COMPARISON OF AIRWAY MANAGEMENT PRACTICES BETWEEN REGISTERED NURSES AND RESPIRATORY CARE PRACTITIONERS. Pulmonary Critical Care. 1.

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1 Pulmonary Critical Care COMPARISON OF AIRWAY MANAGEMENT PRACTICES BETWEEN REGISTERED NURSES AND RESPIRATORY CARE PRACTITIONERS By Mary Lou Sole, RN, PhD, CCNS, and Melody Bennett, RN, MN, CCRN CNE 1. Hour Notice to CNE enrollees: A closed-book, multiple-choice examination following this article tests your under standing of the following objectives: 1. Describe current practices for airway management of intubated patients.. Determine how practices differ between registered nurses and respiratory care practitioners.. Evaluate how knowledge of current practices can help facilitate evidence-based practices to optimize care. To read this article and take the CNE test online, visit and click CNE Articles in This Issue. No CNE test fee for AACN members. 1 American Association of Critical-Care Nurses doi: Background Airway management, an essential component of care for patients receiving mechanical ventilation, is multifaceted and includes oral hygiene and suctioning, endotracheal suctioning, and care of endotracheal tubes. s and respiratory care personnel often share responsibilities for airway management. Knowledge of current practices can help facilitate evidence-based practices to optimize care of patients receiving mechanical ventilation. Objectives To describe current practices for airway management of intubated patients and determine if practices differ between registered nurses and respiratory care practitioners. Methods A descriptive, comparative design was used. Registered nurses and respiratory care practitioners who provided direct care to intubated patients receiving mechanical ventilation were recruited to complete an online survey of self-reported practices. Results A total of participants completed the survey. Most were experienced caregivers with a bachelor s degree and certification or registration in their field. Selected practices have improved, including increasing oxygen saturation before endotracheal suctioning, maintaining pressure of endotracheal tube cuffs, and providing oral hygiene and suctioning. The practices of registered nurses and respiratory care practitioners differed in many ways. The nurses assumed responsibility for oral antisepsis, whereas the respiratory care practitioners managed the endotracheal tube. The groups shared responsibility for oral and endotracheal suctioning. Knowledge of current guidelines for endotracheal suctioning was lacking. Conclusions Practices in airway management have improved, but opportunities exist to develop shared policies and procedures based on current evidence. (American Journal of Critical Care. 1;:191-) AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 1, Volume, No. 191

2 s (RNs) and respiratory care practitioners (RCPs) assume responsibility for airway management and related care for patients who require mechanical ventilation. These patients have an artificial airway, either an endotracheal tube (ETT) or a tracheostomy. Airway management for such patients is multifaceted and includes oral care, oral suctioning, ETT suctioning, management of ETT cuff pressure, and management of specialized ETTs (eg, subglottic suctioning). Airway management practices are not always consistent with current evidence. Airway management is important because the presence of an artificial airway increases the risk for ventilator-associated conditions, including infections such as ventilator-associated pneumonia (VAP). Both ventilator-associated conditions and VAP double the mortality risk and result in prolonged ventilation and lengths of stay in the intensive care unit (ICU) and hospital. 1- Each case of VAP is also associated with up to $ in increased costs. - The pathophysiology of VAP is complex. Endotracheal intubation interferes with mucociliary clearance and the normal cough effort, resulting in retained tracheobronchial secretions. 9- By maintaining the normally closed glottis in an open position, the ETT also provides a direct opening for microaspiration of secretions. Secretions in the oropharynx become colonized with pathogens from dental plaque, equipment, and changes in the oral flora. Gastric contents may also be present in oropharyngeal secretions because of reflux. Microaspiration of these secretions around the ETT cuff contributes to development of infection. 