To Assess the Effectiveness of Hypertonic Saline Nebulized Suctioning On Airway Clearance Among Patients On Mechanical Ventilator In Selected Hospitals
Mr. Dattatrya Pitambar Sutar
Assistant Professor, Vijaysinh Mohite Patil College of Nursing and Medical Research Institute, Akluj.
*Corresponding Author E-mail: ds271094@gmail.com
ABSTRACT:
OBJECTIVES- 1) To assess the airway clearance of patients on mechanical ventilator in experimental and control group in selected hospitals. 2) To assess the effectiveness of hypertonic saline nebulized suctioning on airway clearance of patients on mechanical ventilator in experimental group in selected hospitals. HYPOTHESIS: H0 – There will be no significant difference in the effectiveness of hypertonic saline nebulized suctioning on airway clearance of patients on mechanical ventilator in experimental group in selected hospitals. H1 - There will be a significant difference in the effectiveness of hypertonic saline nebulized suctioning on airway clearance of patients on mechanical ventilator in experimental group in selected hospitals. METHODOLOGY: The research approach adopted in this study is Quantitative experimental approach. Quasi experimental two groups, pre-test & post-test design selected for this study. The sample size of the present study were 40 mechanical ventilated patient in selected hospitals. In this study non-probability purposive sampling was adopted to select the subjects. RESULT: The above table shows Age wise distribution in control group maximum subjects 9(45%) belongs to above 51 yrs and minimum 3(15%) were in between 31-40 yrs. In experimental group maximum subject 10(50%) of them were above 51 yrs and minimum 3(15%) were in age between 31-40 yrs. Gender wise distribution in control group maximum subjects 11(55%) were male and minimum 9 subject (45%) were female. In control group maximum subject 14(70%) were male and 6(30%) were female. Duration of ventilator wise distribution in control group maximum subjects 15(75%) were between 2-5 days and minimum 5(25%) between 6-9 days. In experimental group maximum subject 10(50%) between 2-5 days and minimum 1(5%) were between 10-13 days. Habit wise distribution in control group maximum subjects 11(55%) of them had no habit and minimum 3(15%) were having alcohol consumption habit. In experimental group maximum subject 9(45%) had no habit and minimum 1(5%) had tobacco consumption habit. Occupation wise distribution in control group maximum subject 9(45%) were labourers and minimum 2(10%) were cotton industry workers. In experimental maximum subject 11(55%) were labourers and minimum 1(5%) were cotton industry workers. Area of living wise distribution in control group maximum subject 13(65%) were living in rural area and minimum 7(35%) in urban area. In experimental group maximum subject 13(65%) were living in urban area and minimum 7(35%) were living in rural area. The pre test mean and SD of heart rate in control group is 90.3 and 5.55 and the pre test mean and SD of heart rate in experimental group is 100.40 and 16.31. The pre test mean and SD of Respiration in control group is 22.65 and 1.79 and the pre test mean and SD of Respiration in experimental group is 24.35 and 2.41. The pre test mean and SD of Spo2 in control group is 94.9 and 2.80 and the pre test mean and SD of Spo2 in experimental group is 96.30 and 2.13 respectively. 1. Repeated measures ANOVA test was carried out. The finding shows that in control group pre test mean of heart rate was 90.3 and S.D was 5.55. The post test 1 mean was 88.00 and SD 6.61. The post test 2 mean was 89.8 and SD was 7.07. The post test 3 mean was 91.5 and SD 7.99. The test statistic value of ANOVA was 1.71. The p value was 0.17. The finding shows that in control group pre test mean of Respiration was 22.65 and S.D was 1.79. The post test 1 mean was 22.80 and SD 1.51. The post test 2 mean was 23.30 and SD was 1.87. The post test 3 mean was 23.30 and SD 0.98. The test statistics value of ANOVA was 1.73. The p value was 0.17. The finding shows that in control group pre test mean of Spo2 was 94.9 and S.D was 2.80. The post test 1 mean was 94.95 and SD 2.88. The post test 2 mean was 94.05 and SD was 2.99. The post test 3 mean was 95.25 and SD 2.31. The test statistics value of ANOVA was 0.72. The p value was 0.54. Above study findings revealed that there is no significant difference in the effectiveness of hypertonic saline nebulized suctioning on airway clearance in control group. 