title: A Bedside Decision Tree for Use of Saline With Endotracheal Tube Suctioning in Children.
abstract: 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.
authors.affiliation: Erin 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.
authors.forename: Erin B
authors.initials: EB
authors.lastname: Owen
authors.affiliation: Erin 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.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Woods
authors.affiliation: Erin 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.
authors.forename: Justine A
authors.initials: JA
authors.lastname: O'Flynn
authors.affiliation: Erin 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.
authors.forename: Megan C
authors.initials: MC
authors.lastname: Boone
authors.affiliation: Erin 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.
authors.forename: Aaron W
authors.initials: AW
authors.lastname: Calhoun
authors.affiliation: Erin 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.
authors.forename: Vicki L
authors.initials: VL
authors.lastname: Montgomery
mesh_terms: D002648:Child; D002675:Child, Preschool; D003663:Decision Trees; D005260:Female; D006801:Humans; D007223:Infant; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods*; D008297:Male; D019095:Point-of-Care Systems; D011446:Prospective Studies; D012965:Sodium Chloride / Q000008:administration & dosage*; D013396:Suction / Q000379:methods*
chemical_list: D012965:Sodium Chloride