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Guideline Summary
Guideline Title
Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010.
Bibliographic Source(s)
American Association for Respiratory Care. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010 Jun;55(6):758-64. [89 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Association for Respiratory Care (AARC). AARC clinical practice guideline. Endotracheal suctioning of mechanically ventilated adults and children with artificial airways. Respir Care 1993 May;38(5):500-4. [33 references]

Scope

Disease/Condition(s)

Pulmonary disease or other condition where use of mechanical ventilation is necessary

Guideline Category
Evaluation
Management
Risk Assessment
Clinical Specialty
Anesthesiology
Critical Care
Emergency Medicine
Infectious Diseases
Internal Medicine
Orthopedic Surgery
Pediatrics
Pulmonary Medicine
Surgery
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Respiratory Care Practitioners
Guideline Objective(s)

To provide clinical practice guidelines on endotracheal suctioning of mechanically ventilated adults and children with artificial airways

Target Population

Mechanically ventilated adults and children with artificial airways

Interventions and Practices Considered
  1. Patient preparation
    • Catheter selection
    • Pre-oxygenation (delivery of 100% oxygen) in preparation of suctioning event
    • Check negative pressure of the unit
    • Set suction pressure as low as possible
    • Closed suctioning technique for specific patient groups
    • Open suctioning
    • Pulse oximetry
  2. Shallow suctioning technique
  3. Sterile technique during open suctioning
  4. Lung recruitment maneuvers
  5. Duration of suction event <15 seconds
  6. Monitoring (breath sounds, oxygen saturation, respiratory rate, pattern, hemodynamic parameters, sputum characteristics, cough characteristics, intracranial pressure [as indicated], ventilator parameters)

Note: Deep suctioning and normal saline instillation prior to endotracheal suction was considered but not recommended.

Major Outcomes Considered
  • Improvement in breath sounds
  • Decreased peak inspiratory pressure (PIP) with narrowing of PIP-plateau pressure; decreased airway resistance or increased dynamic compliance; increased tidal volume delivery during pressure-limited ventilation
  • Improvement in arterial blood gas values (ABGs) or saturation as reflected by pulse oximetry (SpO2)
  • Removal of pulmonary secretions

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

An electronic literature search for articles published between January 1990 and October 2009 was conducted by using MEDLINE, CINAHL, and Cochrane Library databases. The update of this clinical practice guideline is the result of reviewing a total of 114 clinical trials, 62 reviews and 6 meta-analyses on endotracheal suctioning.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Grade of Quality of the Evidence

Quality of the Evidence
Grade Quality Description
A High Well-performed randomized controlled trials or overwhelming evidence of some other sort. Further research is very unlikely to change our confidence in the estimate of the effect.
B Moderate Randomized controlled trials that are less consistent, have flaws, or are indirect in some way to the issue being graded, or very strong evidence of some other sort. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
C Low Observational evidence (from observational studies, case series, or clinical experience), or evidence from controlled trials with serious flaws. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
D Very Low Any estimate of effect is very uncertain.

Adapted from: Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-926.

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

The American Association for Respiratory Care (AARC) clinical practice guidelines (CPGs) steering committee has initiated a new process by which the "reference-based" guidelines will be revised and updated by adopting a modification of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system (see "Availability of Companion Documents"). This guideline is the product of this process. Although it is clear that most treatments and interventions in respiratory care are rarely graded A, it is our responsibility to make recommendations based on the best evidence available at the time the CPG is updated. The words "recommended" and "suggested" are used to reflect the strength of the recommendation, as level 1 and level 2, respectively (see "Rating Scheme for the Strength of the Recommendation"). Although grading evidence is complex, the committee has set the goal of recommending what you, the clinician, should do. While the format for most traditional sections of the CPGs remains unchanged, each newly revised CPG includes recommendations with graded evidence. This is the latest in our efforts to improve the value of the AARC CPGs.

Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations

Strength of the Recommendations

Level Strength Description
1 Stronger Benefits clearly outweigh the risks and burdens (or vice versa) for nearly all patients.
2 Weaker Risks and benefits are more closely balanced or are more uncertain

Adapted from: Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-926.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Not stated
Description of Method of Guideline Validation

Not applicable

Recommendations

Major Recommendations

The levels of evidence (grade A-D) and the strength of the recommendations (level 1-2) are defined at the end of the "Major Recommendations" field. The words "recommended" and "suggested" are used to reflect the strength of the recommendation, as level 1 and level 2, respectively.