2. Repeated measures ANOVA test was carried. The finding shows that in experimental group pre test mean of heart rate was 100.40 and S.D was 16.31. The post test 1 mean was 94.95 and SD 13.72. The post test 2 mean was 88.30 and SD was 7.69. The post test 3 mean was 86.30 and SD 8.29. The test statistics value of ANOVA was 20.57. The p value was <0.0001. The finding shows that in experimental group pre test mean of Respiration was 24.35 and S.D was 2.41. The post test 1 mean was 23.20 and SD 1.51. The post test 2 mean was 21.50 and SD was 1.57. The post test 3 mean was 21.10 and SD 1.37. The test statistic value of ANOVA was 31.28. The p value was <0.0001. The finding shows that in experimental group pre test mean of Spo2 was 96.30 and S.D was 2.13. The post test 1 mean was 97.60 and SD 1.70. The post test 2 mean was 98.90 and SD was 1.21. The post test 3 mean was 99.75 and SD 0.65. The test statistics value of ANOVA was 29.8. The p value was <0.0001. CONCLUSION: The above interventional study was a good learning experience for the investigator. The result of this study showed that hypertonic saline nebulized suctioning was effective on airway clearance among mechanical ventilated patients thus the null hypothesis (H0) was rejected and (H1) was accepted. Hypertonic saline nebulized suctioning used in clinical setting for patients in selected hospitals was effective.
KEYWORDS: Hypertonic Saline, Nebulized Suctioning.
INTRODUCTION:
Hypertonic saline (HS) is any solution of sodium chloride (NaCl) in water with a concentration of NaCl higher than that found in physiological saline (0.9%). A solution of 3% and 5% sodium chloride and 0.45% sodium chloride is an example of a hypertonic solution. This solution enhances airway clearance by increasing hydration of the airway surface layer and mucus, making it easier to cough.1
Ventilator associated pneumonia (VAP) is estimated to occur in 9-27 % of all mechanically ventilated patients, with the highest risk being early in the course of hospitalization. It is the second most common nosocomial infection in the intensive care unit (ICU) and the most common in mechanically ventilated patients. Ventilator associated pneumonia rates range from 1.2 to 8.5 per 1,000 ventilator days. Risk for VAP is greatest during the first 5 days of mechanical ventilation (3 %) with the mean duration between intubation and development of VAP being 3.3 days. This risk declines to 2 %/day between days 5 to 10 of ventilation, and 1% day thereafter. Earlier studies placed the attributable mortality for VAP at between 33-50 %, but this rate is variable and relies heavily on the underlying medical illness.2
Airway edema and mucus plugging are the predominant pathological features in patient on ventilator. Commonly used therapies such as bronchodilators, steroids, antibiotics, surfactant and corticosteroids have not been more effective than placebo on clinically important outcomes, therefore current practice guidelines do not recommend routine use of these drugs. Three percent hypertonic saline has been effective in hospitalized patients with bronchiolitis, with a Cochrane review showing a decreased length of stay of 0.94 days, and statistically significant decreases in respiratory scores.3
REVIEW OF LITERATURE:
1. Double-blind trial using by investigator to find out effects of Buffered Saline Solution on nasal mucociliary clearance and nasal airway patency. The investigator find out buffered hypertonic saline and buffered normal saline both improved saccharine clearance times (P < 0.0001 for buffered hypertonic and P = 0.002 for buffered normal saline). Buffered hypertonic saline improved saccharine clearance times more than buffered normal saline (39.6% vs. 24.1%, P = 0.007). Neither buffered hypertonic nor buffered normal saline significantly affected nasal airway patency. So investigator concluded that both buffered hypertonic and buffered normal saline nasal spray significantly improved saccharine clearance times without affecting nasal airway patency and should therefore be beneficial in conditions such as rhinitis and sinusitis, which are associated with disruption of mucociliary clearance.4
2. A randomized crossover trial with concealed allocation was carried out by investigator in Sydney medical school, The university of Sydney, Australia to find out adults with cystic fibrosis prefer hypertonic saline before or during airway clearance techniques: a randomized crossover trial. Investigator choose 50 adults with cystic fibrosis and stable lung function at the end of a hospital admission. Participants performed 3 sessions of airway clearance techniques per day for 3 days. On each day, participants were randomized to inhale hypertonic saline either before, during, or after the airway clearance techniques. Participants readmitted within one year repeated the 3-day study. The result shows that Satisfaction was rated significantly worse on a 100 mm scale when hypertonic saline was inhaled after the airway clearance techniques: mean differences 20 mm (95% CI 12 to 29) compared to before the airway clearance techniques and 15 mm (95% CI 6 to 24) compared to during the techniques.5
