Advanced Airway Lavage and Suction: The Latest Evidence

When it comes to lavage and suctioning patients on a ventilator there is a debate brewing. It's not a new debate, as in my 13 years as an RT I've heard both sides, and both sides have convinced me at one point or another. So my quest by researching and writing this post is to determine which side is best to follow.

First we must define lavage and suction. To lavage and suction means to insert normal saline into the endotracheal tube (ETT) and then to suck it up with the suction catheter. The theory here is that the normal saline will loosen up any thick secretions so they can be suctioned out. This is also believed to be a good method of preventing and removing mucus plugs.

So, why was lavage and suctioning started in the first place.  According to a study by Ji and company in 2002, the following is truer: (6)

• The purpose of endotracheal suctioning is to clear secretions from the airway to maintain a patent airway and to optimize ventilation and oxygenation. 
• Instillation of normal saline prior to suction in patients with an artificial airway is a traditional nursing intervention (and no one knows when or why it was started)
• Lacking empirical evidence to support this practice, nurses may arbitrary decide when instillation of saline is appropriate.
• Nurses routinely instill 3-10 ml of normal saline solution into the airway prior to suction to loosen secretions, lubricate the suction catheter and increase secretion clearance due to an enhanced cough stimulation
• Normal saline was believed to mobilize (due to cough) and dilute (due to no theory whatsoever). 
• Research on the benefits of this have been inconclusive (6)

Now for the two theories.

 #1: Lavage and suction is a good thing because not only does it decrease the chance of VAP, it is a great method of preventing mucus plugs. This crowd usually thinks a patient should be lavaged and suctioned at least once a shift.

Interestingly, there truly was no evidence for this argument when it got started.  It was probably another thing we medical care practitioners started simply because it sounded like a good idea.  To spotlight the absurdity of this, consider the following conclusion by researchers to a 1973 study regarding lavage and suctioning: (1)

Demers and Saklad in 1973 reported "water in the form of a vapor or an aerosol is of proven value in thinning secretions and promoting their clearance: mucus and water in bulk form are immiscible and occupy separate phases in vitro, even after vigorous shaking.  Therefore, endotracheal instillation and rapid removal by suctioning is of dubious value.  (1)

 There was nothing in the article that suggested that water thinned secretions; this was something the author simply made up.  There is plenty of evidence that squirting saline into the airway may help clear secretions, but there is nothing to support the claim that it thins secretions.  Such claims are poppycock, and do nothing to advance science in medicine.

However, there is some evidence to support the argument of lavage and suctioning.  A 2009 article in Critical Care Medicine, "Salin instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia," was performed "To compare the incidence of ventilator-associated pneumonia (VAP) with or without isotonic saline instillation before tracheal suctioning." (2)

The conclusion: "Instillation of isotonic saline before tracheal suctioning decreases the incidence of microbiological proven VAP."  (emphasis added) (2)

There were other studies that showed that saline instillation increased mucus clearance, although many of these revealed other side effects that were undesirable, such as a 1999 study that revealed suctioning with saline resulted in an increased duration of suctioning by nearly 4 minutes, while a similar study in 2002 showed that this resulted in an "undesirable, although not significant, alteration in oxygen saturation and arterial blood gas levels. Other studies show that it increases dyspnea, or causes a "drowning feeling." (3)

#2: Lavage and suction increases the risk of ventilator acquired pneumonia (VAP), and therefore saline bullets should never be instilled into the patient's airway.  This crowd generally thinks a patient should only be suctioned on an as needed basis. 

So it is true that mucus is bacteria all balled up. The theory here is that if you add normal saline to the mix, and break up that mucus ball with your normal saline and forceful bagging, you are basically causing that bad bacteria to spread throughout the lungs, and this can cause pneumonia. Plus this crowd is concerned that you only suction up a quarter of the fluid you put into the lungs.

Based on this theory you definitely do not want to bag with an Ambu Bag because when you do this you are basically pushing the mucus and bacteria back into the lungs and this too can cause pneumonia. So basically the only kind of suctioning that you should do is inline suctioning (like with a Ballard).

