I guess it depends on whether you are asking if it is important to use it, or important not to use it. The current thought is that using it actually increases the chances of VAP (or nosocomial pneumonia if not on a vent) because you are flushing colonized bacteria into the lower airways, which are sterile. Makes a lot of sense. On the other hand, when the patient has thick secretions, you have to do something to thin them out so they can be suctioned up.

In my clinical practice, I really have not seen evidence that using NS to lavage before suctioning causes VAP or nosocomial pneumonia. Then again, it is not our practice to "bag" and lavage, just lavage and that may make a difference.

Thanks for the reply on this one PCMStexas. This is a pet subject of mine. I have used bag and lavage for years and just have not seen any evidence that reasonable lavage has any effect on VAP. There has been some theories that it may have that effect, but I don't recall any cause and effect studies such as we quit instilling and no VAP then we instilled and VAP came back. NS lavage is behind in the voting so far, but I am very certain that this adjunct to airway clearance is often crucial to maintenance of a patent airway and complete secretion clearance. I do beg to differ on the thinning concept. I consider the saline a "floating agent" saline just can't thin tenaceous sputum. I have seen saline pulled into a sxn canister half full of sputum and it just rested on top and did not mix in. I will take this on in more detail at some point in the future, for now if anyone knows of any outcome based studies which prove the theories about increased VAP with NS lavage, please post the references. The following is from a AACN.org forum from a few years back. I don't know about all of the logic, but in general this was well said by this poster then, and much of the logic still applies.Nursing discussion board More thoughts??

texas brotherhood,
I agree that the literature on this subject is not great, mostly nursing journals. They are great. One cites the other and so on and so on, then they come at you with "haven't you read all the research". This always makes me laugh becasue all the articles quote each other. No study shows lavage = VAP. However breaking the circuit does increase VAP and many people do this when they lavage and all do this when the bag sooo...... draw your own conclusions.

I like Gary do not feel that Saline thins secretions. I ask you: When do many health care people suction? When they hear rhonchi, so they levage and suction then rhonchi goes away, right? What I ask you is what if your saline bolus pushed the secretions down the airway making it to where we can not hear the rhonchi and the "sputum" we got out of our suction was the original saline. I have somewhere a article that looked at this very subject and found that most of the "sputum" that was suctioned after a NS lavage was just Saline, so what did we really do?

Now don't get me wrong I do not want to throw NS lavage out the window, but normal everyday use of it, YES get rid of it! It is not needed if AW's are adequatly humidified and simple suctioning is done to the patient that is all that is needed. NS levage should be used if tube is occluded or in severe cases, not normal everyday suctioning. Personal thought is that NS levage elicits a stronger cough, becasue the patient thinks they drowning, and that is why secretions move. Not a felling I would want to have.

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By the way Gary, that JCowan on the nursing board. If he is, who I think he is. He was a hell of a clinician and a role model for me in my carreer as a RT.

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Thanks light for these very thoughtful comments on this subject. I find the vote is coming right now no's by about 2:1. I haven't voted, but I would have to say I would have some real issues feeling confident in my ability to facilitate the best possible outcomes without the ability to instill NS prn. I hate to go against the "evidence", but I just don't think the body of evidence in this case is complete. I have spent nearly the last 10 years at a LTACH that uses bag and lavage for the majority of airway clearance and we had a very low incident of VAP. I am a little surprised on the vote, but in time I will give further explanation of how I arrived at my current opinion.

I was clicking through some of the sights discussion archives and found thisarchived discussionon the topic.

I think lavage and sx works very well, not to thin secretions, but to jar them loose. Likewise, I've found that even with the humidifier and rainout set to the max, a clot can still develop in the ETT. For both of these reasons, we support this technique at our hospital. It's not a policy per se, but I'm pretty sure every one here does it at least once a shift.

I have saved a lot of references on this topic. There is NO study really showing, in anything resembling science, that instilling saline causes anything of harm to occur. Some of the studies are downright ludicrous in design---instilling saline per clinician prefernce in post op CABG patients and looking at insignificant SvO2 drops for instance.

In terms of saline mixing with secretions: if it doesn't do any good in the airways to mobilize secretions why don't we just stop instilling saline to clear our inline suction lines, stop using saline to clear the suction tubing leading back into the cannister, and stop instilling saline during bronks and combicath sampling. And stop instilling when you've got that super tenacious bloody clot while bagging and instilling saline may in fact be life-saving.

I certainly wouldn't lavage just because, but it should definitely be done if there is indication for it.

Even if studies showed that using it did increase VAP, I still think it should be used if the benefits out weigh the contraindications.

IMO of course.