3. A randomized controlled trials and quasi-randomized controlled trials using by investigator for using nebulized hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulized 0.9% saline, or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department trials was rate of hospitalization. Investigator included a total of 28 trials involving 4195 infants with acute bronchiolitis, of whom 2222 infants received hypertonic saline. Result shows that hospitalized infants treated with nebulized hypertonic saline had a statistically significant shorter mean length of hospital stay compared to those treated with nebulized 0.9% saline.6
4. A quasi-experimental study was conducted on effectiveness of 3% hypertonic saline nebulization in acute bronchiolitis among Indian children This prospective study was conducted on one hundred children admitted in the Pediatrics Department of GGS Medical College and Hospital, Faridkot with the diagnosis of acute bronchiolitis between the months of October to February for 2 consecutive years, the typical bronchiolitis season in this part of the country. A written and informed consent was taken from the parents on a prescribed format Participants were divided into three groups, that is, 3% HS group, 0.9% normal saline group and 0.9% saline with salbutamol group. Four doses at interval of 6 h were given daily until discharge. The result show that mean ages of the patients in three groups were 6.03, 5.69 and 5.48 respectively. The 3rd day CS scores for all the groups were 1.0, 1.9 and 3.3 respectively. The average length of hospital stay was 3.4, 3.7 and 4.9 days respectively. The present study concludes that 3% HS nebulization is an effective and safe treatment for nonasthmatic, moderately ill patients of acute bronchiolitis.7
MATERIAL AND METHOD:
The research approach adopted in this study is Quantitative experimental approach. Quasi experimental two groups, pre-test & post-test design selected for this study. The sample size of the present study were 40 mechanical ventilated patient in selected hospitals. In this study non-probability purposive sampling was adopted to select the subjects.
RESULT:
The data was analyzed by using inferential and descriptive statistics on the basis of objectives.
Section I
Table 1: Frequency and Percentage distribution of demographic data of patients (n=40)
|
Sr. no. |
Demographic profile |
Control group |
Experimental group |
||
|
Frequency |
Percentage |
Frequency |
Percentage |
||
|
1 |
Age in years 20-30 31-40 41-50 Above 51 |
5 3 3 9 |
25% 15% 15% 45% |
0 3 7 10 |
0% 15% 35% 50% |
|
2 |
Gender Male female |
11 9 |
55% 45% |
14 6 |
70% 30% |
|
3 |
Duration of ventilator 2-5 days 6-9 days 10-13 days Above 14 days |
15 5 0 0 |
75% 25% 0% 0% |
10 9 1 0 |
50% 45% 5% 0% |
|
4 |
Habit Smoking Alcohol Tobacco chewing No habit |
0 3 6 11 |
0% 15% 30% 55% |
1 4 6 9 |
5% 20% 30% 45% |
|
5 |
Occupation Cotton Industry Industrial worker Farmer Labour |
2 2 7 9 |
10% 10% 35% 45% |
1 2 6 11 |
5% 10% 30% 55% |
|
6 |
Area of living Urban area Rural area |
7 13 |
35% 65% |
13 7 |
65% 35% |
Age wise distribution in control group maximum subjects 9(45%) belongs to above 51 yrs and minimum 3(15%) were in between 31-40 yrs. In experimental group maximum subject 10(50%) of them were above 51 yrs and minimum 3(15%) were in age between 31-40 yrs. Gender wise distribution in control group maximum subjects 11(55%) were male and minimum 9 subject (45%) were female. In control group maximum subject 14(70%) were male and 6(30%) were female. Duration of ventilator wise distribution in control group maximum subjects 15(75%) were between 2-5 days and minimum 5(25%) between 6-9 days. In experimental group maximum subject 10(50%) between 2-5 days and minimum 1(5%) were between 10-13 days. Habit wise distribution in control group maximum subjects 11(55%) of them had no habit and minimum 3(15%) were having alcohol consumption habit. In experimental group maximum subject 9(45%) had no habit and minimum 1(5%) had tobacco consumption habit. Occupation wise distribution in control group maximum subject 9(45%) were labourers and minimum 2(10%) were cotton industry workers. In experimental maximum subject 11(55%) were labourers and minimum 1(5%) were cotton industry workers. Area of living wise distribution in control group maximum subject 13(65%) were living in rural area and minimum 7(35%) in urban area. In experimental group maximum subject 13(65%) were living in urban area and minimum 7(35%) were living in rural area.
