Decreased Oxygen Saturation Levels Due to Suction of Endotracheal

Tube Mucus

Juni Mariati Simarmata, Syatriawati, Rosita Ginting, Isidorus Jehaman, Anita Purba and Samuel

Ginting

Institut Kesehatan Medistra Lubuk Pakam Deli Serdang, Sumatera Utara, Indonesia

Keywords: Oxygen Saturation, Suction, Endotracheal Tube Patient (ETT)

Abstract: The success of treatment in patients with respiratory failure depends not only on early detection, but also on

understanding the mechanism of the cause. One of the conditions that can cause respiratory failure is airway

obstruction, including obstruction of the Endotracheal Tube (ETT). This type of research uses the Pre

Experiment Method using One-Group Pre-test and Post-test Design research design. Determination of the

sample is done by accidental sampling, with a total sample of 20 people. Data analysis was performed using

the Wilcoxon test with a 95% confidence interval and a value of α = 0.05. The results obtained from this study

indicate that there are differences in oxygen saturation levels before and after mucus suctioning measures are

given where there is a difference in the value of oxygen saturation levels of 5.164% and p-value = 0.000 (α

<0.05).

1 INTRODUCTION

According to WHO (World Health Organization)

data the incidence of respiratory failure can result in

death and the incidence of data obtained in 2009 the

incidence of respiratory failure about 67% of all

patients treated in the ICU. And in 2012 respiratory

failure began to be prevented by providing care and

freeing the airway 58%. The incidence and

consequences of acute respiratory failure also depend

on the dysfunction of others. A procedure that

deserves particular attention, given its direct

relationship with the risk of infection, is the

endotracheal aspiration (ETA) of intubated patients.

A common procedure within intensive care units is

the suctioning of respiratory secretions in patients

who have been intubated or who have undergone

tracheostomy. When patients are unable to mobilize

their secretions, they may need suctioning of the

secretions from the oropharynx and/or trachea to

maintain their airway. Patients may be unable to clear

their own airway due to several different problems,

including neuromuscular disease, sedation or

neurological deficits, such as a CVA. In addition,

patients with an artificial airway, such as those who

have been intubated, usually require suctioning while

they are on a ventilator. Many patients are intubated

and mechanically ventilated because of respiratory

distress and respiratory failure. Respiratory failure is

an acute or chronic condition with impaired gas

exchange and pulmonary functions and is

characterized by elevated carbon dioxide or

decreased oxygen in the arterial blood. Respiratory

failure can result from diverse conditions such as

cardiac and respiratory diseases, defects in

neuromuscular systems that control breathing, injury

to chest, and several lung diseases.

Suctioning may be done through an endotracheal

tube, tracheostomy tube, or through the nose or mouth

into the trachea. Although each procedure is slightly

different, indications, supplies, procedures and risks

are similar.

Respiratory failure is one of the causes of increased

mortality and morbidity. Every year an estimated 1

million people are treated in ICU due to respiratory

failure (Wunssch, 2010). In the United States the

incidence of respiratory failure increased from

1,007,549 people in 2001 to 1,917,910 in 2009 (16).

Some cases of respiratory failure end up with

mechanical ventilation aimed at assisting or taking an

expert respiratory function. Based on data on rank 10

non-communicable diseases (PTM) which cause fatal

deaths based on case fetality rate (CFR) in hospital

admissions in 2010, the incidence of respiratory

failure ranks second at 20, 98%) (7).

Simarmata, J., Syatriawati, ., Ginting, R., Jehaman, I., Purba, A. and Ginting, S.

Decreased Oxygen Saturation Levels Due to Suction of Endotracheal Tube Mucus.

DOI: 10.5220/0009468001650171

In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 165-171

ISBN: 978-989-758-460-2

165

Treatment for airway obstruction due to the

accumulation of secretions in the Endotracheal Tube

(ETT) is to perform mucus suctioning by inserting a

suction catheter through the nose / mouth /

Endotrachel tube (ETT) which aims to free the

airway, reduce sputum retention and prevent sputum

suction lung infection. In general, patients who have

ETT installed have a poor body response to expel

foreign bodies, so suctioning is necessary. (9).