1,1 Airway management must be comprehensive to address the many issues associated with the artificial airway: ETT suctioning to remove secretions, management of ETT cuff pressure to prevent microaspiration, and endotracheal suctioning to remove secretions. Both RNs and RCPs regularly participate in airway management activities. Previous studies 1-1 have About the Authors Mary Lou Sole is an Orlando Health distinguished professor and Pegasus professor, University of Central Florida, College of Nursing, and a research scientist at Orlando Health, Orlando, Florida. Melody Bennett is an adjunct faculty member, University of Central Florida, College of Nursing, and a staff nurse at Orlando Health. Corresponding author: Mary Lou Sole, RN, PhD, CCNS, CNL, FAAN, FCCM, Orlando Health Distinguished Professor and Pegasus Professor, University of Central Florida, College of Nursing, Research Parkway, Orlando, FL -1 ( mary.sole@ucf.edu). indicated that practices are not consistently done according to current evidence and that practices differ between RNs and RCPs. Knowledge of current practices is important to identify opportunities for improving airway management and associated outcomes of patients treated with mechanical ventilation. The aims of this study were to describe current practices for airway management of patients receiving mechanical ventilation and compare practices between RNs and RCPs. Methods A descriptive, comparative design and a websitebased instrument were used to survey RNs and RCPs who worked in bedside practice roles and regularly cared for adult patients receiving mechanical ventilation. Staff members (approximately ) employed at ICUs in hospitals in a large multihospital system in the southeastern United States were recruited to participate in the study. The type of ICU varied and included medical-surgical, neurological, cardiac, and burn-trauma patients; the majority of patients on the units received mechanical ventilation. RNs and RCPs who provided direct care less than % of the time or cared primarily for neonates or children were excluded. A sample size of 1 RNs and RCPs was targeted to compare the proportions of the groups to achieve an odds ratio of., a proportion of., an error probability of., and a power of %. Procedures RNs and RCPs were recruited for participation in late by their respective managers, who sent out a standardized electronic mail message provided by one of the investigators (M.L.S.). The message included a hyperlink for the online survey. Recruitment flyers were distributed to all nursing units and respiratory care departments. An electronic reminder message along with the hyperlink was sent by the appropriate manager to staff members 1 week after the initial request for participation. The survey was available for weeks and took approximately 1 minutes to complete. No incentives were provided. 19 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 1, Volume, No.

3 The study was approved by the appropriate institutional review board. When prospective participants accessed the website, they were screened for eligibility, and a cover letter explained the study. Completion of the survey constituted consent for participation. Participants were issued a unique identification number via the survey software, and no personal identifying information was obtained. Instrument The survey of the study of suctioning techniques and airway management practices developed by Sole and colleagues 1,1 was modified according to current evidence-based practices reported in research articles, the procedure manual of the American Association of Critical-Care Nurses, and the clinical practice guidelines of the American Association of Respiratory Care (AARC). Questions related to indicators for ETT suctioning and responsibilities for practices were added. The survey was created in an online format by using the SurveyMonkey program and included items with multiple-response and open-ended questions. Content validity and testretest reliability of the tool had been established previously. 1 Data Analysis Data were analyzed by using SPSS 19. software (IBM SPSS). Demographic data were summarized by using frequencies and descriptive statistics. Practices of RNs and RCPs were described with frequencies and proportions, and were compared by using the crosstabs function. An a priori significance level of P <. was used. Data from open-ended questions were summarized. Results The survey was accessed by 9 individuals. Of these, caregivers completed the survey, yielding a % response rate (/). Among the respondents, % were RNs and % were RCPs; their median experience was years. A total of % had a bachelor s degree or higher; 9% of the RNs were certified in a specialty (CCRN) and 9% of the RCPs were registered therapists. Suctioning Practices In the first part of the survey, respondents indicated the