Related Experiment Video
Updated: Mar 26, 2026
A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation
Published on: January 17, 2011
A Bedside Decision Tree for Use of Saline With Endotracheal Tube Suctioning in Children
Erin B Owen1, Charles R Woods2, Justine A O'Flynn2
1Erin B. Owen is an assistant professor of pediatrics at the University of Louisville and an intensivist for the Just For Kids Critical Care Center at Kosair Children's Hospital, Louisville, Kentucky, and she currently serves as the unit's patient safety and outcomes director.Charles R. Woods is a professor of pediatrics (infectious diseases) and serves as the director of child and adolescent health research design and support for the Department of Pediatrics at the University of Louisville.Justine A. O'Flynn's clinical background includes significant time spent as a bedside nurse in the Just for Kids Critical Care Center at Kosair Children's Hospital. She is currently the patient care systems analyst for the center.Megan C. Boone has spent her nursing career in the Just For Kids Critical Care Center at Kosair Children's Hospital. Initially a bedside nurse, she now serves as the unit's clinical nurse specialist.Aaron W. Calhoun is an associate professor of pediatrics at the University of Louisville and an intensivist for the Just For Kids Critical Care Center at Kosair Children's Hospital. He is also the director of the Simulation for Pediatric Assessment Resuscitation and Communication Program at the University of Louisville.Vicki L. Montgomery is a professor of pediatrics and chief of the Division of Critical Care Medicine at the University of Louisville. She is an intensivist for the Just For Kids Critical Care Center at Kosair Children's Hospital and serves as chief of the Women and Children's Division of Patient Quality, Safety and Clinical Innovation for Norton Healthcare. e0owen01@louisville.edu.
Insights
Saline instillation before endotracheal tube suctioning increases adverse events in pediatric patients. Caution is advised, particularly for children with small tubes and respiratory conditions.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Therapy
- Patient Safety
Background:
- Endotracheal tube suctioning is essential for mechanically ventilated patients.
- Previous studies on saline instillation before suctioning yielded inconclusive results.
Purpose of the Study:
- To investigate the association between saline instillation and suctioning-related adverse events in pediatric patients.
- To identify risk factors for adverse events during endotracheal tube suctioning in this population.
Main Methods:
- A prospective study evaluated adverse events in pediatric patients (≤18 years) requiring mechanical ventilation for ≥48 hours.
- Suctioning episodes were analyzed, comparing those with and without prior saline instillation.
- Patient factors and endotracheal tube characteristics were assessed for association with adverse events.
Main Results:
- Of 1986 suctioning episodes, 1003 involved saline; adverse events were more frequent with saline (P < .001).
- Saline was linked to hemodynamic instability, bronchospasm, and oxygen desaturation.
- Risk factors included younger age, small endotracheal tube size, respiratory/hemodynamic indications for intubation, and underlying respiratory disease.
Conclusions:
- Saline instillation before endotracheal tube suctioning is associated with adverse events like hemodynamic instability, bronchospasm, and hypoxemia.
- Use of saline should be approached with caution in pediatric patients, especially those with small endotracheal tubes and comorbid respiratory conditions.
Background:
Endotracheal tube suctioning is necessary for patients receiving mechanical ventilation. Studies examining saline instillation before suctioning have demonstrated mixed results.
Methods:
A prospective study to evaluate whether saline instillation is associated with an increased risk of suctioning-related adverse events in patients 18 years old or younger requiring mechanical ventilation through an endotracheal tube for at least 48 hours when suctioned per protocol using a bedside decision tree.
Results:
A total of 1986 suctioning episodes (1003 with saline) were recorded in 69 patients. The most common indication for use of saline was thick secretions (87% of episodes). In 586 suctioning episodes, at least 1 adverse event occurred with increased frequency in the saline group (P < .001). Normal saline was more likely to be associated with hemodynamic instability (P = .04), bronchospasm (P < .001), and oxygen desaturation (P < .001). Patient factors associated with adverse events include younger age (P < .001), a cuffed endotracheal tube (P = .001), endotracheal tube diameter of 4.0 mm or less (P < .001), respiratory or hemodynamic indication for intubation (P < .001), underlying respiratory disease (P < .001), and longer duration of mechanical ventilation (P < .001). Saline instillation (P < .001), endotracheal tube size of 4.0 mm or less (P = .03), and comorbid respiratory diseases (P = .03) were associated with an increased risk of adverse events.
Conclusions:
Saline instillation before endotracheal tube suctioning is associated with hemodynamic instability, bronchospasm, and transient hypoxemia. Saline should be used cautiously, especially in children with a small endotracheal tube and comorbid respiratory disease.
Related Concept Videos
01:26Tracheostomy Suctioning I: Pre-Procedural Steps
Equipment Required
First, gather all necessary equipment: a sterile suction catheter, a sterile disposable container, sterile gloves, a towel or...
01:23Tracheostomy Suctioning II: Procedure
01:25Suctioning the Oropharyngeal Airway
After assembling the equipment, the nurse should practice hand hygiene and don appropriate PPE according to infection control guidelines to avoid the...
01:29Suctioning the Nasopharyngeal Airway
Equipment Required
01:26Endoscopic Studies II: Thoracocentesis
Description
Excess pleural fluid or air may accumulate in some respiratory disorders in the thoracic cavity. To treat pleural effusion, a physician conducts thoracentesis by carefully piercing the chest wall and entering...
01:15Endotracheal Intubation I: Procedure
The ET tube comprises various components, including a standard adaptor to attach a bag-valve-mask (BVM) or ventilator, a cuff, a pilot balloon, and radiopaque markings along its length to measure the insertion distance. The tube sizes...