NSG 302 Week 4 Assignment PICO Question

Student Name

University of Phoenix

NSG/302 Professional Contemporary Nursing Role and Practice

Prof. Name

Date

An Evidence-Based Review

Current evidence suggests that routine normal saline instillation (NSI) before endotracheal suctioning is not recommended for mechanically ventilated adult patients. Research indicates that NSI may increase the risk of ventilator-associated pneumonia (VAP), reduce oxygenation, and cause unnecessary physiological stress without providing meaningful clinical benefits. Evidence-based practice guidelines recommend suctioning without routine saline instillation unless there is a specific clinical indication.

Search Strategies for Evidence-Based Practice

A systematic literature search was conducted to identify high-quality evidence regarding best practices for endotracheal suctioning and the use of normal saline instillation in mechanically ventilated patients.

The primary databases searched included:

• University of Phoenix Library

• CINAHL

• MEDLINE

• Cochrane Library

• PsycINFO

• Google Scholar (secondary source)

Priority was given to:

• Peer-reviewed journal articles

• Evidence-based clinical practice guidelines

• Systematic reviews

• Randomized controlled trials

• Studies published on adult ICU patients requiring mechanical ventilation

The search focused on determining whether normal saline instillation before suctioning improves secretion removal or instead contributes to complications such as ventilator-associated pneumonia, impaired oxygenation, prolonged hospitalization, or increased mortality.

Why Endotracheal Suctioning Matters

Endotracheal suctioning is an essential nursing and respiratory therapy intervention for patients receiving mechanical ventilation. The procedure removes pulmonary secretions, maintains airway patency, and helps improve oxygenation.

However, suctioning itself carries risks, including:

• Hypoxemia

• Cardiac dysrhythmias

• Increased intracranial pressure

• Airway trauma

• Infection

Because of these risks, healthcare professionals continuously evaluate whether additional interventions—such as saline instillation—provide benefits or unnecessary harm.

What Is Normal Saline Instillation?

Normal saline instillation involves introducing approximately 1–5 mL of sterile normal saline into the endotracheal tube immediately before suctioning.

Historically, clinicians believed saline would:

• Thin thick secretions

• Improve mucus removal

• Stimulate coughing

• Make suctioning easier

Although this practice became common in many intensive care units, modern evidence questions its effectiveness and safety.

Evidence From Current Research

Comprehensive Literature Review

Caparros (2014) conducted a comprehensive review examining the use of saline instillation during suctioning in mechanically ventilated adult ICU patients.

The review evaluated studies involving adults over 18 years old who:

• Were intubated or had tracheostomies

• Required mechanical ventilation

• Received treatment in intensive care units

Multiple evidence sources, including CINAHL, MEDLINE, Cochrane, PsycINFO, and national clinical guidelines, were analyzed.

Key Findings

The review concluded that routine saline instillation does not improve patient outcomes. Instead, studies consistently demonstrated an association between saline instillation and higher rates of ventilator-associated pneumonia.

One evidence-based investigation compared ICU patients receiving suctioning with saline instillation against patients suctioned without saline.

The findings showed:

• Lower rates of ventilator-associated pneumonia among patients who did not receive saline

• Statistically significant reductions in VAP incidence after eliminating routine saline instillation

• Improved adherence to evidence-based suctioning practices

These findings support moving away from routine saline use during endotracheal suctioning.

Nursing Practice and Current Clinical Evidence

Ayhan et al. (2015) investigated both the scientific evidence and nursing perspectives regarding saline instillation before suctioning.

Although research dating back to the 1970s questioned the effectiveness of saline instillation, the practice remained common among ICU nurses.

Survey Findings

The researchers found that:

• Nearly 88% of ICU nurses routinely administered saline before suctioning.

• Most nurses believed saline helped liquefy secretions.

• Approximately 77% based saline use on secretion consistency.

• Most administered 1–4 mL of normal saline.

However, despite widespread use, many nurses recognized potential risks.

Among nurses using saline:

• 42% believed the practice could be harmful.

• 92% identified increased lung infection risk as the primary concern.

• Many also reported concerns about reduced oxygen saturation.

Nurses who avoided saline generally cited two reasons:

• Lack of proven benefit

• Potential patient harm

The study demonstrated a significant gap between traditional clinical practice and current evidence-based recommendations.

Physiological Effects of Saline Instillation

Another important investigation by Akgül and Akyolcu (2002) examined how saline instillation affects physiological parameters after endotracheal suctioning.

Researchers monitored:

• Heart rate

• Oxygen saturation (SpO₂)

• Arterial blood gases

• Blood pH

Patients were observed for five minutes after suctioning with and without saline instillation.

Major Findings

The study reported:

• Small decreases in oxygenation after saline instillation

• Minor changes in arterial blood gases

• Significant increases in heart rate following saline-assisted suctioning

• No meaningful improvement in oxygen saturation

Although many physiological changes were not statistically significant, saline instillation produced undesirable responses without demonstrating measurable clinical benefits.

The researchers concluded that routine saline instillation should be reconsidered due to its limited effectiveness and potential adverse effects.