frequency of selected airway management practices by using a -point, Likert-type scale: always, most of the time (7%), about half of the time, rarely (% of the time), and never. For analysis, data were collapsed into categories: always or most of time, half of the time, and rarely or never. Findings related to ETT and oral suctioning practices are summarized in Table 1. Closed ETT suctioning is done nearly all of the time, and patients are regularly given extra oxygen to increase oxygen saturation (hyperoxygenation) before the procedure. Gloves are consistently worn for both ETT suctioning and oral care. Suctioning the oropharynx after ETT suctioning and before turning was done most of the time by less than half of the respondents, whereas suctioning the oropharynx before repositioning the ETT was reported more frequently. Compared with RNs, more RCPs reported using hyperinflation (delivery of a tidal volume greater than normal) before ETT suctioning (P =.), using physiological saline during ETT suctioning (P <.1), rinsing the closed suction catheter after use (P=.), and suctioning the mouth before repositioning the ETT (P=.1). Oral Care and ETT Cuff Management In the second part of the survey, respondents indicated the frequency of selected practices for oral care and suctioning and management of the ETT cuff pressure (Table ). Practices differed significantly between RNs and RCPs. Compared with RCPs, RNs assumed greater responsibility for oral suctioning, brushing teeth, and completing oral care with a swab (P <.1). RCPs assumed primary control for monitoring and adjusting ETT cuff pressure (P <.1). A total of 9% of the RNs reported doing oral suctioning at least every hours, and 7% reported cleansing with a swab at least every hours. Tooth brushing was done at least every 1 hours by 9% of RNs. Two longer oropharyngeal suction catheters are included in the oral care kit available at the facilities; 79% of RNs reported using these devices at least every 1 hours, but 1% rarely or never used them. ETT cuff pressure was measured and adjusted at least every 1 hours by 1% of the RCPs, who reported a minimum cuff pressure of at least cm H O. Cues for ETT Suctioning In an open-ended question early in the survey, respondents were asked to list clinical assessments that they use to determine if a patient needs ETT suctioning. A later question provided a checklist of potential cues for suctioning. Respondents were not able to view their earlier responses. Table compares assessments identified in the responses to the questions. Cues are categorized as those recommended Closed suctioning is done almost all the time. Respiratory care providers reported more use of normal saline with suctioning. AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 1, Volume, No. 19

4 Table 1 Comparison of frequency of oral and endotracheal suction practices a Percentage of respondents Practices Always or most of time About half of time Rarely or never P Hyperoxygenate before suctioning Hyperoxygenate/inflate with manual resuscitation bag before suctioning Hyperinflate via ventilator before suctioning 1. Use traditional open suctioning Instill physiological saline with suctioning 9 <.1 Rinse closed suction device after use 1 1. Suction oral cavity after suctioning endotracheal tube Suction oropharynx before repositioning endotracheal tube Suction oropharynx before turning and repositioning patient Wear gloves for closed suctioning of endotracheal tube Wear gloves for oral care 9 1. Wear gloves for oral suctioning 9 1. a Percentages may not total 1% because of rounding. in recent AARC guidelines and other responses. Table compares the checklist responses between RNs and RCPs on the AARC-recommended practices. In responses to the open-ended question, the most frequent were increase in peak airway pressure (or high-pressure alarm), auscultation of rhonchi over lung fields, and (tied) coughing and decrease in oxygen saturation. More respondents selected cues from the checklist, and the findings were ranked differently. The order was as follows: visible secretions, coughing, decrease in oxygen saturation, suspected aspiration, and increase in peak airway pressure (or high-pressure alarm). Additional assessments (not included in guidelines) were listed in the responses to the open-ended question. More RCPs (%) than RNs (%) noted that a sawtooth pattern on the flow pattern on the ventilator was an indicator for ETT suctioning (P =.). Responsibilities for Airway Management Respondents were asked which group is responsible for components of airway management (Table ). 19 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 1, Volume, No.

