American Journal of Nursing Research
ISSN (Print): 2378-5594 ISSN (Online): 2378-5586 Website: Editor-in-chief: Apply for this position
Open Access
Journal Browser
American Journal of Nursing Research. 2020, 8(4), 435-441
DOI: 10.12691/ajnr-8-4-3
Open AccessArticle

Effect of Positioning during Suctioning on Cerebral Perfusion Pressure among Patients with Traumatic Brain Injury

Naglaa EL Mokadem1, and Shimaa EL-Sayed1

1Critical Care Nursing, Lecturer of Critical Care Nursing, Critical Care Nursing Department, Menoufia University, Egypt

Pub. Date: May 12, 2020

Cite this paper:
Naglaa EL Mokadem and Shimaa EL-Sayed. Effect of Positioning during Suctioning on Cerebral Perfusion Pressure among Patients with Traumatic Brain Injury. American Journal of Nursing Research. 2020; 8(4):435-441. doi: 10.12691/ajnr-8-4-3


Background: Traumatic Brain Injury (TBI) is a major cause of morbidity and mortality worldwide. Patients with TBI may need mechanical ventilation because they cannot clear their airway secretions due to decreased consciousness, loss of laryngeal reflexes and an inability to cough. Endotracheal suctioning is important and needed in mechanically ventilated patients for airway clearance, improvement of oxygenation and prevention of atelectasis and infection. However, endotracheal suctioning is an invasive procedure and adversely affects some physiological indicators, such BP, PaO2, O2 saturation, HR, ICP and CPP. Aim: To examine the effect of positioning during endotracheal suctioning on cerebral perfusion pressure among mechanically ventilated patients with traumatic brain injury. Design: A quasi-experimental design (Study-Control) was used. Setting: The current study was conducted at the neurosurgical ICUs in Menoufia University Hospital and the teaching hospital in Shebin AL Khom. Sample: A convenient sample of 100 mechanically ventilated patients with traumatic brain injury were recruited from the neurosurgical ICUs. Tools: A Semi Structured Demographic Sheet; Physiological Measures Recording Sheet including CPP; MAP; CVP and Oxygenation as indicated by ABGs values; and Glasgow Coma Scale (GCS). Results: There was a highly statistically significant increase in CPP (84.30± 6.35, 74.80±8.20) in the study group compared with the control group after endotracheal suctioning and elevating head of bed (HOB) at 30 degrees respectively (P=0.001). Furthermore, there was a statistically significant increase in PaO2 (88. 57±11.50; 73.57±11.24) in the study group compared to the control group after suctioning respectively (P<.05). Also, there was a statistically significant increase in SaO2 (97.43± 2.88, 88.67± 1.72) in the study group compared to the control group after suctioning respectively (P<.05). Recommendations: Initiate the development of clinical practice guidelines for critical care nurses to use head of bed elevation of 30 degrees as routine care during endotracheal suctioning to improve cerebral pressure perfusion and oxygenation for patients with traumatic brain injury.

cerebral pressure perfusion oxygenation endotracheal suctioning traumatic brain injury

