The Correlation between Sputum Retention and Oxygen Saturation in Nasopharyngeal Cancer Patients with Tracheostomy at The Emergency Department of Dharmais Cancer Hospital in 2022

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INTRODUCTION
Nasopharyngeal cancer is a malignancy with unique epidemiological characteristics.Its incidence varies according to race and geographical differences (Sudiono and Hassan, 2013).In general, nasopharyngeal cancer is located in the cavity behind the nose and back of the palate of the oral cavity.In the Ear Nose Throat (ENT) Department, nasopharyngeal cancer incidence is the most common or highest malignancy throughout, affecting more men than women, with a ratio of three to one.Some etiological factors are smoking, alcohol, genetics, pollution, combustion fumes, consumption of burned food, food preserved by salting, smoking, or formalin, and Epsteinbar Virus (EBV) or viruses in the nasopharyngeal area (Jia and Qin, 2012).
Global Burden of Cancer Study (Globocan) from the World Health Organization (WHO) estimated the incidence of nasopharyngeal cancer globally was less than 1 per 100,000 annually.The prevalence of nasopharyngeal carcinoma was higher in some regions, such as China, Hong Kong, and Southeast Asia, with a 10-30 times higher incidence compared to other areas.In addition, 81% of new cases occurred in https://doi.org/10.33086/jhs.v16.i03.3993Repidawati Sinaga -The Correlation between Sputum Retention and Oxygen Saturation in Nasopharyngeal Cancer Patients with Tracheostomy at The Emergency Department of Dharmais Cancer Hospital in 2022 Asia, and 9% occurred in Africa yearly.While in the UK, the incidence of nasopharyngeal carcinoma tended to be lower, which was 0.25 per 1,000,000 population each year (Chang et al., 2021).According to the Globocan, the incidence of nasopharyngeal cancer is the fifth most common cancer disease in Indonesia (Adham et al., 2012).The first place was breast cancer (65,858), followed by cervical cancer (36,633), lung cancer (34,783), liver cancer (21,392), and nasopharyngeal cancer (19,943) (Andinata et al., 2023).Dharmais Cancer Hospital is a cancer hospital located in DKI Jakarta province.The incidence of nasopharyngeal cancer in 2020 was 189, while it increased to 197 in 2021.It indicated that nasopharyngeal cancer has grown every year (Hospital, 2022).
In patients with nasopharyngeal cancer, there are early and advanced symptoms.Early symptoms usually include ringing and feeling full in the ears and decreased hearing ability.In addition, the patient's nose can be blocked due to chronic colds or mucus mixed with blood (Makkawaru and Yunita, 2019).
One of the therapies for nasopharyngeal cancer is surgical therapy, namely by tracheostomy.
Tracheostomy is a surgical procedure by inserting a tube through an opening into the trachea to overcome upper airway obstruction, maintain the airway, or use continuous mechanical ventilation (Rahmi, 2022).
According to Novialdi (2019), the benefits of tracheostomy include improving patient comfort, oral hygiene, and communication.In addition, It improves the possibility of oral feeding and easier and safer treatments.Tracheostomy also has the potential to decrease the use of sedation and analgesic drugs to facilitate the weaning process and avoid pneumonia due to mechanical ventilators.
Phlegm/mucus in the throat is usual, but their production sometimes increases.The increased sputum can cause disorders and discomfort in the throat (Widjaja, 2008).According to Law (2003), the clinical signs of sputum retention are rapid respiratory distress and shallow breathing.Kozier explain that excess sputum affects the airway, including airway obstruction, impacting decreasing oxygen saturation characterized by cyanosis (Kozier et al., 2010).Thus, sputum retention leads to hypoxia or hypoxemia, where oxygen saturation is below 95%.The previous research conducted by Septimar (2018) found that the mean oxygen saturation in patients before suction was 95.78%, while after suction was 97.25%, so there was a significant difference in the mean oxygen saturation among critical patients in the ICU before and after suction (p=0.000).In addition, a study conducted by Wulan and Huda (2022) found that the mean oxygen saturation before suction was 93.38%, while after suction was 94.19%, with p=0.009 (α=0.05).It also indicated a significant influence before and after suction on oxygen saturation among hospitalized patients in the Intensive Care Unit, RSUD RAA Soewondo Pati.
An essential first step to managing respiratory failure is alertness to circumstances and situations that can lead to respiratory failure.According to Maisyaroh and Widianto (2020) airway, maintain a patent airway, and prevent infection due to sputum accumulation in critically ill patients who experience life-threatening organ failure.A preliminary survey of 5 patients with nasopharyngeal cancer with a tracheostomy who came to the Emergency Department (Emergency Room) of Dharmais Cancer Hospital showed their complaint was shortness of breath.In addition, all of them experienced hypoxia; 2 respondents had mild hypoxia (91-94%), and 3 had moderate hypoxia (85-90%).When suctioning, some sputum could be quickly removed, and some were not.So, giving a nebulizer was critical first to dilute the sputum in the patient's airway.This study analyzes the correlation between sputum retention and oxygen saturation in nasopharyngeal cancer patients with tracheostomy at the Emergency Department, Dharmais Cancer Hospital, in 2022.

