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Scientific Inquiry Meets the Bedside

Improving Practices in Airway Management

Alexander, Susan, DNP, ANP-BC, ADM-BC; Column Editor:; O’Neal, Pamela V., PhD, RN

doi: 10.1097/NUR.0000000000000439
DEPARTMENTS: Nurse Entrepreneur

Author Affiliation: Associate Professor (Ms Alexander and Dr O’Neal), College of Nursing, University of Alabama in Huntsville.

The author reports no conflicts of interest.

Correspondence: Susan Alexander, DNP, ANP-BC, ADM-BC, University of Alabama in Huntsville, 301 Sparkman Drive, NB 412, Huntsville, AL 35801 (

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Asking Questions

Many benefits are associated with even minimal amounts of regular physical activity, including increases in life expectancy and improvements in cardiovascular performance.1 Both resting systolic and diastolic blood pressures are reduced in those who perform extended exercise sessions, such as marathon runners.2 In her experience of caring for her husband who underwent a common medical procedure, Pam O’Neal, PhD, RN, quickly gained an appreciation for the clinical manifestations of improved cardiac function. Together completing 20 half-marathons, three 70.3-mile ironman events, and numerous 100-mile bike rides, O’Neal and her husband are well-trained athletes in excellent physical condition. While sitting with her husband as he slept after a colonoscopy, O’Neal noticed that the bedside heart monitor continued to sound an alarm. His enhanced cardiac function, gained from those years of experience as an endurance athlete, has reduced his resting heart rate to 45 to 50 beats per minute, a value that triggered the bedside monitor to sound an alarm. Instead of resetting the parameters for target heart rates on the bedside monitor, a task that would have required more time at the bedside, the nurse in attendance silenced the ringing alarm. O’Neal noted that the nurse visited her husband’s room 7 times over the course of 15 minutes for the purpose of suppressing the alarm, becoming visibly more exasperated with each trip.

A deep interest in the many factors of systems- and patient-level processes of care, and their relationships to patient outcomes, is the basis for a focused program of research that began with O’Neal’s early experiences as a nurse. As an eyewitness to the interaction between nurse, patient, and technology during her husband’s postprocedure recovery, O’Neal finds another example of the need to consider these complex associations, “Are the technological devices we use in our healthcare settings working to make the tasks of clinicians easier and more efficient? Or are we spending our days responding to the demands of these devices?” (P. O’Neal, oral communication, January 2018). Considering the functionality and impact of devices commonly used at the bedside is an aspect of patient care that warrants detailed exploration. “It’s important that we stop to consider how the instruments and tools that we use everyday influence our tasks as clinicians, and even more importantly, their impact on outcomes for patients. How do we know that what we use is safe and effective?” (P. O’Neal, oral communication, January 2018). Finding answers to questions such as these has become the basis for a robust and gratifying program of research, changing O’Neal’s career in ways she could not have anticipated during her initial years in nursing.

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Understanding the Need for Safety and Efficacy in Airway Management

O’Neal’s educational preparation in nursing began with the completion of her associate’s degree in nursing in 1989. Her clinical practice in caring for patients in pulmonary, coronary, and other high-acuity care units stimulated an interest in a broader scope of factors that lead to patient outcomes. After noticing that mechanically ventilated patients often endured lengthier recovery times, higher rates of complications, and greater mortality rates, she became curious about strategies to provide care that would reduce these complications. Searching the literature associated with care of ventilated patients, O’Neal noted a gap in evidence describing additional factors related to safety and efficacy in airway management. Her desire to optimize techniques in suctioning and oral hygiene for mechanically ventilated patients to prevent complications such as endocarditis, pneumonitis, and periodontitis became the basis for her research in mechanical and human factors influencing airway clearance. O’Neal was also interested in the perceptions of dyspnea in patients who were being suctioned, finding this topic to be “…very patient-centered as no one ever asked patients how they felt” (P. O’Neal, oral communication, January 2018).

O’Neal began her research in the mechanics of suctioning and respiratory secretions while completing her doctoral studies, culminating with the award of her terminal degree (PhD) at Virginia Commonwealth University in 2000. In her thesis, O’Neal et al3 assessed patient perceptions of dyspnea during endotracheal suctioning, publishing the results in 2002. O’Neal’s efforts in evaluating patient-level experiences of mechanical ventilation gained her national recognition, when she was selected to be a member of a national team that developed the Richmond Agitation-Sedation Scale.4 Designed to assess agitation and sedation in mechanically ventilated adults, the scale continues to be used internationally as a standard of care in assessing agitation and sedation. At last count, the article describing development and implementation of the Richmond Agitation-Sedation Scale has accrued more than 1200 citations, attesting to the interest in integrating the scale in practice at the bedside.

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Tripartite Focus

O’Neal realized that her desire to assist in the development of safe and effective airway management practices was characterized by 3 themes: factors influencing airway clearance, the physiologic characterization of secretions, and a population focus across the life span (Figure). A clear understanding of these themes and their associations in patient populations has helped her to identify opportunities for collaboration and mentorship throughout her career.



