONTENTS Page ABSTRACT • • . • iv LIST OF TABLES • viii ACKNOWLEDGMENTS x Chapter I. INTRODUCTION . . . . . . . . . . . . . . . . . 1 Literature Review • • • • • • • • • • • • • •. 2 Purpose and Complications of Suctioning 3 Suctioning Components • • • . • • • • •• 4 Manipulation of suctioning Components to Minimize Complications • • •• ••• 10 Research Question . • • • . • • • . . • • • •• 19 II. METHOD Setting Sample • • • Instruments • . Procedure • Data Analysis . III. RESULTS . 21 21 21 22 23 24 25 Sample • • • • • • 25 Nurses • • . • • • 25 Neonates • •••• • • . • • • 29 Methods of Neonatal Endotracheal suction • •• 29 Number of Catheter Insertions • . • • •. 29 Head Rotation • . . • • • . • • • • • 29 Depth of Catheter Insertion . • • • . •• 33 Irrigant Administration . .• •••. 39 Negative Pressure Application • • .• 40 Oxygen Delivery • • . 40 Procedural Findings • •.••.•••••• 42 IV. DISCUSSION . . . . . . . . . . . . . . Summary • . • • • • • • • • • • • • • Recommendations for Future Studies 45 45 50 Appendices Page A. NURSING BACKGROUND QUESTIONNAIRE 52 B. SUCTIONING DATA SHEET • • • 55 C. INFORMED CONSENT: NURSING 59 D. INFORMED CONSENT: UNIVERSITY HOSPITAL 61 E. INFORMED CONSENT: PRIMARY CHILDREN'S MEDICAL CENTER • • • • • • • • • • • • • • • • • • •• 65 REFERENCES • • • • • • 69 vii LIST OF TABLES Table 1. 2. Mean, Standard Deviation, and Range of Experience for Fifty Neonatal Nurses Performing Suctioning Procedures in Two Hospitals • • • • • • • • • . • • Mean, Standard Deviation, and Range of Professional Behaviors for Fifty Neonatal Nurses Performing Suctioning Procedures in Two Hospitals • • • . • • 3. Frequency of Professional Education and Activities for Fifty Neonatal Nurses Performing Suctioning Procedures in Page 26 28 Two Hospitals • • • • • • • • . • • . . • • 30 4. Mean, Standard Deviation, and Range of Age, Gestation, and Weight of Ten Neonates Observed for Fifty Suctioning Procedures Performed by Neonatal Nurses in Two Hospitals. 31 5. Frequency of Diagnoses of Ten Neonates suctioned by Fifty Neonatal Nurses in Two Hospitals • • • • • • • . • • • • • • 6. Frequency of Head Rotation with catheter Insertions During Fifty Suctioning Procedures by Neonatal Nurses in Two Hospitals . . • . • • • • • • . • • • • 7. Frequency of Catheter Insertions at Various Depths Beyond the Endotracheal Tube Tip in Fifty suctioning Procedures of Ten Neonates by Neonatal Nurses in Two Hospitals • • 8. Mean, Standard Deviation, and Range of Experience for Fifty Neonatal Nurses Performing Shallow and Deep Suctioning Procedures in Two Hospitals • • • . . • 9. Mean, Standard Deviation, and Range of Professional Behaviors for Fifty Neonatal Nurses Performing Shallow and Deep 32 32 34 35 suctioning Procedures in Two Hospitals • • •• 36 Table 10. Mean, Standard Deviation, and Range of Age, Gestation, and Weight of Ten Neonates suctioned During Fifty Shallow and Deep Procedures by Neonatal Nurses in Two Page Hospitals • • • • • • • • • • • • • • • • • •• 37 11. 12. Frequency of Head Rotation During Fifty Shallow and Deep Suctioning Procedures Performed by Neonatal Nurses in Two Hospitals • • • • • • • • • • • • • • • • Frequency of Shallow and Deep Suctioning Procedures by Hospital for Fifty Neonatal Nurses in Two Hospitals • • • • • • • 13. Frequency of Secretion Consistency as Interpreted by Fifty Neonatal Nurses Performing Shallow and Deep Suctioning 38 38 Procedures in Two Hospitals • • • • • • 39 14. Frequency of Irrigant Administration Before Catheter Insertions During Fifty Suctioning Procedures by Neonatal Nurses in Two Hospitals • • • • • • • • • • • • • • • • • 41 15. Mean, Standard Deviation, and Range of Negative Pressure (in rom Hg) utilized in the Sample and Subgroup for the Fifty suctioning Procedures in Two Hospitals • • • • • • • • • • • • • •• 41 16. Frequency of Gloveless Second Person in Thirty­Nine Two-Person Suctioning Procedures Performed by Neonatal Nurses • • • • • • • • • • • • •• 43 ix ACKNOWLEDGMENTS I would like to thank (a) my committee members Dr. Karin T. Kirchhoff, Dr. David P. Carlton, and Ms. Susan J. squire for their guidance throughout this research; (b) the nursing staff at Primary Children's Medical Center, Salt Lake City, Utah, and University (of Utah) Hospital, Salt Lake City, Utah, for their participation in this study; (c) the parents of babies observed in this study for their permission; and (d) my family, friends, and colleagues for their support and encouragement throughout this process. This work is dedicated to the babies who, by residing in neonatal care units, have taught us so much. CHAPTER I INTRODUCTION Several methods of endotracheal suctioning (ETS) have been used in intubated neonates to maintain patency of the airway. Suctioning involves a sequence of activities, some of which have not been researched in neonates. Suctioning must involve a conscious effort to minimize the impact of this invasive procedure on patients. Professional nursing requires optimal patient care that is research based. By describing the methods of ETS performed by the nursing staff, discrepancies between the research base and current practice can be identified. The purpose of this study was to describe methods of neonatal ETS regarding number of catheter insertions, head rotation (change in position of head), depth of catheter insertion, irrigant administration, negative pressure application and oxygen delivery. This study was a pilot study to guide future research of neonatal ETS. Clinical practice was the source of the research question in this study. ETS is performed by nurses alone or nurses working with respiratory therapists. Many components in ETS can be manipulated by nurses, including oxygen concentration, depth of catheter insertion, method of negative pressure application, and patient position. Before manipulating components in the suctioning procedure, it is imperative that the scope of current practice is known. The literature contains minimal descriptive information regarding current neonatal suctioning practices. 2 Tolles and stone (1990) surveyed nurses about their neonatal suctioning practices on a national level. They surveyed centers providing ventilatory assistance to infants. Data from 203 centers were compiled. Each questionnaire was answered by a nurse with 2 years experience. Each center received one questionnaire. Information from the questionnaires provided a basic outline of suctioning practices, but they were unable to address many suctioning practices in their questionnaire. Although general information was gathered such as the type of irrigant used, important questions remain unanswered such as the mode of irrigant administration, temperature of the administered irrigant, depth of catheter insertion, use of head rotation, number of catheter passes per procedure, and duration of suctioning. Literature Review This review consists of the following sections: (a) purpose and complications of suctioning, (b) suctioning components, and (c) manipulation of suctioning components to minimize complications. The components of suctioning 3 were described in nursing protocols and textbooks, medical management textbooks, and published research. Past research has focused on decreasing or minimizing the complications of suctioning. Much of the research in suctioning has focused on the adult population and may have limited application to the neonatal population. purpose and Complications of Suctioninq The suctioning procedure is performed to remove secretions (Hagedorn, Gardner, & Abman, 1989) and ensure patency of the airway (Hodson & Belenky, 1975) in intubated infants. This common procedure has numerous complications, including hypoxemia (cassani, 1984; Simbruner et al., 1981; Urban & Weitzner, 1969); atelectasis (Brandstater & Muallem, 1969); mucosal trauma (Bailey, Kattwinkel, Teja, & Buckley, 1988; Brodsky, Reidy, & Stanievich, 1987; Kuzenski, 1978); heart rate alterations (Gunderson, stone, & Hamlin, 1991); cardiac arrhythmias (Shim, Fine, Fernandez, & Williams, 1969; Simbruner et al., 1981); infection (Rutala, Stiegel, & Sarubbi, 1984; Storm, 1980); blood pressure and intracranial pressure fluctuations (Perlman & Volpe, 1983); pneumothorax (Alpan, Glick, Peleg, Amit, & Eyal, 1984; Vaughan, Menke, & Giacoia, 1978); and cardiac arrest (Nicholson, 1960). 4 suctioninq Components Little descriptive research has been published regarding neonatal suctioning. Turner (1990) discussed current neonatal suctioning methods. General neonatal suctioning practices were surveyed on a national level by Tolles and stone (1990). A questionnaire was completed by one individual per unit; from this, an outline of suctioning practices was developed. Although suctioning practices within specific neonatal intensive care units have not been observed, Kerr, Menzel, and Rudy (1991) observed suctioning practices in a pediatric intensive care unit. Data were collected regarding oxygen delivery, glove technique, head position, type of suction, number of breaths and catheter insertions, secretion amount, and suctioning rationale while nurses suctioned 24 pediatric patients. Most often, the procedure included two nurses, two-handed glove technique, continuous suction pressure, and 02 flow rate > 16L. Differences in technique included the number of catheter insertions, intermittent suction pressure application, and ventilation. The authors raised concern regarding potential dangers with the large number of catheter insertions (three to eight times) and number of breaths delivered. Even though pediatric research cannot be applied directly to the neonatal population, these concerns warrant examination in neonatal research. 