Nursing Process related to nursing focus "Airway Clearance": A Scoping Review “Nursing Process related to nursing focus "Airway Clearance": A Scoping Review”

doi:10.21203/rs.3.rs-2973249/v1

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Nursing Process related to nursing focus "Airway Clearance": A Scoping Review “Nursing Process related to nursing focus "Airway Clearance": A Scoping Review”

https://doi.org/10.21203/rs.3.rs-2973249/v1

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Background

Each year, more than a billion people suffer from respiratory diseases leading to about 4 million deaths worldwide. Airway Clearance impairment is deeply related to these diseases causing a significant impact on self-care and quality of life. Therefore, it is essential to identify clinical data, nursing diagnoses and nursing interventions, providing a solid basis for clinical reasoning and integrating the best scientific evidence to enhance nursing care. This scoping review aims to map the existing evidence on clinical data, nursing diagnoses and nursing interventions addressing nursing focus “Airway Clearance”.

Methods

A scoping review was performed according to Joanna Briggs Institute framework. We searched MEDLINE, CINAHL Complete, Scopus, Web of Science, and PEDro databases for published English, Portuguese, and Spanish literature between 1975 and 2021. It included all studies on airway clearance in adult patients in all contexts of nursing care. Quantitative, qualitative, and mixed-methods studies, as well as systematic reviews, were included. The PRISMA-ScR checklist was used.

Results

In total 1355 studies were identified. After removing duplicates, 104 matched the inclusion criteria and were included in the review. The findings of this review showed two areas of nursing attention: one related to signs and symptoms management and the other related to health/illness transition. The data that lead to nursing diagnoses can be divided into cognitive and clinical data. The nursing diagnoses were mostly related to secretions retention, excessive mucus production and airway obstruction. The most commonly identified nursing interventions were the educational interventions assembled into pre-design education programs rather than patient-tailored programs.

Conclusions

The findings of this review can add substantial value for systematising the nursing process related to nursing focus “Airway Clearance”. Reaching a consensus seems highly relevant, as it could improve nursing decision-making, nursing care quality and produce more reliable nursing outcomes.

Advanced Practice Nursing

Airway Clearance

Nursing

Nursing Process

Scoping Review

Respiratory diseases are an important cause of death and disability worldwide (1). The mortality rate related to these diseases increases in people over 65 years and should be expected to go exponential in the coming years (2) (3). According to the World Health Organization in 2019, respiratory diseases comprised three of the top ten causes of death, leading to more than 8 million deaths annually. It´s estimated that 200 million people have COPD becoming the third-leading cause of death worldwide, killing 3.2 million people every year and accounting for an 81.7% of the total number of deaths from chronic respiratory disease (4). Lower respiratory tract infections, remained the world’s most deadly communicable disease, ranked as the 4th leading cause of death and lung cancer deaths have risen from 1.2 million to 1.8 million and are now ranked 6th (5).

The impact on society of these diseases is even greater. Four of the “big five” lung diseases are among the top 20 causes of disability-adjusted-life-years (6).

The International Classification of Nursing Practice (ICNP) defines airway clearance as the process which allows "keeping air passage open from mouth to lung alveoli through the ability to clear secretions or obstruction from the respiratory tract" (7). Airway clearance impairment usually is a consequence of respiratory diseases with a significant impact on patient’s care.

The mucociliary clearance and the cough reflex protect the respiratory system by enabling pulmonary secretion clearance, preventing airway obstruction as well as infections. Many factors make it difficult to mobilize and expel lung secretions, such as aging, tobacco use, environmental exposures, pulmonary diseases, neurodegenerative conditions, or complications related to acute pulmonary infections or invasive ventilation related problems (8)

Nurses play an essential role in caring for people with airway clearance impairment, whether by enhancing airway clearance or by stabilising the impairment itself. The continued increase complexity of health problems, along with the need for patient-centred care, required the development, improvement, and mastering of nurses intellectual, interpersonal and technical abilities to make clinical decisions compatible with safe and effective practices (9). This path leads to data standardization introducing taxonomies, like International Classification for Nursing Practice (INCP) or NANDA-I, allowing the use of the standard language regarding nursing care, enhancing continuity of care and nursing outcomes production (10) (11).

The nursing process is a critical thinking model used to promote competent care. It includes five steps: assessment, diagnosis, planning, implementation and evaluation (12). In the assessment phase, nurses collect all the data essential to predict, detect, prevent and manage actual and potential problems. In the diagnostic phase, nurses analyse the gathered data, draw conclusions and determine whether there are real or potential problems requiring nursing management. The third and fourth phases, nurses determine nursing interventions and put the plan into action (12). Each phase of the nursing process should be conducted using a standardized nursing language since the use of common terminology is crucial to present nursing practices (7). Although airway clearance is a prevalent phenomenon in all contexts of care being represented in all nursing classifications, no published studies were found about the nursing process related to this nursing focus. Furthermore, despite some research to evaluate the efficacy and effectiveness of nursing interventions, literature that summarises those interventions still needs to be identified. This lack of research also extends to clinical data and nursing diagnoses, leading to inadequate knowledge.

