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Closed-system suctioning triggered a sharp but short-lived rise in patient-reported dyspnea even as oxygen saturation went up

Frontiers in Medicine (PubMed)Jun 23, 2026

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Brief summary

In a prospective self-controlled study of 42 awake mechanically ventilated ICU patients, closed-system suctioning was followed by a sharp rise in self-reported dyspnea that largely resolved within 5 minutes, and this worsening occurred even though oxygen saturation went up.

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Endotracheal suctioning is a routine airway care procedure in mechanically ventilated patients, but its immediate effect on how breathless patients feel has not been well quantified. In this prospective self-controlled observational study conducted from May to October 2025 in a tertiary ICU in Sichuan Province, China, awake mechanically ventilated adults with a Richmond Agitation-Sedation Scale score of 0 to +1 who required closed-system suctioning were enrolled. Dyspnea was assessed with the Dyspnea Visual Analog Scale (D-VAS, 0 to 10) before suctioning (T0), immediately after (T1), and 5 minutes after (T2), while peripheral oxygen saturation (SpO2) and heart rate were recorded at the same times. Fifty-three suctioning procedures from 42 patients were included. D-VAS scores rose from 2.8 plus or minus 1.9 at T0 to 6.4 plus or minus 2.1 at T1 (mean increase 3.6, 95 percent CI 3.1 to 4.1, P less than 0.001), then fell to 3.2 plus or minus 1.7 at T2 (P less than 0.001 versus T1). Dyspnea worsened in 92.5 percent of procedures at T1, and 15.1 percent had not returned to baseline at T2. Even though SpO2 rose from 97.2 plus or minus 2.1 percent to 99.1 plus or minus 1.3 percent at T1, dyspnea worsened substantially, pointing to a possible dissociation between oxygenation and subjective respiratory distress. The authors conclude that closed-system suctioning may cause clinically significant but transient worsening of dyspnea that appears independent of oxygenation, and that individual dyspnea assessment during routine suctioning warrants attention, while noting the study was a single-center convenience sample.

Why this matters for nurses

Suctioning is one of the most frequent things ICU nurses do for ventilated patients, and it is easy to assume that a stable or rising oxygen saturation means the patient is comfortable. This study may matter for critical care nurses because it shows that awake ventilated patients can feel markedly more breathless right after suctioning even when their SpO2 improves.

Bedside takeaway

Worth knowing that in a small ICU study, closed-system suctioning caused a sharp but short-lived rise in patient-reported breathlessness even as oxygen saturation rose, so a good SpO2 may not mean an awake ventilated patient feels comfortable.

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Key takeaways

Across 53 closed-system suctioning procedures in 42 awake ventilated ICU patients, self-reported dyspnea rose sharply immediately after suctioning (D-VAS 2.8 to 6.4, mean increase 3.6, P less than 0.001) and largely settled by 5 minutes (3.2).
Dyspnea worsened in 92.5 percent of procedures right after suctioning, and 15.1 percent had not returned to baseline 5 minutes later.
Oxygen saturation actually increased with suctioning (97.2 percent to 99.1 percent), yet patients still felt more breathless, suggesting SpO2 and subjective distress can move in opposite directions.
The authors call the worsening clinically significant but transient and recommend assessing individual patients' dyspnea during routine suctioning.

Practice implications

For ICU nurses, the findings suggest watching for and, where possible, asking about breathlessness around suctioning rather than relying on the oxygen saturation number alone, since most patients in this study felt worse immediately afterward. Knowing the distress is usually brief but occasionally lingers can support brief reassurance and reassessment before assuming an awake ventilated patient is at ease.

Limitations & cautions

This was a single-center convenience sample of only 42 patients and 53 procedures, with no prospective sample size calculation and a one-dimensional dyspnea scale, so the estimates are preliminary. It enrolled only awake, lightly sedated patients able to self-report, so the findings may not apply to more deeply sedated patients, and confirmatory multicenter studies are needed.
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Citations

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Frontiers in Medicine (PubMed)

Frontiers in Medicine (PubMed). Impact of closed-system suctioning on self-reported dyspnea in mechanically ventilated patients: a prospective observational study.

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https://pubmed.ncbi.nlm.nih.gov/42415791/

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Nursing in Critical Care (PubMed)Jul 1, 2026Research Article

In a quasi-experimental study of 60 ICU nurses, adding short text-message reminders to a training session significantly improved nurses' knowledge and performance in ventilator-associated pneumonia prevention compared with the training session alone.