The American –European Consensus On

ARDS found an incidence of acute respiratory

distress syndrome (ARDS) between 12.6-28.0 cases /

100,000 population / year and deaths from respiratory

failure were reported to be around 40%. Under these

conditions, the optimal management of respiratory

failure patients is very important and we estimate

there is a relationship between the basic disease and

the results of its management (Bongard, 2014).

The use of mechanical ventilation is a

multinational survey of 5000 clients in Europe used

in cases of acute respiratory failure (69%), coma

(17%), chronic respiratory failure (13%) and

neuromuscular use (2%) (Rodriquez, Dojat, and

Brocard , 2005). Respiratory assistance should be

given adequately according to indications to prevent

muscle weakness in breathing because of rest

(Smelzer, 2012).

Research conducted by France, (2011) in 12

ICU rooms in Brazil found 843 people (49%) were

treated in ICU rooms due to acute respiratory failure

and 141 people suffered respiratory failure after being

treated in ICU, of the total sufferers of acute

respiratory failure 475 people died in the ICU room,

and 56 people died after leaving the ICU room.

From the results of studies in Germany and

Sweden reported that the incidence of acute

respiratory failure in adults 77.6-88.6 cases / 100,000

population / year. Respiratory failure is an indication

that the patient is being treated in an intensive care

unit (ICU).

One condition that can cause respiratory failure

is airway obstruction, including obstruction of the

Endotrachel Tube (ETT). Airway obstruction is an

abnormal condition due to the inability to cough

effectively, can be caused by thick secretions or

excess due to infectious diseases, immobilization,

static secretions, and ineffective cough due to

neurological diseases such as cerebrovascular

accident (CVA), effects of sedative treatment, and

others (Hidayat, 2013).

Data obtained from the ICU patient

registration book Prof. Dr. Dr.R.D. Kandou Manado

starting from January-October 2013 the total number

of patients treated at the ICU were 411 patients and

those who experienced respiratory failure as many as

132 patients (32.1%). The average patient treated in

the ICU is 41-42 patients / month and the average who

has experienced respiratory failure is 13-14 patients /

month died due to respiratory failure.

Respiratory failure occurs when the exchange

of oxygen to carbon dioxide in the lungs is unable to

maintain the rate of oxygen consumption (O2) and the

formation of carbon dioxide (CO2) in body cells. This

results in arterial oxygen pressure of less than 50

mmHg (hypoxemia) and an increase in carbon

dioxide pressure greater than 45 mmHg

(hypercapnia). Although advances in diagnostic

techniques and intervention therapy have progressed

rapidly, respiratory failure is still a cause of high

morbidity and mortality rates in the treatment room

intensive (Brunner & Suddarth, 2010).

According to Wiyoto (2010), if suction is not

performed on patients with impaired airway

clearance, these patients will experience a lack of O2

supply (hypoxemia), and if O2 supply is not met

within 4 minutes it can cause permanent brain

damage. An easy way to find out hpoxemia is by

monitoring oxygen saturation (SpO2) levels which

can measure how much percentage of O2 the

hemoglobin can carry. And data that can be obtained

and health services in each province of Riau, West

Sumatra and North Sumatra which says patients fail

to breathe in almost every hospital that has ICU room.

Starting from 2009-2013, it can be estimated that the

total number of patients treated in the ICU is 1,680

and 756 patients (46.7%) have experienced

respiratory failure. and it is estimated that patients

treated in the ICU in each hospital are 40 patients each

month and patients who experience respiratory failure

Between 12 patients each month and 8 patients each

month die of respiratory failure (Health Office, 2014).

Based on preliminary surveys conducted by

researchers, it is known that in the ICU room of

Grandmed Hospital, in 2016 there were 72 patients

who were installed with ventilators. In 2017, 86

patients were installed with ventilators. In 2018 a total

of 67 patients had ventilators. The average patient

who experienced respiratory failure as many as 9

patients per month, 3 patients died from respiratory

failure per month. And in early 2019 who were

treated in the ICU room as many as 27 patients who

installed ventilators. This is what prompted

researchers to conduct research on the Effect of

Suctioning Mucus Measures on Oxygen Saturation in

Patients with Endotracheal Tube (ETT) in the ICU at

Grandmed Lubuk Pakam Hospital in 2019.