Clinical reasoning, as well as clinical judgment or decision-making process, are terms that commonly refer to the processes through nurses guide their clinical practice. Nurses collect, analyse, and interpret data related to airway clearance daily. This allows to create nursing diagnoses and also prescribe, implement, and evaluate nursing interventions. Hence, nurses must identify and define the relationship between different sets of data, transforming it into information that simultaneously includes the best scientific evidence and is applicable, ensuring better nursing care (13) (14).

Nowadays the way nurses conceptualise and integrate airway clearance impairment into the nursing process is very heterogeneous. This fact creates a massive amount of different data, limiting the exchange of information and the continuity of care, significantly impacting the delivery of the best evidence-based nursing knowledge.

The evolution of nursing informatics lead to complex data processing systems, able to help clinical reasoning, suggesting solutions and presenting outcomes of nursing care (15). The development of nursing clinical data models provides evidence-based data, allowing information to be structured. This structuration, will systematize the relations between the nursing process elements, describing complex information structures that indicate how information should be expressed and what is optional or mandatory according to the most actual scientific evidence (16) (17). Synthesising the clinical data, nursing diagnoses and nursing interventions to a nursing-led classification will help translate the existing knowledge into precise, interoperable data, enhancing nursing care and providing a solid basis for nurses’ decision-making process.

By resuming each step of the nursing process, this review can lead the way to a clinical data model comprising the elements of the nursing process centred on airway clearance.

We did a preliminary search in PROSPERO, MEDLINE, Cochrane Database of Systematic Reviews, and the JBI Evidence Synthesis and no current or underway scoping reviews or systematic reviews on the topic were identified.

This review aimed to map the evidence on clinical data, nursing diagnoses and nursing interventions addressing nursing focus "Airway Clearance". Thus it was focused on the following questions: 1) What nursing diagnoses are related to the nursing focus “airway clearance”? 2) What clinical data do nurses use to identify those diagnoses? 3) What nursing interventions positively address nursing diagnoses focused on airway clearance?

This review was conducted according to Joanna Briggs Institute's methodology for scoping reviews (18). In addition, we followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (19). The review protocol is registered in the Open Science Framework in https://doi.org/10.17605/OSF.IO/KN27G

Search methods

A comprehensive search strategy aimed to identify published studies related to "airway clearance”. The study identification used a three-step search approach (20). The first step involved an initial limited search in MEDLINE (PubMed) and CINAHL (EBSCO) databases to identify studies on the topic, followed by analysing the index terms and text words from its titles and abstracts. The second step was an extensive search including all identified index terms and keywords across the following databases: CINAHL Complete, MedicLatina; MEDLINE (PubMed) and PEDro. Finally, in the third step, the reference lists of all selected studies were screened for additional studies (see Appendix 1 in the Supplementary Material).

Inclusion and exclusion criteria

Participants

This scoping review considered all studies that include adult patients (above 18 years old) related to nursing focus “airway clearance”, except studies linked to the deglutition process and studies that included caregiver or parental role.

Concept

The concept of this scoping review is the nursing knowledge used in the nursing clinical reasoning process, particularly nursing assessment, nursing diagnosis, planning and implementation of nursing interventions.

Context

This scoping review included all studies developed in hospital, primary care, and home care, regardless of country of origin or sociocultural settings.

Types of evidence sources

It considered quantitative, qualitative and mixed methods study designs. Quantitative designs include experimental, quasi-experimental study designs (including randomised controlled trials, non-randomised controlled trials, and other quasi-experimental studies) and observational designs (descriptive, cohort, cross-sectional, case, and case series studies). Qualitative designs include studies that focus on qualitative data, including but not limited to phenomenology, grounded theory and ethnography designs. In addition, it had systematic reviews and text and opinion papers. Conference abstracts and posters were excluded from this review due to their brevity. Only studies published in English, Spanish and Portuguese from 1975 to 2021 were considered, as 1975 was the beginning of the Rehabilitation Nurses Journal due to the close relationship between airway cleaning techniques and rehabilitation nursing.

Search strategy

All identified records were uploaded into EndNote 8.0 (Clarivate Analytics, PA, USA) after the search.

Two researchers (LG and NR) performed the study selection independently, and disagreements between reviewers were solved through discussion with a third reviewer (NM).

After removing the duplicates, the analysis was performed by reading the titles and the abstracts. The full text was then retrieved for all studies that met the inclusion criteria. Finally, the two researchers examined the article's full text to confirm that it met the inclusion criteria.

It identified a total of 1384 studies. After removing the duplicates, 1355 papers were reviewed, considering inclusion criteria by reading the title and abstract. Finally, 104 articles were considered for inclusion in the final dataset after full-text reading and analysis guided by the research questions.

The procedure used to select the included papers is presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (Fig. 1).

Data extraction and analysis

Data were extracted from included studies by LG and NR using a data extraction tool developed by the reviewers, aligned with the objectives and research questions.

This tool was based on the Joanna Briggs model instrument for extracting details, characteristics and results of the studies (20). It included author[s], year of publication, study design, nursing diagnoses, clinical data that led to the diagnoses, and interventions addressing the focus airway clearance.

Any reviewer disagreements were solved through discussion with a third reviewer (NM). The two reviewers charted the first “ten studies using the data charting form and met to determine whether their approach to data extraction is consistent with the research question and purpose," as Levac, Colquhoun, and O'Brien suggested. (21).

Quality appraisal

In line with scoping review methodology, the quality of the studies included in this review was not assessed.