5 Table Frequency of oral care and management of endotracheal tube cuff pressure Percentage of respondents Practice Frequency Nurses Respiratory care practitioners P Oral suctioning Done by 9% of nurses at least every hours Every hours Every hours Every hours Only as needed Every hours Every hours Every hours Every 1 hours Only as needed Rarely or never Every hours Every hours Every hours Every 1 hours Only as needed Rarely or never Every hours Every hours Every 1 hours Rarely/never use Every hours Every hours Every 1 hours Do not know 1 cm H O cm H O cm H O Varies; minimal leak Do not know <.1 Tooth brushing Done by 9% of nurses at least every 1 hours <.1 Oral swabbing Done by 7% of nurses at least every hours <.1 Oral suctioning with deep suctioning catheter Done by 79% of nurses at least every 1 hours <.1 Frequency of measurements of endotracheal tube cuff pressure Done by 1% of respiratory care practitioners at least every 1 hours.1 Minimum endotracheal tube cuff pressure Maintained at cm H O or higher by 1% of respiratory care practitioners <.1 They reported that RNs are responsible for oral care, whereas RCPs are responsible for managing the ETT, including the specialized subglottic suctioning tube, and for changing the oral airway. RNs and RCPs share responsibility for oral and ETT suctioning. Factors Influencing Practice The last question asked respondents to indicate factors that influence their airway management practices. Items selected by more than % of participants were policies and procedures (%), continuing education (%), basic education preparation (1%), and preceptors and coworkers (%). Published research (%), journals and textbooks (1%), and online resources (%) were not commonly used. Open-Ended Comments A total of respondents provided additional comments. Four respondents identified the need for greater collaboration and communication between RNs and RCPs and the need for both groups to follow evidence-based practices. In contrast, one respondent wrote that collaboration was better than in previous employment. Another respondent commented on the need for being updated on new practices. Two respondents commented on equipment. Discussion Suctioning Practices As in previous studies, 1 closed ETT suctioning is a common practice, and traditional open suctioning is rarely used. Studies have shown no differences in outcomes between open and closed suctioning methods. Giving extra oxygen for to seconds before ETT suctioning is a recommended practice, yet routine use of the procedure was not reported by 1% of the respondents. Although RCPs reported giving extra oxygen via the ventilator more often than RNs did, the difference between the groups was not significant. This finding differs from that of Kjonegaard et al, 1 who found that RNs gave extra oxygen to patients more frequently than RCPs did. AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 1, Volume, No. 19

6 Table Cues for endotracheal suctioning: checklist versus open-ended responses Item Percentage of respondents Open-ended American Association of Respiratory Care recommendations Sawtooth pattern on flow pattern on ventilator Auscultation of coarse crackles over trachea Increase in peak airway pressure (or pressure alarm) Decrease in oxygen saturation Visible secretions in artificial airway Sudden onset of respiratory distress Suspected aspiration Patient unable to generate adequate cough Other items Coughing Auscultation of rhonchi over lung fields Increase in respiratory rate Patient s request for suctioning Turbulence or gurgling in endotracheal tube Patient agitated Increased work of breathing Change in heart rate Low or change in exhaled tidal volume Increase in end-tidal carbon dioxide Assessment of neurological status After turning Every--hour policy Change in level of consciousness Table Comparison of suctioning cues identified on checklist between nurses and respiratory care practitioners American Association of Respiratory Care recommendations Sawtooth pattern on flow pattern on ventilator Auscultation of coarse crackles over trachea Increase in peak airway pressure (or pressure alarm) Decrease in oxygen saturation Visible secretions in artificial airway Sudden onset of respiratory distress Suspected aspiration of gastric or airway secretions Percentage of respondents Nurses Respiratory care practitioners Checklist RCPs reported using a manual resuscitation bag to increase oxygen saturation more often than RNs did (P =.1). However, AARC guidelines do not recommend this practice because of potential inconsistent delivery of oxygen P..79 > Like RCPs in previous studies, 1-1 RCPs in our study reported using hyperinflation to increase oxygen saturation before suctioning, instilling physiological saline as part of the suctioning procedure, and rinsing the closed suction device after use. Using hyperinflation to increase oxygen saturation is not included in the AARC guidelines and is not supported by systematic reviews. Hyperinflation may be used as a lung-recruitment maneuver and may decrease airway resistance in VAP. Instillation of physiological