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Contents lists available at ScienceDirect

Australian Critical Care

journal homepage: www.elsevier.com/locate/aucc

Research paper

Normal saline instillation before suctioning: A meta-analysis of

randomized controlled trials
Chia-Hui Wang RN, PhD a,b ,
Jui-Chen Tsai RN, MSN a,b ,
Shu-Fen Chen RN, MSN a,b ,
Chien-Ling Su RT, MSc c,d ,
Lawrence Chen MS e ,
Chao-Chun Lin RN e ,
Ka-Wai Tam MD, PhD e,f,g,h,∗
a
Department of Nursing, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
b
School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
c
School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
d
Department of Thoracic Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
e
Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
f
Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
g
Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
h
Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan

article information a b s t r a c t

Article history: Background: For airway management of intensive care unit (ICU) patients who are intubated, a 5–10-mL
Received 18 May 2016 bolus of sterile normal saline (NS) solution is commonly instilled into an endotracheal or tracheostomy
Received in revised form 31 October 2016 tube before suctioning. However, NS instillation has been associated with adverse events such as dyspnea,
Accepted 6 November 2016
increasing heart rate, decreasing of oxygenation, blood pressure, and other vital parameters.
Objective: To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to
Keywords:
evaluate the necessity of NS instillation before suctioning in ICU patients.
Normal saline instillation
Data sources: The PubMed, Embase, Cochrane Library, and Scopus databases and the ClinicalTrials.gov
Suctioning
Oxygen saturation registry were searched for studies published before May 2016.
Meta-analysis Review methods: RCTs evaluating the outcome of NS instillation before suctioning in ICU patients under-
going endotracheal intubation or tracheostomy were included. Individual effect sizes were standardised,
and a meta-analysis was conducted to calculate the pooled effect size by using a random-effect model.
The primary outcome was the oxygen saturation immediately and 2 and 5 min after suctioning. The
secondary outcomes were the heart rate and blood pressure after suctioning.
Results: We reviewed 5 RCTs including 337 patients. Oxygen saturation was significantly higher in the
non-NS group than in the NS group 5 min after suctioning. The pooled mean difference in oxygen satu-
ration was −1.14 (95% confidence interval: −2.25 to −0.03). The heart rate and blood pressure did not
differ significantly between the non-NS and NS groups.
Conclusion: NS instillation before suctioning does not benefit patients undergoing endotracheal intuba-
tion or tracheostomy. Moreover, it reduces oxygen saturation 5 min after suction. However, our reviewed
studies had a low methodological quality. Thus, additional studies involving large-scale RCTs are war-
ranted.
© 2016 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

∗ Corresponding author at: Center for Evidence-Based Health Care, Shuang Ho Airway management is of particular importance when car-
Hospital, Taipei Medical University, 291 Zhongzheng Road, Zhonghe District, New ing for critically ill patients. Critically ill patients often require
Taipei City 23561, Taiwan. Fax: +886 2 22490088. endotracheal intubation or tracheostomy along with mechanical
E-mail address: kelvintam@h.tmu.edu.tw (K.-W. Tam).