Now for the evidence.  A 2010 article in Advance for Respiratory Care and Sleep Medicine, "Saline Instillation: helpful or harmful," by C. Farnan and M. Patrick noted the following: (3)

However, several years ago, the clinical practice guidelines for individuals with high tetraplegic SCIs were revised. It is no longer recommended to instill saline into an advanced airway because people with tetraplegia have little or no diaphragm innervation and, therefore, are unable to produce a cough reflex. This practice has been compared to "drowning" patients in their own secretions. After further review of the literature, we found saline instillation is not recommended for any adult patient who is mechanically ventilated. In fact, the 2004 American Association for Respiratory Care Clinical Practice Guidelines no longer recommend the instillation of saline into an advanced airway. (3)

Other studies were also noted by Advance, such as: (3)

Hagler and Travers in 1994 examined the colonization of bacteria on 10 endotracheal tubes removed from patients after 48 hours of intubation. They found "the number of bacteria dislodged into the lower airway as a result of inserting a suction catheter increased fivefold with saline instillation compared to that without saline instillation."In 2003, Freytag, et al., also determined instillation of saline disperses bacteria to the lower respiratory tract.More research is needed in this area to determine whether suctioning increases pneumonia rates or ventilator-associated pneumonias. (3)

But, wait!  There is more.  Studies by E. Zhahran in 2011 (4) and M. Halm in 2008 (5) and Yi in 2002 (6), concluded the following:

• Elevation of PaCO2% immediately after suctioning
• SaO2% decreases, and this desaturation worsens over time after suctioning in following 5 minutes
• Increased stimulation of cough reflex was associated with increased MAP, ICP
• Dislodge bacterial colonies in tube, contaminating lower airway  (4)(5)(6)
• Lavage and suctioning results in increased anxiety, dread, pain (5)
• Increased perceived dyspnea in patients greater than 60 that persisted up to 10 minutes after suctioning, related to decrease in pulmonary compliance with aging (5)
• Normal saline and mucous do not mix, even when shaken vigorously together.Therefore, normal saline does not thin or mobilize secretions (5)  (Emphasis added my me)

Okay, now which theory is best?

In a previous version of this post, I gave the old-time respiratory therapists the benefit of the doubt, and recommended the following:

 Personally, without doing any research, I believe that whichever theory you believe in, you should do a good lavage and suction at least once a shift, and if you have a patient in respiratory distress and you suspect thick secretions to be the culprit. It's invasive, so it should only be done on an as needed basis. Some say this is the common sense approach to suctioning.

Today, in view of the latest evidence, I would like to go one step further, and eliminate the recommendation to lavage and suction once per shift.  Or, as noted by Advance:

The majority of evidence in the literature supports a change in practice. Eliminating saline instillation prior to and during suctioning of a patient with mechanical ventilation or a population without diaphragm innervation has the potential for improved outcomes by decreasing risks associated with this practice such as decreased infection. It may also improve patient comfort and satisfaction by eliminating that "drowning" sensation. 

Many studies have shown instillation of saline has negative effects on oxygenation, level of dyspnea, heart rate and blood pressure. Some studies, however, report no significant differences between the two methods (suctioning with or without saline). If the theory that normal saline instillation is beneficial in removing secretion is to be supported, one would expect to see consistent, research-based evidence indicating secretion removal is greater and oxygenation is improved. This is not the case.

It is time to abandon this non-research based practice. Respiratory therapists should focus on alternative measures of preventing dried and tenacious secretions in the patient who is mechanically ventilated. Respiratory therapists may want to recommend mycolytics and improved hydration to assist in secretion management.

Where I work "to lavage and suction or not to lavage and suction" is generally left to the discretion of the on duty respiratory therapist.  Most suctioning is performed by the nurse or respiratory therapist via an inline suction catheter (notably a Ballard).

Generally speaking, if humidification is adequate, there should be no need for ever performing lavage and suctioning.  However, should the endotracheal tube become occluded, then, and only then, should lavage and suctioning be attempted, and this should only be performed by a trained respiratory therapist.  In other words, routine use of lavage and suctioning is not a good idea.

This is my opinion based on the evidence.  What do you think?

Note:  This post was originally published on Respiratory Therapy Cave on 1/13/2010.  This is the edited and updated version with the latest evidence.  If you have any further evidence to add to the discussion, please note so in the comments below, or email me by clicking on the "contact me" icon in the right hand column of this page.  