saline during ETT suctioning has not been recommended for many years, yet the practice continues. -7 Instillation of physiological saline may enhance removal of secretions by stimulating a cough reflex, and a recent study indicated a decrease in VAP when physiological saline was used. However, the AARC guidelines note that use of physiological saline most likely is not beneficial and that routine use of it should be avoided. Use of gloves for suctioning and oral care has increased to nearly 1%. This practice helps reduce cross-contamination and also protects staff members. Suctioning the oropharynx before repositioning the ETT may reduce the risk of microaspiration of secretions during the procedure. More than 9% of RCPs in our study, who assume responsibility for repositioning the ETT, stated that they regularly suction the oropharynx before repositioning the ETT. Their responses were significantly higher than those reported by the RNs. Similar findings have been reported, 1 but Kjonegaard et al 1 found no differences between RNs and RCPs. Suctioning the oropharynx before repositioning or turning the patient may also reduce the risk for microaspiration and VAP, 9, but this practice was not common in our study. Although oral suctioning before repositioning was reported more frequently by RCPs than by RNs, RNs are the caregivers who generally assume responsibility for coordinating repositioning of a patient. Oral Care and ETT Cuff Management Oral hygiene is an important part of VAP prevention.,1 In our study, RNs assumed greater responsibility than did RCPs for oral care interventions; approximately 9% of RNs cleansed and suctioned the mouth every hours and brushed the patient s teeth every 1 hours. Frequency of cleansing with a swab, brushing teeth, and oral suctioning was reported more often in our study than in earlier surveys. 1-1 The importance of oral care for VAP prevention has been emphasized for many years throughout the hospital system. The availability of oral care kits at the bedside facilitates oral hygiene. 19 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 1, Volume, No.

7 Maintaining a pressure in the ETT cuff greater than cm H O is a recommended practice to prevent microaspiration of secretions around the ETT cuff and decrease the risk for VAP., All of the RCPs in our study reported values in this range as minimum pressure and reported assessing the cuff pressure either every or every 1 hours, an improvement from earlier studies. 1,1 In contrast, one-third of RNs in our study stated that they did not know how frequently cuff pressure was monitored, and nearly half did not know the minimal cuff pressure. Nurses perception that RCPs assume responsibility for ETTs is a likely rationale for the nurses lack of knowledge about ETT cuff pressure. Cues for ETT Suctioning Because the AARC suctioning guidelines are fairly new (1), respondents were asked to list assessments they use to identify the need for suctioning. Later they selected items from a checklist of assessments commonly observed. We think that responses to the open-ended questions are a more accurate reflection of practices than are the responses to the list. The guidelines specify that a sawtooth pattern on the ventilator flow-volume loop display, and coarse crackles over the trachea are the strongest indicators for ETT suctioning., For the open-ended question, only 1% of our respondents listed the sawtooth pattern, and no one listed crackles over the trachea. Auscultation of rhonchi over the lung fields was a common response to the open-ended question. However, this assessment is not listed in the guidelines., The AACN Procedure Manual for Critical Care includes of the 7 assessments recommended in the AARC guidelines: visible secretions, ineffective cough, high peak airway pressure, decreased oxygen saturation, and respiratory distress. The most sensitive indicators sawtooth waveform and crackles over the trachea are not listed in the manual. Both RNs and RCPs need updates on assessment cues for ETT suctioning. Responsibilities for Airway Management Although airway management includes many components, respondents were clear about responsibilities. RNs are expected to clean the mouth, RCPs are expected to manage the ETT, and both share responsibility for oral and ETT suctioning. Shared responsibility may result in both duplication and omission of important aspects of airway management. For example, we observed an RCP assess the ETT cuff pressure and suction a patient s ETT at the beginning of a shift. Thirty minutes later, Table Percentages of responses about responsibilities of nurses and respiratory care practitioners for various airway management practices a Practice Endotracheal tube suctioning Oral suctioning Oral care Change oral airway Subglottic suctioning, endotracheal tube management Repositioning endotracheal tube Endotracheal tube cuff management Nurses 7 a Percentages may not total 1% because of rounding. we observed an RN suctioning the ETT despite no obvious physiological cues. When asked, the RN responded that it was necessary