Patient Preparation

It is recommended to use smaller catheters whenever possible, since suction pressure seems to have less influence on lung volume loss than catheter size. (Copnell et al., 2009) For a given diameter of the endotracheal tube (ETT), the level of negative pressure transmitted to the airway is determined by the combination of the catheter size and the suction pressure. The larger the diameter of the catheter size, the less attenuation of the suction pressure through the airways. (Kiraly et al., 2008)

  • Diameter of the suction catheter should not exceed one half the inner diameter of the artificial airway in adults, providing an internal-to-external diameter ratio of 0.5 in adults (Tiffin, Keim, & Frewen, 1990; Vanner & Bick, 2008) and 0.5–0.66 in infants and small children. (Singh et al., 1991)
  • In preparation for the suctioning event, delivery of 100% oxygen in pediatric (Kerem, Yatsiv, & Goitein, 1990) and adult patients (Bourgault et al., 2006) and 10% increase of baseline in neonates (Pritchard, Flenady, & Woodgate, 2001; González-Cabello et al., 2005; Pritchard, Flenady, & Woodgate, 2003) for 30–60 seconds prior to the suctioning event is suggested, especially in patients who are hypoxemic before suctioning. (Demir & Dramali, 2005; Oh & Seo, 2003) This may be accomplished either:
    • By adjusting the fractional inspired oxygen (FiO2) setting on the mechanical ventilator
    • By use of a temporary oxygen-enrichment program available on many microprocessor ventilators (Campbell & Branson, 1992)
    • Manual ventilation of the patient is not recommended, as it has been shown to be ineffective for providing delivered FiO2 of 1.0. (Barnes & McGarry, 1990; Woodgate & Flenady, 2001) Practitioners should ensure that positive end-expiratory pressure (PEEP) is maintained if no other alternative is available to hyper-oxygenate.
  • The negative pressure of the unit must be checked by occluding the end of the suction tubing before attaching it to the suction catheter, and prior to each suctioning event. Suction pressure should be set as low as possible and yet effectively clear secretions. Experimental data to support an appropriate maximum suction level are lacking. Negative pressure of 80–100 mmHg in neonates (Wilinska et al., 2008) and less than 150 mmHg in adults have been recommended. (Plevak & Ward, 1997)
  • The closed suctioning technique facilitates continuous mechanical ventilation and oxygenation during the suctioning event. (Johnson et al., 1994; Lee et al., 2001)
    • It may prevent lung derecruitment associated with the use of open-suction system in patients at higher risk of desaturation (e.g., premature newborns). (Woodgate & Flenady, 2001; Lindgren et al., 2007; Kalyn et al., 2003; Tan et al., 2005; Cordero, Sananes, & Ayers, 2000; Choong et al., 2003; Kiraly et al., 2009; Hoellering et al., 2008)
    • It should be considered in patients requiring high FiO2 and positive end expiratory pressure (PEEP) (e.g., acute lung injury). (Maggiore et al., 2003; Brochard et al., 1991; Lasocki et al., 2006; Tingay et al., 2007; Cereda et al., 2001; Caramez et al., 2006; Fernandez et al., 2004)
    • It neither increases nor decreases the risk of ventilator-associated pneumonia. (Subirana, Sola, & Benito, 2007; Topeli et al., 2004; Zeitoun, de Barros, & Diccini, 2003)
    • Daily changes of in-line suction catheters do not decrease the risk of ventilator-associated pneumonia and is not cost-effective. (Kollef et al., 1997; Stoller et al., 2003)
  • A patient should be placed on a pulse oximeter to assess oxygenation during and following the procedure.

Procedure

The suctioning event consists of the placement of a suction catheter through the artificial airway into the trachea and the application of negative pressure as the catheter is being withdrawn. Each pass of the suction catheter into the artificial airway is considered a suctioning event. (Gardner & Shirland, 2009)

  • Shallow suctioning is recommended to prevent trauma to the tracheal mucosa.
  • Deep suctioning has not shown superior benefit over shallow suction (Spence, Gillies, & Waterworth, 2003) and may be associated with more adverse events. (Boothroyd et al., 1996; Ahn & Hwang, 2003; Youngmee & Yonghoon, 2003)
  • The duration of each suctioning event should be no more than 15 seconds. (Kerem, Yatsiv, & Goitein, 1990; Pederson et al., 2009; Morrow & Argent, 2008)
  • Sterile technique is encouraged during open suctioning technique. (Koeppel, 2006)
  • Normal saline instillation. Instillation refers to the administration of aliquots of saline directly into the trachea via an artificial airway. It is hypothesized that normal saline instillation may loosen secretions, increase the amount of secretions removed, and aid in the removal of tenacious secretions. However, there is insufficient evidence to support this hypothesis. Normal saline instillation appears to enhance secretion clearance through cough stimulation in adults, (Gray, MacIntyre, & Kronenberger, 1990) and a recent report suggests that normal saline instillation prior to suctioning is associated with decreased incidence of ventilator-associated pneumonia in ventilated adult patients. (Caruso et al., 2009) The great majority of the references used to update this guideline indicate that normal saline instillation is unlikely to be beneficial, and may in fact be harmful. (Woodgate & Flenady, 2001; Morrow & Argent, 2008; Branson, 2007; Celik & Kanan, 2006; Ridling, Martin, & Bratton, 2003) Therefore, it should not be routinely performed prior to performing endotracheal suctioning.

