From the Guidelines
When managing secretions in patients requiring airway support, I recommend implementing a scheduled secretion suctioning protocol rather than relying solely on calling trials.
Suctioning Frequency
The frequency of suctioning should be based on individual patient characteristics, including age, muscular and neurological status, activity level, ability to generate an effective cough, viscosity and quantity of mucus, and maturity of the stoma 1.
- Suctioning should be performed every 2-4 hours for intubated patients, with additional suctioning as needed based on clinical assessment.
- Clinical indicators for additional suctioning include audible or visible secretions, increased peak airway pressures, decreased oxygen saturation, patient restlessness, or changes in breath sounds.
Suctioning Protocol
The protocol should include pre-oxygenation with 100% oxygen for 30-60 seconds before suctioning, limiting suction duration to 10-15 seconds, and using appropriate catheter size (half the internal diameter of the endotracheal tube) 2, 3.
- Negative pressure should be maintained between 80-120 mmHg for adults.
Benefits of Scheduled Suctioning
This approach is superior to calling trials (where suctioning is performed only when respiratory distress is observed) because it prevents secretion accumulation that can lead to airway obstruction, ventilator-associated pneumonia, and atelectasis 2.
- Regular suctioning maintains airway patency, improves ventilation, and reduces infection risk.
Individualization
However, individualization is important - patients with excessive secretions (such as those with pneumonia, COPD exacerbations, or bronchiectasis) may require more frequent suctioning, while those with minimal secretions might need less 1.
- The use of closed endotracheal suction systems that are changed for each new patient and as clinically indicated is recommended 2, 3.
- Subglottic secretion drainage may be associated with decreased incidence of VAP, especially early-onset VAP, and should be considered by clinicians 2, 3.
From the FDA Drug Label
WARNINGS After proper administration of acetylcysteine, an increased volume of liquified bronchial secretions may occur. When cough is inadequate, the open airway must be maintained by mechanical suction if necessary. The relationship between secretion suction frequency and the need for calling trials is not directly addressed in the provided drug label.
- The label discusses the management of increased bronchial secretions, but does not provide information on calling trials.
- It is not possible to draw a conclusion about the relationship between secretion suction frequency and calling trials based on the provided information 4.
From the Research
Secretion Suction Frequency and Need for Calling Trials
- The relationship between secretion suction frequency and the need for calling trials is not directly addressed in the provided studies 5, 6, 7, 8, 9.
- However, the studies discuss the importance of secretion management in mechanically ventilated patients, including the use of suctioning and other techniques to remove secretions 5, 8.
- One study found that the use of a secretion detector device can reduce unnecessary suctionings and anticipate clinical deterioration due to secretion retention 5.
- Another study compared the incidence of ventilator-associated pneumonia in patients using a subglottic secretion drainage device versus a conventional endotracheal tube, but found no significant difference between the two groups 6.
- A systematic review of randomized trials comparing continuous and intermittent subglottic secretion drainage found no apparent differences between the two methods for preventing ventilator-associated pneumonia 7.
- The studies also discuss various techniques for secretion management, including humidification, mobilization, and airway suctioning, but do not specifically address the relationship between secretion suction frequency and the need for calling trials 8, 9.
Techniques for Secretion Management
- The studies discuss various techniques for secretion management, including: + Humidification: a standard of care for secretion management, with both active and passive humidification options available 8. + Airway suctioning: the most important secretion removal technique, with open-circuit and closed-circuit suctioning having similar efficacy 8. + Intermittent techniques: such as percussion, postural drainage, manual hyperinflation, and insufflation-exsufflation, which may be used to simulate a cough or loosen secretions 8. + Non-invasive ventilation (NIV): a mainstay of management for chronic respiratory failure, with various techniques available for secretion management in conjunction with NIV use 9.