5 ETS consists of introduction of a sterile catheter into the endotracheal tube (ETT) and application of negative pressure while the catheter is withdrawn. Components of the procedure include oxygen delivery, ventilation method and duration, irrigant, catheter size, depth of insertion, amount of negative pressure, length of time negative pressure is applied, intermittent or constant negative pressure during catheter withdrawal, number of catheter insertions, and head rotation (Turner, 1990). oxygen Delivery Tolles and stone (1990) surveyed centers providing ventilatory assistance to infants. They compiled data from 203 centers. Each questionnaire was answered by a nurse with at least 2 years' experience. The data were self-reported without any observation of practice. In this survey, Tolles and stone (1990) found that oxygen delivery during the ETS procedure was interrupted with disconnection from the ventilator or manual resuscitation bag (MRB) , unless an in-line adapter was in use. Hyperoxygenation was performed routinely before suctioning by 66% of responding neonatal nurses. Sixty percent of those utilizing in-line adapters hyperoxygenated routinely during suctioning. After suctioning, 67% of those using MRB and 82% of those returning the infant to the ventilator routinely 6 hyperoxygenated. Of those who did not routinely increase inspired oxygen, 75% used it prior, 77% used it between suction passes, and 78% utilized it after suctioning. The amount of oxygen used to hyperoxygenate the infant was reported to vary with infant needs by 88% of the respondents. Hyperoxygenation with 10% over maintenance level was reported by 45% of the respondents. Of those who do not routinely hyperoxygenate, 80% reported determination of need by the infant's past response to suctioning. The infant's appearance was the guide according to 80%, whereas a decrease in tcp02 during suctioning was the indicator for 75% of those who did not routinely hyperoxygenate (Tolles & stone, 1990). Ventilation Method ventilation during the suctioning procedure was provided by a ventilator or hand ventilation with an MRB according to Tolles and stone's (1990) respondents. Hyperventilation was utilized more frequently by those using the MRB (72%) than those returning the infant to the ventilator between passes (42%). Hyperinflation was used routinely by few respondents (9%). The duration of hyperventilation or hyperinflation was not addressed by Tolles and stone in their survey. Irrigant Use of 0.9% sodium chloride (normal saline) as an irrigant was reported by 91% of Tolles and stone's (1990) 7 respondents. The amount of 0.5 cc or less was reported by 72% and was administered after disconnecting the infant from the ventilator. Wilson, Hughes, Rennie, and Morley (1992) reported saline instillation of 0.5 cc in their suctioning procedure. Bailey et ale (1988) surveyed physicians associated with level II and III perinatal centers. Routine instillation of saline was reported by 78% of these physicians, although the amount was not specified. Catheter Size The catheter size used with various ETT diameters was referred to as the ratio of the outside diameter (00) of the suction catheter to the inside diameter (10) of the ETT: 00:10. The most common 00:10 ratios, according to Tolles and stone (1990), were 0.6:1 and 0.9:1. Depth and Number of Catheter Insertions and Head Rotation Clinical practice regarding the depth of catheter insertion has not been reported on a national level in the literature. Historically, infant position has been manipulated during the suctioning procedure, for example, rotation of the head away from the bronchus into which entry was attempted (Ounn & Lewis, 1973). Oeep suctioning 8 consisted of advancing the suction catheter until obstruction or slight resistance was met (Kleiber, 1986). A shallow method consisted of suctioning only as far as the tip of the ETT (Brodsky et al., 1987) or 1 cm beyond the tip of the ETT (Bailey etal., 1988). In addition to their own observations, Bailey et ale (1988) surveyed physicians associated with level II and level III perinatal centers. Of the 405 respondents, 64% reported use of deep suctioning, 19% reported use of shallow suctioning, and 18% utilized both techniques without a standard routine. This information was self-reported data without any observation of practice. Although physicians were surveyed, nurses perform suctioning procedures without the presence of a physician. Information regarding the number of c'atheter insertions and frequency of head rotation during suctioning is unknown. A recent nursing protocol (Hodge, 1991) suggested one to two passes, unless the amount of secretions warranted another pass; it did not suggest any change in head position during the procedure. A nursing care management textbook (Hagedorn et al., 1989) recommended catheter passes, as indicated by results obtained with head in midline position only. Hodson and Belenky (1975) recommended one catheter pass with the infant's head to the side, then another catheter pass after the infant's head was rotated to the opposite side. Harper and Yoon (1987) recommended one catheter pass in each of several infant positions. Amount. Length. and Type of Negative Pressure Application The amount of negative pressure used in the clinical 9 setting was 60 to 80 mm Hg, according to 54% of Tolles and stone's (1990) respondents. The duration of negative pressure was reported to be 5 seconds or less by most of the respondents. Wilson et ale (1992) reported a maximum negative pressure of 13 kPa (98 mm Hg) and an average disconnection time from the ventilator of 17 seconds for the procedure. The use of constant or intermittent negative pressure while withdrawing the catheter was not addressed in Tolles and stone's (1990) survey. Hodge's (1991) protocol did not mention constant or intermittent negative pressure suction, whereas a st. Louis Children's Hospital (1984) protocol suggested constant negative pressure. Constant negative pressure was recommended by a neona~al nursing care textbook (Hagedorn et al., 1989) and medical management textbooks (Harper & Yoon, 1987; Hodson & Belenky, 1975). Intermittent negative pressure application was practiced in adult and pediatric populations (Kerr et al., 1991). Hypoxemia Manipulation of suctioninq components to Minimize complications 10 It is common for variables in the suctioning routine to be manipulated to prevent complications. The most frequently researched complication of suctioning is hypoxemia. Increased inspired oxygen, hyperinflation, hyperventilation coupled with hyperoxygenation, in-line adapters, sedation, activity, irrigant administration, and length of negative pressure application have been examined by researchers to prevent hypoxemia. ventilation. According to Walsh et ale (1987), controlled supplemental oxygen without manual ventilation during chest vibration was adequate to prevent hypoxemia. Their study using transcutaneous oxygen monitors was conducted on premature infants with respiratory distress requiring tracheal intubation and assisted ventilation with an oxygen requirement of greater than 30%. Procedure A consisted of chest vibration for 2 minutes, followed by 0.5 cc of normal saline instilled into the ETT and returned to mechanical ventilation for 30 seconds. The infant was suctioned with the head held to one side before returning to the ventilator. This routine was repeated with the head turned to the opposite side. In Procedure B, the inspired oxygen was increased until the tcp02 was 90 to 100 torr for 2 minutes before the steps in Procedure 11 A were performed. Each subject underwent both procedures in a random order. The mean recovery time in Procedure B (2.75 minutes) was significantly less than Procedure A (4.87 minutes). In Procedure A, the decrease of tcpoz was four to five times that of Procedure B. A sharp decline in tcp02 with chest vibration in both procedures was blunted in Procedure B. The order of procedures did not affect the tcp02 measurements. These findings led the researchers to recommend tcp02 monitoring be used during ETS and that the tcp02 be 80 to 100 torr before the procedure. They also recommended that chest vibration and suctioning be performed only when indicated, rather than routinely. Hyperinflation was used by Brandstater and Muallem (1969) to prevent atelectasis following suctioning. six infants with tetanus neonatorum were studied. The infants received room air, mechanical ventilation, and paralytic agents. The researchers found that supplemental oxygen was needed when hypoxemia resulted from extensive atelectasis after suctioning. At the beginning of each procedure "expansion history of the infant's lungs was standardized" (p. 469) by a series of inflations with 25 cm H20. Instillation of 2 cc sterile saline was followed by tracheal suction performed by skilled nurses with standard neonatal equipment. The catheter was inserted until an obstruction was met and then suction was applied 12 for 3 to 4 seconds while the catheter was moved gently, then quickly withdrawn. The researchers found that when the infant was returned to the ventilator without reinflation, the lungs remained partially collapsed until high pressure or large tidal volume was applied. Full reinflation could be achieved by three deep breaths of 25 cm H20 pressure maintained for 2 seconds. Studies have been published using hyperoxygenation and hyperventilation in combination to combat hypoxemia resulting from suctioning. Raval, Yeh, Mora, and Pildes (1980) examined differences in oxygenation after (a) returning the infant to the ventilator, (b) using manual ventilation for 60 seconds with a 10% increase in oxygen for 60 seconds between suctioning passes, and (c) using manual ventilation with 100% oxygen between suctioning passes. Simbruner et al. (1981) studied oxygenation with manual ventilation using 100% oxygen after suctioning from the ETT. Barnes, Asonye, and Vidyasagar (1981) observed oxygenation with manual ventilation (a) presuctioning and between passes; (b) between passes and after suctioning; and (c) before, between, and after suctioning. All manual ventilation was with 100% oxygen and an increase in ventilation rate of 50%. All three of these studies reported tcp02 measurements. A decrease in tcp02 during suctioning was reported by all groups. Barnes et al. (1981) found that 13 bagging with 100% oxygen between passes and after suctioning resulted in the shortest duration of hypoxemia and hyperoxemia. Raval et ale (1980) discovered a significant transient decrease in tcp02 with all procedures, but manual ventilation with 100% oxygen resulted in a rapid recovery of tcp02. Simbruner et ale (1981) reported different results, a decrease in tcp02 which was not immediately reversible with bag ventilation and 100% oxygen. Barnes et al., as well as Raval et al., noted that hyperoxemic levels were reached using manual ventilation with 100% oxygen. Raval et ale used 5 cm H20 negative pressure and Barnes et ale used 10 cm H20 negative pressure, whereas Simbruner et ale reported negative pressure at 200 cm H20. Perhaps, this large difference in negative pressure played a role in their findings. Neither Raval et ale nor Simbruner et ale stated the rate of hyperventilation. Barnes et ale (1981) reported that stabilization and recovery time were significantly less with manual ventilation with 100% oxygen between and after suctioning compared to hand ventilation with 100% oxygen before, between, and after suctioning because of high tcp02 during the latter practice. Raval et ale (1980) also reported high tcp02 levels were reached with manual ventilation with 100% oxygen. In-line adapters. In-line adapters appear to decrease the degree of hypoxemia associated with suctioning. Zmora and Merritt (1980) used side-hole adapters and Gunderson, McPhee, and Donovan (1986) used end-hole adapters to examine the extent of hypoxemia during suctioning. An adapter allows suctioning without disconnecting the infant from the ventilator. Both research teams found a significantly smaller decrease in tcp02 with the use of adapters. Zmora and Merritt also reported slightly less frequent bradycardia, whereas Gunderson et ale found little effect on the frequency on bradycardia using adapters. Sedation. Ninan, O'Donnell, Hamilton, and Sankaran (1985) studied the effect of sedation on the hypoxemia associated with ETS. They found that sedation with phenobarbital blunted the hypoxemia that occurs with suctioning. 