Follow-Up Care

Following the suctioning event:

  • Hyper-oxygenation for at least 1 min by following the same technique(s) used to pre-oxygenate the patient may be used, especially in patients who are hypoxemic before and/or during suctioning. (Pritchard, Flenady, & Woodgate, 2001)
  • Hyperventilation should not be routinely used.
    • Lung-recruitment maneuvers may be attempted in patients with clear evidence of derecruitment. (Maggiore et al., 2003; Morrow, Futter, & Argent, 2007; Dyhr, Bonde, & Larsson, 2003)
  • The patient should be monitored for adverse reactions.

Setting

Endotracheal suctioning may be performed by properly trained persons in a wide variety of settings that include (but are not limited to):

  • Hospital
  • Extended care facility
  • Home
  • Out-patient clinic
  • Physician's office
  • Transport vehicle

Indications

  • The need to maintain the patency and integrity of the artificial airway
  • The need to remove accumulated pulmonary secretions as evidenced by one of:
    • Sawtooth pattern on the flow-volume loop on the monitor screen of the ventilator and/or the presence of coarse crackles over the trachea are strong indicators of retained pulmonary secretions. (Guglielminotti et al., 2000; Wood, 1998)
    • Increased peak inspiratory pressure during volume-controlled mechanical ventilation or decreased tidal volume during pressure-controlled ventilation (Morrow, Futter, & Argent, 2004)
    • Deterioration of oxygen saturation and/or arterial blood gas values (Morrow, Futter, & Argent, 2004)
    • Visible secretions in the airway (Morrow, Futter, & Argent, 2004)
    • Patient's inability to generate an effective spontaneous cough
    • Acute respiratory distress (Morrow, Futter, & Argent, 2004)
    • Suspected aspiration of gastric or upper-airway secretions
  • The need to obtain a sputum specimen to rule out or identify pneumonia or other pulmonary infection or for sputum cytology

Contraindications

Endotracheal suctioning is a necessary procedure for patients with artificial airways. Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical condition as result of the procedure. When indicated, there is no absolute contraindication to endotracheal suctioning, because the decision to withhold suctioning in order to avoid a possible adverse reaction may, in fact, be lethal.

Hazards/Complications

  • Decrease in dynamic lung compliance (Main et al., 2004) and functional residual capacity (Heinze et al., 2008)
  • Atelectasis (Lasocki et al., 2006; Subirana, Sola, & Benito, 2007)
  • Hypoxia/hypoxemia (Sabirana, Sola, & Benito, 2007; Jongerden et al., 2007)
  • Tissue trauma to the tracheal and/or bronchial mucosa (Runton, 1992)
  • Bronchoconstriction/bronchospasm (Guglielminotti, Desmonts & Dureuil, 1998; Heinze et al., 2008)
  • Increased microbial colonization of lower airway (Tiffin, Keim, & Frewen, 1990; Freytag et al., 2003)
  • Changes in cerebral blood flow (Skov et al., 1992; Shah et al., 1992) and increased intracranial pressure (Kerr et al., 1997; Kerr et al., 1998; Rudy et al., 1991)
  • Hypertension (Evans, 1992)
  • Hypotension (Woodgate & Flenady, 2001)
  • Cardiac dysrhythmias (Woodgate & Flenady, 2001)
  • Routine use of normal saline instillation may be associated with the following adverse events:
    • Excessive coughing (Gray, MacIntyre, & Kronenberger, 1990)
    • Decreased oxygen saturation (Ridling, Martin, & Bratton, 2003; Ackerman & Gugerty, 1990; Reynolds, Hoffman, & Schlicting, 1990; Kinloch, 1999; Akgul & Akyolcu, 2002; Ji, Kim, & Park, 2002)
    • Bronchospasm
    • Dislodgement of the bacterial biofilm that colonizes the ETT into the lower airway (Caruso et al., 2009; Ackerman, 1993; Hagler & Traver, 1994; Estes & Meduri, 1995)
    • Pain, anxiety, dyspnea (Jablonski, 1994; O'Neal et al., 2001)
    • Tachycardia (Ridling, Martin, & Bratton, 2003)
    • Increased intracranial pressure (Evans, 1992; Chulay, 1994)

Limitations of Method

Endotracheal suctioning is not a benign procedure, and operators should remain sensitive to possible hazards and complications and take all necessary precautions to ensure patient safety. Secretions in peripheral airways are not and should not be directly removed by endotracheal suctioning.