http://dx.doi.org/10.1016/j.aucc.2016.11.001
1036-7314/© 2016 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Wang C-H, et al. Normal saline instillation before suctioning: A meta-analysis of randomized controlled
trials. Aust Crit Care (2016), http://dx.doi.org/10.1016/j.aucc.2016.11.001
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ventilation. Endotracheal or tracheostomy suctioning is one of the
most common procedures used for removing respiratory secretions
that may occlude the airway. In patients with pulmonary disease,
infection, or dehydration, the ability to remove secretions through
suctioning can prove difficult because of viscous mucus and deep
infection site.1
A 5–10-mL bolus of sterile normal saline (NS) solution is com-
monly instilled into the endotracheal or tracheostomy tube before
suctioning and in practice, is carried out according to the clinician’s
experience. The instillation of NS is purported to elicit coughing
and to liquefy and mobilise secretions.2–7 This is not supported
by studies that have indicated mucus and water do not mix in
vitro, even after vigorous shaking.8,9 Of greater concern, suctioning
is associated with potentially serious and life-threatening compli-
cations, such as hypoxemia, cardiac dysrhythmia, and increased
intracranial pressure.10–13 Despite these drawbacks, in one study
25% of health practitioners considered NS instillation not harmful
to patients.14
As a routine procedure and perhaps a ritualistic practice, the
necessity of NS instillation has been questioned in many stud-
ies. Several trials indicated that NS instillation before suctioning
did not increase heart rate, and arterial oxygen saturation dur-
ing endotracheal suctioning.15,16 Previous systematic reviews were
inconclusive and could not provide sufficient evidence regarding
the efficacy of NS instillation before suctioning.17,18 Moreover, sev-
eral randomized controlled trials (RCTs) evaluating the practice of
NS instillation have been published recently.15,16 Therefore, the aim
of our study was to conduct a systematic review and meta-analysis
of the evidence available thus far and evaluated the necessity of NS
instillation before suctioning in intensive care units (ICU) patients.
2. Materials and methods
2.1. Selection criteria
Our analysis included RCTs evaluating the outcome of NS instil-
lation before suctioning in ICU patients undergoing endotracheal
intubation or tracheostomy. These RCTs were required to clearly
report the patient inclusion and exclusion criteria, the suctioning
technique, the variables used to measure response, and the use of
appropriate study controls. RCTs were excluded if (1) patients were
not admitted to an ICU, (2) patients were younger than 18 years, or
(3) duplicate reporting of patient cohorts had occurred.
2.2. Search strategy and study selection
A comprehensive literature search was conducted using several
databases. These included PubMed, Embase, Scopus, and Cochrane
Central Registers of Controlled Trials, as well as the ClinicalTrials.
gov registry (http://clinicaltrials.gov/). The keywords used for the
medical-subject-heading and free-text searches were instilling OR
instillation, saline OR normal saline, suctioning OR suction, endotra-
cheal OR tracheal OR tracheostomy. References of the similar articles
reported by the Pubmed (displayed at right column of the search
page) were also concerned as possible data to be analyzed. We
reviewed all the retrieved abstracts, study reports, and related cita-
tions. No language restrictions were imposed. The final search was
performed in May 2016. We also identified additional studies by
reviewing the reference sections of relevant publications and by
consulting pulmonary care experts.
2.3. Data extraction
Two reviewers independently extracted the baseline and out-
come cardiorespiratory parameters from the included studies.
Information of study designs, participant characteristics, inclusion,
Please cite this article in press as: Wang C-H, et al. Normal saline instillation before suctioning: A meta-analysis of randomized controlled
trials. Aust Crit Care (2016), http://dx.doi.org/10.1016/j.aucc.2016.11.001
exclusion, and matching criteria, suctioning techniques, and com-
plications were also retrieved. Inconsistencies between the findings
of the 2 reviewers were resolved by a third reviewer.
2.4. Methodological quality assessment
Two reviewers independently assessed the methodological
quality of each study by using the risk of bias method recommended
by the Cochrane Collaboration. Several domains were assessed,
including the adequacy of the randomization, allocation conceal-
ment, blinding of patients and outcome assessors, length of the
follow-up period, reporting of study withdrawals, and performance
of an intention-to-treat analysis.
2.5. Statistical analysis of RCT outcomes
The primary outcome was the oxygen saturation immediately
and 2 and 5 min after suctioning. The secondary outcomes were
the heart rate and blood pressure after suctioning. All data were
analyzed using the Review Manager (version 5; Cochrane Collab-
oration, Oxford, England). Meta-analysis was performed according
to the PRISMA guidelines.19 Standard deviations were estimated
when necessary from the confidence interval (CI) limits, standard
errors, or range values provided in the previous studies. Effect sizes
of continuous outcomes were reported as weighted mean differ-
ences (WMDs). The precision of the effect sizes was based on their
95% CIs. A pooled estimate of the WMDs was computed using the
DerSimonian and Laird random-effect model.20
To evaluate the statistical heterogeneity and the inconsistency
of treatment effects among the studies, the Cochrane Q and I2 tests
were used, respectively. Statistical significance was set at 0.10 for
the Cochrane Q test. The proportion of the total outcome variability,
attributable to the variability among the studies, was quantified as
I2 .
3. Results
Fig. 1 illustrates the process used for RCT screening and selec-
tion. The initial search yielded 634 citations. On the basis of
the screening criteria for titles and abstracts, 548 articles were
excluded. We reviewed the full text of the remaining 86 articles,
and 81 were excluded for the following reasons: 11 were retro-
spective or prospective studies; 4 included pediatric patients; 8
evaluated non-NS irrigation; and 58 addressed other aspects of
endotracheal intubation. This left 5 RCTs meeting the selection
criteria.10,15,16,21,22 The characteristics of each are listed in Table 1.
The 5 RCTs were published between 1987 and 2014, with
sample sizes of 29–150 patients. All RCTs compared the out-
comes of NS instillation before suctioning with those of controls.
One crossover study applied 3 NS instillation volumes (0, 2, and
5 mL) in each patient.22 Two trials recruited patients undergo-
ing cardiac surgeries.10,15 Three trials10,15,16 only included patients
with endotracheal intubation, one only recruited patients with
tracheostomy22 , and one included patients with both types of intu-
bation (Table 1).21 All RCTs instilled 5 mL of NS before suction;
furthermore, 2 RCTs investigated the outcomes of 2-mL NS instilla-
tion and only one evaluated the efficacy of 10-mL NS instillation.10
The assessment of the methodological quality of 5 RCTs is sum-
marised in Table 2. No study specified its randomization methods.
Schmollgruber et al. assigned every second patient to group 1 after
assigning the first patient to group 2.15 No study reported the meth-
ods of allocation concealment. Two studies reported the blinding of
patients and outcome assessors.16,21 All studies, except that of Ack-
erman and Mick21 performed an intention-to-treat analysis. Only
1 patient withdrew during the follow-up among all five RCTs.21
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Table 1
Characteristics of selected randomized controlled trials.