14 caregiver activity. Activity such as vibration, percussion, postural drainage, and positioning associated with suctioning merit discussion. Long, Philip, and Lucey (1980) reported that caregiver activity such as suctioning, position changes, diaper changes, physical examinations, injections, feedings, and vital sign recordings accounted for 75% of the time their intubated infants were hypoxemic. A large decrease in p02 during suctioning was described by FOx, Schwartz, and Shaffer (1978) during coughing, insertion of the suction catheter, 15 and increased patient activity. Handling before, during, and after the suctioning routine affects oxygenation. Raval et ale (1980) performed chest physiotherapy (CPT) as part of their suctioning procedure. Walsh et ale (1987) used vibration as a part of their suctioning routine. Neither Simbruner et ale (1981) nor Barnes et ale (1981) discussed infant activity concerning the suctioning routine. All these researchers except Simbruner et ale mentioned handling (i.e., turning infant's head) as part of the suctioning routine. xrrigant. Normal saline initially was used to stimulate coughing in adults (Demers & Saklad, 1973) and to liquify and mobilize secretions (Turner, 1983). Several investigators have reported conflicting results concerning these points. Normal saline in bolus form does not thin secretions according to Turner (1990). Ackerman (1985) stated that saline instillation had little or no value in thinning, mobilizing, or removing dried secretions. Hanley, Rudd, and Butler (1978) found that a normal saline bolus did not induce coughing in either of the study patients but did in a pilot patient. Bostick and Wendelgass (1987) established that normal saline boluses of 5 cc and 10 cc in adult patients often caused a cough reflex. Although Downs (1989) suggested that the presence of 16 saline occupying space in the airway may contribute to hypoxemia during suctioning, there appears to be no supporting evidence. There was no significant difference in the p02 level of adult patients 5 minutes before and 20 minutes after instillation of 5 cc or 10 cc of normal saline as a part of the suctioning procedure (Bostick & Wendelgass, 1987). Shorten (1988) found no significant difference in the oxygenation of stable infants with respiratory distress with or without the use of normal saline bolus during suctioning when hyperventilation and 100% oxygen were used. The weight of secretion retrieval in adults, as examined by Bostick and Wendelgass (1987), was found to be greatest with the instillation of 5 cc normal saline as opposed to 10 cc. Hanley et ale (1978) found the amount of normal saline bolus recovered with suctioning was 10% in dogs and 18% in adult humans. Using radio-labeled saline, Hanley et ale found distribution of the saline label to be predominately in the mainstem bronchus, remaining present in the proximal airways for the entire 30-minute study period in some of the patients. The temperature of normal saline instilled during suctioning affected heart rate and gas exchange, according to Gunderson (1989). In a study using anesthetized newborn piglets, Gunderson reported that heart rate and arterial blood gas values returned to baseline faster when saline was instilled at body temperature compared to saline instilled at room temperature. Duration of negative pressure application. The duration of suctioning is a significant variable, according to Rindflesh and Tyler (1983). They studied dogs and found less hypoxemia with a shorter duration of negative pressure. Mucosal Trauma 17 Bronchioaveolar lavage damages cilia and goblet cells in rabbits (Konradova, Kanta, & Solova, 1990). Microscopic evaluation of rabbit tracheal epithelium after repeated instillation and withdrawal of 10 cc isotonic saline revealed impaired mucus flow and goblet cell hyperplasia. Although bronchioaveolar lavage is different than routine instillation of normal saline in the suctioning procedure, the effect of irrigant instillation on the tracheal epithelium may not be benign. Depth of catheter insertion. Bailey et al. (1988) and Brodsky et al. (1987) observed the effect of suction catheters on the tracheobronchial tree. Bailey et al. compared deep suctioning to shallow suctioning by suctioning only as far as the end of the ETT plus 1 cm in 3-week old rabbits. Brodsky et al. studied autopsy findings from low-birth-weight infants in 1977 when deep suctioning was routine and from similar infants in 1980 when suctioning to the tip of the ETT was the practice. Both groups found significantly increased incidence and severity of tracheal injury'with deep suctioning practices. 18 Size of catheter. The size of suction catheters used in neonates is limited by the small internal diameter of the airway. If the suction catheter is small and fits loosely in the ETT, then air from the environment can flow around the catheter. Negative pressure in the lungs is then less, and risk of lung collapse is decreased. Rosen and Hillard (1962) recommended that the suction catheter occludes no more than half the diameter of the airway. Harper and Yoon (1987) recommended use of a suction catheter no larger than two thirds the diameter of the ETT. Due to the small diameter of the neonatal airway, it was impossible to follow these general recommendations. Salyer's (1990) recommendation for the infant and child was the largest catheter that will pass easily into the ETT. Nurses are faced with the dilemma of the benefit of a larger catheter that may remove more secretions or a smaller catheter with less risk of atelectasis. Magnitude of negative pressure. The magnitude of negative pressure used during suctioning varies in the literature. Kuzenski (1978) described the effect of negative pressure on the tracheobronchial mucosa of dogs. Areas of denuded epithelium, leukocytic infiltration, and edema were reported with a negative pressure of 100 mm Hg. Abnormal histologic findings were even more pronounced, with a negative pressure of 200 mm Hg. 19 Frequency of suctioning procedures. The interval of suctioning procedures was studied by Wilson et ale (1992). They reduced the frequency of endotracheal lavage from every 6 hours to every 12 hours. They evaluated the effect of this change on duration of ventilation, incidence of pneumothorax, ETT occlusion, mortality, and intraventricular hemorrhage in uncomplicated cases of respiratory distress syndrome. They found no significant difference in the outcome variables between the groups. They suggested that it is probably safe to reduce the frequency of endotracheal lavage during the first few days in these infants. Commenting on this report, Cassani (1992) cautioned against generalizing the results of this study because the study population was limited to babies who produced minimal secretions. Research Question Information received by Tolles and stone's (1990) questionnaire was self-report data without validation. General practices reported by Tolles and stone were on a national level, but little information is available on specific practices within newborn intensive care units. This study was designed to describe current ETS practice at two local level III newborn intensive care units using data collected by direct observation. The research question was as follows: What are the methods of neonatal ETS regarding (a) number of catheter insertions, (b) head rotation, (c) depth of catheter insertion, (d) irrigant administration, (e) negative pressure application, and (f) oxygen delivery at two local level III newborn intensive care units? 