Does Saline Reduce Ventilator-Associated Pneumonia?

The available evidence consistently suggests the opposite.

Research indicates that saline instillation may actually increase the likelihood of ventilator-associated pneumonia.

Several mechanisms may explain this relationship.

Bacterial Migration

Laboratory studies demonstrated that saline may carry bacteria deeper into the lower respiratory tract during suctioning.

Reduced Oxygen Exchange

Residual saline remaining inside the lungs can interfere with gas exchange and temporarily worsen oxygenation.

Incomplete Saline Removal

Studies have shown that only a small percentage of instilled saline is recovered during suctioning, meaning much of the fluid remains within the airway.

Collectively, these findings explain why many current critical care guidelines discourage routine saline instillation.

Clinical Implications for Healthcare Providers

Modern critical care practice increasingly emphasizes evidence-based interventions.

Current evidence supports:

• Performing suctioning only when clinically indicated

• Avoiding routine saline instillation

• Maintaining sterile suctioning techniques

• Monitoring oxygenation before and after suctioning

• Using humidification and adequate hydration to manage thick secretions

Respiratory therapists and critical care nurses play essential roles in implementing these evidence-based recommendations.

PICO Question

Clinical Question

In older adult patients with chronic obstructive pulmonary disease (COPD) receiving mechanical ventilation through an endotracheal tube (P), does the use of normal saline instillation during endotracheal suctioning (I), compared with suctioning without saline instillation (C), increase the risk of ventilator-associated pneumonia, mortality, and prolonged hospital stay (O)?

Application to Clinical Practice

Evidence-based practice requires clinicians to integrate research findings with clinical expertise and patient preferences.

The reviewed literature indicates that routine saline instillation before suctioning offers little clinical benefit while increasing potential risks.

Healthcare organizations should consider:

• Updating suctioning protocols

• Educating nurses on current evidence

• Reducing unnecessary saline instillation

• Promoting guideline-based respiratory care

Applying evidence-based interventions can improve patient safety, reduce preventable infections, and enhance quality of care.

Evidence-based thinking also extends beyond respiratory care.

For example, a nursing practice question may ask:

In older adults with diabetes living in long-term care facilities, does scheduled subcutaneous insulin therapy compared with oral metformin improve blood glucose control while reducing complications?

Developing focused PICO questions allows clinicians to evaluate interventions using high-quality research and improve patient outcomes across multiple areas of nursing practice.

Evidence Summary

Evidence Snapshot

Question: Should normal saline be routinely instilled before endotracheal suctioning?

Short Answer: No.

Key Findings

• Routine saline instillation has not been shown to improve secretion clearance.

• Evidence associates saline instillation with higher ventilator-associated pneumonia rates.

• Saline may temporarily worsen oxygenation.

• Increased heart rate has been observed after saline-assisted suctioning.

• Current evidence supports suctioning without routine saline instillation unless clinically indicated.

Key Takeaways

• Endotracheal suctioning remains an essential intervention for mechanically ventilated patients.

• Routine normal saline instillation is no longer considered best practice in most critical care settings.

• Research demonstrates potential harms, including increased infection risk and impaired oxygenation.

• Evidence-based guidelines recommend individualized suctioning based on patient assessment rather than routine saline use.

• Ongoing education helps bridge the gap between historical practices and current evidence.

Frequently Asked Questions (FAQs)

Is normal saline instillation recommended before endotracheal suctioning?

No. Current evidence does not support routine saline instillation because it has not demonstrated significant clinical benefits and may increase the risk of complications such as ventilator-associated pneumonia.

Why was saline instillation traditionally used?

Historically, clinicians believed saline would loosen thick secretions and make suctioning easier. Research has not consistently supported these assumptions.

Can saline instillation increase ventilator-associated pneumonia?

Yes. Several studies suggest that saline may facilitate bacterial movement into the lower airways, increasing the likelihood of ventilator-associated pneumonia.

Does saline improve oxygen levels?

No. Research generally shows no meaningful improvement in oxygen saturation. Some studies report temporary decreases in oxygenation following saline instillation.

What is the preferred evidence-based approach?

Healthcare providers should suction only when clinically indicated, use sterile technique, optimize humidification, maintain adequate hydration, and avoid routine saline instillation unless specifically indicated.

References

Akgül, S., & Akyolcu, N. (2002). Effects of normal saline on endotracheal suctioning. Journal of Clinical Nursing, 11, 826–830.

Ayhan, H., Tastan, S., Iyigun, E., Akamca, Y., Arikan, E., & Sevim, Z. (2015). Normal saline instillation before endotracheal suctioning: What does the evidence say? What do nurses think? Journal of Critical Care, 30(4), 762–767. https://doi.org/10.1016/j.jcrc.2015.02.019

NSG 302 Week 4 Assignment PICO Question

Caparros, A. C. S. (2014). Mechanical ventilation and the role of saline instillation in suctioning adult intensive care unit patients. Dimensions of Critical Care Nursing, 33(4), 246–253. https://doi.org/10.1097/DCC.0000000000000049