Chapter –Ii

Review Of Literature

CHAPTER-II
 REVIEW OF LITERATURE

A Review of Literature is defined by Polit & Beck (2008) as a critical summary

of researcher on a topic of interest often prepared to put a research problem in
context.

Review of literature is an important step in the development of

carrying research project. It helps the research to analyse what is known about
the topic and to describe methods of enquiry used in earlier work including the
success and short comings. It gives abroad understanding of the problem
keeping these aspects in mind, the researcher probed into available resources of
document, information and studies related to hypertonic saline nebulised
suctioning on airway clearance and prevention of VAP.

The literature reviews for the present study has been organized and presented
under the following headings.

2.1 Literature related to hypertonic saline nebulised suctioning on airway

clearance

2.2 Literature related to prevention of VAP

2.1 Literature related to hypertonic saline nebulised suctioning on

airway clearance

An experimental study was conducted to assess the effect of 3%hypertonic

saline nebulized suctioning on airway clearance among patients connected to
mechanical ventilator in intensive care unit of PES Institute Of Medical Sciences And
Research , Kuppam, Andhra Pradesh(2020) in random of 30 patients grouped into
experimental group(n=15) and control group(n=15).experimental group received
nebulization in the endotracheal tube using a nebulizer kit for 10-15 minutes with
2ml of 3% hypertonic saline with a break of two times daily for 3 days pursed by
endotracheal suctioning were performed for about 10-20 seconds. Semi structured
interview schedule and modified bio-physiological parameters with arterial blood gas
analysis scale were used to record for the level of airway clearance before and after
administration of 3% hypertonic saline. Descriptive statistics (mean, frequency
distribution and standard deviation) and inferential statistics (chi square test and
paired‘t test). The analysis shows that , there was significant difference in mean value
between pretest (7.96+ 2.93) and post test (2.74 2.93).paired t calculated value was
greater than the table value, known there is an effectiveness of 3% hypertonic saline
nedulisation on airway clearance among the patients connected with mechanical
ventilator.

An experimental study was conducted to assess the effect of hypertonic

saline nebulized suctioning on airway clearance among patients connected to
mechanical ventilator in multi-speciality intensive care unit, porur, Chennai (2013) in
randomly 30 patients were recruited and grouped into experimental (N=15) and
control group (n=15). Experimental group received administrative 5ml of 3%
hypertonic saline nebulization followed by endotracheal (ET) suctioning for about 10
to 20 seconds. Whereas, the control group received routine ET suctioning and oral
hygiene. Post-test was clone after 15 to 20 minutes of procedure, measurements of the
bio-physical parameters were obtained from continuous hemodynamic distribution,
mean and standard deviation) and inferential statistics ( independent ‘t’ test, paired ‘t’
test and Anova). The effect of hypertonic saline nebulized suctioning on airway
clearance as estimated by the bio-physiological parameters (heart rate, spo 2, etco2 and
ABG) showed significant difference in spo2 (p<0.001) and ABG-po2 (p<0.05). the
study concluded that hypertonic saline nebulized is the cheapest, safe, effective and
easiest way in maintaining the airway patency for a patient connected to a mechanical
ventilator. 15

An experimental study was conducted to compare the efficiency of 3%

hypertonic saline (HS) with salbutamol on management of acute asthma in outpatient
adults in emergency medicine, Iran, Khomeini general hospital, Iran in 2017. A total
of 340 adults patients with acute asthma attacks admitted to emergency department
were enrolled during 2014-2015. The patients were allocated randomly to intervention
group. Nebulized 2.5mg of salbutamol and 2.5ml of 3% HS solution for three
consecutive 20 min periods and control group. Nebulized only salbutamol in the same
dose and time of the intervention group. The principle outcome measures were forced
expiratory volume in 1 second and peak expiratory flow rate which were assessed at
baseline and 20, 40 and 60 minutes after treatment in both groups. Hypertonic saline
with salbutamol in both PERF and FEVI in the 40 th min (0.11±1.36 and 0.005±1.66;
p=0.033 respectively) and 60th min (0.15±1.12, p=0.011 respectively) while no
significant difference was observed in baseline and 20th min. Also, PERF and FEVI in
both groups significantly increased as the treatment processed and the time passed.
the study concluded that short term efficiency of 3% Normal saline in acute asthma
attack. These pre if may be used as a supplemented drug along with salbutamol in
patients with acute asthma attack admitted to emergency department.16