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Shafi S, Barnes S.A., Millar D, (2014). Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries. J Neurosurg, 7: 865.
[2]  Kochanek PM, Dixon CE, Shellington DK, (2013). Screening of biochemical and molecular mechanisms of secondary injury and repair in the brain after experimental blast-induced traumatic brain injury in rats. J Neurotrauma; 30: 920.
[3]  Joseph B, Aziz H, Sadoun M, (2013). The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. J Trauma Acute Care Surg; 75:102.
[4]  CDC (2016). Traumatic brain injury. Available at: http://www.
[5]  Joseph B, Friese RS, Sadoun M, (2014). The Brain Injury Guidelines Project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg; 76:965.
[6]  Taha.M., and Brakat, M. (2016). Demographic characteristic of Traumatic Brain Injury in Eygpt. Journal of Spine Neurosurg. 5: 6.
[7]  Galbiati G, Paola C. (2015). Effects of Open and Closed Endotracheal Suctioning on Intracranial Pressure and Cerebral Perfusion Pressure in Adult Patients With Severe Brain Injury: A Literature Review. J Neurosci Nurs. 47(4): 239-46.
[8]  Kirkman MA, Smith M. (2014) Intracranial pressure monitoring, cerebral perfusion pressure estimation, and ICP/CPP guided therapy: a standard of care or optional extra after brain injury? Br J Anaesth; 112(1): 35-46.
[9]  Chesnut R, Videtta W, Vespa P, Le Roux P. (2014). Intracranial pressure monitoring: fundamental considerations and rationale for monitoring. Neurocrit Care; 21(Suppl 2): S64-84.
[10]  Feigin, V., Theadom, A., Barker-collo, S., Starkey, N., Mcpherson, K., and Kahan, M. (2013). Incidence of traumatic Brain Injury in New Zealand: A population based study. Lancet Neuro Journal, 12, 53-64.
[11]  Linda C.H, Chang AM. (2015). Are nurses using best practice in tracheal suctioning of artificial airways? Australian Critical Care; 22(1):53.
[12]  Gemma, M., Tommasino, C., Cerri, M., Giannotti, A., Piazzi, B., & Borghi, T. (2002). Intracranial effects of endotracheal suctioning in the acute phase of head injury. Journal of Neurosurgical Anesthesiology, 14(1), 50-54.
[13]  Uraz, G. A., & Aksoy, G. (2012). The effects of open and closed endotracheal suctioning on intracranial pressure and cerebral perfusion pressure: A crossover, single-blind clinical trial. Journal of Neuroscience Nursing, 44(6), E1-E8.
[14]  Sullivan J. (2000). Positioning of patients with severe traumatic brain injury: research-based practice. Journal of Neuroscience Nursing; 32(4): 204-9.
[15]  Kerr, M. E., Weber, B. B., Sereika, S. M., Darby, J., Marion, D. W., & Orndoff, P. A. (1999). Effect of endotracheal suctioning on cerebral oxygenation in traumatic brain-injured patients. Critical Care Medicine, 27(12), 2776-2781.
[16]  Kose G, Hatipoglu S. (2012). Effect of head and body positioning on cerebral blood flow velocity in patients who underwent cranial surgery. J Clin Nurs.21 (13-14): 1859-1867.
[17]  Ledwith MB, Bloom S, Maloney-Wilensky E, et al. (2010). Effect of body position on cerebral oxygenation and physiologic parameters in patients with acute neurological conditions. J Neurosci Nurs. 42(5):280-287.
[18]  Mahfoud F, Beck J, Raabe A. (2010). Intracranial pressure pulse amplitude during changes in head elevation: a new parameter for determining optimum cerebral perfusion pressure? Acta Neurochir. 152: 443-450.
[19]  Ng I, Lim J, Wong HB. (2004) Effects of head posture on cerebral hemodynamics: Its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation. Neurosurg. 54(3): 593-598.
[20]  Nyholm L, Steffansson E, FrPjd C, Enblad P. (2014). Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study. J Neurosci Nurs. 46(5): 285-291.
[21]  PalazFn JH, Asensi PD, LFpez SB, Bautista FP, Candel AG. (2008). Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and regional cerebral oxygen saturation in patients with cerebral hemorrhage. Rev Esp Anestesiol Reanim. 55(5): 289-93.
[22]  Rao V, Klepstad P, Losvik OK, Solheim O. (2013).Confusion with cerebral perfusion pressure in a literature review of current guidelines and survey of clinical practice. Scand J Trauma Resusc Emerg Med; 21: 78.
[23]  Thomas E, Czosnyka M, Hutchinson P. (2015).Calculation of cerebral perfusion pressure in the management of traumatic brain injury: Joint position statement by the Councils of the Neuroanaesthesia and Critical Care Society of Great Britain and Ireland (NACCS) and the Society of British Neurological Surgeons (SBNS). Br J Anaesth in press.