A total of 104 studies were included in this scoping review. Concerning the type of articles identified, 71,1% were quantitative experimental designs (36,6% systematic reviews, 27,8% randomised controlled trials and 6,7% pseudo-randomised controlled trials), 22,1% Observational studies, 5,8% quasi-experimental studies and 1% expert opinion.

Most of the studies were related to signs and symptoms management (59,7%) and 40,3% were related to coping strategies and education.

Clinical studies were mainly performed in the United States (20,2%), the United Kingdom (19,2%), and Brazil (12,5%). The theme most frequently identified in the papers was “Interventions” (n=291), followed by “Clinical Data” (n=207), and “Diagnoses” (n=154). Table 1 shows clinical data, diagnoses and nursing interventions included in the studies.

Table 1. Clinical Data, Diagnoses and nursing interventions as described in the included studies

Abbreviations: ACT: Airway clearance techniques

Authors	Design	Clinical Data	Diagnoses	Interventions
Templeman et al. (2020)	Systematic review	Cough Efficacy Cough reflex	Inspiratory muscle training
Westerdahl et al. (2020)	Cross-sectional study	Amount of sputum	Impaired airway clearance	Respiratory ACT Airway clearance with respiratory devices
Jaiswal & Das et al. (2019)	Randomised controlled trial		Impaired airway clearance	Respiratory ACT Airway clearance with respiratory devices Education about ACT
Shamali et al. (2019)	Randomised controlled trial	Presence of bronchial secretions	Impaired airway clearance	Airway suction
Sherman et al. (2019)	Observational study	Adherence to airway clearance Awareness of ACT	Lack of airway clearance adherence
Yazdannik et al. (2019)	Cross-sectional study	Oxygen Saturation	Impaired airway clearance	Airway suction
Tomar et al. (2019)	Randomised controlled trial	Presence of bronchial secretions	Impaired airway clearance	Manual ACT
Wilson et al. (2019)	Systematic review	Presence of bronchial secretions	Impaired airway clearance Lack of airway clearance self-management	Airway clearance with respiratory devices Respiratory ACT Manual ACT Education about ACT
Allen et al. (2018)	Case study	Peak cough flow	Impaired airway clearance	Airway clearance with respiratory devices
Ferreira de Camillis et al. (2018)	Randomised controlled trial	Amount of sputum Breathing sounds Oxygen Saturation	Impaired airway clearance	Postural drainage Airway clearance with respiratory devices Manual ACT
Pozuelo-Carrascosa et al. (2018)	Systematic review	Oxygen Saturation Cough Efficacy Cough reflex	Impaired airway clearance	Manual ACT Postural drainage
Hester et al. (2018)	Qualitative study	Access to educational programs Ability to perform ACT Knowledge about airway clearance Meaning about ACT	Lack of knowledge about airway clearance Lack of airway clearance adherence	Educating about ACT
Hill et al. (2018)	Systematic review		Impaired airway clearance	Education about ACT Inspiratory muscle training
Kelly et al. (2018)	Systematic review	Adherence to airway clearance	Impaired airway clearance Lack of airway clearance self-management Lack of knowledge about airway clearance	Promoting care plan Education about ACT
Ghaleb et al. (2017)	Cross-sectional study		Impaired airway clearance	Airway suction Hyperoxygenation before suction
Spapen et al. (2017)	Systematic review	Oxygen Saturation Amount of sputum	Impaired airway clearance	Manual ACT
McIlwaine et al. (2017)	Expert panel	Peak cough flow	Impaired airway clearance Lack of knowledge about airway clearance	Respiratory ACT Airway clearance with respiratory devices Postural drainage Education about ACT
Gonçalves et al. (2017)	Systematic review	Breathing sounds Oxygen Saturation Respiratory rate Cough efficacy Amount of Sputum	Impaired airway clearance	Airway suction Hyperoxygenation before suction Manual hyperinflation
Wang et al. (2017)	Cross-sectional study	Oxygen Saturation Cough efficacy	Impaired airway clearance
Chuang et al. (2017)	Randomised controlled trial	Oxygen Saturation Cough efficacy	Impaired airway clearance	Airway clearance with respiratory devices Manual ACT
D'Abrosca et al. (2017)	Observational study	Amount of sputum	Impaired airway clearance Lack of ability to perform ACT Lack of knowledge about airway clearance	Airway clearance with respiratory devices Education about ACT
Morrison et al. (2017)	Systematic review		Impaired airway clearance	Airway clearance with respiratory devices Manual ACT Respiratory ACT
Auger et al. (2017)	Systematic review	Peak cough flow Amount of sputum	Impaired airway clearance	Airway clearance with respiratory devices Respiratory ACT
Borges et al. (2017)	Systematic review		Impaired airway clearance	Manual ACT
McCormack et al. (2017)	Systematic review	Amount of sputum	Impaired airway clearance Lack of airway clearance self-management Lack of ability to perform ACT Lack of knowledge about ACT.	Airway clearance with respiratory devices Manual ACT Respiratory ACT Education about ACT
Rodriguez Hortal et al. (2017)	Randomised controlled trial		Impaired airway clearance	Airway clearance with respiratory devices
Rose et al. (2017)	Systematic review	Presence of bronchial secretions Cough efficacy Cough reflex Peak cough flow	Impaired airway clearance	Respiratory ACT Airway clearance with respiratory devices
Torres-Sanchez et al. (2017)	Systematic review		Impaired airway clearance	Manual ACT
Boulet (2016)	Expert panel	Ability to perform ACT Knowledge about airway clearance	Lack of airway clearance self-management Lack of ability to perform ACT Lack of knowledge about ACT Lack of meaning about ACT Lack of meaning about ACT	Promoting care plan Educating about ACT
Berry et al. (2016)	Observational study	Breathing sounds Thoracic palpation Presence of bronchial secretions Ventilator waveform sawtooth pattern	Impaired airway clearance
Arcuri et al. (2016)	Systematic review	Cough efficacy	Impaired airway clearance	Manual ACT Airway clearance with respiratory devices
Laciuga et al. (2016)	Observational study	Cough efficacy Peak cough flow
Lucchini et al. (2016)	Observational study		Impaired airway clearance	Airway suction
Pascoal et al. (2016)	Cross-sectional study	Presence of bronchial secretions Cough efficacy Respiratory rate Breathing sounds Amount of sputum	Impaired airway clearance