Study Study design Inclusion criteria Setting Type of intubation No. of patients Age, y Intervention
(% of male)

Ackerman and Mick21 RCT Age > 18 years with SICU/MICU/burn trauma ICU Endotracheal N5: 14 60 ± 18.2 N5: 5 mL
pulmonary infection intubation/tracheostomy C: 15 (62.1) C: control
Bostick and Wendelgass10 RCT Age > 18 years; s/p open Cardiac SICU Endotracheal intubation N5: 15 N5: 61.1 N5: 5 mL
heart surgery; mechanical N10: 15 N10: 57.7 N10: 10 mL
ventilation > 12 h C: 15 C: 61.1 C: control
Kalra et al.16 RCT Age > 18 years SICU/MICU Endotracheal intubation N2: 50 (70.0) 67 (51–70) N2: 2 mL
N5: 50 (64.0) N5: 5 mL
C: 50 (68.0) C: control
Ji et al.22 RCT crossover Pneumonic patients with a Neurosurgical ICU Tracheotomy 16 (50%) 65.1 N amount (0, 2, or

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tracheotomy tube 5 mL) randomly

C.-H. Wang et al. / Australian Critical Care xxx (2016) xxx–xxx

assigned, crossover
after 80-min rest
Schmollgruber et al.15 RCT Age > 18 years; s/p cardiac Cardiac SICU Endotracheal intubation N5: 33 (66.7) N5: 56 ± 14 N5: 5 mL
surgery C: 32 (59.4) C: 55 ± 14 C: control

Abbreviations: C, control; N, normal saline; ICU, intensive care unit; SICU, surgery intensive care unit; MICU, medical intensive care unit. Data are presented as the mean ± standard deviation or mean (range).

Table 2
Methodological quality assessment of selected randomized controlled trials.

Study [year] Country Allocation Allocation Blinding of Data analysis Loss to follow-up Selective Other biases
generation concealment patients and (%) reporting
outcome
assessors

Ackerman and Mick [1998]21 USA Unclear Unclear Assessor blinded PP 3.3 Complication not evaluated
Bostick and Wendelgass [1987]10 USA Unclear Unclear Unclear ITT 0 Complication not evaluated
Kalra et al. [2014]16 India Unclear Unclear Double blinded ITT 0 Low risk
Ji et al. [2002]22 South Korea Unclear Unclear Unclear ITT 0 Low risk
Schmollgruber et al. [2014]15 South Africa Simple random Unclear Unclear ITT 0 Low risk Every second patient was
assigned to group 1 after
the first patent was
assigned to group 2

Risk of bias was assessed according to the method recommended by the Cochrane Collaboration. Abbreviations;: ITT, intention to treat; PP, per protocol.