Related posts:

• Suctioning: How deep do you go
• How to suction a patient with thinning blood

References: 

1. Demers, R.R., & Saklad, M. (1973). Minimizing the harmful effects of mechanical aspiration. Heart & Lung, 2(4), 542-545; 
2. Pedro, Caruso, et al., "Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia," Critical Care Medicine, January, 2009, 37 (1) pages 32-38; The article was also referenced to in a Ventworld.com discussion. 
3. Farnan, C., M. Patrick, "Saline Instillation: Helpful or Harmful," Advance for Respiratory Care and Sleep Medicine, (posted 8/9/2010), 
4. Zahran, E.M. and A.A. El-Razik, "Tracheal suctioning with verses without saline instillation," Journal of American Science, 2011, 7 (8), pages 23-32
5. Halm, M.A., K. Krisko-Hagal, "Instilling normal saline with suctioning: beneficial technique or potentially harmful sacred cow," American Journal of Critical Care, 2008, 17, pages 469-472
6. Ji, Y., H. Kim, J. Park, "Instillation of normal saline before suctioning in patients with pneumonia," Yonsei Medical Journal, 2002, 43 (5), pages 607-612

Suctioning: how deep do you go?

Your Question: I've actually looked in several places for this info before bugging you, but I can't seem to find it. How do you (or do you) measure how deep to place a suction catheter?

My preceptor asked me the other day just before I suctioned someone, and I wasn't really sure. I thought it should probably be to the depth of the carina, so I said I should measure from the sternal notch to the tip of the tube, but I was not terribly confident. It seemed to work fine. My preceptor just kinda eyeballed me.

My humble answer: First of all, any question any time is my policy. Your preceptor shouldn't give you a funny look because the purpose of clinicals is to learn. The same policy holds true at the RT Cave.

Actually, I think the sternal notch would be too deep. So that might explain the eyeball.

I actually think in RT school we were taught to go down to the corina. Actually, according to critical care nurse (aacnjournals.org), a study was performed and determined that up to 75% of those who suction patients regularly insert the suction catheter until they meet resistance.

And while studies like this show there is no conclusive evidence shallow tracheal suctioning is any better than deep tracheal suctioning, common sense might prevail here. However, other studies performed on animals has shown evidence of more necrosis and inflammation of tissues when deep suctioning was performed.

It is of my opinion, and the opinion of many of my colleagues, that banging into the corina with a narrow tip is not good practice. This is especially bad if the patient is on blood thinners such as coumadin, or if the patient has DIC. It can cause bleeding.

Other research shows it's not the actual suctioning process itself that causes most damage from suctioning, but the hitting of the corina with the suction catheter. To be blunt, this is common sense.

So what kind of trauma can deep suctioning do:

• Epithelial denudement (stripping of the surface of the tissues in that area)
  
• Hyperemia (more blood flow to damaged tissue due to increased tissue activity. In this case it's caused by tissue damage. It decreases oxygen and ph in that area. It also increases temperature and potassium ions in that area. Source: Wikepedia)
  
• Loss of cilia (due to banging the corina and the act of suctioning itself)
  
• edema (swelling of tissue)
  
• fibrosis (generally caused by the repair process of damaged tissue)
  
• granuloma formation (mass or nodule of caused by damaged tissue; infection)

According to critical care nurse, this damage can be made when tissue is sucked into catheter holes after the tissue is traumatized by the tip of the catheter banging into the corina. It can increase the risk of infection and bleeding.

As mentioned above, one study comparing deep and shallow suctioning of rabbits showed evidence of all the above types of damage in 100% of rabbits deep suctioned, and 0-10% in rabits shallow suctioned.

This is why it is important to suction gently:

• Use special tipped catheters when possible
• Use low levels of suction pressure when possible

Another thing to note is that intermittent suctioning has not been proven to reduce trauma. So again, it's not so much the suctioning process itself that causes damage to the patient, it's the tip of the catheter itself.

So there are generally four methods of inserting the suction catheter:

1. Insert the suction catheter until you meet resistance and suction
2. Insert catheter until you meet resistance, pull back 1cm, then suction
3. Insert catheter to corina the first time you suction, note the cm mark at lip, and during subsequent attempts suction suction 1cm above where you met resistance the 1st time.
4. Insert catheter 1cm beyond the end of the ETT. Insert suction catheter until the cm marker on ETT and suction catheter are aligned, and then insert 1cm further. Or, add the length of the ETT plus the adaper and add 1 cm. If ETT is shortened you'll have to adjust for this.
   
5. Eyeball it. Just try not to hit the corina. This may be needed if tape or other obstructs view of cm markers on the ETT

Obviously method #4 above is the best, and the most often recommended. That's the method I use. I find that by using this method the process is still very successful. The cm mark you determine should be marked at the bedside so everyone who suctions that patient knows how deep to insert the catheter.