Jena et al. (2016)	Randomised controlled trial		Impaired airway clearance	Airway suction
Berry et al. (2016)	Observational study	Peak cough flow Meaning about ACT	Lack of airway clearance adherence Lack of meaning about ACT	Education about ACT
Button et al. (2016)	Systematic review	Presence of bronchial secretions	Impaired airway clearance	Respiratory ACT Airway clearance with respiratory devices Postural drainage Education about ACT
McKoy et al. (2016)	Systematic review		Impaired airway clearance Lack of airway clearance self-management	Respiratory ACT Airway clearance with respiratory devices Education about ACT
Dwyer et al. (2015)	Randomised controlled trial		Impaired airway clearance	Manual ACT Respiratory ACT Airway clearance with respiratory devices
Gastaldi et al. (2015)	Cross-sectional study		Impaired airway clearance	Airway clearance with respiratory devices
Liu et al. (2015)	Quasi-experimental study	Oxygen saturation Respiratory rate Breathing sounds Presence of bronchial secretions	Impaired airway clearance	Airway suction
Ozden et al. (2015)	Quasi-experimental study	Presence of bronchial secretions Oxygen saturation Cough efficacy Breathing sounds Ventilator waveform sawtooth pattern Amount of sputum	Impaired airway clearance	Airway suction
Sole et al. (2015)	Descriptive Study	Presence of bronchial secretions Oxygen saturation Cough efficacy Breathing sounds Ventilator waveform sawtooth pattern Amount of sputum	Impaired airway clearance	Airway suction
Reychler et al. (2015)	Observational study	Ability to perform ACT Adherence to airway clearance	Lack of airway clearance adherence Lack of airway clearance self-management	Airway clearance with respiratory devices
Lee et al. (2015)	Systematic review		Impaired airway clearance	Respiratory ACT Airway clearance with respiratory devices
Lee & Park et al. (2017)	Systematic review	Amount of sputum	Impaired airway clearance	Respiratory ACT Airway clearance with respiratory devices
McCullough et al. (2014)	Systematic review	Adherence to airway clearance	Lack of airway clearance adherence	Education about ACT
Morgan et al. . (2016)	Systematic review	Amount of sputum	Impaired airway clearance	Respiratory ACT
Anand (2014)	Comparative Study	Amount of sputum Presence of bronchial secretions	Impaired airway clearance	Manual ACT Respiratory ACT Education about ACT
Caparros (2014)	Systematic review	Oxygen Saturation Presence of bronchial secretions	Impaired airway clearance	Airway suction
Cork et al. (2014)	Case Study	Presence of bronchial secretions	Impaired airway clearance	Airway suction Manual hyperinflation Manual ACT Postural drainage
Dos Santos et al. (2014)	Quasi-experimental study	Oxygen Saturation	Impaired airway clearance	Manual hyperinflation Manual ACT
Esguerra-Gonzales et al. (2014)	Cross-sectional study	Adherence to airway clearance	Impaired airway clearance Lack of airway clearance adherence	Manual ACT Airway clearance with respiratory devices
Guimarães et al. (2014)	Randomised controlled trial	Presence of bronchial secretions Knowledge about airway clearance Ability to perform ACT	Impaired airway clearance Lack of ability to perform ACT Lack of knowledge about airway clearance	Respiratory ACT Airway clearance with respiratory devices Education about ACT
Kohan et al. (2014)	Randomised controlled trial	Cough efficacy	Impaired airway clearance	Manual ACT Airway suction
O'Donohoe & Fullen et al. (2014)	Systematic review	Adherence to airway clearance Meaning about ACT	Lack of airway clearance adherence Lack of meaning about ACT Lack of awareness about ACT
Ntoumenopoulos et al. (2014)	Observational study	Breathing sounds Thoracic palpation Cough reflex Oxygen saturation Peak cough flow	Impaired airway clearance	Manual hyperinflation Hyperoxygenation before suction Respiratory ACT
Zanni et al. (2014)	Quasi-experimental study	Adherence to airway clearance Awareness of airway clearance techniques Knowledge about airway clearance Ability to perform ACT	Lack of airway clearance adherence Lack of ability to perform ACT Lack of knowledge about airway clearance	Education about ACT
Gbiri & Shittu (2014)	Observational study	Amount of sputum	Impaired airway clearance	Respiratory ACT Airway clearance with respiratory devices
Standford et al. (2014)	Observational study		Impaired airway clearance	Respiratory ACT
Torres-Castro et al. (2014)	Cross-sectional study	Peak cough flow Cough efficacy	Impaired airway clearance	Respiratory ACT
Savage (2014)	Systematic review	Knowledge about airway clearance Adherence to airway clearance	Lack of airway clearance adherence Lack of knowledge about airway clearance	Education about ACT
Zwerink et al. (2014)	Systematic review	Ability to perform ACT	Lack of airway clearance adherence Lack of airway clearance self-management
Flores et al. (2013)	Cross-sectional study	Adherence to airway clearance Meaning about ACT	Lack of airway clearance adherence Lack of airway clearance self-management	Education about ACT
Esguerra-Gonzalez et al. (2013)	Experimental Study		Impaired airway clearance	Manual ACT Airway clearance with respiratory devices
Yang (2013)	Systematic review		Impaired airway clearance	Manual ACT Respiratory ACT Airway clearance with respiratory devices
Volsky (2013)	Systematic review	Presence of bronchial secretions Cough reflex Cough efficacy Adherence to airway clearance	Impaired airway clearance Lack of airway clearance self-management Lack of airway clearance adherence	Manual ACT Respiratory ACT Airway clearance with respiratory devices Postural drainage
Maggiore et al. (2013)	Observational study	Breathing sounds Oxygen Saturation Presence of bronchial secretions	Impaired airway clearance	Manual Hyperinflation Airway suction
Nicolini et al. (2013)	Randomised controlled trial	Presence of bronchial secretions	Impaired airway clearance	Manual ACT Airway clearance with respiratory devices
Warnock et al. (2015)	Systematic review		Impaired airway clearance	Manual ACT Respiratory ACT Airway clearance with respiratory devices
Andrews et al. (2013)	Systematic review	Cough reflex Peak cough flow Oxygen Saturation Breathing Sounds Presence of bronchial secretions Amount of sputum Cough efficacy	Impaired airway clearance	Manual ACT Respiratory ACT Airway clearance with respiratory devices Postural drainage