An experimental study was conducted to examine two ETS intervention

(i.e.) normal saline instillation an lung recruitment to determine if it is feasible to
conduct a full efficiency trail. The target sample size for the trail is 100 providing. So
participate per intervention and 50 per compassion. Normal saline instillation verses
no normal saline instillation and lung recruitment verses to normal recruitment with
paediatric endotracheal suction is a single centric, Two interventional pairs will be
compared using a 2*2 factorial design. (1) Normal saline instillation verses no lung
recruitment. the primary outcome is study feasibility measured by a composite
analysis of eligibility, recruitment, retention, protocol adherence and missing data.
Secondary outcome are ventilator – associated pneumonia. Spo2, fio2 ratio lung
compliance and expiratory level and regional tidal volume. The study concluded that
has resulted in un standardized practice. To progress knowledge regarding the
benefits and the risk of NSI with paediatric CTS a large RCT’S needs to be under
taken to provide defective on the safety and efficiency of NSI.17
 An experimental study was conducted to assess the mucolytic agents such
as nebulized hypertonic saline may improve airway clearance and shorten the duration
of mechanical ventilation children undergoing mechanical ventilation. Children less
than 18 year old who had been intubated for <12 and had an expected duration of
mechanical ventilation of >48 additional were prophylactically given 3ml of either
nebulized hypertonic saline or placebo (0.9% saline) 4times/d. The primary outcome
was duration of mechanical ventilation .ventilator parameters and the presence of
wheezing were recorded before and after study drug administration. The duration of
mechanical ventilation was significantly longer in children treated with hypertonic
saline (208.1(interquartile range 136.3 – 319.8)h) verses those treated with placebo
(129.5 (inter quartile range 74.4-146.1)h) (p=0.03 by Wilcoxon rank sum test) after
adjusting for baseline levels of peep, duration of mechanical ventilation did not differ
between groups. Mechanical ventilation parameters including dead space and
dynamic compliance, did not differ between measurements taken before study drug
administration was rare (1.0% with hypertonic saline vs. 3.0% with placebo, p=0.36
by chi square test) this study has showed the administering prophylactic nebulized
hypertonic saline to mechanical ventilated children did not improve clinically relevant
outcomes including duration of mechanical ventilation. Wheezing after hypertonic
saline treatment was rare.18

An experimental study was conducted to determine the utility of inhaled

hypertonic saline solution to treat infants hospitalized with viral bronchiolitis., fifty
two hospitalized infants (mean ± 3d age, 2.9± 2.1 month) with viral bronchiolitis
received either inhalation of epinephrine 1.5mg on 4 ml of 0.9% saline solution
(group 1; n=25) or inhalation of epinephrine, 1.5 mg in 4 ml of 3% saline solution
(group 2n=27) . this therapy was replaced three times every hospitalization day until
discharge . This device has an output of 3ml in 6 min an dynamic diameter man
medium of 0.5 to 4µm range, and a geometric SD of 96% of all liquid nebulized. The
nebulized were administered until empty. The percentage improvement in the clinical
severity score. After inhalation therapy was not significant in group 1 on the first,
second and third days after hospital admission. In group 2 significant improvements
was observed on these days between the two groups. Using 3% saline solution
decreased the hospitalization stay by 25% from 4±1.9 days in group 1 to 3± 1.2 days
in group 2 (p<0.05 the study shows that in non-asthmatics, non-severely ill infant
hospitalized with viral bronchiolitis, aerosolized 3% saline solution 1.5 mg
epinephrine decreases symptoms and length of hospitalization as compared to 0.9%
saline solution 1.5 mg epinephrine is more effective than normal saline solution
epinephrine in non-severely ill infant population hospitalized with acute bronchiolitis.
additionally, there was no difference in safety profile.