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

166

2 RESEARCH METHODS

This type of research is quantitative research. This

study uses a Pre Experiment research design with a

One Group Pretest-Posttest Design, because this

study is directed to see how the Effect of

Endotracheal Suction on Suction Oxygen Saturation

Levels in the ICU at Grandmed Lubuk Pakam

Hospital in 2019.

Location and Time of Research Research on

the Effects of Endotracheal Tube Suction on Oxygen

Saturation Levels in ICU at Grandmed Lubuk Pakam

Hospital in 2019. The reasons researchers chose

research sites are 1) No research has been conducted

on the Effect of Suction of Endotracheal Tube

Suction in the ICU at Grandmed Lubuk Pakam

Hospital in 2019. The reasons for researchers

choosing research sites are 1) Research on the Effects

of Suction on Endotracheal TubeI (ETT) on Oxygen

Saturation Levels in the ICU Room of the Grandmed

Lubuk Pakam Hospital in 2019, b) The location of the

study is close to the researcher, c) There is a problem

regarding the action of mucus suctioning with

changes in oxygen saturation in patients who are

installed Endotrachel Tube (ETT).

The study was conducted in April to May 2019.

And the population of this study were patients who

installed Endotracheal Tube (ETT) in the ICU room

at the Grandmed Lubuk Pakam Hospital, in April-

May 2019 as many as 20 patients. The sampling

technique used in this study used an accidental

sampling technique where only patients who met with

researchers were sampled (Hidayat, 2011). So the

sample in this study is ICU patients who have

Endotracheal Tube (ETT) installed at Grandmed

Lubuk Pakam Hospital in April - May 2019.

Description:

01: The group before the Suction action is taken.

X: Suction Action Treatment Group

02: Group after Suction action

Figure1: Research Design

Inclusion Criteria

 Patients who have ETT and Ventilator

installed

 Patients with mucus buildup (secret) and

suction will be performed

 Patients with SpO2 <95%

Exclusion Criteria

 Patients in the process of CPR (Pulmonary

resuscitation)

 Patients who have Post ROSC (Return Of

Spontaneous Circulation) <3 hours

The instrument used in this study is the

observation sheet consisting of the respondent's

general identity contained at the top of the

observation sheet. While at the bottom there are

results of the pre-test and post-test assessment of the

action of mucus suctioning.

The procedure in this study, preliminary data

about oxygen saturation levels were collected through

a pre-test. Including values from the measurement

results used an oximetry device. Then the respondent

will be given suction action. After taking action

through treatment, the final data of this study were

taken through a posttest including data on oxygen

saturation levels by monitoring using an oximetry

device

Collecting Data Techniques

Premier Data

This data was obtained based on statements in the

form of observation sheets filled out by researchers

that can be seen from the state of the patient while

being treated in the ICU room at the Grandmed Lubuk

Pakam Hospital.

Secondary Data

Secondary data from this research were taken from

nurses and doctors to determine the diagnosis of

patients while being treated in the ICU at Grandmed

Lubuk Pakam Hospital.

Research variable

The variables of this research are :

 The independent variable (independent

variable) in this research is the act of mucus

suctioning

 The dependent variable (dependent variable) is

the change in oxygen saturation.

Data analysis

Processing and analysis data were done using

computer software. Data analysis included univariate

analysis was used to obtain a description of the

distribution of research subjects of each variable from

the Effect of Endotracheal Tube Suction on Oxygen

Saturation Levels in ICU at Grandmed Lubuk Pakam

Hospital in 2019 and to establish further data analysis.

Analysis was needed to explain or find out

whether there are significant influences or differences

between the independent variables and the dependent

variable. Bivariate analysis was performed after the

characteristics of each variable are known. From the

01 X 02

Decreased Oxygen Saturation Levels Due to Suction of Endotracheal Tube Mucus

167

results of statistical calculations with the probability

value (p) with a real level α = 0.05 with a confidence

level of 95% (P Value <α) means that there is a

significant relationship between the independent and

dependent variables. To test the hypothesis used is to

use the Wilcoxo Test.