Assessment of Need

Qualified personnel should assess the need for endotracheal suctioning as a routine part of the patient/ventilator system assessment as detailed in section titled "Indications" above.

Assessment of Outcomes

  • Improvement in appearance of ventilator graphics and breath sounds (Wood, 1998; Morrow, Futter, & Argent, 2004)
  • Decreased peak inspiratory pressure with narrowing of peak inspiratory pressure-plateau pressure; decreased airway resistance or increased dynamic compliance; increased tidal volume delivery during pressure-limited ventilation
  • Improvement in arterial blood gas values or saturation, as reflected by pulse oximetry (SpO2)
  • Removal of pulmonary secretions

Resources

  • Necessary equipment:
    • Vacuum source
    • Calibrated, adjustable regulator
    • Collection bottle and connecting tubing
    • Disposable gloves
      • Sterile (open suction)
      • Clean (closed suction)
    • Sterile suction catheter
      • For selective main-bronchus suctioning, a curved-tip catheter may be helpful. (Kubota et al., 1990) The information related to the effectiveness of head turning for selective suctioning is inconclusive.
    • Sterile water and cup (open suction)
    • Goggles, mask, and other appropriate equipment for standard precautions (Siegal et al., 2007)
    • Oxygen source with a calibrated metering device
    • Pulse oximeter
    • Manual resuscitation bag equipped with an oxygen-enrichment device for emergency backup use
    • Stethoscope
  • Optional equipment
    • Electrocardiograph
    • Sterile sputum trap for culture specimen
  • Personnel. Licensed or credentialed respiratory therapists or individuals with similar credentials (e.g., MD, RN) who have the necessary training and demonstrated skills to correctly assess need for suctioning, perform the procedure, and adequately evaluate the patient after the procedure.

Monitoring

The following should be monitored prior to, during, and after the procedure:

  • Breath sounds
  • Oxygen saturation
    • Skin color
    • Pulse oximeter
  • Respiratory rate and pattern
  • Hemodynamic parameters
    • Pulse rate
    • Blood pressure, if indicated and available
    • Electrocardiogram, if indicated and available
  • Sputum characteristics
    • Color
    • Volume
    • Consistency
    • Odor
  • Cough characteristics
  • Intracranial pressure, if indicated and available
  • Ventilator parameters
    • Peak inspiratory pressure and plateau pressure
    • Tidal volume
    • Pressure, flow, and volume graphics, if available
    • FIO2

Frequency

Although the internal lumen of an ETT decreases substantially after a few days of intubation, due to formation of biofilm, (Shah & Kollef, 2004) suctioning should be performed only when clinically indicated in order to maintain the patency of the artificial airway used. (Van de Leur et al., 2003; Cordero, Sananes, & Ayers, 2001; Wilson et al., 1991) Special consideration should be given to the potential complications associated with the procedure.

Infection Control

  • Centers for Disease Control guidelines for standard precautions should be followed. (Siegal et al., 2007)
    • If manual ventilation is used, care must be taken not to contaminate the airway.
    • Sterile technique is encouraged during the entire suctioning event.
  • All equipment and supplies should be appropriately disposed of or disinfected.

Recommendations

The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) (Guyatt et al., 2008; Jaeschke et al., 2008) criteria:

  • It is recommended that endotracheal suctioning should be performed only when secretions are present, and not routinely. (1C)
  • It is suggested that pre-oxygenation be considered if the patient has a clinically important reduction in oxygen saturation with suctioning. (2B)
  • Performing suctioning without disconnecting the patient from the ventilator is suggested. (2B)
  • Use of shallow suction is suggested instead of deep suction, based on evidence from infant and pediatric studies. (2B)
  • It is suggested that routine use of normal saline instillation prior to endotracheal suction should not be performed. (2C)
  • The use of closed suction is suggested for adults with high FIO2, or PEEP, or at risk for lung derecruitment (2B), and for neonates (2C).
  • Endotracheal suctioning without disconnection (closed system) is suggested in neonates. (2B)
  • Avoidance of disconnection and use of lung-recruitment maneuvers are suggested if suctioning-induced lung derecruitment occurs in patients with acute lung injury. (2B)
  • It is suggested that a suction catheter is used that occludes less than 50% of the lumen of the ETT in children and adults, and less than 70% in infants. (2C)
  • It is suggested that the duration of the suctioning event be limited to less than 15 seconds. (2C)