Morrow et al. (2013)	Systematic review	Peak cough flow Cough efficacy	Impaired airway clearance	Airway clearance with respiratory devices
Strickland et al. (2013)	Systematic review	Peak cough flow Cough efficacy Oxygen Saturation Presence of bronchial secretions Knowledge about airway clearance Ability to perform ACT	Impaired airway clearance Lack of airway clearance self-management Lack of ability to perform ACT Lack of knowledge about airway clearance	Manual ACT Respiratory ACT Airway clearance with respiratory devices Education about ACT
Clinkscale et al. (2012)	Randomised controlled trial	Presence of bronchial secretions Knowledge about airway clearance Ability to perform ACT	Impaired airway clearance Lack of airway clearance self-management Lack of ability to perform ACT Lack of knowledge about airway clearance	Education about ACT
Corley et al. (2012)	Randomised controlled trial	Oxygen Saturation Amount of sputum	Impaired airway clearance	Airway suction
Cross et al. (2012)	Randomised controlled trial	Oxygen Saturation Amount of sputum Breathing sounds Knowledge about airway clearance Ability to perform ACT	Impaired airway clearance Lack of ability to perform ACT Lack of knowledge about airway clearance	Manual ACT Respiratory ACT Education about ACT
Figueiredo et al. (2012)	Randomised controlled trial	Presence of bronchial secretions Knowledge about airway clearance Ability to perform ACT	Impaired airway clearance Lack of ability to perform ACT Lack of knowledge about airway clearance	Airway clearance with respiratory devices Education about ACT
Ozden & Gorgulu (2015)	Observational study	Oxygen Saturation Presence of bronchial secretions	Impaired airway clearance	Hyperoxygenation before suction Airway suction
Park et al. (2012)	Randomised controlled trial	Amount of sputum Oxygen Saturation	Impaired airway clearance	Manual ACT Airway clearance with respiratory devices
Lewis & Olds (2012)	Systematic review		Impaired airway clearance	Respiratory ACT
Osadnik et al. (2012)	Systematic review		Impaired airway clearance	Manual ACT Respiratory ACT Airway clearance with respiratory devices
Paulus et al. (2012)	Systematic review	Presence of bronchial secretions Cough reflex Oxygen saturation	Impaired airway clearance	Manual hyperinflation
Naue et al. (2011)	Randomised controlled trial	Presence of bronchial secretions	Impaired airway clearance	Manual hyperinflation Manual ACT Airway suction
Lavery et al. (2007)	Randomised controlled trial	Knowledge about airway clearance Meaning of ACT	Lack of airway clearance self-management Lack of airway clearance adherence Lack of airway clearance self-management	Education about ACT
Mahajan et al. (2011)	Randomised controlled trial	Amount of sputum	Impaired airway clearance	Airway clearance with respiratory devices
Suh et al. (2011)	Experimental Study	Oxygen saturation	Impaired airway clearance	Airway suction hyperoxygenation before suction Manual ACT
Aggarwal et al. (2010)	Randomised controlled trial	Oxygen saturation Respiratory rate Peak cough flow Knowledge about airway clearance Ability to perform ACT	Impaired airway clearance Lack of airway clearance self-management Lack of ability to perform ACT Lack of knowledge about airway clearance	Manual ACT active cycle of breathing Airway clearance with respiratory devices Education about ACT
Davidson et al. (2010)	Case Study	Sputum characteristic	Impaired airway clearance	Postural drainage
Mattos de Castro et al. (2010)	Randomised controlled trial	Amount of sputum Presence of bronchial secretions Breathing sounds	Impaired airway clearance	Manual ACT
Pattanshetty et al. (2010)	Randomised controlled trial		Impaired airway clearance	Manual ACT Manual Hyperinflation airway suction Postural drainage
Kempainen et al. (2010)	Randomised controlled trial	Amount of sputum Cough efficacy	Impaired airway clearance	Airway clearance with respiratory devices
Kjonegaard et al. (2010)	Comparative study	Oxygen saturation Amount of sputum	Impaired airway clearance	Airway suction Manual hyperinflation Hyperoxygenation before suction
Naraparaju et al. (2010)	Randomised controlled trial	Amount of sputum Ability to perform ACT Knowledge about airway clearance	Impaired airway clearance	Airway clearance with respiratory devices Education about ACT
Osman et al. (2010)	Randomised controlled trial	Oxygen Saturation Amount of sputum	Impaired airway clearance	Respiratory ACT Airway clearance with respiratory devices Postural drainage Education about ACT
Wang et al. (2017)	Randomised controlled trial		Impaired airway clearance	Airway clearance with respiratory devices Education about ACT
Saowanee et al. (2010)	Multicase Study	peak cough flow Ability to perform ACT	Impaired airway clearance Lack of airway clearance self-management Lack of ability to perform ACT	Respiratory ACT Education about ACT
Hill et al. (2010)	Systematic review	Oxygen saturation	Impaired airway clearance	Manual ACT Airway clearance with respiratory devices
Nowobilski et al. (2010)	Systematic review	Oxygen Saturation	Impaired airway clearance	Manual ACT Respiratory ACT Airway clearance with respiratory devices Postural drainage Education about ACT
Darlene Reid et al. (2010)	Systematic review	Cough efficacy	Impaired airway clearance	Manual ACT Airway clearance with respiratory devices
Allen & O'Leary (2018)	Quasi-experimental study	Oxygen Saturation Presence of bronchial secretions	Impaired airway clearance	Manual ACT Airway clearance with respiratory devices
Chatwin & Simonds (2009)	Randomised controlled trial	Oxygen Saturation Breathing sounds Cough efficacy Amount of sputum Presence of bronchial secretions Peak cough flow Respiratory rate	Respiratory ACT Airway clearance with respiratory devices
Pedersen et al. (2009)	Systematic review	Cough reflex Cough efficacy Presence of bronchial secretions Oxygen Saturation Breathing sounds	Impaired airway clearance	Airway suction
Toussaint (2009)	Cross-sectional study	Cough efficacy Peak cough flow	Impaired airway clearance	Respiratory ACT
Lavery et al. (2007)	Focus group study	Adherence to airway clearance Knowledge about airway clearance Ability to perform ACT Meaning about ACT	Lack of airway clearance self-management Lack of meaning about ACT Lack of awareness of the relation between ACT and airway clearance Lack of auto-efficacy to perform ACT