Med-Surg ICUAI summaryReview source

Research ArticleResearchInfection ControlAI summary · original source linked below

Sixty intensive care unit nurses in Kermanshah, Iran attended a training session on ventilator-associated pneumonia (VAP) prevention and were randomly split into a 30-nurse intervention group and a 30-nurse control group. The intervention group received educational text messages with key points from the session every other day for two weeks; the control group received none. Most participants were women (n = 40, 66 percent), more than half were over 30 years old (n = 28, 53 percent), and most had less than 10 years of experience (n = 52, 86 percent). At pre-test the groups were similar, with mean knowledge scores of 21.1 plus or minus 2.9 (intervention) and 20.2 plus or minus 2.9 (control) and performance scores of 120.8 plus or minus 10.4 and 120.1 plus or minus 13.4. At post-test the SMS group scored significantly higher than the control group on knowledge (22.1 plus or minus 1.9 vs 20.2 plus or minus 1.5; p less than 0.001) and on performance (126.9 plus or minus 8.2 vs 120.8 plus or minus 9.7; p less than 0.02). The authors conclude that ongoing SMS reminders improved nurses' VAP-prevention knowledge and performance.

Key takeaways

Sixty ICU nurses were randomized to receive VAP-prevention text-message reminders every other day for two weeks (n = 30) or training alone (n = 30).
At post-test, the SMS group scored significantly higher than the control group on knowledge (22.1 vs 20.2; p less than 0.001) and performance (126.9 vs 120.8; p less than 0.02).
The two groups had similar knowledge and performance scores before the intervention.
The authors describe the reminders as a low-cost microlearning approach that can reinforce infection-prevention behaviours, including in resource-limited settings.

Why this matters on shift

Ventilator-associated pneumonia is a serious ICU infection, and sustaining nurses' prevention knowledge and bedside adherence after a single training session is a common challenge. This study may matter for nurses and educators because it tests a simple, low-cost reinforcement, brief text messages, and finds it improved both knowledge and performance over training alone.

Bedside takeaway

Worth knowing that in a small ICU study, adding brief text-message reminders after a training session significantly improved nurses' knowledge and performance on ventilator-associated pneumonia prevention compared with training alone.

Nursing implications

For ICU nurses and educators, the findings suggest that short, repeated text-message reminders after a training session can be a practical way to keep VAP-prevention steps front of mind and improve measured performance. Because the effect was seen over a two-week window in one setting, such reminders are best viewed as a supplement to established VAP-prevention bundles rather than a replacement.

Limitations & cautions

This was a single-center quasi-experimental study of only 60 nurses in one Iranian city, so the results may not generalise to other units or countries. Performance was measured with a questionnaire over a short two-week period, so the study does not show whether gains persisted longer term or whether they translated into lower VAP rates for patients.
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Citations · exact source links

Nursing in Critical Care (PubMed). Effect of Short Messages on ICU Nurses' Knowledge and Performance Regarding Ventilator-Associated Pneumonia Prevention: A Quasi-Experimental Study.

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American Journal of Critical Care (PubMed)Jul 1, 2026Research Article

In a prospective cohort at one 900-bed center, nasogastric tube-related pressure injuries were significantly more frequent on the internal medicine ward than in the ICU, an unexpected reversal the authors link to comorbidity burden, staffing ratios, and tube-fixation technique.

ICU Med-SurgAI summaryReview source

Research ArticleResearchAI summary · original source linked below

This prospective cohort study followed adults who had a nasogastric tube placed during or within four hours before admission to the ICU (88 patients) or internal medicine ward (48 patients) of a 900-bed medical center, monitoring daily for tube-related pressure injuries from July 2022 to July 2024. Contrary to the expectation that sicker ICU patients would fare worse, incidence was significantly lower in the ICU (4 patients; 0.47 per 100 patient-days) than on the internal medicine ward (13 patients; 3.02 per 100 patient-days; P < .001). Internal medicine ward patients had a higher Charlson Comorbidity Index (mean 7.7 vs 3.0; P = .02), and nasogastric tube fixation methods differed between the departments. The authors name comorbidity burden, nurse-to-patient ratios, and fixation technique as possible contributors that warrant further study.

Key takeaways

Nasogastric tube-related pressure injury incidence was significantly lower in the ICU (0.47 per 100 patient-days) than on the internal medicine ward (3.02 per 100 patient-days; P < .001).
Four of 88 ICU patients versus 13 of 48 internal medicine ward patients developed a tube-related pressure injury.
Internal medicine ward patients carried a higher comorbidity burden (Charlson index 7.7 vs 3.0; P = .02).
Nasogastric tube fixation methods differed between the two departments and are a suspected contributor.

Why this matters on shift

Medical device-related pressure injuries from nasogastric tubes are painful, largely preventable, and easy to overlook under the tape. This study may matter for nurses because it challenges the assumption that these injuries cluster in the ICU, pointing instead to comorbidity, staffing, and fixation technique as drivers that apply on any ward.

Bedside takeaway

Worth knowing that nasogastric tube-related pressure injuries were more common on the internal medicine ward than in the ICU (3.02 vs 0.47 per 100 patient-days), pointing to comorbidity, staffing, and tube fixation as drivers.