Endotracheal Tube Implementation Procedures:

 Tools preparation (figure 2), A) The distal

expanded portion of the suction tubing

connector is cut off, B) The tip of the suction

tubing is wedged into the ETT connector, C)

Scissors are used to cut a proximal hole in the

suction tubing, D) Scissors are used to cut a

distal hole in the suction tubing, E) The stylet is

passed through the distal hole in the suction

tubing into the ETT, F) When suction is

required, an assistant occludes the proximal hole

in the suction tubing. Once the tip of the ETT is

in the larynx, the suction tubing and stylet are

removed together and positive pressure

ventilation can be provided (Abrons,

Zimmerman, ElHattab, 2017)



Figure 2: Construction of the ETT as a suction wand

 Intubation installation (Figure 3): (1) Deflate

the laryngeal mask airway (LMA) cuff to a

smooth low profile shape. Grasp LMA between

thumb and index finger. (2) Extend the patient’s

head with the nondominant hand, while the

LMA is inserted with thumb and index finger

grip toward the hard palate. (3) Advance the

LMA into position by applying pressure with

the index finger along the palate. Advance until

resistance is felt in the orophaynx. (4) Withdraw

the dominant hand from the patient’s mouth,

while stabilizing the LMA shaft with the

nondominant hand. (5) Inflate the LMA cuff,

often the device will move slightly out of the

patient’s mouth with cuff inflation. Suggested

inflation pressure is 6 0 cm H2O, do not

overinflate (Hernandez, Klock, Ovassapian,

2012, 2012). 

Figure 3: Manufacturer's recommended insertion

technique (Courtesy of LMA North America, San

Diego, CA)

 The results of installing Endotracheal Tube

in patients

Figure 4: Pasien Endotracheal Tube

RESULTS AND DISCUSSION

Based on the results of the study in Table 1,

Characteristics of respondents by gender, namely 12

men (60.0%), and 8 women (40.0%).

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168

Table 1: Characteristics of Respondents

Characteristic

Frequency

(people)

Percentage

(%)

Gender

Man 12 60,0

Woman 8 40,0

Total 20 100,0

Based on the results of the study in Table 2,

Characteristics of respondents by Mucus Suction in

Patients with Endotracheal Tube Installed

Table 2: Mucus Suction in Patients with Endotracheal

Tube Installed

Mucus Suctioning

Frequency

(Orang)

Percentage

(%)

Good 2 10,0%

Deficient 18 90,0%

Total 20 100%

Based on the research results in Table 3 of the

Effect of Endotracheal Tube (ETT) Suction againts

the Oxygen Saturation Level in the ICU in the

Grandmed Lubuk Pakam Hospital in 2019, before the

Suction of Endotracheal Tube (ETT) in the Good

category 2 people (10.0%) and deficient category as

many as 18 people (90.0%), and after the

Endotracheal Tube (ETT) mucus suctioning act the

good category as many as 17 people (85.0%) and

deficient category as many as 3 people (15.0%) at

ICU room Grandmed Lubuk Pakam Hospital in 2019.

Table 3: After the action of mucus suctioning

Mucus Suctioning

Frekuensi

(Orang)

(%)

Good 17 85,0%

Deficient

3 15,0%

Total 20 100%

Based on the results of the study in Table 4

about the Effect of Endotracheal Suction (ETT)

Suction on the Oxygen Saturation Level in the ICU in

the Grandmed Lubuk Pakam Hospital in 2019,

alteration in Oxygen Saturation Endotracheal Tube

(ETT) in the Grandmed Lubuk Pakam Hospital In

2019 there were 17 good categories (85.0%), and bad

mucus suctioning measures were 3 people (15.0%).

Table 4: Changes in Oxygen Saturation in Patients

with Endotracheal Tube (ETT)

Alteration in

Oxygen

Saturation

Frequency

(Orang)

(%)

Good 17 85,0%

Deficient 3 15,0%

Total 20 100%

Based on the results of the study in Table 5

This study was conducted on 20 patients treated at

Grandmed Lubuk Pakam Hospital and in 209 patients

on the Effects of Endotracheal Tube (ETT) Suction

on the Oxygen Saturation Level in the ICU Room at

Grandmed Lubuk Pakam Hospital in 2019 based on

sociodemography which includes Gender, it can be

seen the characteristics of respondents based on the

sex of the majority of men as many as 12 people

(60.0%) and the majority of women 8 people (40.0%).

Table 5: The Effects of Endotracheal Tube (ETT)

Mucus Suction on Oxygen Saturation Levels

Mucus

Suctioning

Std.