Clinical Data

In this review, we encountered data related to clinical signs and symptoms and data related to coping strategies and education.

Regarding the clinical data, it reflected the physiological impact of impaired airway clearance in respiratory functions (e.g. oxygen saturation (8,7%) or respiratory rate (2,7%)), the presence of bronchial secretions (e.g. breathing sounds (8%) or amount of sputum (6, 7%)) and sputum characteristics (4%) (e.g., colour, consistency or odour). In addition, it was also found other clinical data that, despite not being directly linked to airway clearance, can lead to impaired airway clearance like those related to cough mechanism (e.g. cough efficacy (13,3%), peak cough flow (9,3%), cough reflex (2%)).

Concerning coping strategies and education, we found data related to adherence to airway clearance (12%), knowledge (8,7%) and ability (6,7%) to perform airway clearance techniques, awareness of airway clearance techniques (2%) and meaning about airway clearance techniques. In addition, data related to access to educational programs or technical information was also found.

Nursing Diagnoses

Concerning the nursing diagnoses, results were linked to secretions retention, excessive mucus production and airway obstruction. Impaired airway clearance was the nursing diagnosis more frequently found in the review (58,2%).

It was also found that some diagnoses comprise two nursing focus, which is relevant to the nursing process focus. Diagnoses such as "Lack of airway clearance self-management” (14,9%) (focuses: “Airway clearance” and “Self-management”) or "Lack of airway clearance adherence” (6,9%) (focuses: "Airway clearance" and "Adherence" ") were also mentioned and considered in this review.

Nursing Interventions

Finally, regarding nursing interventions, the following set shows some of the most commonly identified in this review: educational interventions (26,3%), airway clearance with respiratory devices (21,7%) (e.g. oscillatory devices, Mechanical insufflation/exsufflation device, High-Frequency Chest Wall Compressions device), manual airway clearance techniques (16,8%) (e.g. vibration, percussion and percussion manoeuvres), airway suction (9,5%) and respiratory airway clearance techniques (8,3%) (e.g. active cycle of breathing, forced expiratory technique, autogenic drainage).