Unfortunately some of the newer suction catheters don't have cm marks, and in this case you'll have no choice but to use method #5. Where I work this is the method we use, considering we so happen to have unmarked catheters.

Whether or not I use intermittent suctioning pretty much depends on the situation and the patient. If there's copious (lots) or thick tenacious secretions I find it's better to not use intermittent suction.

However, common sense applies. If you have a little lady or child who becomes hypoxic (low spo2) while suctioning you'll want to use intermittent suctioning.

Many RTs will pre-oxygenate a patient prior to suctioning. Most studies (like this one) show this is effective and should be performed. After suctioning make sure you properly reconnect the patient to the ventilator.

Ideally, however, you'll want to use inline suction catheters in order to prevent the loss of PEEP and to prevent ventilator acquired pneumonia. Actually, best practice evidence suggests the use of inline suction catheters, and these are now common at Shoreline medical.

Lavage and suctioning (as I wrote here) at least once per shift has also been proven to reduce the risk of infection. This can be done using the port on the inline suction catheter. However, from time to time, especially if you suspect a plug in the ETT, the patient may need to be removed from the ventilator to perform a good lavage and suction.

You absolutely do not want to be suctioned

As I was reviewing my patients chart at around 10 p.m. last night, a saw an order that I as not informed about in report. The order was this: "RT to NT suction patient Q4-6 hours with breathing treatments."

I just about flipped. You can bet that I cursed. I couldn't help it, this may simply be one of the stupidest (is that a word?), doctor orders in the history of my life.

It was about as stupid as when i was a patient last October, and this very same doctor ordered a foley catheter for me -- of which I so duly refused. I certainly didn't need a tube stuck into my privates when I was fully capable of going to the bathroom on my own.

Thank you, but no thanks.

I looked further, and the doctor wanted the NT suctioning to be done in order to get a sputum sample. I have to tell you something dear readers, and this brings me back to my very first RT Cave Rule:

RT Cave Rule #1: NT suctioning is a very traumatic procedure to be done only when excessive secretions are disrupting a patient's breathing and all other options have been exhausted.

Now, allow me to tell you about this patient. He was a 29-year-old man who came to the hospital seven days ago because he had been suffering with very bad side pain for about three days. The general surgeon ended up having to do a laparastoc surgery on him to remove his appendix.

On his second day after the surgery an RRT was called on him because his SpO2 dropped into the 70s. He had developed some atelectasis and maybe even pneumonia due to his not taking deep enough breaths for all this time he has been hurting.

But, in the past two days we had weaned his Oxygen down from 100% to 4LPm. He was obviously getting better. So, now, why the hell would a doctor want a sputum sooooooo bad that he has to order this invasive procedure? I'm telling you, this procedure is really terrible.

"We need to suction this patient after the next treatment, Rick," the patient's nurse said. She was a relatively new nurse, and was quite laconic.

I was blunt: "Absolutely not. There is no damn reason this patient needs to be suctioned."

"Well, it was ordered, and if you're not going to do it than I'm going to."

"How would you like it if I poked a tube into your nose and sucked the air out of you while you were completely awake, and do this very traumatic procedure for no flipping reason at all."

"The doctor needs a sputum sample. And the patient isn't spitting anything up."

"The patient has been here for four days, and has been on antibiotics all that time. What good is a sputum going to do now. It's an absolutely stupid procedure." Besides, the doctor doesn't NEED this sputum, he WANTS it. "Would you want someone sticking a tube up your nose?"

I looked at the other nurses: help anyone???

"Absolutely not," one of the other nurses put a finger in her throat and feigned a gag. "No way would someone stick that down me. That's absolutely inhumane." Ah, right on cue.

"It is inhumane," I said. I looked at the melodramatic nurse, a nurse I knew had excellent common sense and I knew she would agree with me on finding a way not to suction just because an order was written, and then at the attending nurse.

"Well, we really need to do it," the attending nurse said.

"Awwww, I would never..,." the melodramatic nurse made a noise like a disgusted cow, "No way. I.... whooooo.... I would never want THAT done to me. NOOOOOO Wayyyyyyy."

I was hoping this melodramatic display would convince her coworker here that this was one doctor order that should be skipped, but in a professional way of course.

"Well, we still need to do it."