20 CHAPTER II METHOD setting A descriptive study was used to determine routine methods of neonatal ETS by nurses in the Newborn Intensive Care units of two local hospitals, Primary Children's Medical Center and university (of Utah) Hospital. Primary Children's Medical Center is a regional referral center for infants and children. Their patients are exclusively transported in and include infants with medical and surgical conditions. The University Hospital is a regional perinatal referral center. Their patients are predominately inborn very-low-birth-weight infants. Sample A convenience sample consisted of nursing staff who were willing to have their suctioning procedure observed during the researcher's data collection period. Informed consent was obtained from parents of the infants in this study. The sample size for this study was 50 nurses: (a) 25 nurses from university Hospital Newborn Intensive Care unit and (b) 25 nurses from Primary Children's Medical Center Newborn Intensive Care Unit. The subjects in this study were nurses who worked at least 30% full-time 22 equivalent (FTE) for the past 6 months in their respective Newborn Intensive Care unit. Nurses caring for intubated neonates who required ETS as a part of their routine nursing care were identified by the researcher based on nursing assignments for ventilated patients and parental consent. Instruments Instruments used in this study included a Nursing Background Questionnaire and a suctioning Data Sheet. The Nursing Background Questionnaire (see Appendix A) identified by number the subject and hospital and included questions regarding experience and professional activities. The information requested included level of nursing education, length of time as a nurse, length of time as a neonatal nurse, number of hospitals employed in, certifications, professional organizations, conference attended, and participation in nurse orientation and in­services. The Suctioning Data Sheet (see Appendix B) had several sections. The preliminary information section detailed the subject number, hospital, and patient information, including age, weight, gestation at birth, medical diagnosis, MRB style, ventilator support, ETT size, ETT length, and negative pressure setting. The section labeled immediately prior to suctioning contained information regarding patient position, saline 23 temperature, changes made in oxygen or ventilator settings, and instruction to the nurse before suctioning. The procedure sequence section detailed the use of gloves during the procedure and suctioning activities, including head position changes, saline instillation, ventilation, insertion depth (cm), method of negative pressure application, and withdrawal movement. The section immediately following suctioning identified one- or two-person technique, oral suction, sterile technique, number of saline vials, type of saline administration, and a question asking the nurse to rate the consistency of secretions. Calculations to be done anytime after the procedure included depth of catheter passed beyond the tip of the ETT for each insertion and total number of catheter insertions. Procedure Each subject completed the Nursing Background Questionnaire (see Appendix A). A statement regarding consent (see Appendix C) was given to each nurse, along with the Nursing Background Questionnaire. Although nurses were subjects for this study, their care of infants was observed and the researcher measured each infant's ETT length. Parents of intubated neonates, therefore, were identified and approached. The researcher explained the study. Consent forms (see Appendices D and E) were given for the parents to read and discuss. After parental consent was received, the researcher compiled a list of eligible neonates. The researcher was present in the unit to observe suctioning procedures during a variety of day and night shifts on both weekdays and weekends within a 6-week period. Two hours after the beginning of each shift the researcher contacted those nurses who were caring for an eligible neonate requiring ETS. The researcher inquired as to the time the nurse expected to suction the infant, completed the preliminary information on the Suctioning Data Sheet, and measured the length of the ETT in the infant. The researcher stayed in the vicinity of the bedside around the expected time of suctioning and recorded the procedure on the Suctioning Data Sheet (see Appendix B). The nurses were not informed of specific behaviors observed, nor were they shown the Suctioning Data Sheet. Data Analysis Descriptive statistics for data analysis were the mean and mode, frequency distribution, and percentages. Variability was described in terms of the range and standard deviation. Tables were used to detail information on the nurses' background and details of the suctioning procedure. 24 CHAPTER III RESULTS Sample Nurses Fifty nurses completed the questionnaire and allowed their suctioning procedures to be observed by the researcher. Twenty-one nurses (42%) had completed an associate degree, whereas 21 nurses (42%) had completed a bachelor's degree. Five nurses (10%) held a nursing diploma, and 3 nurses (6%) held a master's degree. The mean number of years education after high school was 5. The subjects had been nurses for an average of 10 years, with 7.2 years experience in neonatal nursing. The subjects worked in an average of 3.2 hospitals during their careers as nurses and were neonatal nurses in 2.4 of these hospitals. The experience of the nurses in this study is detailed in Table 1. Nurses in this study subscribed to an average of 0.9 professional journals. Thirty nurses (60%) subscribed to only one professional journal. Two nurses (4%) subscribed to two professional journals, and 3 nurses (6%) subscribed to more than two professional journals. Fifteen nurses (30%) did not subscribe to a professional journal. In the Table 1 Mean, Standard Deviation, and Range of Experience for Fifty Neonatal Nurses Performing Suctioning Procedures in Two Hospitals Hospital 1 Hospital 2 Sample Experience Mean (SO) Range Mean (SO) Range Mean (SO) Range Years of education and experience Posthigh school 4.8 (2.0) 2.0-10.0 5.2 (1.6) 3.0-10.0 4.9 (1.8) 2.0-10.0 education Neonatal nursing 8.0 (4.8) 1.1-17.0 6.5 (4.2) 0.5-14.0 7.3 (4.5) 0.5-17.0 experience Nursing experience 10.1 (6.7) 1.1-25.0 10.0 (6.0) 0.5-24.0 10.0 (6.3) 0.5-25.0 Number of hospitals Neonatal nursing 2.4 (1.7) 1.0- 8.0 2.3 (2.8) 1.0-15.0 2.4 (2.3) 1.0-15.0 Nursing 3.1 (1.9) 1.0- 8.0 3.3 (3.0) 1.0-15.0 3.2 (2.5) 1.0-15.0 ~ 0\ 27 previous calendar year, nurses in this study attended an average of 1.1 professional conferences; 82% of the conferences were in their neonatal specialty. Twenty-eight of the 50 nurses (56%) attended at least one professional conference during the previous year, whereas 22 of the nurses (44%) reported they attended no professional conferences in the previous year. Professional behaviors of the nurses in this study are reported in Table 2. Forty-eight nurses were certified in the American Heart Association's Neonatal Resuscitation Course. Three nurses had neonatal specialty certifications, and 2 nurses had other specialty certifications. seventeen nurses (34%) reported they oriented new staff during the past year, and 11 nurses (22%) reported giving two or more in­services during the past year. Fifteen nurses (30%) held membership in one professional organization, 12 nurses (24%) held membership in two professional organizations, and 2 nurses (4%) held membership in three professional organizations. Twenty-one nurses (42%) held no membership in professional organizations. Of the 29 nurses who belonged to professional organizations, 20 nurses (69%) belonged to the National Association of Neonatal Nurses. Five nurses (17%) held membership in the Utah Association of Neonatal Nurses, 8 nurses (28%) held membership in the Utah Nurses Association, and 4 nurses (14%) held Table 2 Mean, Standard Oeviation, and Range of Professional Behaviors for Fifty Neonatal Nurses Performing Suctioning Procedures in Two Hospitals Hospital 1 Hospital 2 Sample Professional Mean (SO) Range Mean (SO) Range Mean (SO) Range behaviors Organizations 0.7 (0.9) 0.0-3.0 1.1 (0.9) 0.0-3.0 0.9 (0.9) 0.0-3.0 Journal 0.8 (1.0) 0.0-5.0 1.0 (0.8) 0.0-3.0 0.9 (0.9) 0.0-5.0 subscriptions Neonatal 1.3 (1.0) 0.0-4.0 0.5 (0.8) 0.0-3.0 0.9 (1.0) 0.0-4.0 conferences 1991 Total conferences 1.3 (1.2) 0.0-4.0 0.9 (1.4) 0.0-5.0 1.1 (1.3) 0.0-5.0 1991 tv ():) membership in Sigma Theta Tau-the honor society for nurses. Frequency of professional education and activities is demonstrated in Table 3. Neonates 29 Ten infants were suctioned in the 50 observations of nurses. Four infants were at Hospital 1 and 6 infants were at Hospital 2. Mean age of the neonates suctioned during this study was 21.5 days. Mean gestational age at birth was 29 weeks, and the mean weight was 1,437 grams at time of observation. Table 4 displays the age, gestational age, and weight of neonates experiencing suctioning during this study. Diagnoses of neonates suctioned during this study is reported in Table 5. Methods of Neonatal Endotracheal suction Number of Catheter Insertions The number of catheter insertions was 186 for the 50 procedures. The mean number of catheter insertions per procedure was 3.7, with a minimum of 1 and a maximum of 5. Head Rotation Head position change (head rotation) was part of 34 ETS. In six of the procedures, the infant's head was rotated twice, and in one procedure the infant's head was rotated three times. Head rotation during suctioning is detailed in Table 6. Most frequently, in 74% of the observations, head rotation occurred between the second 30 Table 3 Frequency of Professional Education and Activities for Fifty Neonatal Nurses Performing Suctioning Procedures in Two Hospitals Professional education and activities Hospital 1 (n = 25) (frequency) Entry level of nursing education Diploma Associate degree Bachelor's degree Master's degree Certification Specialty certification (neonatal) Specialty certification (other) American Heart Association Neonatal Resuscitation course National Association of Neonatal Nurses Membership Utah Nurses Association Utah Perinatal Association Sigma Theta Tau No memberships 3 12 9 1 1 o 25 6 2 1 4 14 Staff development involvement orients new nurses Give ~2 in-services in past year 9 4 Hospital 2 (n = 25) (frequency) 2 9 12 2 2 2 23 14 6 2 o 7 8 7 Table 4 Mean, Standard Deviation, and Range of Age, Gestation, and Weight of Ten Neonates Observed for Fifty Suctioning Procedures Performed by Neonatal Nurses in Two Hospitals Hospital 1 Hospital 2 Sample Neonate Mean (SO) Range Mean (SO) Range Mean (SO) Range characteristics Age (days) 16.5 9.7) 3- 37 26.5 24.4) 7- 99 21.5 19.0) 3- 99 Gestation at 25.9 0.3) 25- 26 32.1 4.1) 27- 40 29.0 4.3) 25- 40 birth (weeks) Weight (grams) 797 (149) 550-1,047 2,078 (809) 990-3,610 1,437 (866) 550-3,610 Note. Age, gestation, and weight were identified for each suctioning procedure, although 10 different infants were observed. eN """" 32 Table 5 Frequency of Diagnoses of Ten Neonates suctioned by Fifty Neonatal Nurses in Two Hospitals Neonate diagnoses Prematurity Respiratory distress syndrome/hyaline membrane disease Bronchopulmonary dysplasia Hydrops or cardiac condition Pulmonary hemorrhage Pulmonary interstitial emphysema Pneumonia Hospital 1 (frequency) 25 19 3 o o o o Hospital 2 (frequency) 21 10 7 11 2 2 1 Note. Each neonate may have more than one diagnosis. Diagnoses were identified for each suctioning procedure, although 10 different neonates were observed. Table 6 Frequency of Head Rotation with Catheter Insertions During Fifty Suctioning Procedures by Neonatal Nurses in Two Hospitals Catheter insertion (before) First catheter insertion Second