Nursing implications

For nurses on any unit with tube-fed patients, the findings reinforce routinely inspecting the skin under and around nasogastric tube fixation (nares and cheeks), rotating or adjusting securement to relieve pressure, and not assuming lower-acuity wards are low risk. Consistent, pressure-relieving fixation technique and regular skin checks may matter as much as patient acuity.

Limitations & cautions

This was a single-center study with a small sample (88 ICU and 48 internal medicine ward patients), so the counterintuitive finding may not generalize, and the authors flag comorbidity burden, nurse-to-patient ratios, and fixation technique as confounders needing further investigation. Patients with pre-existing facial injuries or wounds were excluded, and the observational design cannot establish why incidence differed between departments.
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Citations · exact source links

American Journal of Critical Care (PubMed). Incidence of Nasogastric Tube-Related Pressure Injuries in Intensive Care Unit and Internal Medicine Ward.

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The Cochrane database of systematic reviews (PubMed)Jun 4, 2026Systematic Review

A Cochrane review of 11 trials found little certain evidence that more frequent repositioning prevents pressure injuries, while wearable-sensor reminders and operating-room micromovement showed more promising, though still limited, signals.

Med-Surg ICUAI summaryReview source

Systematic ReviewResearchAI summary · original source linked below

This second update of a Cochrane review pooled 11 randomized trials involving 4,462 adults aged 18 to 90 in acute and aged-care settings to test repositioning regimens for pressure injury prevention. Comparisons of different turning frequencies were inconclusive: 2-hourly versus 4-hourly repositioning showed no clear difference (RR 1.05, 95% CI 0.79 to 1.39; 4 trials, 1,104 participants), rated very low certainty. A single ICU trial of real-time wearable patient sensors with visual repositioning reminders versus standard care reported fewer pressure injuries (RR 0.28, 95% CI 0.10 to 0.75; 1,226 patients; moderate certainty). Micromovement in the operating room also suggested a reduction (RR 0.28, 95% CI 0.11 to 0.67; 2 trials, 477 participants; low certainty, few events), while prone positioning in the ICU was associated with more pressure injuries than supine (RR 4.55, 95% CI 2.31 to 8.98; low certainty). Most of the evidence was low or very low certainty.

Key takeaways

Across 11 trials and 4,462 adults, more frequent repositioning did not clearly reduce pressure injuries: 2-hourly versus 4-hourly turning showed no significant difference (RR 1.05, 95% CI 0.79 to 1.39).
The strongest signal came from one ICU trial where wearable sensors with visual repositioning reminders reduced pressure injuries (RR 0.28, 95% CI 0.10 to 0.75; moderate certainty).
Operating-room micromovement suggested fewer pressure injuries (RR 0.28, 95% CI 0.11 to 0.67), but events were few and certainty was low.
Most of the evidence was low or very low certainty, and no trials reported quality of life, procedural pain, or patient satisfaction.

Why this matters on shift

Repositioning is one of the most time-consuming parts of skin care, and units often standardize on a fixed turn schedule such as every two hours. This review suggests the exact frequency may matter less than assumed, and that the clearest benefit came from technology prompting repositioning rather than the clock alone. Because the evidence base is thin and mostly low-certainty, it argues for humility more than a protocol overhaul.

Bedside takeaway

Worth knowing that 2-hourly versus 4-hourly turning showed no clear difference in pressure injuries, while sensor-based repositioning reminders showed the strongest signal and prone ICU patients had higher risk.

Nursing implications

Keep repositioning as standard care, but recognize the evidence does not strongly favor one turning interval over another, so individualize frequency to skin assessment and risk rather than treating a rigid two-hour rule as proven. Where wearable repositioning-reminder systems are in use, support them, since the one ICU trial testing them showed a reduction. In the OR, micromovement and pressure-redistribution measures are reasonable adjuncts, and be alert that prone patients in the ICU may be at higher risk and need closer skin surveillance.

Limitations & cautions

Most included trials were small and rated low or very low certainty, so the findings are uncertain and the apparent benefits of sensor reminders and micromovement each rest on limited data. The wearable-sensor result came from a single ICU trial, and no trials reported quality of life, procedural pain, or patient satisfaction. Economic data were sparse, drawn from two older nursing-home evaluations, limiting conclusions about the relative costs of different regimens.
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Citations · exact source links

The Cochrane database of systematic reviews (PubMed). Repositioning for pressure injury prevention in adults.

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Key takeaways

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Exact source links

More updates for this clinical area

Repeated text-message reminders improved ICU nurses' VAP-prevention knowledge and performance in a quasi-experimental study

Nasogastric tube-related pressure injuries were more common on the internal medicine ward than in the ICU

More frequent turning didn't clearly prevent pressure injuries; the clearer signals were sensor reminders and OR micromovement