Deviat

ion

Min Max

Pre Suction 220 6,90 4.553 79 95

,00

Post Suction 220 95,85 4.760 84 100

According to the assumptions of research

conducted by Irawan (2014) regarding the effect of

endotracheal tube (ETT) suctioning action on oxygen

saturation levels in patients treated in ICU room of

RSUP Prof. Dr. Dr. R. D. Kandou Manado, 12

patients or about 75% of patients have male sex and

7 people (44%).

While in a study conducted by Irawan (2015)

regarding the effect of suction action on changes in

peripheral oxygen saturation in patients treated in the

ICU room at Abdul Wahab Sjahranie Hospital

Samarinda, as many as 20 people out of 26 samples

taken were male and 11 were male. used as a sample

having a head injury medical diagnosis.

Based on the total score of each dimension in

the table above, statistical analysis of the Wilcoxon

test means that Ho is rejected so there is available the

effect of Endotracheal Tube (ETT) Suction on the

Oxygen Saturation Level in the ICU of the Grandmed

Lubuk Pakam Hospital in 2019. Easier interpretation

of data is by looking at the P Value index of = .000 <

(0.05).

Therefore it can be concluded that Ho is

rejected. So there is the effect of Endotracheal Tube

Decreased Oxygen Saturation Levels Due to Suction of Endotracheal Tube Mucus

169

(ETT) Suction on the Oxygen Saturation Level in the

ICU of the Grandmed Lubuk Pakam Hospital in 2019.

And Distribution of Frequency and Percentage of

Endotracheal Tube (ETT) Suction on the Oxygen

Saturation Level in the ICU Grandmed Lubuk Pakam

Hospital in 2019.

In the Saskatoon Health Regional Authority

(2010) said that complications that may arise from the

action of sucking mucus one of which is hypoxemia /

hypoxia. And strengthened by Maggiore et al ,.

(2013) about the side effects of ETT mucus

suctioning, one of which is that there can be a

decrease in oxygen saturation levels of more than 5%.

So that patients suffering from diseases of the

respiratory system will be very vulnerable to

experience a significant decrease in the value of

oxygen saturation at the time of the action of mucus

suctioning.

The results obtained from this research indicate

that there are differences in oxygen saturation levels

before and after mucus suctioning action is given. The

results showed a decrease in the oxygen saturation

level of the respondents namely the difference in the

value of oxygen saturation levels by 5.174%. Besides

that, from the results of the t-Test statistical test on

respondents, there is a significant effect where the p-

value = 0,000 (α <0.05).

According to the assumptions of the research

conducted by Maggiore, et al (2013), about

Decreasing the Adverse Effects of Endotracheal

Suctioning During Mechanical Ventilation by

Changing Practice, where 46.8% of respondents

experienced a decrease in oxygen saturation and 6.5%

due to suction. Based on these studies it can be

concluded that the action of suction can cause a

decrease in oxygen saturation levels.

According to the assumptions of research

conducted by Maulidia, Rosina (2017), the effect of

mucus suction action on changes in oxygen saturation

levels in critical patients treated in the ICU room at

An-Nisa Hospital in Tangerang with a mean value

obtained is 1.475 with a standard deviation of 1.358

and the mean standard error of 0.215. The P value

obtained in this study is 0,000 (≤ 0.05), so it can be

concluded that there is an effect of suctioning on

changes in oxygen saturation levels in critical patients

treated in the ICU at An-Nisa Hospital Tangerang.

Based on the research conducted, the

researcher's assumption is that before 2 people

(10.0%) Good category of Endotracheal Tube (ETT)

mucus suction and 18 people (90.0%) less good

category, and after mucus suctioning Endotracheal

Tube (ETT) Good category as many as 17 people

(85.0%) and Poor category as many as 3 people

(15.0%) in the ICU Room Grandmed Lubuk Pakam

Hospital in 2019.

The experts recorded a 24% respiratory failure

rate with a 33.33% mortality rate. Mucus suction is

one of the components and bronchial toilets for

aspiration of mucus on clients with artificial airways.

Suctioning mucus (Suction) is the act of cleaning the

airway through an artificial airway using a suction

catheter and a suction device (Wilson, 2010).