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Studies identified from PubMed,
Embase, and Cochrane Library
databases (n = 630)
Search for potentially relevant RCTs (n = 634)
Studies retrieved for further
review (n = 86)
Selected studies (n = 5)
Fig. 1. Process of randomized controlled trial selection for meta-analysis.
3.1. Oxygen saturation
Although all RCTs reported oxygen saturation outcomes, the
oxygen saturation measurements varied. Bostick and Wendelgass
reported only degrees of oxygenation through arterial blood gas
analysis,10 the data cannot be compared with others and thus not
included in the meta-analysis. Data from Schmollgruber et al. and
Ackerman and Mick were not used in our analysis because the RCTs
did not report the standard deviations of their SaO2 values.15,21 Ji
et al. and Karla et al. reported the SaO2 values immediately after
suctioning then at 2 and 5 min intervals.16,22 Compared with those
in the NS group, the SaO2 values were significantly higher in the
non-NS group 5 min after suctioning (WMD −1.14, 95% CI: −2.25
to −0.03; Fig. 2). The SaO2 values of the 2 groups did not differ signif-
icantly either immediately (WMD −0.60, 95% CI: −1.65 to 0.45) or
2 min (WMD −0.76, 95% CI: −2.83 to 1.30) after suctioning (Fig. 2).
Ackerman and Mick reported significantly higher SaO2 values 4,
5, and 10 min after suctioning in the non-NS group compared with
those in the NS group.21 Schmollgruber et al. reported significant
differences in the return rate to baseline oxygen saturation as mea-
sured by pulse oximetry (SaO2 ) after 30 min of suctioning: 63.6% of
patients in the NS group did not to return to baseline, whereas this
occurred in only 37.5% of non-NS group patients (p = 0.035 [2 test]
and 0.048 [Fisher’s exact test]).
3.2. Heart rate
Three studies reported the heart rate after suctioning.15,16,21
Two studies15,21 did not provide standard deviation values; there-
fore, we could not pool this data. Ackerman and Mick and
Schmollgruber et al. observed no difference in the heart rate
between the NS and non-NS groups.15,21 Karla et al. reported
that the heart rate was lower but not significant in the non-NS
group than in NS group immediately (106.1 ± 18.4 vs 113.6 ± 20.4,
Please cite this article in press as: Wang C-H, et al. Normal saline instillation before suctioning: A meta-analysis of randomized controlled
trials. Aust Crit Care (2016), http://dx.doi.org/10.1016/j.aucc.2016.11.001
Additional studies identified through
Scopus and reference searches
(n = 4)
Studies excluded according to the
titles and abstract screening
criteria
Non relevant (n = 548)
Studies excluded
Different comparisons (n = 8)
Different interventions (n = 58)
Not adult patients (n = 4)
Non randomized (n = 11)
p = 0.150), 2 min (105.0 ± 17.7 vs 112.7 ± 20.5, p = 0.119), and 5 min
(100.8 ± 18.4 vs 109.5 ± 19.3, p = 0.073) after suctioning.16
3.3. Other measurements
Two studies reported the blood pressure after suctioning.16,21
Ackerman and Mick and Kalra et al. observed that the systolic blood
pressure did not differ between the NS and non-NS groups.16,21
Schmollgrubr et al. investigated the pH after suctioning, and
reported a significant decrease in the pH (7.38–7.36, p = 0.04) after
suctioning in the NS group.15
4. Discussion
The results of this meta-analysis revealed that 5-mL NS instil-
lation before suctioning can significantly lower SaO2 values 5 min
after suctioning. In the RCTs reviewed patients not receiving NS
instillation showed higher SaO2 values immediately and 2 min after
suctioning, although these differences were not significant. Differ-
ence in heart rate before and after NS instillation was not included
in the meta-analysis due to inconsistent reporting. The results from
this study with the inclusion of more recent RCTs,15,16 is consistent
with findings of previous reviews.17,23–26 Significantly lower SaO2
values was observed in patients receiving 5-mL NS instillation com-
pared with those receiving a lesser NS volume or no NS. There was
insufficient evidence in this review to support its continued use in
clinical practice.
Accumulation of secretions in the respiratory tract causes
airways obstruction, hypoxia, acidosis and other dangerous compli-
cations for the patients through disruption in the oxygen supply.27
Halm and Krisko-Hagel reviewed the current evidence and indi-
cated that only 10.7%–18.7% of the NS instillation was discharged
through suctioning and the rest remain in the tracheal tube and
respiratory system, diminishing the tube diameter which, per se,
leads to further resistance in the airway to airflow and reduce the
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Normal saline Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 SaO values immediately after suctioning
2
Ji 2002 96.91 1.82 16 97.56 1.74 16 72.3% -0.65 [-1.88, 0.58]
Kalra 2014 96.56 6.04 50 97.04 3.9 50 27.7% -0.48 [-2.47, 1.51]
Subtotal (95% CI) 66 66 100.0% -0.60 [-1.65, 0.45]

Heterogeneity: Tau² = 0.00; Chi² = 0.02, df = 1 (P = 0.89); I² = 0%

Test for overall effect: Z = 1.13 (P = 0.26)

1.1.2 SaO values 2 min after suctioning

2
Ji 2002 96.03 2.15 16 97.69 1.61 16 58.1% -1.66 [-2.98, -0.34]
Kalra 2014 97.28 6.41 50 96.8 4.33 50 41.9% 0.48 [-1.66, 2.62]
Subtotal (95% CI) 66 66 100.0% -0.76 [-2.83, 1.30]

