Nursing Evidence-Based Practice Guidelines for Impaired Airway Clearance in ICU - Systematic Literature Review

Mariana Magalhães Chagas, Isabel CF da Cruz


Introduction: The Systematization of Nursing Care (SAE) is a tool that helps nurses in decision making, being relevant mainly in the context of intensive care. Ineffective Airway Clearance (IAC) is a nursing diagnosis commonly present in adult/elderly patients under intensive care, especially those using mechanical ventilation. Therefore, the nurse needs to be attentive to the indicators of this diagnosis and the interventions to achieve airway permeability in this population. Objective: To review the nursing guidelines based on evidence that will help the intensive care nurse in the identification and treatment of the IAC diagnosis, within 7 days. Methodology: Integrative literature review, which searched for articles about nursing interventions to resolve the IAC diagnosis, published between 2012 and 2019 on the virtual portals of PubMed, BVS and SciELO databases. 761 articles were found, and after two analyzes regarding the inclusion criteria, 10 articles were selected. Results: 2012 was the year with the highest number of publications. The country of predominance of publications was Brazil. As for the methodology, cross-sectional and descriptive studies represented the majority, with a low level of evidence. The population studied in the articles was the adult/elderly patient, mainly under high complexity care and using mechanical ventilation. Discussion: Lung auscultation helps to detect adventitious sounds, which are defining characteristics of IAC, especially thick crackles. Airway aspiration reduces obstruction and improves the permeability of the respiratory system, also decreasing the risk of VAP. There is a discrepancy between the aspiration practice performed by the nursing team and the evidence for this procedure, requiring continuing education actions. There are controversies in the literature about the instillation of saline solution before aspiration, but the article’s majority contraindicate the practice and some of them report a decrease in patient’s oxygenation. Conclusion: This study can assist in the establishment of evidence-based guidelines for the systematization of high complexity nursing care for adult/elderly patients, as well as in the implementation of electronic medical records. The defining characteristics and interventions addressed can be directly attributed to the resolution of the IAC diagnosis, facilitating decision
making, optimizing nursing team’s practice and contributing to the patient’s treatment.


Nursing Care; Airway Obstruction; Suction; Artificial Respiration

Full Text:



Truppel TC, Meier MJ, Calixto RC, Peruzzo SA, Crozeta K. Sistematização da Assistência de Enfermagem em Unidade de Terapia Intensiva. Rev Bras Enferm [Internet]. 2009 mar-abr [cited 2020 out 12];62(2): 221-7. Available from:

Ferreira AM, Rocha EN, Lopes CT, Bachion MM, Lopes JL, Barros ALBL. Diagnósticos de enfermagem em terapia intensiva: mapeamento cruzado e Taxonomia da NANDA-I. Rev Bras Enferm [Internet]. 2016 mar-abr [cited 2020 out 25];69(2):307-15. Available from:

Braga CG, Cruz DALM. A taxonomia II proposta pela North American Nursing Diagnosis Association (NANDA). Rev Latino-am Enferm [Internet]. 2003 mar-abr [cited 2020 out 12];11(2): 240-4. Available from:

Herdman TH, Kamitsuru S. Diagnósticos de enfermagem da NANDA-I: definições e classificação 2018-2020 [Internet]. 11.ed. Porto Alegre: Artmed; 2018. [cited 2020 out 25]. Available from:

Shutes BL, Evans LR, Moore-Clingenpeel MD, Karsies TJ. Validity and reliability of a new tool to evaluate impaired airway clearance in hospitalized pediatric subjects with respiratory distress. Respir Care [Internet] 2019 jul [cited 2020 out 25]; 64(7): 771-7.Available from:

Coutinho DTR. Desobstrução Ineficaz das Vias Aéreas: mapeamento das intervenções de enfermagem para idosos em terapia intensiva [Dissertação de Mestrado]. Fortaleza – CE: Universidade Estadual do Ceará – UEC; 2016.

Martins MFM. Estudos de Revisão de Literatura. Coordenação de Informação e Comunicação – Fundação Oswaldo Cruz (FIOCRUZ). 2018 set; 1-37.