Graph 1: Bar diagram representing distribution of patients in relation to Age
Graph 2: Pie diagram representing distribution of patients in relation to Gender
Graph 3: Cluster pyramid representing distribution of patients according to Duration of Ventilator
Graph 4: Cylindrical diagram representing distribution of patients according to Habits
Graph 5: Cluster pyramid representing distribution of patients according to Occupation
Graph 6: Doughnut diagram representing distribution of patients according to Area of living
Section II
Table 2: Findings related to pre test mean and SD related to airway clearance of patients on mechanical ventilator in selected hospitals. Pre Test
|
|
Control Group |
Experimental Group |
||||
|
|
Heart rate |
Respiration |
Spo2 |
Heart rate |
Respiration |
Spo2 |
|
Mean |
90.3 |
22.65 |
94.9 |
100.40 |
24.35 |
96.30 |
|
SD |
5.55 |
1.79 |
2.80 |
16.31 |
2.41 |
2.13 |
The pre test mean and SD of heart rate in control group is 90.3 and 5.55 and the pre test mean and SD of heart rate in experimental group is 100.40 and 16.31. The pre test mean and SD of Respiration in control group is 22.65 and 1.79 and the pre test mean and SD of Respiration in experimental group is 24.35 and 2.41. The pre test mean and SD of Spo2 in control group is 94.9 and 2.80 and the pre test mean and SD of Spo2 in experimental group is 96.30 and 2.13 respectively.
SECTION III
Table 3: Findings related to airway clearance of patients on mechanical ventilator admitted in selected hospitals in control group.
|
Control Group |
||||||
|
|
Heart rate |
Respiration |
Spo2 |
|||
|
|
Mean |
SD |
Mean |
SD |
Mean |
SD |
|
Pre test |
90.3 |
5.55 |
22.65 |
1.79 |
94.9 |
2.80 |
|
Post-test 1 |
88 |
6.61 |
22.80 |
1.51 |
94.95 |
2.88 |
|
Post-test 2 |
89.8 |
7.07 |
23.30 |
1.87 |
94.05 |
2.99 |
|
Post-test 3 |
91.5 |
7.99 |
23.30 |
0.98 |
95.25 |
2.31 |
|
F Statistic |
1.71 |
1.73 |
0.72 |
|||
|
p value |
0.17 |
0.17 |
0.54 |
|||
Pre Test And Post Test
Repeated measures ANOVA test was carried out. The finding shows that in control group pre test mean of heart rate was 90.3 and S.D was 5.55. The post test 1 mean was 88.00 and SD 6.61. The post test 2 mean was 89.8 and SD was 7.07. The post test 3 mean was 91.5 and SD 7.99. The test statistic value of ANOVA was 1.71. The p value was 0.17. The finding shows that in control group pre test mean of Respiration was 22.65 and S.D was 1.79. The post test 1 mean was 22.80 and SD 1.51. The post test 2 mean was 23.30 and SD was 1.87. The post test 3 mean was 23.30 and SD 0.98. The test statistics value of ANOVA was 1.73. The p value was 0.17. The finding shows that in control group pre test mean of Spo2 was 94.9 and S.D was 2.80. The post test 1 mean was 94.95 and SD 2.88. The post test 2 mean was 94.05 and SD was 2.99. The post test 3 mean was 95.25 and SD 2.31. The test statistics value of ANOVA was 0.72. The p value was 0.54. Above study findings revealed that there is no significant difference in the effectiveness of hypertonic saline nebulized suctioning on airway clearance in control group.