catheter insertion Third catheter insertion Fourth catheter insertion Fifth catheter insertion sixth catheter insertion Head rotation (frequency) 1 2 25 8 2 1 33 and third suction catheter insertions. In 16 procedures, the infant's head position was not changed. Depth of Catheter Insertion During the 50 suctioning procedures, 186 catheter insertions were recorded. In 17 of 186 insertions, the catheter was not inserted beyond the end of the ETT. In 22 of the 186 catheter insertions, the tip of the catheter was advanced beyond the end of the ETT by a distance of 0.5 cm or less. Frequency of catheter insertion distance is outlined in Table 7. The catheter was inserted 5.0 cm in a 660-gram neonate. Of the 186 passes, 147 (79%) consisted of the catheter passing further than 0.5 cm beyond the tip of the ETT. The 50 procedures were split into two groups based on depth of catheter insertion. The mean depth of catheter insertion for each procedure was calculated. The "shallow" group consisted of those procedures with a mean catheter insertion depth of 0.5 cm or less. The "deep" group consisted of all procedures with a mean catheter insertion depth of greater than 0.5 cm. Shallow suctioning occurred in 9 procedures, and deep suctioning occurred in 41 procedures. Analysis of shallow and deep suctioning procedures was not reported due to the small number of shallow suctioning procedures. The experience and professional behavior of nurses performing shallow and deep suctioning procedures are 34 Table 7 Frequency of Catheter Insertions at Various Depths Beyond the Endotracheal Tube Tip in Fifty Suctioning Procedures of Ten Neonates by Neonatal Nurses in Two Hospitals Insertion depth beyond ETT tip (cm) Frequency (n = 186) 0.00 17 0.01-0.50 22 0.51-1.00 26 1.01-2.00 40 2.01-3.00 49 3.01-4.00 24 4.01-5.00 8 Note. ETT = Endotracheal tube. similar (see Tables 8 and 9). The neonatal age, gestation, and weight of the shallow and deep groups are displayed on Table 10. Though head rotation as a part of the suctioning procedure is to assist in catheter placement in the bronchus, head rotation was performed during the shallow as well as deep suctioning procedures (see Table 11). Many deep suctioning procedures were performed at each hospital (see Table 12). The nurses' perception of secretion consistency, as related to suctioning depth, is displayed on Table 13. Table 8 Mean, Standard Deviation, and Range of Experience for Fifty Neonatal Nurses Performing Shallow and Deep Suctioning Procedures in Two Hospitals Shallow (n = 9) Deep (n = 41) Experience Mean (SO) Range Mean (SO) Range Years of education and experience Posthigh school education 4.4 (1.1) 3.0- 6.0 5.1 (1.9) 2.0-10.0 Neonatal nursing experience 7.2 (5.1) 0.5-16.0 7.2 (4.5) 1.1-17.0 Nursing experience 9.7 (7.2) 0.5-25.0 10.1 (6.2) 1.1-24.0 Number of hospitals Neonatal nursing 1.6 (1.0) 1.0- 4.0 2.5 (2.4) 1.0-15.0 Nursing 2.6 (1.5) 1.0- 5.0 3.3 (2.7) 1.0-15.0 w Ul Table 9 Mean, Standard Deviation, and Range of Professional Behaviors for Fifty Neonatal Nurses Performing Shallow and Deep Suctioning Procedures in Two Hospitals Shallow (n = 9) Deep (n = 41) Professional behaviors Mean (SO) Range Mean (SO) Range Organizations 1.0 (1.1) 0.0-3.0 0.9 (0.9) 0.0-3.0 Professional journal 0.4 (0.5) 0.0-1.0 1.0 (0.9) 0.0-5.0 subscriptions Neonatal conferences 1991 0.9 (0.9) 0.0-3.0 0.9 (1.0) 0.0-4.0 Total conferences 1991 1.4 (1.7) 0.0-5.0 1.0 (1.2) 0.0-4.0 W 0'\ Table 10 Mean, Standard Deviation, and Range of Age, Gestation, and Weight of Ten Neonates suctioned During Fifty Shallow and Deep Procedures by Neonatal Nurses in Two Hospitals Shallow (n = 9) Deep (n = 41) Neonate characteristics Mean (SD) Range Mean (SD) Range Age (days) 38.4 ( 36.3) 5.0- 99.0 17.8 ( 10.2) 3.0- 46.0 Gestation at birth 30.3 ( 4.6) 26.0- 40.0 28.7 ( 4.2) 25.0- 40.0 (weeks) Weight (grams) 1841.8 (1165.1) 580.0-3610.0 1348.6 (776.4) 550.0-3360.0 Note. Age, gestation, and weight were identified for each suctioning procedure, although 10 different infants were observed. w ...,J 38 Table 11 Frequency of Head Rotation During Fifty Shallow and Deep Suctioning Procedures Performed by Neonatal Nurses in Two Hospitals Head rotation Head rotation No head rotation Table 12 Shallow (n = 9) (frequency) 4 5 Deep (n = 41) (frequency) 29 12 Frequency of Shallow and Deep Suctioning Procedures by Hospital for Fifty Neonatal Nurses in Two Hospitals Group Hospital 1 Hospital 2 Shallow (n = 9) (frequency) 3 6 Deep (n = 41) (frequency) 22 19 39 Table 13 Frequency of Secretion Consistency as Interpreted by Fifty Neonatal Nurses Performing Shallow and Deep Suctioning Procedures in Two Hospitals Secretion consistency Thin Moderate Thick Shallow (n = 9) (frequency) 3 4 2 Irriqant Administration Deep (n = 41) (frequency) 14 22 5 Normal saline administered in a bolus form was the irrigant used for the suctioning procedures. Two procedures were completed without irrigant. For the remaining 48 procedures, a 1 cc (Hospital 1) or 5 cc (Hospital 2) vial of Modudose saline was used. Saline at room temperature was used in 39 (78%) procedures. Saline that was warmed in the open warmer or isolette was used in 4 (8%) procedures. Saline that was warmed on the top of the ventilator was administered in 5 (10%) procedures. In the one-person suctioning procedures (Hospital 2 only) using the Ballard in-line suction catheter, the nurse performing the procedure administered irrigant by squeezing the 5 cc saline vial into the irrigant port. In the remaining procedures, the second person assisting in the procedure administered the irrigant by squeezing on 40 the 1 cc or 5 cc saline vial at the end of the ETT. Saline insertion during the procedures is demonstrated in Table 14. Irrigant was administered before 95 of the 186 (51%) catheter insertions during the 50 procedures. Neqative Pressure Application The mean negative pressure setting was 97 rom Hg for the procedures. The highest negative pressure recorded in use during this study was 155 rom Hg (see Table 15). Oxyqen Delivery Oxygen was delivered by mechanical ventilation and MRB. No in-line adapters (end hole or side hole) were used at either hospital. Thirty-nine suctioning procedures involved another nurse or a respiratory therapist ventilating with the MRB between catheter insertions by the nurse assigned to the neonate. The ventilator was used in 11 procedures in which the nurse suctioned alone using the Ballard in-line suction catheters. The Fi02 setting on the MRB ranged from 21% to 100%. Nine nurses reported a change in the Fi02 setting prior to suctioning. These changes consisted of an increase from 5% to 40%. Three nurses increased the oxygen by 5%, 4 nurses increased the oxygen by 10%, and the remaining 2 nurses increased the oxygen by 30% and 40%. 41 Table 14 Frequency of Irrigant Administration Before Catheter Insertions During Fifty Suctioning Procedures by Neonatal Nurses in Two Hospitals Catheter insertions (before) First catheter insertion (n = 50) Second catheter insertion (n = 49) Third catheter insertion (n = 42) Fourth catheter insertion (n = 31) Fifth catheter insertion (n = 8) sixth catheter insertion (n = 5) Table 15 Irrigant administration (frequency) 45 14 30 2 4 o Mean, Standard Deviation, and Range of Negative Pressure (in mm Hg) utilized in the Sample and Subgroup for the Fifty Suctioning Procedures in Two Hospitals Group Mean SD Range Hospital 1 76 14 50-115 Hospital 2 118 21 70-155 sample 97 27 50-155 42 Procedural Findings During two-person suctioning, the nurse assigned to the infant inserted the suction catheter, while another nurse or respiratory therapist ventilated the infant using an MRB between suction catheter insertions. The 39 nurses using conventional (not in-line) suction catheters wore sterile gloves on both hands. sterile technique was broken in 6 of the 39 procedures. The following is an example of broken sterile technique. The nurse touched the outside rim of the ETT during insertion of the catheter. The nurse then withdrew the catheter, touching it with the contaminated glove and reinserted the catheter. The second person in the two-person suctioning technique was a nurse in 8 procedures and a respiratory therapist in 31 procedures. In 16 of the 39 two-person procedures, the second person was not wearing gloves. Table 16 specifies the gloveless second person in these procedures. ventilation during the procedures was observed. ventilation was recorded during the procedures after previous catheter insertion (if applicable), after head rotation or irrigant administration, and immediately before catheter insertion. ventilation was recorded immediately before 179 of the 186 catheter insertions. ventilation was administered by the ventilator in the one-person suctioning technique and by the second person 43 Table 16 Frequency of Gloveless Second Person in Thirty-Nine Two­Person suctioning Procedures Performed by Neonatal Nurses Group Nurse Respiratory therapist Nurse Respiratory therapist Second person (gloveless) (n = 16) (frequency) Hospital 1 Hospital 2 3 3 1 9 using an MRB in the two-person suctioning technique. Neither number of breaths nor length of time ventilated between catheter insertions was recorded. Negative pressure application was continuous in 182 of the 185 catheter insertions. In 3 of the catheter insertions, negative pressure was applied intermittently during catheter withdrawal. These 3 intermittent negative pressure applications were made by 1 nurse during one suctioning procedure. Catheter withdrawal following each insertion was recorded as a twisting motion or straight withdrawal movement. withdrawal during 89 of the 186 catheter insertions (48%) was observed to be a twisting motion. A straight withdrawal movement was observed in 96 of the 186 44 (52%) catheter insertions. Each nurse performing a suctioning procedure was asked to rate the consistency of the secretions as I-thin, 2-moderate, or 3-thick. Secretions were labeled moderate in 26 (52%) of the 50 procedures and were labeled thick in 7 (14%) of the procedures. In 17 of the procedures (34%), the nurse performing the procedure labeled the secretions as thin. CHAPTER IV DISCUSSION Summary One of the limitations of this study was that each infant did not receive a uniform number of procedures. The number of observations for each infant varied, as demonstrated by 4 infants observed in a total of 25 procedures at Hospital 