How to Suction the Trach Patient Part 1

 

   Interventions and Practices Considered.....

1. Patient preparation
   • Catheter selection
   • Pre-oxygenation (delivery of 100% oxygen) in preparation of suctioning event
   • Check negative pressure of the unit
   • Set suction pressure as low as possible
   • Closed suctioning technique for specific patient groups
   • Open suctioning
   • Pulse oximetry
2. Shallow suctioning technique
3. Sterile technique during open suctioning
4. Lung recruitment maneuvers
5. Duration of suction event <15 seconds
6. Monitoring (breath sounds, oxygen saturation, respiratory rate, pattern, hemodynamic parameters, sputum characteristics, cough characteristics, intracranial pressure [as indicated], ventilator parameters)

Note: Deep suctioning and normal saline instillation prior to endotracheal suction is not recommended.

1.  Patient Prep:

• Diameter of the suction catheter should not exceed one half the inner diameter of the artificial airway
• Deliver 100% oxygen in adults and peds and 10% increase of baseline in neonates, for 30-60′s sec.
•   Can do this by either adjusting the fractional inspired oxygen (FiO2) setting on the mech. vent. or by use of the temporary oxygen-enrichment program on many microprocessor ventilators (Campbell & Branson, 1992)
  • Manual ventilation of the patient is not recommended, as it has been shown to be ineffective for providing delivered FiO₂ of 1.0. (Barnes & McGarry, 1990; Woodgate & Flenady, 2001) Practitioners should ensure that positive end-expiratory pressure (PEEP) is maintained if no other alternative is available to hyper-oxygenate.
• The negative pressure of the unit must be checked by occluding the end of the suction tubing before attaching it to the suction catheter, and prior to each suctioning event. Suction pressure should be set as low as possible and yet effectively clear secretions. Experimental data to support an appropriate maximum suction level are lacking. Negative pressure of 80–100 mmHg in neonates (Wilinska et al., 2008) and less than 150 mmHg in adults have been recommended. (Plevak & Ward, 1997)
• The closed suctioning technique facilitates continuous mechanical ventilation and oxygenation during the suctioning event. (Johnson et al., 1994; Lee et al., 2001)
• A patient should be placed on a pulse oximeter to assess oxygenation during and following the procedure.

Procedure:

•  The suctioning event consists of the placement of a suction catheter through the

artificial airway into the trachea and the application of negative pressure as the catheter is being withdrawn.

•  Each pass of the suction catheter into the artificial airway is considered a suctioning event. (Gardner & Shirland, 2009).
•  Shallow suctioning is best practice. Suction for no more than 15 sec. at a time.
• Sterile technique is best practice
• To see if you should add NS to the trach to stimulate clearing of secretions, see your P & P.  Not shown to be beneficial.

Follow-up care:

• Hyperoxygenate for at less 1 min (see your P & P) after.
• Hyperventilation should not be routinely used.
• Monitor the pt. for adverse reactions.

When should you perform suctioning:

• when the patency of the airway needs to be maintained
• when secretions need to be removed:
• Sawtooth pattern on the flow-volume loop on the monitor screen of the ventilator and/or the presence of coarse crackles over the trachea are strong indicators of retained pulmonary secretions. (Guglielminotti et al., 2000; Wood, 1998)
• Increased peak inspiratory pressure during volume-controlled mechanical ventilation or decreased tidal volume during pressure-controlled ventilation (Morrow, Futter, & Argent, 2004)
• Deterioration of oxygen saturation and/or arterial blood gas values (Morrow, Futter, & Argent, 2004)
• Visible secretions in the airway (Morrow, Futter, & Argent, 2004)
• Patient’s inability to generate an effective spontaneous cough
• Acute respiratory distress (Morrow, Futter, & Argent, 2004)
• Suspected aspiration of gastric or upper-airway secretions
• When a specimen is needed.

Necessary equipment:

• Suction equipment either wall mounted or portable
• Calibrated, adjustable regulator
• Collection bottle and connecting tubing
• Disposable gloves
  • Sterile (open suction)
  • Clean (closed suction)
• Sterile suction catheter
  • For selective main-bronchus suctioning, a curved-tip catheter may be helpful. (Kubota et al., 1990) The information related to the effectiveness of head turning for selective suctioning is inconclusive.
• Sterile water and cup (open suction)
• Goggles, mask, and other appropriate equipment for standard precautions (Siegal et al., 2007)
• Oxygen source with a calibrated metering device
• Pulse oximeter
• Manual resuscitation bag equipped with an oxygen-enrichment device for emergency backup use
• Stethoscope

Optional equipment

• Electrocardiograph
• Sterile sputum trap for culture specimen

Personnel. Licensed or credentialed respiratory therapists or individuals with similar credentials (e.g., MD, RN) who have the necessary training and demonstrated skills to correctly assess need for suctioning, perform the procedure, and adequately evaluate the patient after the procedure.

Monitoring

The following should be monitored prior to, during, and after the procedure:

• Breath sounds
• Oxygen saturation

• Skin color
• Pulse oximeter

Respiratory rate and pattern

Hemodynamic parameters

• Pulse rate
• Blood pressure, if indicated and available
• Electrocardiogram, if indicated and available

Sputum characteristics

• Color
• Volume
• Consistency
• Odor

• Cough characteristics
• Intracranial pressure, if indicated and available

Ventilator parameters

• Peak inspiratory pressure and plateau pressure
• Tidal volume
• Pressure, flow, and volume graphics, if available
• FIO₂

see:http://guidelines.gov/content.aspx?id=23992