To resume the information of this review, table 2 presents a schematic summary of the results found.

Table 2 – Scoping review main results (Clinical Data, Nursing Diagnoses, Nursing Interventions)

Abbreviations: ACT: Airway clearance techniques

Clinical Data	Nursing Diagnoses	Nursing Interventions
Oxygen Saturation	Impaired airway clearance	Airway suction
Respiratory rate	Lack of airway clearance adherence	Hyperoxygenation prior suction
Breathing sounds	Lack of airway clearance self-management	Manual hyperinflation
Thoracic palpation	Lack of ability to perform ACT	Inspiratory muscle training
Peak Cough	Lack of airway clearance knowledge	Body position
Cough efficacy	Meaninglessness of airway clearance	Manual ACT
Cough reflex	Lack of airway clearance awareness	Airway clearance with respiratory devices
Ventilator waveform sawtooth pattern	Lack of auto-efficacy to perform ACT	Patient education about manual ACT
Amount of Sputum	Lack of awareness about ACT	Patient Educating about Respiratory devices
Presence of bronchial secretions	Lack of meaning about ACT	Access to educational programs
Adherence to airway clearance	Lack of meaning about ACT	Evaluate the capacity to perform airway clearance
Knowledge about airway clearance		Evaluate the knowledge about airway clearance
Ability to perform ACT		Assessing the evolution of the ability to perform ACT
Meaning about ACT		Promoting care plan
Access to educational programs
Awareness of ACT

The current scoping review is the first to explore the nursing process addressing "Airway clearance". Thus, the nursing diagnoses that arise from this nursing focus, the data that can lead to those diagnoses and the nursing interventions related to them were described to answer the review questions.

Clinical Data

According to this review, there are two kinds of clinical data: data addressing signs and symptoms and cognitive data related coping strategies and education.

As we know, retention of bronchial secretions may lead to airway obstruction, increased work of breathing, hypoxia and ultimately, respiratory failure. Therefore, the most commonly referred clinical data were related to the presence of retained secretions, such as oxygen saturation (e.g. Yazdannik et al., 2019), amount of sputum (e.g. Westerdahl et al., 2019), or breathing sounds (e.g. Ferreira de Camillis et al. 2018). These findings align with various studies in all contexts of nursing practice, such as Goetz et al. (2022) in mechanically ventilated ICU patients, Belli et al. (2021) in conventional wards or Trimble et al. (2022) in community-based care. All of these studies considered that the most important data that leads to airway clearance impairment was oxygen desaturation, increasing sputum and the presence of rhonchi in the auscultation.

Furthermore, we found other data related to cough, as an effective cough is crucial to airway clearance. Data like cough reflex (e.g. Rose L. et al., 2017), peak cough flow (e.g. McIlwaine et al., 2017) and cough efficacy (e.g. Wang et al., 2017) were found in this review and seemed to be aligned with the scientific literature. In a Cochrane systematic review, Morrow et al. (2021) stated that patients with neuromuscular diseases are more likely to have acute respiratory infections due to respiratory muscle weakness, which is explained mainly by a lack of muscular tonus. In 2017 Auger et al., in a systematic review, concluded that peak expiratory flow below 160 L/min indicates a high risk of ineffective cough. Although not directly linked to airway clearance, these data are highly relevant to lead to nursing diagnoses.

The literature reviewed in this study suggests that patients with airway clearance disorders must adapt to physical and psychological changes. This fact requires processing a large amount of information concerning airway clearance, demanding new skills. These patients experience a health/illness transition, being necessary to integrate new knowledge and new skills leading to behaviour change in order to achieve a healthy transition⁽²²⁾. The most common data in this domain were: adherence to airway clearance (e.g. Sherman et al., 2019), knowledge and ability to perform airway clearance techniques (e.g. Boulet et al., 2016), meaning about airway clearance techniques (e.g. McCullough et al., 2015) and access to educational programs (e.g. Hester et al., 2018). Overall, these findings match the literature. A study by Sherman et al. (2019) highlighted a critical gap regarding adherence to airway clearance techniques over time in a routine clinical setting. Hester et al. (2018), reviewing the provision and the requirement for education and information in bronchiectasis patients, concluded that these patients needed better health information and self-management guidance, despite the clear potential for such interventions to produce tangible benefits for patients. According to these authors, this lack of provision should be addressed with a patient-centred approach, incorporating knowledge and self-management in other chronic respiratory diseases. Thus, these data seem to be adequate to lead to a nursing diagnosis

Nursing Diagnoses

The most frequent diagnosis was related to the inability to clear secretions or obstructions from the respiratory tract. This diagnostic is already present in ICNP® described as “Impaired Airway clearance” ICNP®⁽⁷⁾ or NANDA International, Inc. as “Ineffective airway clearance”⁽²³⁾.

In addition to "Impaired airway clearance", there is another dimension of nursing care related to the coping strategies and education following the patient-centred care mode⁽²²⁾. The main goal is to develop the patient's cognitive, behavioural and emotional skills, hoping to obtain mastery to deal with new situations. This process is dynamic and involves the identification of physical and psychological responses to the limitations, requiring permanent planning and action. Therefore, it is crucial to help the patient deal with these changes, facilitating the transition process⁽²²⁾.