Definitions:

Strength of the Recommendations and Grade of Quality of the Evidence

Strength of the Recommendations
Level Strength Description
1 Stronger Benefits clearly outweigh the risks and burdens (or vice versa) for nearly all patients.
2 Weaker Risks and benefits are more closely balanced or are more uncertain
Quality of the Evidence
Grade Quality Description
A High Well-performed randomized controlled trials or overwhelming evidence of some other sort. Further research is very unlikely to change our confidence in the estimate of the effect.
B Moderate Randomized controlled trials that are less consistent, have flaws, or are indirect in some way to the issue being graded, or very strong evidence of some other sort. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
C Low Observational evidence (from observational studies, case series, or clinical experience), or evidence from controlled trials with serious flaws. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
D Very Low Any estimate of effect is very uncertain.

Adapted from: Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso- Coello P, Schünemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-926.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for many recommendations (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate and effective application of endotracheal suctioning of mechanically ventilated adults and children with artificial airways

Potential Harms
  • Decrease in dynamic lung compliance and functional residual capacity
  • Atelectasis
  • Hypoxia/hypoxemia
  • Tissue trauma to the tracheal and/or bronchial mucosa
  • Bronchoconstriction/bronchospasm
  • Increased microbial colonization of lower airway
  • Changes in cerebral blood flow and increased intracranial pressure
  • Hypertension
  • Hypotension
  • Cardiac dysrhythmias
  • Routine use of normal saline instillation may be associated with the following adverse events:
    • Excessive coughing
    • Decreased oxygen saturation
    • Bronchospasm
    • Dislodgement of the bacterial biofilm that colonizes the endotracheal tube (ETT) into the lower airway
    • Pain, anxiety, dyspnea
    • Tachycardia
    • Increased intracranial pressure

Contraindications

Contraindications

Endotracheal suctioning is a necessary procedure for patients with artificial airways. Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical condition as result of the procedure. When indicated, there is no absolute contraindication to endotracheal suctioning, because the decision to withhold suctioning in order to avoid a possible adverse reaction may, in fact, be lethal.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Safety

Identifying Information and Availability

Bibliographic Source(s)
American Association for Respiratory Care. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010 Jun;55(6):758-64. [89 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1993 May (revised 2010 Jun)
Guideline Developer(s)
American Association for Respiratory Care - Professional Association
Source(s) of Funding

American Association for Respiratory Care (AARC)

Guideline Committee

American Association for Respiratory Care Clinical Practice Guidelines Steering Committee

Composition of Group That Authored the Guideline

Committee Members: Ruben D. Restrepo, MD, RRT, FAARC (Chair); Joel M Brown II, RRT; John M Hughes, MEd, RRT, AE-C

Financial Disclosures/Conflicts of Interest

No conflicts of interest

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Association for Respiratory Care (AARC). AARC clinical practice guideline. Endotracheal suctioning of mechanically ventilated adults and children with artificial airways. Respir Care 1993 May;38(5):500-4. [33 references]

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Association for Respiratory Care (AARC) Web site External Web Site Policy.

Print copies: Available from AARC, 9425 N. MacArthur Blvd., Ste. 100, Irving, TX 75063.

Availability of Companion Documents

The following is available:

  • Restrepo RD. American Association for Respiratory Care (AARC) clinical practice guidelines: from "reference-based" to "evidence-based." Respir Care. 2010 Jun;55(6):787-9. Available in Portable Document Format (PDF) from the American Association for Respiratory Care (AARC) Web site External Web Site Policy.

Print copies: Available from AARC, 9425 N. MacArthur Blvd., Ste. 100, Irving, TX 75063.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on November 30, 1998. The information was verified by the guideline developer on December 15, 1998. This summary was updated by ECRI Institute on November 23, 2010. The updated information was verified by the guideline developer on December 27, 2010.

Copyright Statement

Interested persons may photocopy these clinical practice guidelines (CPGs) for noncommercial purposes of scientific or educational advancement. Please credit the American Association for Respiratory Care (AARC) and RESPIRATORY CARE. All of the AARC CPGs can be downloaded at no charge at http://www.rcjournal.com/cpgs External Web Site Policy.

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