1, and 6 infants observed in a total of 25 procedures at Hospital 2. Infants at Hospital 1 were similar to each other, whereas infants at Hospital 2 were more varied. The range of age, gestational age, and weight of the infants were larger at Hospital 2 than the infants observed at Hospital 1. Individual biobehavioral responses to the procedures were not measured or observed. Each n~rse was observed for one procedure. possible effects on nurse behavior due to observation were not measured. The nurses observed in this study were experienced neonatal nurses, as demonstrated by the mean years of neonatal nursing experience, 8.0 and 6.5 at Hospitals 1 and 2, respectively. Many of these nurses had been exposed to neonatal ETS at more than one hospital, as shown by the mean number of hospitals in which they had 46 practiced neonatal nursing, 2.4 and 2.J at Hospitals 1 and 2, respectively. Surprisingly, many of the nurses did not follow current recommendations for neonatal ETS. A number of nurses did not subscribe to a professional journal (JO%) and attended no professional conferences in the previous year (44%). Many advances in nursing research in the area of neonatal ETS are presented in the literature and at conferences. Nurses without exposure to these advances in nursing research would not be able to incorporate current recommendations into their practice. A large number of nurses, however, did subscribe to at least one professional journal (70%) and attended at least one professional conference (56%). These nurses may have been exposed to current research recommendations, but it was not routinely applied during the observations in this study. This highlights a major problem in the nursing profession, which is how to communicate nursing research findings and have these incorporated into nursing practice. The mean number (J.7) of catheter insertions in this study was similar to the mean number (4.J) of catheter insertions reported by Kerr et ale (1991) in the pediatric population. The range of catheter insertions was less in the neonatal population (one to five insertions) than in the 24 pediatric observations in which Kerr et ale 47 reported a range of three to eight insertions. Duration of the suctioning procedure is affected to a large degree by the number of catheter insertions; thus, fewer insertions in a procedure may help to minimize complications of suctioning. Minimizing complications of suctioning has been the focus of research and recommendations. Though shallow suctioning has been recommended in the research, in 147 of 186 catheter insertions (79%) the catheter was inserted farther than 0.5 cm beyond the tip of the ETT. Head rotation was performed as part of the suctioning procedure in 68% of the observations. Because the purpose of head rotation is to assist in placing the catheter in each of the mainstem bronchi, this practice is of no value when performing shallow suctioning. In Turner's (1990) report, head rotation and deep suctioning were not encouraged. Deep suctioning and head rotation in this study were prevalent despite complications documented with this practice. This is alarming, as many of the patients are very-low-birth-weight infants. Due to their immaturity, they are prone to severe complications with suctioning (i.e., airway perforation, tissue damage, hypoxia, hypercarbia, and intraventricular hemorrhage). Prior recommendations regarding routine ETS should be emphasized. Shallow suctioning without a change in head position should be routine practice, unless clinical evidence is present to justify risking complications of deep suctioning. 48 Although Gunderson (1989) recommended body temperature saline, warmed saline was used in only 9 (18%) procedures. In this study, the saline vials were warmed on top of a warm ventilator, or in an isolette, or in an open warmer. Although these methods of warming saline have not been investigated, the temperature of the saline is between room air and body temperature. sterile technique was broken in 15% of the procedures using conventional catheters. The Ballard in-line suction catheter is contained within a sterile sleeve, thus eliminating the need for the nurse to use sterile technique. Nurses performing suctioning procedures should be careful to maintain sterile technique with conventional catheters because suctioning is an invasive procedure and the population requiring this procedure is at risk for infection. The mean negative pressure applied during suctioning was not the same in"both hospitals. For Hospital 1, the mean negative pressure application was lower (76 mm Hg), but there was a higher mean number of catheter insertions (4.0) per procedure. Hospital 2 had a higher mean negative pressure application (118 mm Hg), but the mean number of catheter insertions per procedure was fewer (3.5). In Hospital 2, the Ballard in-line suction catheter was used and associated with fewer catheter insertions per procedure, but the suction procedures may have been more frequent. The mean negative pressure application at Hospital 1 (76 mm Hg) was consistent with the 60 to 80 mm Hg reported by respondents in Tolles and stone's (1990) national survey. 49 The MRB was used to ventilate during most of the suctioning procedures (88%) in this study, and the ventilator was used by 22% who suctioned with the Ballard in-line suction catheter. Tolles and stone (1990) reported that of their 204 survey respondents, 137 returned the infant to the ventilator between suction passes and 105 used an MRB. Thus, the MRB was used to ventilate during the suctioning procedures more frequently in this study than the national practice reported by Tolles and stone. Only 20% of the nurses in this study reported a change in the Fio2 setting prior to suctioning, which is in contrast to Tolles and stone's (1990) finding that 66% of the respondents surveyed routinely increase the inspired oxygen before suctioning. Hyperoxygenation before suctioning has been shown to decrease hypoxemia. The lack of adherence to current recommendations may be due to the nurses' efforts to minimize periods of hyperoxygenation as a preventative measure in premature infants susceptible to retinopathy of prematurity. 50 possibly, these nurses may comply with current recommendations by increasing inspired oxygen prior to suctioning to improve saturation based on pulse oximetry. Because oxygen concentration, both hypoxia and hyperoxia, can be harmful to preterm infants, a reasonable suggestion might be to increase inspired oxygen to achieve oxygen saturation at the maximum-ordered level 2 minutes before suctioning. Implications for nursing practice included minimizing the complications of neonatal ETS by following current research recommendations. These recommendations involve shallow suctioning without head rotation, using warmed saline, using sterile technique, and increasing inspired oxygen setting prior to suctioning. Recommendations for Future studies components in the suctioning procedure require further research. For instance, the use of irrigant needs attention. How much irrigant should be used? What is the optimal method of irrigant administration? Should irrigant be used routinely? Does the routine use of irrigant stimulate increased secretion production? The depth of catheter insertion during suctioning should be addressed. If research shows damage to the tissues when the catheter is inserted further than the ETT tip, why is routine deep suctioning in use clinically? Does this damage from deep suctioning stimulate increased 51 production of secretions? Does this damage play a role in reactive airway disease? There seems to be a belief among caregivers that most secretions cannot be retrieved unless deep suctioning is performed. Is this an accurate perception? What is the best method of secretion retrieval? As described in this study, head rotation is performed as part of the suctioning procedure. If recommendations have been made against head rotation during the suctioning procedure, why is it routine in the clinical setting? Does head rotation increase the amount of secretions retrieved in the procedure? This study examined only nursing actions during suctioning. What about patient responses to the procedure? How does the patient respond to various components of the procedure? How can the suctioning procedure be modified to minimize patient discomfort and complications? There are many unanswered questions regarding the suctioning procedure. Further research is vital to improve patient care. APPENDIX A NURSING BACKGROUND QUESTIONNAIRE 53 Subject # Hospital 1-U~- ---2---P--C-Nursing Background Questionnaire completion of this questionnaire signifies consent to participate in this study. 1. Circle how many hours you work per week in this unit. 1 - Less than 12 hours 2 - 12 hours or more 2. How much formal school have you attended since high school? years 3. Circle your levels of nursing education. 1 - diploma 2 - associate degree 3 - bachelor's degree 4 - master's degree 4. How long have you worked as a nurse? years months 5. How long have you worked as a neonatal nurse? years months 6. How many hospitals have you worked for in your nursing career? 7. In how many of these hospitals were you a neonatal nurse? 8. Are you currently certified in the American Heart Association's Neonatal Resuscitation course? 1 - Yes 2 - No 9. Do you have a specialty certification? 1 - Yes (indicate type) 2 - No 3 - Neonatal 4 - Other: 10. How many professional organizations do you belong to? 11. Circle the organizations you are a member of: 1 - NANN 2 NAACOG 3 UNA 4 ANA 5 UANN 6 Others: 12. How many professional journals do you receive? 13. How many professional conferences did you attend in 1991? 54 14. Were any of the above neonatal specialty conferences? 1 - Yes (#) 2 - No 15. In your present position, have you performed the following tasks in the past year? oriented any new nurses. 1 - Yes 2 - No Given two or more different in-services. 1 - Yes 2 - No APPENDIX B SUCTIONING DATA SHEET preliminary Information Subject # ---- Patient's age _____ /days Weight /gms Medical Diagnosis: 1 - Prematurity 2 - RDS 3 - Pneumonia 4 - Pulmonary edema 5 - Pulmonary hemorrhage 6 - BPD 7 - Pneumothorax 8 - Other: MRS bag 1 - U: manual Hospital 1-U Gestation ___ /wks 2 - PCMC: Dragger (flow dependent) Flow rate Fi02 set at _____ _ Vent type 1 - Infant Star 2 SeaChrist 3 Bear Cub 4 Baby Bird Settings Fi02 __ It PIP/PEEP /cm H20 56 2-PC Rate /min ETT size 1: 2.