METHOD
This study was correlational quantitative research with a cross-sectional approach.Of the 25 patients with nasopharyngeal cancer with a tracheostomy with good sputum retention, 17 had mild hypoxemia (68%).Meanwhile, of the 40 respondents with poor sputum retention, 33 experienced moderate hypoxemia (82.5%) (Table 3).The chi-square test obtained a p=0.000 (p<0.05).Thus, there was a correlation between sputum retention and oxygen saturation in nasopharyngeal cancer patients with tracheostomy in the Emergency Department of Dharmais Cancer Hospital.The statistical tests also obtained an Odds Ratio (OR) value of 10.018 and a Confidence Interval (CI) value of 3.106-32.311.Thus, nasopharyngeal cancer patients with a tracheostomy who experienced good sputum retention had a 10.018 times greater chance of experiencing mild hypoxemia than nasopharyngeal cancer patients with a tracheostomy who had poor sputum retention.The lowest chance value was 3.106, and the highest chance value was 32.311 times greater.

DISCUSSION
This study found that of the 65 respondents of nasopharyngeal cancer patients with tracheostomy at the Emergency Department, most of them had poor sputum retention (61.5%).Nasopharyngeal carcinoma is a malignancy in the nasopharyngeal region (above the throat and behind the nose) (Sudiono and Hassan, 2013).Some of the treatments for nasopharyngeal cancer, according to Rowshan and Baur (2010), include surgery through tracheostomy.Sputum (phlegm) is material released from the lungs and trachea through the mouth (Muttaqin, 2008).Good sputum quality was evaluated by observing sputum characteristics (color, viscosity, and amount of sputum).Poor sputum is greenish-yellow or mucopurulent, thick or mucoid, and amounts to 3-5ml (Rab, 2012).Kozier et al. (2010) explain the complications of excess sputum can affect the airway, namely airway obstruction and limited airflow.The classification of sputum and its possible causes, according to Price and Wilson (1978), the yellowish sputum is likely an infectious process.In addition, bleeding sputum or hemoptysis is often found in Tuberculosis.The color (mucopurulent) is yellow-greenish, indicating that antibiotic treatment can reduce symptoms.Meanwhile, milky white or opaque mucus usually means that antibiotics will not effectively treat symptoms.Yellow-greenish and milky white sputum can be related to bacterial or viral infections, although current research does not support that generalization.Furthermore, white foamy sputum may stem from obstruction or even edema.
Some factors that can trigger increased sputum production, according to Widjaja (2008), are inflammation in the respiratory tract or surrounding areas, throat exposure to infections or allergies to foreign substances, stomach disorders, sinusitis inflammation, and the body's lack of fluids.Muttaqin (2008) explains how to remove sputum retention, including deep breathing, coughing, and suctioning.
The authors found that nasopharyngeal cancer patients with tracheostomy mostly had poor sputum quality or abnormal trachea secretion (color, viscosity, and amount).Most of the sputum was yellow and greenishyellow.There was also pink, white foamy, and milky white mucus.There was also poor sputum viscosity.
In addition, the amount of sputum was between 3 to 5 ml.The results of these observations indicated that the respondents had abnormalities in the respiratory tract, either experiencing inflammation in the respiratory tract, allergies to foreign objects or stomach disorders, and so on.It is crucial to do deep breathing exercises or cough to naturally remove phlegm in the body to clear the airway in patients with good sputum retention.Meanwhile, health workers perform suction for poor sputum retention, which an authorized doctor treats.
In addition, this paper revealed that of the 65 respondents of nasopharyngeal cancer patients with tracheostomy at the Emergency Department, most had moderate hypoxemia (63.1%).Tracheostomy is a procedure where a hole is made into the trachea.The term tracheostomy is when an indwelling tube is inserted into the trachea.The decision to perform a tracheostomy can generally be made within seven days of intubation (Smeltzer, 2010).
The previous research by Sari and Ikbal (2019) revealed that the mean oxygen saturation before suction in the control group was 94.77 and 99.48 after suction.In addition, Kitu, Rohana and Widyaningsih (2020) study found that the mean oxygen saturation after the endotracheal tube (ETT) secretion suction increased from 94% to 97.87%.
The author found that most respondents had moderate hypoxia; their oxygen saturation was between 86% and 94%.Thus, the respondent's oxygen saturation was categorized as moderate hypoxia, between 85 to 90%.It indicated that the respondents had an airway disorder, one of which was sputum retention.Thus, suctioning is critical to clear the airway so the oxygen exchange process can run well.(Muttaqin, 2008).
Decreased oxygen saturation due to airway obstruction can decrease diffusion, resulting in hypoxemia.
Unwell management of hypoxemia has a high potential to become hypoxia or tissue oxygen insufficiency (inability to carry out its functions adequately) for body metabolism.Further, hypoxia is a cause of injury and cell death.Cells depend on a continuous supply of oxygen.Therefore, without oxygen, cell maintenance and synthesizing activities stop quickly (Price and Wilson, 1978).Without oxygen for a particular time, body cells will experience damage that causes death.The most sensitive organ to a lack of oxygen is the brain.If the brain does not get oxygen for more than 5 minutes, permanent brain cell damage can occur (Kozier et al., 2010).
In previous research conducted by Dengo, Suwondo and Suroto (2018), oxygen saturation due to sputum retention was abnormal (70.0%).In addition, a study by Sari and Ikbal (2019) indicated that the mean oxygen saturation in the control group before the suction was 94.77, while after the suction was 99.48.
Thus, there was an influence between suctioning and oxygen saturation with a p=0.000.
The oxygen saturation of arterial blood with PaO2 100 mmHg is about 97.5%, while that of venous blood with PaO2 40 mmHg is about 75%.The affinity of hemoglobin to oxygen can affect oxygen release.When hemoglobin has a greater affinity for oxygen, there is reduced oxygenation to tissues.Conditions such as increased pH, decreased temperature, and decreased carbon dioxide partial pressure will increase hemoglobin's affinity for oxygen and limit oxygen to tissues, and hypoxemia occurs.Thus, hypoxemia can occur due to reduced blood oxygen pressure (PaO2) (Kozier et al., 2010).