Garcia AKA, Fonseca LF, Aroni P, Galvão CM. Estratégias para o alívio da sede: revisão integrativa da literatura. Rev Bras Enferm [Internet]. 2016 nov-dez [cited 2020 out 30];69(6):1148-55. Available from:

Galvão CM. Níveis de Evidência. Acta Paul Enferm [Internet]. 2006 [cited 2020 nov 3];19(2). Available from:

Santos NA, Cavalcante TF, Lopes MVO, Gomes EB, Oliveira CJ. Profile of nursing diagnoses in patients with respiratory disorders. Invest Educ Enferm [Internet]. 2015 [cited 2020 nov 3];33(1):112-118. Available from:

Sallum AMC, Santos JLF, Lima FD. Diagnósticos de enfermagem em vítimas fatais decorrentes de trauma no cenário da emergência. Rev Latino-Am Enferm [Internet]. 2012 [cited 2020 dez 2];20(1): 1-8. Available from:

Lopes CT, Carneiro CS, Santos VB, Barros ALBL. Diagnósticos de Enfermagem validados em cardiologia no Brasil: revisão integrativa de literatura. Acta Paul Enferm [Internet]. 2012 [cited 2020 dez 2];25(n.esp.1):155-60. Available from:

Frota OP, Loureiro MDR, Ferreira AM. Aspiração endotraqueal por sistema aberto: práticas de profissionais de enfermagem em terapia intensiva. Esc Anna Nery Rev Enferm [Internet]. 2014 [cited 2020 dez 2];18(2):296-302. Available from:

Favretto DO, Silveira RCCP, Canini SRMS, Garbin LM, Martins FTM, Dalri MCB. Aspiração endotraqueal em pacientes adultos com via aérea artificial: revisão sistemática. Rev Latino-Am Enferm [Internet]. 2012 [cited 2020 dez 2]; 20(5): 1-11. Available from:

Mwakanyanga ET, Masika GM, Tarimo EAM. Intensive care nurses' knowledge and practice on endotracheal suctioning of the intubated patient: a quantitative cross-sectional observational study. PLoS ONE [Internet]. 2018 [cited 2020 dez 2]; 13(8): 1-13. Available from:

Canto DF, Almeida MA. Resultados de enfermagem para padrão respiratório ineficaz e ventilação espontânea prejudicada em terapia intensiva. Rev Gaúcha Enferm [Internet]. 2013 [cited 2020 dez 2]; 34(4): 137-145. Available from:

Caparros ACS, Forbes A. Mechanical ventilation and the role of saline instillation in suctioning adult intensive care unit patients: an evidence-based practice review. Dimens Crit Care Nurs [Internet]. 2014 [cited 2020 dez 2]; 33(4): 246-253. Available from:

Chow MCM, Kwok SM, Luk HW, Law JWH, Leung BPK. Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: A pilot randomized controlled trial. Int J Nurs Stud [Internet]. 2012 [cited 2020 dez 2]; 49(11): 1333-41. Available from:

Sole ML, Bennett M, Ashworth S. Clinical Indicators for Endotracheal Suctioning in Adult Patients Receiving Mechanical Ventilation. Am J Crit Care [Internet]. 2015 [cited 2020 dez 2]; 24(4): 318-24. Available from:

Sousa GGS, Pascoal LM, Nunes SFL, Lima Neto PM, Santos FDRP, Santos Neto M, et al. Nursing outcome “airway permeability” in postoperative patients. Rev Bras Enferm [Internet]. 2020 [cited 2020 dez 2];73(3): 1-8. Available from:

Martins I, Gutiérrez MGR. Intervenções de enfermagem para o diagnóstico de enfermagem Desobstrução Ineficaz de Vias Aéreas. Acta Paul Enferm [Internet]. 2005 [cited 2020 dez 2]; 18(2):143-9. Available from:

Souza CR, Santana VTS. Impacto da aspiração supra-cuff na prevenção da pneumonia associada à ventilação mecânica. Rev Bras Ter Intensiva [Internet]. 2012 [cited 2020 dez 2]; 24(4): 401-406. Available from:

Balbino CM, Braz MR, Ribeiro JC, Rodrigues LMS, Silvino ZR. Avaliação da técnica de aspiração de paciente em ventilação mecânica realizada pela enfermagem. J Nurs UFPE on line [Internet]. 2016 [cited 2020 dez 2]; 10(Suppl. 6):4797-803. Available from:

Ayhan H, Tastan S, Iyigun E, Akamca Y, Arikan E, Sevim Z. Normal saline instillation before endotracheal suctioning: What does the evidence say? What do the nurses think?: Multimethod study. J Crit Care [Internet]. 2015 [cited 2020 dez 2]; 30(4): 762-7. Available from:


Share |