A transition starts only after an awareness process, usually with shortness of breath and an inability to perform daily living activities. This fact leads to incorporating life changes to better adapt to the new condition. Unlike the diagnoses related to airway clearance impairment, in this dimension, we seek to integrate the patient into the care plan to promote self-management skills and move from a model centred only on professional knowledge to a collaborative model focused on patients’ needs and decisions. Nurses recognise the patient's potential to adapt to the new condition, leading to the development of response patterns that express the presence of risks or reveal signs of a healthy transition, with the initial negative feelings being replaced by a sense of well-being and mastery to deal with disability⁽²²⁾. Therefore, diagnoses like “Lack of awareness of the relation between airway clearance techniques and airway clearance” (e.g. Lavery et al., 2007), “Lack of airway clearance adherence” (e.g. Hester et al., 2018), or “Lack of airway clearance self-management” (e.g. Kelly et al. 2018) are essential to developing patient cognitive, behavioural and emotional skills. This fact leads to mastery and is particularly relevant to nursing as it facilitates the transition process⁽²²⁾.

Nursing interventions

Finally, the reviewed literature pinpointed some nursing interventions that positively address airway clearance diagnoses. The majority of nursing interventions found in this review were related to signs and symptoms management, such as airway suction (e.g. Shamali et al., 2019), manual airway clearance techniques (e.g. Tomar et al., 2019), respiratory airway clearance techniques (e.g. Wilson et al., 2019) or airway clearance with mechanical devices (e.g. McIlwaine, 2017). The airway suction technique is particularly relevant. A systematic review carried out by Blakeman et al. (2022) aimed to establish evidence-based guidelines on endotracheal suctioning in intubated adult patients, especially recommendations related to the suction time, pressure, diameter of the aspiration probe, pre-oxygenation before suction, sustaining that endotracheal suction should not be performed routinely but only in the presence of bronchial secretions. Manual airway clearance techniques, such as chest percussion and chest vibration, are also essential nursing interventions in reducing airway clearance impairment. There is some evidence of these techniques' physiological effects on patients unable to clear their airway, either because they are unconscious, with cognitive problems, neuromuscular disease or other particular reasons.

There are several mechanical devices available to clear the airway. The most used (mainly in patients with neuromuscular diseases or respiratory muscle impairment) is the mechanical Insufflator/Exsufflator ⁽²⁴⁾. Several studies confirmed that mechanical Insufflator/Exsufflator increases cough effectiveness by increasing peak cough flow, particularly in patients with neuromuscular diseases⁽²⁵⁾. Other mechanical devices frequently used are oscillatory and high-frequency chest-wall oscillators. Although there is no difference in efficacy compared to each other and with manual techniques.

In a systematic review centred on airway clearance techniques for patients with stable homed-based cystic fibrosis patients, Wilson (2019) concluded that there is little evidence to support one airway clearance technique over another. Therefore, patients should choose the airway clearance technique that best meets their needs after considering comfort, convenience, flexibility, practicality, cost, or other factors. This is an important conclusion as these patients are experiencing a transition health/illness adjusting to the new reality⁽²²⁾.

As we all know, a transition only begins after recognising what has changed⁽²²⁾. This is significant as adjustment does not exist if knowledge is absent⁽²⁶⁾. Therefore, empowerment and engagement are vital parts of this process, starting with awareness and evolving to knowledge and ability improvement, optimising decision-making. An example is the nursing interventions relating to education. Although the educational interventions appear particularly relevant to diminish airway clearance impairment, we need more information regarding patient-tailored education programs. All the studies of this review reported pre-design educational programs rather than patient-tailored programs. This fact is significant as properties like awareness, engagement, knowledge, and ability are key factors in nursing practice. This fact is particulary important because is very difficult to evaluate its efficiency if we do not isolate these variables.

Strengths and limitations

A strength of this scoping review is that the evidence found is movable to other contexts, considering that studies from different regions worldwide were included in the review. On the other hand, specific limitations were inherent to a scoping review: the amount of data generated and the absence of synthesis, as a scoping review does not synthesise. Furthermore, a systematic evaluation of the quality of the articles included in this review was not carried out. This option was based on the inclusive nature of the review, as it would be essential to provide a wide view of the topic of the study. This study did not include grey literature, as the authors have opted for peer-review articles.

The findings of this review provide a vital contribution to systematising the nursing process related to the focus "Airway clearance”, highlighting the diagnostic hypotheses that derive from this focus, the relevant clinical data that can lead to those diagnoses and nursing interventions that positively address the nursing diagnoses identified. The clinical data model from arised from this review may improve nursing decision-making and nursing care quality in patients with airway clearance impairment.

Acknowledgements

Not applicable.

Authors’ contributions

Methodology: LG, NM, NR, PS, APS, AC, MB,

Data collection: LG, NR, NM

Data analysis and interpretation: LG, NR, NM

Validation: NM, APS, FP, EM

Writing – original draft: LG, NR

Writing – review & editing: LG, NM, PS, APS, FB, MO, IS, MC, PG

Funding

Not applicable.

Availability of data and materials

Data is available in supplementary information files

Ethics approval and consent to participate

No patients or public were involved in the development of either the protocol

or conduct of the scoping review.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

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Nursing Process related to nursing focus "Airway Clearance": A Scoping Review “Nursing Process related to nursing focus "Airway Clearance": A Scoping Review”

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BACKGROUND

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RESULTS

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