-0-- 2: 2.5 3: 3.0 4: 3.5 5: 4.0 ETT length /cms (measured by researcher from last visible mark outside the mouth to the end of the connector) Negative pressure setting: Immediately Prior to suctioning suction catheter: Brand 1 - Ballard Size 3 - Baxter 4661A 1 - 5/6 French 2 - 8 French Saline stored at bedside: 1 - Room temperature 2 - Other: 2 - Baxter 4660A 4 - Other: 3 - 5 French 4 - 6 French 5 - 10 French 57 Circle position of patient: 1 - 2 Prone with head toward right shoulder at bedside Prone with head toward left shoulder 3 Supine with head toward right shoulder 4 Supine with head toward left shoulder 5 Right lateral with head midline 6 Left lateral with head midline 7 Supine with head midline Question to the RN: Have any changes been made in ventilator or oxygen setting before suctioning? 1 - Yes: What changes have been made? a. Change Fi02 based on saturation (to what minimum ) b. Increase Fi02 from % to % (what %. ) c. New vent settings PIP/PEEP rate d. Other: 2 - No Instructions to the RN before suctioning Follow your normal routine. Please suction so catheter numbers are visible to me and tell me when you are applying suction prior to withdrawing the catheter. Thank you. Procedure sequence sterile gloves on suction hand? on both hands? 1st 2nd 3rd 1 - Yes 1 - Yes 4th 2 - No 2 - No 5th 6th Head position changes ss sm ms ss sm ms ss sm ms ss sm ms ss sm ms ss sm ms Saline instillation Y N Y N Y N Y N Y N Y N Ventilation afterward Y N Y N Y N Y N Y N Y N Insertion depth (em) Negative pressure (C or C I C I C I C I C . I C I I) Withdrawal movement T S T S T S T S T S T S 1st 2nd 3rd 4th 5th 6th Abbreviations: Y = yes, N = no, SS = side by side, SM = side to midline, MS = mid to side, T = twisting, and S = straight out. Immediately Following suctioning Circle persons involved in suctioning 1 - RN 2 - RN-RN 3 - RN-RT 4 - Other: Gloves worn by helper 1 - Yes 2 - No Oral suction after passes 1 - Yes 2 No 3 Before return to vent 4 During return to vent 5 After return to vent sterile technique maintained throughout 1 - Yes 2 - No Total saline vials used # --- Saline administration 1 - Bolus from bullet 2 - Other: size --- Question to the RN After Procedure: 58 On a scale of 1 to 3, how would you rate the consistency of secretions, with 1 being thin, 2 being moderate, and 3 being thick? 1 - Thin 2 - Moderate 3 - Thick Calculations to be Done Anytime After Procedure centimeter length of catheter passed beyond tip of ETT each pass: 1st: 2nd: 3rd: 4th: 5th: 6th: Total # of suction passes in procedure: APPENDIX C INFORMED CONSENT: NURSING 60 Entry into this study is entirely vOluntary. You may withdraw from this study at any time without repercussion. Your subject number is # ----- If you have any questions or wish to withdraw from this study, you may do so by contacting Diane Opp at 581-2747 and identifying your subject number. Completion of this questionnaire signifies consent to participate in this study. APPENDIX D INFORMED CONSENT: UNIVERSITY HOSPITAL Authorization to participate in Research Project: University Hospital Xethods of Neonatal Endotracheal suctioning 62 Background. This is a research project to describe methods of endotracheal tube suctioning of newborns. Your baby has a small tube in the airway called an endotracheal tube. To remove mucus which gathers in the tube, a frequent procedure called endotracheal suctioning is performed by nurses caring for your baby. A smaller tube called a suction catheter is put into your baby's endotracheal tube and connected to a vacuum that removes the mucus or lung secretions. There are a variety of effective methods of endotracheal suction. We do not know which method is best. The purpose of this study is to record and summarize the methods used routinely in this nursery. You are being asked to allow your baby to participate in this study because your baby has nurses performing endotracheal suctioning as a part of routine care. study procedure. The researcher will be present in the nursery when your baby needs to be suctioned. The researcher will watch the nurse suctioning and record the methods used. The researcher will measure the endotracheal tube with a measuring tape. The researcher will also record information from your baby's medical record such as weight, gestational age, medical diagnosis, and respiratory support. The researcher may repeat this observation procedure during various shifts when different nurses who have not been observed are caring for your baby. Twenty-five nurses from this hospital will be observed. Fifty nurses will be observed in this study. Risks. There is no risk to your baby from participation in this study in addition to the usual risk of suctioning and measuring the endotracheal tube. By participating in this study the only change in your baby's routine care is that the researcher will measure the endotracheal tube. This measurement is easy to make and is done routinely several times a day by your baby's nurse. There is a very slight chance that measuring the tube will dislodge it. This is a usual risk to any baby with an endotracheal tube in place. Should this tube be dislodged, it will be replaced if needed by the nursery staff. 63 Benefits. Your baby will receive no direct benefit from participating in this study. This study will guide further research which may change suctioning techniques to benefit future babies receiving endotracheal suctioning. Alternative procedure. If you decide not to allow your baby to be observed in this study, your baby will still receive the usual medical and nursing care. Your baby will still have the endotracheal tube suctioned and the position of the tube measured several times a day because these are part of routine nursing care. Confidentiality. Your baby's name will not be recorded as a part of study procedure. All information will be kept confidential along with the consent form. Data from observations will be reported in summary fashion only. Person to contact. If you have any questions about the study, the researcher will be happy to discuss these with you. Please call Diane Opp, RN, at [phone], or talk with the attending neonatologist in charge of your baby. Institutional Review Board. If you have questions regarding your rights as a research subject, or if problems arise which you do not feel you can discuss with the Investigator, please contact the Institutional Review Board Office at [phone]. Medical treatment or compensation for injury. In the event you sustain physical injury resulting from your participation in the research project, the University of Utah will provide to you, without charge, emergency and temporary medical treatment not otherwise covered by your own insurance. If you believe that you have sustained a physical injury as a result of your participation in this research program, please contact the Office of the Vice President for Research at 581-7236. voluntary participation. participation in this study is entirely voluntary. You may choose not to have your baby participate in this study and your baby will still receive the same care he or she would otherwise have received. If you do participate, you can withdraw your baby at any time without any effect on his or her medical care. If you desire to withdraw your baby from this study, please contact Diane Opp, RN, at [phone]. Consent. Upon consideration of the possible benefits and risks of the study outlined, I voluntarily agree to allow the participation of my baby, , in the 64 study. I understand that effective medical care is my doctors', nurses', and the investigators' main concern and that they may stop the study and change my child's treatment according to their best judgment. My questions regarding participation in this study have been answered and I understand the explanation. I give permission for the information gathered in this study and pertinent information from my baby's medical records to be released to Diane Opp with the understanding that they may be published for scientific purposes but that my baby's identity will not be publicly revealed by the investigators or the sponsor without my written consent. I acknowledge receipt of a copy of this consent document. Signature of Parent/Guardian Date signature of witness Date APPENDIX E INFORMED CONSENT: PRIMARY CHILDREN'S MEDICAL CENTER Authorization to Participate in Research Project: primary Children's Medical Center Methods of Neonatal Endotracheal suctioning 66 Introduction. I am conducting a research project to describe methods of endotracheal tube suctioning of newborns. Your baby has a small tube in the airway called an endotracheal tube. To remove mucus which gathers in the tube, a procedure called endotracheal suctioning is performed by nurses caring for your baby. A smaller tube called a suction catheter is put into your baby's endotracheal tube and connected to a vacuum that removes the mucus or lung secretions. This care is part of the normal routine for babies with an endotracheal tube in place. I am asking you to allow your baby to participate in this study because your baby frequently has nurses performing endotracheal suctioning as a part of routine care. purpose. The purpose of this study is to record and summarize the methods of endotracheal suctioning used routinely in this nursery. study procedure. If I am present in the nursery when your baby needs to be suctioned, your baby's nurse will tell me. I will watch the suctioning procedure and record information about the suctioning procedure. I will measure the baby's endotracheal tube with a measuring tape and record information from your baby's medical record such as weight, gestational age, medical diagnosis, and respiratory support. I may repeat this study procedure during different shifts when another nurse, whom I have not observed, is caring for your baby. Risks and benefits. By participating in this study the only change in your baby's routine care is the following: I will measure the endotracheal tube. This measurement is easy to make and is done several times a day by your baby's nurse. Although highly unlikely, there is a slight chance that measuring the tube will dislodge it. If the endotracheal tube comes out, your baby could have difficulty breathing (respiratory distress). Should this occur, the tube will be replaced by the nursery staff. Your baby will receive no direct benefit from participating in this study. I expect to learn how nurses suction and this study will guide further nursing research which may benefit future babies receiving endotracheal suctioning. Alternatives. If you decide not to allow your baby to be observed in this study, your baby will receive the usual nursing care. Confidentiality. All information will be kept confidential along with the consent form. Data will be reported in summary fashion only. Your baby's name will not be recorded. 