I said no more. I knew a losing battle when I saw it. Besides, I had a great working relationship with all these nurses, and I didn't want to insight flames. There's more than one way to skin a cat, and I'll figure something out here.

Now I had to do some damage control.

"Sorry, I didn't mean to get you mad at me," I said to the attending nurse, " I just think this is an asinine order." Plus I'm extremely tired, and have lost my ability to be diplomatic.

"That's okay. You don't have me upset. I understand your point-of-view. I'll just do it myself."

Now she had me feeling guilty.

I did a review of the chart, and learned that my co-worker on day shift yesterday, the same one who had, I thought, conveniently forgotten to tell me about this order, had attempted the NT
suctioning of this patient immediately after the initial order was written.

Joy rushed up my veins as I read her charting.

"I see here that my co-worker had already attempted to do this yesterday," I said, "And all she got was a little blood." Figures, thought, because the blood was probably from scraping the back of his nose with the catheter.

"Well, still, I'm just going to have to try for it after your next treatment. That's okay, just let me know when you do your next treatment."

Ahhh, you're about as obstinate as myself. Okay, you win. I will find a way to get a sputum out of this man one way or another.

I woke the guy up from a sound sleep. "Oh, please, do you have to do this now," he grumbled.

"No," I said.

He went back to sleep.

"He refused," I said to the nurse.

"Okay," she said. Wow, that was easy.

But, the responsible thing to do was to try again.

Two hours later.

"It's time for your treatment. We have to do it this time." Whether you need it for those crackles or not.

"Oh, okay," he grumbled.

"After this treatment," of which you do not need either, "I'm going to to have to suction you like that lady did yesterday."

"What's that?" His eyes became big.

"That tube in your nose."

"How often?" He was looking me square in the eyes. Looking in those things, I could read his thoughts.

"Every four hours. That's what the doctor wants."

Why don't you simply refuse? Please just refuse. I don't want to do this to you, and you don't want me to do it to you. Please just refuse.

I watched him as he did his treatment. I could see he was deep in thought.

"Okay, we're finished, why don't you roll over so I can listen to you," I said, after I snatched the nebulizer from his, rolled up the O2 tubing and stuffed it into the plastic bag.

He painfully rolled. He took in a deep breath. He produced a mouthful.

"Don't spit."

"Oh, I most certainly will not," he mumbled through closed lips, making sure not to swallow.

I placed the cup by his mouth, and he let the thick yellow and blood tinged sputum slide into the cup. I closed the lid.

"I got your sputum," I said to the attending nurse as I left the room. " I scared the S#$# out of him, and he responded. Works every time."

She gave a faint smile, "Awesome."

RT Cave #29: If the doctor orders for a patient to be NT suctioned because the patient cannot obtain a sputum sample on his or her own, explain the procedure, make it sound as miserable as it really is, and wait for that sputum to find its way into the cup.

A case against NT suctioning (agree or disagree)

RT Cave Rule #1: NT suctioning is a very traumatic procedure to be done only when excessive secretions are disrupting a >patients breathing and all other options have been exhausted.

"How would you like it if I took this suction catheter here, stuffed it down your nose and made you gag with it?" That's what I wanted to tell a nurse last night, but I held my tongue.

I like working nights, but there are some nights, like last night, where it would be nice to have someone here to back me up. In fact, if I had someone to tell me that I was right, or that I was being ridiculous, then I could have avoided the whole confrontation.

I was initially called at 8 p.m. to NT suction a patient who was in obvious respiratory distress. She had recently been moved from a recliner back to bed and her heart rate skyrocketed up to 177. Two days ago she had an abdominal surgery and now she was refusing to cough, and had some audible crud in her throat.

"I can't suction this patient," I said to the nurse. The nurse's name was Cindy.

"Well, we need to."

"I think I can fix her without NT suctioning," I said, and with a size 10 catheter I tickled the back of her throat and the patient spontaneously coughed producing a lot of phlegm, which I proceeded to suck up with the yankaur. Her sats increased, her work-of-breathing improved over the next 10 minutes, and, by the time I left the room, the patient was resting comfortably with a normal heart rate.

An hour later I was paged back to the room. "The patient won't swallow," Cindy said, "I have to give her oral medication for her thrush and she won't swallow. We need to NT suction her."

I said, "Look, I would be more than happy to suction her if I thought it was indicated, but suctioning isn't going to help the patient swallow. "

"Well, I put water in her mouth and she gurgles and spits it out. We need to NT suction her. She has a bunch of secretions in the back of her throat that she can't bring up."