And distribution of Frequency and Percentage

Change in Oxygen Saturation in Patients with

Endotracheal Tube (ETT) in the ICU of Grandmed

Lubuk Pakam Hospital in 2019.

According to the assumptions of research

conducted by Marlisa, Idjradinata, Kosasih (2013)

about the effect of oxygen supply through the catheter

mouth during suction on oxygen saturation in

ventilator head mounted patients, where the use of

catheter mouth is more effectively used during

suction to reduce the risk of decreasing saturation

oxygen in patients with severe head injury with

ventilators compared with those not using catheter

mouth.

According to the assumptions of research

conducted by Nizar, Haryati (2015) the results of this

study indicate an increase in oxygen saturation levels

after suction. That is because the free airway to

accumulate secretions makes oxygen transfer from

the atmosphere into the lungs effective. Therefore the

researcher took suction action on the respondent in

accordance with the inclusion criteria based on

standard operating procedures.

Based on the research conducted, the

researcher's assumption is that the Oxygen Saturation

Change in Endotracheal Tube (ETT) patients in the

ICU Room in the Grandmed Lubuk Pakam Hospital

in 2019 is good for 17 people (85.0%), and changes

in oxygen saturation are as good as 3 people (15.0%).

Frequency Distribution and Percentage Effect of

Endotracheal Tube (ETT) Mucus Suction Actions on

Oxygen Saturation Levels in ICU in Grandmed

Lubuk Pakam Hospital in 2019.

According to the assumptions of research

conducted by Bayu (2013) regarding the effect of

suction action on changes in peripheral oxygen

saturation in patients treated in the ICU room Abdul

Wahab Sjahranie Hospital Samarinda, before the

action of mucus suctioning, a mean value of 93.65

and a median of 94, with a standard deviation of

1,623, a minimum value of 90 and a maximum

saturation level of 96. After mucus suctioning, a mean

of 97.46 and a median of 98, obtained a standard

deviation of 1.606 with a minimum value of 94 and a

maximum of 100.9.

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

170

Based on the research assumptions of Kitong,

Mulyadi, & Malara (2014) entitled "The effect of the

action of aspiration of endotracheal tube mucus

(ETT) on oxygen saturation levels in patients treated

in ICU room of RSUP Prof. DR. D. Kandou Manado

"which shows the differences in oxygen saturation

levels before and after given mucus suctioning action

where there is a difference in the value of saturation

levels of 5.174% and pvalue = 0,000 (α <0.05).

Based on the total score of each dimension in the

table above, statistical analysis of the Wilcoxon test

means that Ho is rejected so that there is an Influence

of Endotracheal Tube (ETT) Suction on the Oxygen

Saturation Level in the ICU of the Grandmed Lubuk

Pakam Hospital in 2019. Easier interpretation of data

is by looking at the p value index of = .000 <(0.05).

Therefore it can be concluded that Ho is rejected. So

there is the effect of Endotracheal Tube (ETT) Mucus

Suction Act on the Oxygen Saturation Level in the

ICU in Grandmed Lubuk Pakam Hospital in 2019.

The action of mucus suctioning performed on patients

with ventilators installed at Grandmed Hospital has

an effect on changes in oxygen saturation in the ICU

at Grandmed Lubuk Hospital in 2019..

The obstacle found in this study is the

uniformity in using suction cannula size is not the

same, because the size is different so that it affects the

difference in the value of oxygen saturation in

patients with suctioning measures. The size of a larger

suction cannula (14 Fr) can reduce Oxygen Saturation

levels more than the smaller size (12 Fr). Another

obstacle found in this study is regarding the level of

education and tenure of nurses who perform

suctioning actions. This can have an indirect effect on

nurses' skills in performing suctioning actions.

4 CONCLUSION

For Bivariate analysis was got the results obtained

based on the Wilcoxon test have a significant

difference between before and after the results. The

value before the suction action includes the mean

value is 86.90%, the standard deviation value is

4.553%, the minimum value is 79%, the maximum

value is 95%, and the value after suction action

includes: the mean value is 95.85%, the standard

deviation value is 4760%, the minimum value is 84%,

the maximum value is 100%. Then conclusions There

is an influence before and after the suction action on

the value of oxygen saturation (p <0.005), so that Ha

is accepted.

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