In an era of evidence-based practice, it is no longer acceptable to continue a practice because “that’s the way it’s always been done.” One such practice is the instillation of saline into an advanced airway such as an endotracheal tube or tracheostomy prior to or during suctioning.
At the Regional Spinal Cord Injury Center of the Delaware Valley at Thomas Jefferson University Hospital, Phildelphia, in an attempt to stay current with evidence-based practice for the care of individuals with spinal cord injury (SCI) and have standardized practice guidelines, we reviewed the literature on the installation of saline prior to and during suctioning. What we found was interesting, not only for the SCI population but the non-SCI population as well.
Reviewing the Research
Throughout our years of clinical practice, we often instilled small unit-dose vials of saline into an open tracheostomy to elicit a more productive cough or loosen secretions in patients with SCI, or so we thought. Even though the patients gagged and gagged, we never imagined we could be inflicting harm, just temporary discomfort for the greater result of airway clearance.
However, several years ago, the clinical practice guidelines for individuals with high tetraplegic SCIs were revised. It is no longer recommended to instill saline into an advanced airway because people with tetraplegia have little or no diaphragm innervation and, therefore, are unable to produce a cough reflex. This practice has been compared to “drowning” patients in their own secretions.
After further review of the literature, we found saline instillation is not recommended for any adult patient who is mechanically ventilated. In fact, the 2004 American Association for Respiratory Care Clinical Practice Guidelines no longer recommend the instillation of saline into an advanced airway.
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11. Halm, M. & Krisko-Hagel, K. (2008). Instilling normal saline with suctioning: Beneficial technique or potentially sacred cow? American Journal of Critical Care,17(5), 469-472.
Catharine Farnan is clinical nurse specialist and Mary Patrick is project coordinator of the Regional Spinal Cord Injury Center of the Delaware Valley, both at Thomas Jefferson University Hospital, Philadelphia.