[24]  O'Driscoll BR, Howard LS, Earis J. (2017). BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax; 72:ii1.
[25]  Holzheimer R., Mannick, j. (2001). Surgical treatment: Evidence- Based and problem-oriented. Munich: Zuckschwerdt Availble from:
[26]  Graham D., Adams, J., and Doyle, D. (1978). Ischemic brain damage in fetal non missile head injuries. Journal of Neurological Sciences, 39, 213-234.
[27]  Thiesen, R. A., Dragosavac, D., Roquejani, A. C., Falc,o, A. L., Araujo, S., Dantas Filho, V. P., I Terzi, R. G. (2005). Influence of the respiratory physiotherapy on intracranial pressure in severe head trauma patients. Arquivos de Neuro-psiquiatria, 63(1), 110-113.
[28]  Cerqueira-Neto, M. L., Moura, A. V., Scola, R. H., Aquim, E. E., Rea-Neto, A., Oliveira, M. C., & Cergueira, T. C. (2010). The effect of breath physiotherapeutic maneuvers on cerebral hemodynamics. Arquivos de Neuro-psiquiatria, 68(4), 567-572.
[29]  Durward, Q.J., Amacher, A.L., Del Maestro, R. F., & Sibbold, W. J. (1983). Cerbral and Cardiovascular responses to changes in head elevation in patients with intracranial hypertension. Journal of Nurosurgery, 59, 938-944.
[30]  Feldman, Z., Kanter, M. J., Robertson, C. S., Cosstant, C.F., Hayes, C., Sheinberg, M.A., Villareal, C. A., Narayan, R. K., & Grossman, R. G. (1992); Effect of head elevation on intracranial pressure, cerebral pressure perfusion, and cerebral blood flow in head-injured patients. Journal of Nurosurgery, 76, 207-211.
[31]  Marchall, S.B., Marshall, L. F., Vos H. R., & Chesnut, R. M. (1990). Neuroscience critical care: pathophysiology & patient management. Philadephia: Saunders. Maset. A.L., Marmarou, A., Ward, J.D., Choi, S., Lutz, H. A., Brooks, D., Moulton, R.mJ., DeSalles, A., Muizelaar, J.P., Turner, H., & Young, H. F. (1987). Pressure volume dynamics in head-injured patients. Journal of Neurosurgery, 67, 832-840.
[32]  Parson, L.C. & Wilson, M.M. (1984). Cerebrovascular status of severe closed head injured patients following passive position changes. Nursing Research, 33, 68-75.
[33]  Rosner, M.J. & Coley, I.B. (1986). Cerebral perfusion pressure, intracranial pressure and head elevation. Journal of Neurosurgery, 65, 636-641.
[34]  Bourgault, A. M., Brown, C. A., Hains, S. M., & Parlow, J. L. (2006). Effects of endotracheal tube suctioning on arterial oxygen tension and heart rate variability. Biological Research for Nursing, 7(4), 268-278.
[35]  El Masry, A., Williams, P. F., Chipman, D. W., Kratohvil, J. P., & Kacmarek, R. M. (2005). The impact of closed endotracheal suctioning systems on mechanical ventilator performance. Respiratory Care, 50(3), 345-353.
[36]  Barker, E. (2008). Intracranial pressure and monitoring. In Neuroscience nursing, a spectrum of care (3rd ed., pp. 305-336). St. Louis, MO: Mosby Elsevier.
[37]  Hickey, J. V., & Olson, D. M. (2009). Intracranial hypertension: Theory and management of increased intracranial pressure. In: J. V. Hickey (Ed.), The clinical practice of neurological and neurosurgical nursing (6th ed., pp. 270-307). Philadelphia, PA: Lippincott Williams and Wilkins.Prata, P., Improta, T., Reis, D., Silva, V., Rivail, B., Assuncao, G., Gomes, M., and Alberto, L. (2015). Influence of different degrees of head elevation on respiratory mechanics in mechanically ventilated patients. J. Rev. Bras. Ter. Intensive, 27(4)347-352.
[38]  Okasha, M.I., Anbar,S.K., and Seloma A.Y.(2013). Cerebral Oxygenation and Physiological Parameters among Acute traumatic brain Injury Patients Supine versus Semi-fowler position. Advances in Life Science and Technology Journal: 12, 2224-7181E.
[39]  Akbaryan Deheki N, Sanagoo A, Amri P, Moghaddam S, Vakili MA, Nasiri H, et al. Comparing the effect of using normal saline, N-acetyl cysteine and not using them in endotracheal tube suction on physiologic parameters and the amount of secretions in intubated patients under mechanical ventilation. (2014). Iranian Journal of Critical Care Nursing; 6(4): 152-9.
[40]  Adib M, Ghanbari A, Alavi CE, Leyli EK. (2014). Effect of endotracheal suctioning with and without normal saline on hemodynamic and respiratory parameters in patients undergoing mechanical ventilation in ICU of hospitals supervised by Guilan University of Medical Sciences. Biomedical & Pharmacology Journal; 7(2): 515-23.