2.2 Literature related to prevention of VAP

A study was conducted a systematic collection of data on review and meta-

analysis of ventilator-associated pneumonia in adults in asia. Here in the study the
researcher systematically reviewed literature published on ovid medline, embase
classic, and embace from 1 january 1990 to 17 august 2017 to estimate incidence,
prevalence, and etiology of VAP and performed a meta-analysis to give pooled rates
and rates by country income level. The results showed that the VAP was high in
lower and upper-middle-income countries and lower in high-income countries (18.5,
15.2, and 9.0 per 1000 ventilator-days, respectively). Acinetobacter baumanni (n =
3687 [26%] ) and pseudomonas aeruginosa (n = 3176 [22%] ) were leading causes of
VAP; staphylococcus aureus caused 14% (n = 1999). Carbapenem resistance was
common (57.1%) and concluded VAP remains a common cause of HAI, especially in
low and middle-income countries, and antibiotic resistance is high.

A prospective observational study on incidence bacteriology and clinical

outcome of VAP at tertiary care hospital, Maharashtra, India. Totally 74 (27.71%)
patients were developed VAP among 74 with VAP, 53 (71.62%) were males and 21
(28.37%) were females (p<0.0001). The overall incidence of VAP rate per 1000
ventilator days were 39.59
 A prospective study on incidence and risk factors of VAP in a tertiary care
hospital,Pondicherry, India. 76 mechanical ventilated patients were prospectively
evaluated at frequent intervals for the development of VAP by using clinical and
micro biological criteria. 18 (23.7%) developed VAP during ICU stay, early onset
VAP occurred in 13 (72.2%) while late onset VAP 5 (27.8%) patients. Ninety – four
percent (17 out 18) of VAP cases occurred within the first week of mechanical
ventilation. The incidence of VAP was 53.25 per 1000 ventilator days and the study
concluded that awareness about various risk factors will aid in reduction of mortality
and morbidity associated with VAP.

A cohort study on incidence, outcome, risk factor and measures to be taken for
prevention of VAP in ICU in a tertiary care centre, Gujarat, India. Here in this study
100 patients are randomly selected and kept on ventilator more than 48 hours. The
level of significance kept at p<0.05. It was found that 37 patients developed VAP.
The incidence of early- onset VAP (within 96 h) was found to be 27% while the late-
onset type (>96 h) was 73%. Late-onset VAP had poor prognosis in terms of mortality
(66%) as compared to the early-onset type (20%). So, the study concluded preventing
VAP should be implemented to improve patient outcome and reduce length of
intensive care unit stay and costs.

A study was conducted at both public and private tertiary care hospitals,
Peshwar on “Nurses knowledge regarding prevention of VAP”. In this study nurses
knowledge was assessed by using close-ended questionnaire from 100 critical-care
nurses by using convenient sampling technique. The results showed that the overall
knowledge of nurses regarding VAP prevention Mean (18.22 from 40) was a poor
result. The study concluded that several educational programme’s should be arranged
for nurses to improve their knowledge from average to excellence to decrease VAP
among pateints.

A prospective randomized controlled trail study was conducted to evaluate the

effectiveness of tapered-cuff endotracheal tubes with intermittent subglottic
suctioning in prevention of VAP in critically ill patients. A total 276 mechanically
ventilated patients more than 72 hours were randomly assigned group-E. subglottic
suctioning was performed every 6 hours. The mean cuff pressure on group E was
significantly less than group C (p<0.001). The study was associated with a significant
decrease in the incidence of the VAP in critically ill patients.

A Quasi experimental study was conducted on prevention of VAP in

emergency care unit as an intervention study in zagazing university hospital, Sharkia,
Egypt. The aim of the study is to examine the effect of a series of interventions of
VAP rate, MDR rate, antibiotic susceptibility pattern and health care provides
practice. By using a pre-intervention phase-I and intervention phase-II and a post
intervention phase-III of the effect of the selected interventions. After intervention the
study showed that reduction of VAP rate from 48.8% to 40%. The Mean significant in
total infection control practice was 14.02%. The study showed a significant reduction
in VAP rates with evidence based prevention strategies.

A prospective study was conducted to assess the effect of multi-dimensional

approach on the reduction of VAP rates in INICC member hospital in Havana, Cuba.
The study recorded 114 mechanical ventilator (MV) days, whereas the researcher
recorded 2350 MV days during the intervention period. The baseline rate of VAP was
52.63% per 1000 MV days and 15.32 per 1000 MV days during the intervention. The
study achieved 70% reduction in the rate of VAP (RR 0.3; 55%, P value 0.33). So, the
study found to be significant.