67 If you have any questions about the study, I will be happy to discuss these with you. Please call Diane Opp, RN, at [phone]. If you have questions regarding research subject's rights or if problems arise which you do not feel you can discuss with me, please contact J. Ross Milley, MD, PhD, Chairman of the Research and Human Subjects Committee at Primary Children's Medical Center at [phone]. Limitations. Realistically, neither the hospital nor I can guarantee or assure that unknown consequences from the additional measurement of the endotracheal tube will not occur. If your child sustains injuries caused by negligent acts or omission of the employees acting in the course and scope of their employment, Primary Children's Medical Center may be liable, subject to limitations prescribed by law, for additional medical costs and other damages your child sustains. If you believe that your child has suffered an injury as a result of participation in this research program, please contact Mr. James Wilson, Primary Children's Medical Center Administration at [phone]. No funds are committed in advance to pay for such care, nor is financial compensation available for such things as disability or discomfort due to an injury. You will not give up any of your or your child's legal rights by signing this form. Voluntary participation. Participation in this study is entirely voluntary and you may choose not to have your baby participate in this study. If you do participate, you can withdraw your baby at any time without any effect on his/her medical care. If you desire to withdraw your baby from this study, please contact Diane Opp, RN, at [phone]. 68 consent Upon consideration of the possible benefits and risks of the study outlined, I voluntarily agree to allow the participation of my baby, , in the study. I understand that effective medical care is my doctors', nurses', and investigator's main concern and that they may stop the study and change my child's treatment according to their best judgment. My questions regarding participation in this study have been answered, and I understand the explanation. I give permission for the information gathered in this study and pertinent information from my baby's medical records to be released to Diane Opp, RN, with the understanding that they may be published for scientific purposes but that my baby's identity will not be publicly revealed by the investigators or the sponsor without my written consent. I acknowledge receipt of a copy of this consent document. Signature of Parent/Guardian Date Signature of witness Date REFERENCES 70 Ackerman, M. H. (1985). The use of bolus normal saline instillations in artificial airways: Is it useful or necessary? Heart and Lung, 14, 505-506. Alpan, G., Glick, B., Peleg, 0., Amit, Y., & Eyal, F. (1984). Pneumothorax due to endotracheal tube suction. American Journal of Perinatology, £, 345-348. Bailey, C., Kattwinkel, J., Teja, K., & Buckley T. (1988). Shallow versus deep endotracheal suctioning in young rabbits: Pathologic effects on the tracheobronchial wall. Pediatrics, 82, 746-751. Barnes, C., Asonye, u. 0., & Vidyasagar, D. (1981). The effects of bronchopulmonary hygiene on Ptc02 values in critically ill neonates. critical Care Medicine, ~, 819-822. Bostick, J., & Wendelgass, S. T. (1987). Normal saline instillation as part of the suctioning procedure: Effects on Pa02 and amount of secretions. Heart and Lung, 16, 532-537. Brandstater, B., & Muallem, M. (1969). Atelectasis following tracheal suction in infants. Anesthesiology, 31, 468-473. Brodsky, L., Reidy, M., & Stanievich, J. F. (1987). The effects of suctioning techniques on the distal tracheal mucosa in intubated low birth weight infants. International Journal of Pediatric otorhinolaryngology, 14, 1-14. Cassani, V. L., III. (1984). Hypoxemia secondary to suctioning in the neonate. Neonatal Network, ~(6), 8-16. cassani, V. L., III. (1992). Evaluation of two endotracheal suction regimes in babies ventilated for respiratory distress syndrome. Neonatal Network, 11(7), 45. Demers, R. R., & Saklad, M. (1973). Minimizing the harmful effects of mechanical aspiration. Heart & Lung, ~, 542-545. Downs, J. (1989). Endotracheal suction: A method of tracheal washout. Physiotherapy, 75, 454. 71 Dunn, D., & Lewis, A. T. (1973). Some important aspects of neonatal nursing related to pulmonary disease and family involvement. Pediatric Clinics of North America, 20, 481-498. Fox, W. W., Schwartz, J. G., & Shaffer T. H. (1978). Pulmonary physiotherapy in neonates: Physiologic changes and respiratory management. The Journal of Pediatrics, 92, 977-981. Gunderson, L., McPhee, A., & Donovan, E. (1986). Partially ventilated endotracheal suction. American Journal of Diseases of Children, 140, 462-465. Gunderson, L. P. (1989). Factors contributing to endotracheal suctioning induced heart rate alterations in anesthetized newborn piglets. Doctoral dissertation, Ohio state University, Columbus. Gunderson, L. P., Stone, K. S., & Hamlin, R. L. (1991). Endotracheal suctioning-induced heart rate alterations. Nursing Research, 40, 139-143. Hagedorn, M. I., Gardner, S. L., & Abman, S. H. (1989). Respiratory diseases. In G. B. Merenstein & S. L. Gardner, Handbook of neonatal intensive care (2nd ed.) (pp. 380-382). st. Louis: The C. V. Mosby Company. Hanley, M., Rudd, T., & Butler, J. (1978). What happens to intratracheal saline instillations? American Review of Respiratory Disease, 117(Suppl.), 124. Harper, R. G., & Yoon, J. J. (1987). Handbook of neonatology (2nd ed.). Chicago: Year Book Medical Publishers Incorporated. Hodge, D. (1991). Endotracheal suctioning and the infant: A nursing care protocol to decrease complications. Neonatal Network, ~(5), 7-15. Hodson, W. A., & Belenky, D. A. (1975). Management of respiratory problems. In G. B. Avery (Ed.), Neonatology: Pathophysiology and management of the newborn (p. 270). Philadelphia: J. B. Lippincott corporation. Kerr, M., Menzel, L., & Rudy, E. (1991). suctioning practices in the pediatric intensive care unit. Heart & Lung, 20, 300. Kleiber, C. (1986). Clinical implications of deep and shallow suctioning in neonatal patients. Focus on Critical Care, 13(4), 36-39. 72 Konradova, V., Kanta, J., & solova, J. (1990). Effect of bronchioaveolar lavage on the ultrastructure of the tracheal epithelium in rabbits. Respirati~n, 57, 14-20. Kuzenski, B. M. (1978). Effect of negative pressure on tracheobronchial trauma. Nursing Research, 27, 260-263. Long, J. G., Philip, A. G. S., & Lucey, J. F. (1980). Excessive handling as a cause of hypoxemia. Pediatrics, 65, 203-207. Nicholson, M. (1960). Case history, cardiac arrest during therapeutic tracheal suction. Anesthesia and Analgesia, 39, 568-569. Ninan, A., O'Donnell, M., Hamilton, K., & Sankaran, K. (1985). Physiological changes induced by endotracheal instillation and suctioning in critically ill preterm infants with and without sedation. Pediatric Research, 19, 355A. Perlman, J. M., & Volpe, J. J. (1983). Suctioning in the preterm infant: Effects on cerebral blood flow velocity, intracranial pressure, and arterial blood pressure. Pediatrics, 72, 329-334. Raval, D., Yeh, T., Mora, A., & Pildes, R. (1980). Changes in transcutaneous P02 during tracheobronchial hygiene in neonates. Perinatology-Neonatology, ~(4), 41-44. Rindflesh, S. H., & Tyler, M. L. (1983). Duration of suctioning: An important variable. Respiratory Care, 28, 457-459. Rosen, M., & Hillard, E. K. (1962). The effects of negative pressure during tracheal suction. Anesthesia and Analgesia, 41, 50-57. Rutala, W. A., Stiegel, M. M., & Sarubbi, F. A., Jr. (1984). A potential infection hazard associated with the use of disposable saline vials. Infection Control, ~, 170-172. 73 Salyer, J. W. (1990). Suctioning. In J. L. Blumer (Ed.), A practical guide to pediatric intensive care (3rd ed.) (pp. 972-978). st. Louis: Mosby Year Book. Shim, c., Fine, N., Fernandez, R., & Williams, M., Jr. (1969). Cardiac arrythmias resulting from tracheal suctioning. Annals of Internal Medicine, 71, 1149-1153. Shorten, D. (1988). Infant responses to saline instillations. Master's thesis, University of Alberta, Edmonton. Simbruner, G., Coradello, H., Fodor, M., Havelec, L., Lubec, G., & Pollak, A. (1981). Effect of tracheal suction on oxygenation, circulation, and lung mechanics in newborn infants. Archives of Disease in Childhood, 56, 326-330. st. Louis Children's Hospital, st. Louis, Missouri. (1984). Endotracheal tube suctioning in the neonate. Neonatal Network, ~(6), 56. Storm, W. (1980). Transient bacteremia following endotracheal suctioning in ventilated newborns. Pediatrics, 65, 487-490. Tolles, C. L., & Stone, K. S. (1990). National survey of neonatal endotracheal suctioning practices. Neonatal Network, ~(2), 7-14. Turner, B. (1983). Nursing interventions: Current concepts in endotracheal suctioning. Journal of the California Perinatal Association, III, 104-106. Turner, B. S. (1990). Maintaining the artificial airway: Current concepts. Pediatric Nursing, 16, 487-493. Urban, B. J., & Weitzner, S. W. (1969). Avoidance of hypoxemia during endotracheal suction. Anesthesiology, 31, 473-475. Vaughan, R. S., Menke, J. A., & Giacoia, G. P. (1978). Pneumothorax: A complication of endotracheal tube suctioning. The Journal of Pediatrics, 92, 633-634. Walsh, C. M., Bada, H. S., Korones, S. B., Carter, M. A., Wong, S. P., & Arheart, K. (1987). Controlled supplemental oxygenation during tracheobronchial hygiene. Nursing Research, 36, 211-215. 74 Wilson, G., Hughes, G., Rennie, J., & Morley, C. (1992). Evaluation of two endotracheal suction regimes in babies ventilated for respiratory distress syndrome. Neonatal Network, ~(7), 43-44. Zmora, E., & Merritt, T. (1980). Use of side-hole endotracheal tube adapter for tracheal aspiration. American Journal of Diseases of Children, 134, 250-254.