Table 4: Findings related to airway clearance of patients on mechanical ventilator admitted in selected hospitals in experimental group.
|
Experimental Group |
||||||
|
|
Heart rate |
Respiration |
Spo2 |
|||
|
|
Mean |
SD |
Mean |
SD |
Mean |
SD |
|
Pre test |
100.40 |
16.31 |
24.35 |
2.41 |
96.30 |
2.13 |
|
Post-test 1 |
94.95 |
13.72 |
23.20 |
1.51 |
97.60 |
1.70 |
|
Post-test 2 |
88.30 |
7.69 |
21.50 |
1.57 |
98.90 |
1.21 |
|
Post-test 3 |
86.30 |
8.29 |
21.10 |
1.37 |
99.75 |
0.65 |
|
F Statistic |
20.57 |
31.28 |
29.8 |
|||
|
p value |
<0.0001 |
<0.0001 |
<0.0001 |
|||
Repeated measures ANOVA test was carried
The finding shows that in experimental group pre test mean of heart rate was 100.40 and S.D was 16.31. The post test 1 mean was 94.95 and SD 13.72. The post test 2 mean was 88.30 and SD was 7.69. The post test 3 mean was 86.30 and SD 8.29. The test statistics value of ANOVA was 20.57. The p value was <0.0001. The finding shows that in experimental group pre test mean of Respiration was 24.35 and S.D was 2.41. The post test 1 mean was 23.20 and SD 1.51. The post test 2 mean was 21.50 and SD was 1.57. The post test 3 mean was 21.10 and SD 1.37. The test statistic value of ANOVA was 31.28. The p value was <0.0001. The finding shows that in experimental group pre test mean of Spo2 was 96.30 and S.D was 2.13. The post test 1 mean was 97.60 and SD 1.70. The post test 2 mean was 98.90 and SD was 1.21. The post test 3 mean was 99.75 and SD 0.65.
The test statistics value of ANOVA was 29.8. The p value was <0.0001.
Here p value was less than 0.05 level of significance. Hence H0 hypothesis rejected and H1 hypothesis accepted thus hypertonic saline nebulized suctioning was effective in airway clearance.
REFERENCES:
1. Tyagi R, Donaldson K, Loftus CM, Jallo J. Hypertonic saline: A clinical review. Neurosurg Rev.2007 Oct;30(4):277-89.
2. Kalanuria AA, Ziai W, Mirski.Ventilator-associated pneumonia in the ICU. Crit Care.2014; 18(2):208.
3. Keojampa BK, Nguyen MH, Ryan MW. Effects of buffered saline solution on nasal mucociliary clearance and nasal airway patency. Otolaryngology—Head and Neck Surgery. 2004 Nov; 131(5):679-82.
4. Zhang L, Mendoza‐Sassi RA, Wainwright C, Klassen TP. Nebulized hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database of Systematic Reviews. 2008 Oct;8(4):1-2
5. Dentice RL, Elkins MR, Bye PT. Adults with cystic fibrosis prefer hypertonic saline before or during airway clearance techniques: a randomized crossover trial. Journal of Physiotherapy. 2012 Mar 1;58(1):33-40.
6. Zhang L, Mendoza‐Sassi RA, Wainwright C, Klassen TP. Nebulized hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database of Systematic Reviews. 2017;(12):3-12
7. Gupta HV, Gupta VV, Kaur G, Baidwan AS, George PP, Shah JC et al. Effectiveness of 3% hypertonic saline nebulization in acute bronchiolitis among Indian children: A quasi-experimental study. Perspectives in Clinical Research. 2016 Apr; 7(2):88.
Received on 09.12.2022 Modified on 05.02.2023
Accepted on 10.03.2023 ©A&V Publications All right reserved
A and V Pub J. of Nursing and Medical Res. 2023; 2(2):32-37.
DOI: 10.52711/jnmr.2023.10