to suction the ETT to assess the patient s neurological response. If responsibilities are shared, better guidance for methods to ensure that patients receive adequate care is needed. The American Association of Critical- Care Nurses has established strong liaisons with medical professional organizations. A focused partnership with the AARC should be targeted to identify strategies for optimizing airway management, especially because many responsibilities are shared between RNs and RCPs. Articles and website-based continuing education programs available simultaneously to both groups may be valuable resources. At the hospital and unit levels, open dialogue to discuss and outline roles and responsibilities is another step for ensuring continuity and quality care. Shared education related to airway management is also important to ensure that both RNs and RCPs are aware of current, evidence-based practices. Influences on Practices Similar to the respondents in an earlier study, 1 our respondents reported that their practices were influenced by policies, basic education preparation, and preceptors and coworkers. More respondents (nearly two-thirds) in our study reported continuing education programs as a source of information. Responsibility Respiratory care practitioners Shared Both registered nurses and respiratory therapists need updates on cues for endotracheal tube suctioning. AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 1, Volume, No. 197

8 Print and online resources, including published research, were infrequently relied upon to update knowledge and skills. Therefore, educators and clinical nurse specialists who develop educational programs for nurses and respiratory care practitioners and update policies and procedures should be knowledgeable about current research and clinical practice guidelines. Multimodal strategies for education that incorporate expectations for evidencebased practice are needed. Limitations We examined the practices of experienced RNs and RCPs from a single hospital system. Although many of our findings are similar to those of a large multisite study, 1 our results may not be representative of staff members who did not respond or of other institutions. Most of our respondents had at least a bachelor s degree and were credentialed (eg, CCRN for nurses or registration for respiratory care practitioners). Their practices may differ from those of caregivers who do not have these credentials. Another limitation is that we used self-reporting of practices rather than observation or documentation. The number of respondents was less than our target sample size, but the study had adequate power to detect significant differences between RNs and RCPs for many practices. The short time the survey was available may have contributed to the low rate of return; however, duration was predetermined by the clinical site, and follow-up requests for participation were disseminated. The lower enrollment may also have been due to a lack of incentives for participation. We had planned to allow participants to be included in an optional drawing for a textbook, but the institutional review board did not give approval for a drawing. Last, survey fatigue caused by multiple online surveys from competing studies may have contributed to the low response rate. Conclusions Selected practices for airway management have improved since. These include increasing oxygen saturation via the ventilator before suctioning; reduced use of physiological saline during ETT suctioning; maintenance of ETT cuff pressure at cm H O or higher; gloving for oral and ETT suctioning; and regular and more frequent oral care, including oral suctioning, swabbing, and tooth brushing. Practices for assessing patients need for ETT suctioning need to be updated; most respondents to the survey were not aware of the updated AARC guidelines. Practices often differed between RNs and RCPs even though they share responsibilities for airway management, yet each group has defined expectations as to responsibilities. Collaboration between RNs and RCPs is important to outline and test best practices for meeting patients needs for airway management. Last, not all practices reflect knowledge and implementation of evidence-based strategies. Opportunities exist to develop joint nursing and respiratory care policies, procedures, and education to promote evidence-based practice for airway management. FINANCIAL DISCLOSURES None reported. eletters Now that you ve read the article, create or contribute to an online discussion on this topic. Visit and click Responses in the second column of either the full-text or PDF view of the article. REFERENCES 1. Klompas M, Magill S, Robicsek A, et al; CDC Prevention Epicenters Program. Objective surveillance definitions for ventilator-associated pneumonia. Crit Care Med. 1;(1): Niederman MS, Craven DE. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. ;171:-1.. Rello J, Ollendorf DA, Oster G, et al; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. ;1():-.. Scott RD II. 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