Clinician’s Commentary on Triemstra et al.

To roster for tracheal suctioning with the College of Physiotherapists of Ontario, physiotherapists must “show that they are able to safely and competently perform the controlled act.”^2(p.1) But where does that knowledge come from? For some, it is through recent entry-level training. For others, it comes from literature reviews, presentations, and hands-on learning from experienced colleagues when rostering was implemented. Although learning is not standardized, researchers have developed clinical practice guidelines (CPGs) for the safe and competent performance of tracheal suctioning.

CPGs provide recommendations for a number of components, from whether to hyperoxygenate and hyperinflate patients to what personal protective equipment (PPE) is worn. More than 800 physiotherapists are rostered in Ontario for tracheal suctioning, but are they following these CPGs?³ It has been 20 years since the last review of tracheal suctioning clinical practice, so Triemstra and colleagues sought to update the literature by determining physiotherapists’ common practices when performing tracheal suctioning and whether they align with the CPGs.¹

Triemstra and colleagues found variability between CPGs and practice in a number of areas, but particularly with regard to the use of PPE and hyperoxygenation.¹ Despite this variability, physiotherapists identified CPGs as the second most common influence on their suctioning practice. Previous suctioning experience outweighed any other influence and may be the link between practice and how closely the respondents followed CPGs. The complexity of practice decisions and behaviour is linked to one’s own experiences, both those observed and those experienced alongside colleagues in the work environment.

At the time of this survey, PPE was not a common topic of conversation among anyone except health care professionals. However, with the coronavirus disease 2019 (COVID-19) pandemic, many people are talking about masks, shields, and N95 respirators. Why were physiotherapists not following PPE guidelines before COVID-19? Going by personal experience, the environmental set-up (e.g., whether signs are posted that stipulate the appropriate PPE to don before entering a room) and observation of the PPE worn by colleagues could have influenced practice. With COVID-19, one could expect that these findings would change. A number of hospitals have implemented a mask-and-shield policy for all patient interactions. The pandemic has demonstrated how experience can lead to a shift in culture that can promote or divert from CPGs.

Physiotherapy culture has also shifted. Intensive care physiotherapy is now heavily focused on early mobility and encouraging independent secretion clearance. Before, physiotherapists entered a room prepared to perform chest physiotherapy and suctioning, but now they are focused on maximizing mobility. In this instance, suctioning is a potential consequence of treatment instead of one of the main components. Physiotherapists need to learn to don PPE in preparation for all treatment options.

Triemstra and colleagues found that the practice of hyperoxygenating before suctioning has declined.¹ Although prolonged periods of hyperoxia have been shown to be harmful to patients, this has not yet been shown for short bursts.⁴ This brings us back to the impact of clinical experience. Brooks and colleagues discovered that previous hyperoxygenation rates among physiotherapists, registered nurses (RNs), and respiratory therapists (RTs) were similar.⁵ Although RTs’ current practice is not known, they are the health care professionals most often consulted for their expertise in suctioning.⁵ The experience physiotherapists share with colleagues appears to influence their practice. How do physiotherapists ensure that practice in their clinical environment and that of their colleagues and themselves aligns with CPGs?

Evaluating the translation to practice of musculoskeletal CPGs has indicated that multifaceted interactive strategies led to some improvement in adherence.⁶ Medical colleagues have recommended that key team members monitor adherence and provide frequent education.⁷ Both of these approaches focus on creating a culture of learning with continued education and personal experience with hands-on practice. Although it is important for physiotherapists at individual institutions to organize education and review hands-on skills, the majority of experiences occur among colleagues at the unit level. Suctioning is not isolated to physiotherapists and therefore provides an opportunity to collaborate and engage in shared education with RT and RN colleagues.

Triemstra and colleagues’ article has updated the literature, identified gaps between CPGs and practice, and laid the groundwork for determining the factors that can influence tracheal suctioning practice.¹ Moving forward, research should explore identifying the factors that influence practice and strategies for improving clinical practice to match established CPGs.