CONCLUSION
In conclusion, sputum retention correlates with oxygen saturation in nasopharyngeal cancer patients with tracheostomy at the Emergency Department of Dharmais Cancer Hospital.The hospital should continue improving the ability of nurses to manage airway blockage through regular training.

Table 1 .
Frequency Distribution of Sputum Retention in Nasopharyngeal Cancer Patients with Tracheostomy at the Emergency Department The study population was all nasopharyngeal cancer patients with tracheostomy at the Emergency Department, Dharmais Cancer Hospital, from August to November 2022, totaling 65 respondents.There were 65 respondents with a total sampling technique.The data collection used secondary data, namely the level of sputum retention and oxygen saturation in nasopharyngeal cancer patients with tracheostomy.Data collection was through observation of the Management Information System of Dharmais Hospital.Data analysis was univariate analysis and bivariate analysis through chi-square test.The Ethics Commission of Dharmais Hospital has ethically tested this study.It has been declared to have passed the ethical test with the Ethical Code 054/KEPK/II/2023.RESULTTable1shows that of the 65 respondents of nasopharyngeal cancer patients with tracheostomy at the Emergency Department, most of them had poor sputum retention (61.5%).https://doi.org/10.33086/jhs.v16.i03.3993Repidawati Sinaga -The Correlation between Sputum Retention and Oxygen Saturation in Nasopharyngeal Cancer Patients with Tracheostomy at The Emergency Department of Dharmais Cancer Hospital in 2022

Table 2 .
Frequency Distribution of Oxygen Saturation in Nasopharyngeal Cancer Patients with Tracheostomy at the Emergency Department

Table 3 .
The Correlation between Sputum Retention and Oxygen Saturation in Nasopharyngeal Cancer Patients with Tracheostomy at the Emergency Department The Correlation between Sputum Retention and Oxygen Saturation in Nasopharyngeal Cancer Patients with Tracheostomy at The Emergency Department of Dharmais Cancer Hospital in 2022 hypoxemia (82.5%).The statistical analysis obtained a p=0.000 (p<0.05).Thus, there was a correlation between sputum retention and oxygen saturation in nasopharyngeal cancer patients with tracheostomy in the Emergency Department of Dharmais Cancer Hospital.It might be because nasopharyngeal cancer patients had difficulty removing sputum or sputum retention.