"Not only that, but she has a sensitive heart. You have to remember NT suctioning is very invasive and traumatic."

"But we have that under control right now. Can we just try it once?"

I explained the procedure to the patient and she exclaimed, "No way!"

I looked at Cindy, "She's in no distress, has no audible upper airway secretions, and has no loud rhonchi. Let's just leave her alone."

"Well, we need to do something," Cindy said kindly. "We have to get this medicine down her throat, there's thrush all the way down there."

I encouraged the nurse to assist the patient with a drink of water which caused the patient to produce phlegm and gurgle. I simply sucked the junk up.

"There," I said, "Now you can give her her medicine." Cindy did and the patient took it just fine -- and we did not NT suction.

By this time I thought I had made headway with Cindy, but Cindy continued to call me back to the room several times during the night, and each time the patient denied any distress, denied she had secretions in her lungs, and I explained cordially to the RN that suctioning was not indicated. I even went out of my way to check on the patient every hour on the hour to assess her. Suctioning was never indicated, not even oral suctioning.

This whole thing really didn't bother too much, as I really enjoy working with nurses and educating them as appropriate. But, in this case, I felt I wasn't getting anywhere. I felt like I was trying to communicate with a brick wall.

"Look," I finally said, "You have a right to over rule me. If you want to suction this patient, I will be more than happy to assist you."

"No," she said, "I won't do that." Great, I finally got to her.

Wrong.

I was called back at 4:00 in the morning. By this time I'm exhausted and have a headache. I approach the nurse as professionally as I did each of the other times during the night and explain for the umpteenth time why NT suction is not indicated.

"I'm concerned about this patient," Cindy said. I think the patient deserves close watching, but I think she is fine right now.

"Look," I said. "The patient is watching a good movie right now. I'll sit in here and watch it so I can keep an eye on her." And I did. The movie was good too. This was one of my regular patients, and she really enjoyed me keeping her company.

Anyway, after the movie was over, I left the room and saw my boss thumping down the hall. "What's going on with this patient," she said.

Shit! I thought, as a rush of adrenaline flowed through my veins. Up to this point I didn't think there was a problem whatsoever, nothing worth getting my supervisor involved anyway. "How did you know about this patient?" I had a good idea, just wanted to hear it.

"Alex came to me." Alex is the nursing supervisor. "The RN complained the you were refusing to suction a patient. She thought that you were being lazy."

"Is checking on a patient every hour all night being lazy." I pointed at the patient. "Look at that patient. Does she look like she needs to be suctioned? If they'd just leave her alone she's be just fine, but they've been in there bugging her all night."

"I agree with you," my boss said. "I told Alex that you are a professional with a lot of experience, and if you thought suctioning was indicated you would do it. I had this same problem yesterday with Dave. He refused to suction a patient last night. Deja vu." She smiled.

"Well," I said, "I've been more than patient and professional with Cindy. And she seemed like she was really nice about the whole thing, but she didn't seem to be understanding what I said to her. But I certainly didn't think she would complain about me.

"Well, she did."

"I told Cindy very clearly that it was perfectly fine if she didn't agree with me, that she could suction if she wanted. Nurses can suction too."

"I told Alex that I backed you, like I backed Dave last night."

Certainly is nice to have the support of your boss. Damn nice.

Then, to be diplomatic, I said, "I could be wrong, Boss. I mean, when do you think suctioning is indicated? I mean, I think suctioning is very traumatic, so when would you determine to do it."

She said, "When a patient is full of secretions, gurgling, and the secretions are effecting her breathing."

"Okay, then we're on the same page."

We started down the hall toward the cave when the patient's doctor breezed around the corner.

"Hold on a minute," I said as I turned around. "I'm not letting this linger this time. I'm ending this once and for all."

I rushed to the nurses station where Dr. Matt was shuffling through the patient's chart. "Dr. Matt," I said, "May I have a quick word with you."

"Yes."

"Would you recommend that we NT suction this patient."

He looked at me like I was an idiot. "Absolutely not! It's all in her throat. If we could just get her to cough I think she'd be just fine. You can use a yankaur if you want, but I definitely wouldn't deep suction her."

"Thank you."

I turned around and saw that Cindy was standing right behind me, and a rush of joy flowed through my veins. I couldn't help but to smile. I said nothing and walked away.