Heterogeneity: Tau² = 1.47; Chi² = 2.78, df = 1 (P = 0.10); I² = 64%

Test for overall effect: Z = 0.72 (P = 0.47)

1.1.3 SaO values 5 min after suctioning

2
Ji 2002 96.56 1.94 16 98.09 1.55 16 67.6% -1.53 [-2.75, -0.31]
Kalra 2014 97.8 6 50 98.12 3 50 32.4% -0.32 [-2.18, 1.54]
Subtotal (95% CI) 66 66 100.0% -1.14 [-2.25, -0.03]

Heterogeneity: Tau² = 0.09; Chi² = 1.14, df = 1 (P = 0.29); I² = 12%

Test for overall effect: Z = 2.01 (P = 0.04)

-10 -5 0 5 10
Favours controlFavours normal saline
Testforsubgroupdifferences:Chi ²= 0.48,df = 2(P = 0.79),I ²= 0%

Fig. 2. Forest plot of the comparison: normal saline versus no normal saline; outcome: 1.1.1 SaO2 values immediately after suctioning. 1.1.2 SaO2 values 2 min after suctioning.
1.1.3 SaO2 values 5 min after suctioning.

oxygen available for lungs to gas exchang.17 In a study involving
24 critically ill children, Ridling et al. found that subjects who had
NS instilled experienced significantly greater oxygen desaturation
1 and 2 min after suctioning compared with patients who did not.28
Despite the aforementioned complications, the practice of NS instil-
lation continues and that clinicians should review the evidence
and think again about instilling NS during suctioning. Similarly, our
results did not support the use of NS for instillation because lower
SaO2 values were observed 5 min after suctioning. Therefore, this
procedure should be discontinued.
Our meta-analysis included patients of various ethnicities
and ages having various health conditions: 2 had pulmonary
infection21,22 and 2 had undergone open heart surgery10,15 ; 3
RCTs10,15,16 recruited patients with endotracheal intubation, one22
included patients with tracheostomy, and one included both21 .
However, regardless of the differences in patient characteristics
and intubation methods, our results do not support the use of NS
instillation before suctioning.
The amount of NS used for instillation may also affect oxygen
saturation. Because the measurement and reporting methods var-
ied across the selected RCTs, we could only detect a significant
disadvantage of 5-mL NS instillation only 5 min after suctioning.
Moreover, Bostick and Wendelgass reported a trend of lower post-
PaO2 values with the use of larger amounts of NS solution (10 mL).10
In addition, Giakoumidakis et al. demonstrated that the amount of
secretions doubled with NS instillation, possibly because of aspi-
ration of the applied NS.24 Future studies investigating the use of
different amounts of NS may provide further evidence regarding
the requirement of NS instillation.
The studies included in our analysis demonstrated considerable
heterogeneity because of various clinical factors. First, the patient
selection criteria were inconsistent across the studies. Second, dif-
ferent intubation types were used. Third, the outcome measure of
oxygen saturation was not totally standardised. Finally, differences
in the experience level of the nurses might also have contributed
to heterogeneity in the data.
This meta-analysis has several limitations. First, the sample
size of patients recruited per treatment group in some selected
RCTs was relatively small, which might have reduced the statistical
power of the results. Second, several primary and secondary out-
comes varied across studies. Third, randomization and allocation
concealment were not reported in most selected RCTs; this might
have introduced selection or confirmation bias. Finally, 3 selected
RCTs did not discuss the blinding of patients and outcome assessors,
potentially limiting inferences based on our analysis.
5. Conclusion
This meta-analysis revealed that NS instillation does not provide
clinical benefits in heart rate, blood pressure, and pH in patients
undergoing endotracheal intubation or tracheostomy, and it can
even lead to decreased oxygen saturation 5 min after suctioning.
According to this review, evidence so far suggests that NS instilla-
tion should not be used in clinical practice. Because the sample size
of patients recruited in some selected RCTs was relatively small,
additional large-scale RCTs are warranted to further evaluate the
effectiveness of NS instillation before suctioning.
Funding support
This work was supported by a research grant from Taipei
Medical University (grant no. TMU102-AE1-B10). The sponsoring
organization was not involved in the study design, data analysis, or
interpretation.

Please cite this article in press as: Wang C-H, et al. Normal saline instillation before suctioning: A meta-analysis of randomized controlled
trials. Aust Crit Care (2016), http://dx.doi.org/10.1016/j.aucc.2016.11.001
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