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Suctions: Clearing the Airway

O’Neal has explored aspects of mechanical ventilation by evaluating suction pressures associated with the viscosity of subglottic secretions in ventilated adult patients. Suction pressures in portable suction machines were evaluated over time, and suction pressures measures were found to be inconsistent over time, which impacts airway clearance.5 Other studies focused on manual suction devices and human factors–associated hand placement and pressures generated.6 Manual bulb suction is commonly used to promote naso-oropharyngeal airway clearance. Her work in studying the unknown influences of human factors of hand placement (radial versus axial) upon relative negative pressures generated in manual bulb suctioning techniques represents the initial step in development of clinical guidelines for safe and effective mechanical use of the devices to reduce and prevent upper airway injury.7

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Secretions: Characterizing the Physiology

Biomarkers and microbial descriptions of secretions can aid in understanding the secretion rheology, leading to more effective techniques in clearing airways. Exploring the microbiome of the mother-baby dyad, along with current suctioning practices following birth, is a current area of interest. Describing the project, O’Neal explains, “We knew that pathogenic organisms had been found in blue bulb syringes routinely used within hospital settings and wanted to understand more about the source and species of the organisms” (P. O’Neal, oral communication, January 2018). Commonly found throughout the intrapartum and postpartum periods, blue bulb syringes are used to clear the airways of newborns. O’Neal collaborated with experts in maternal/child health, infectious disease, and epidemiology to evaluate the presence of microorganisms within the bulbs. O’Neal and her colleagues examined a total of 50 blue bulb syringes used in the intrapartum and postpartum periods, finding that 42% of the bulbs had at least 1 isolate identified in cultures; 57 distinct isolates were identified in the cultures of the 50 bulbs.8 These results offer strong evidence that the bulb syringes may serve as a reservoir for bacterial growth and increase the risk of nosocomial infections in neonates.8 “These bulb syringes are used internationally, and there are no national standards regarding appropriate use, cleaning, and storage,” states O’Neal, who hopes that the results can be used to develop appropriate guidelines. “We are asking the question: Do babies who are breathing adequately really need to be suctioned? Are we exposing them to unnecessary risk in doing so?”

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Populations: Considering the Life Span

People of all ages may experience compromised airways. While traditional research methods are needed to expand knowledge about the impact of compromised airways upon vulnerable subpopulations, translating existing knowledge into bedside care is also important to O’Neal. She has mentored many students in projects to design evidence-based protocols that may improve clinical practice. Development of a treatment guide integrating a screening tool for respiratory distress to improve nasal airway clearance for infants with bronchiolitis helped to identify methods to reduce the distress and trauma associated with invasive suctioning of infants.9 The project, designed and implemented by a doctoral student in nursing, integrated national guidelines from the American Academy of Pediatrics on recommended suctioning techniques for infants with bronchiolitis into local practice. Other clinical benefits of the project revealed improvements in oxygenation status associated with noninvasive suctioning and prompt identification of signs of infant respiratory distress in patients’ families.9

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A Lifetime of Work

In addition to her catalogue of scholarly work, O’Neal has actively participated in other aspects of research. She has served as chair of the institutional review board (IRB) at the University of Alabama in Huntsville, where she completed an in-depth review of the IRB processes. She developed an educational area on the IRB website, providing on-demand guidance to faculty who wished to request approval for research necessitating protection of human subjects. After service as associate dean of Undergraduate Affairs, College of Nursing, University of Alabama in Huntsville, O’Neal made the decision to refocus her energies upon research, returning to the classroom so that she could work more closely with students. Since making the change in 2013, O’Neal estimates that she has worked with more than 40 students across all educational programs in nursing, and she is understandably proud of her enduring connections with students. She describes her commitment to engaging students in early exposure to clinical question that drives practice outcomes saying, “To this day—if you go to Huntsville Hospital and see a little purple dot on the suction manometers, you know that’s Pam’s study—our undergraduate nursing students love that!” (P. O’Neal, oral communication, January 2018).

O’Neal will continue to direct her energies toward research in effective airway management practices, stating, “We all breathe, and when our airway becomes compromised, effective airway clearance is an immediate priority of care. Much more research is necessary to develop and establish safe and effective airway clearance standards in variety of populations with manual and mechanical suctioning devices.”

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1. Wen CP, Wai JPM, Tsai MK, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet. 2011;378(9798):1244–1253.
2. Schattke S, Xing Y, Lock J, et al. Increased longitudinal contractility and diastolic function at rest in well-trained amateur Marathon runners: a speckle tracking echocardiography study. Cardiovasc Ultrasound. 2014;12(1):11.
3. O’Neal PV, Grap MJ, Thompson C, Dudley W. Level of dyspnoea experienced in mechanically ventilated adults with and without saline instillation prior to endotracheal suctioning. Intensive Crit Care Nurs. 2001;17(6):356–363.
4. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338–1344.
5. Ng YC, O’Neal PV, Frith KH, Riley LP. Safety and quality concern of in-home suction equipment failure over time. J Clin Eng. 2017;42(2):80–84.
6. Adams ED, O'Neal PV, Hanson LA, Norris C, Ayers A, Harbin B. Airway clearance of the term newborn. MCN Am J Matern Nurs. 2018;43(6):306–312.
7. O’Neal PV, Black CB, Adams ED, Armentrout DL. Human factors associated with the mechanical use of manual bulb suction devices [published online ahead of print January 21, 2019]. Nurs Res. 2019.
8. O’Neal PV, Adams ED, Hanson LA, et al. Microbial profile and characterization of blue bulb manual suction devices used to promote airway clearance in newborns in intrapartum and postpartum units. Am J Infect Control. 2017;45(12):1378–1381.
9. Norris CL, O’Neal PV, Adams ED, Wyatt TH. Nasal airway clearance for bronchiolitis. MCN Am J Matern Nurs. 2018;43(6):318–323.
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