Tips on Suctioning your Patient......

 Airway Management

 

1. HUMIDIFICATION – heated cascade provides 100% humidification of inhaled gases. Ensure systemic hydration is monitored to help keep secretions thin.
2. AEROSOL THERAPY – nebulizers delivering aerosols increase secretion clearance and liquefy mucus; nebulizers may become a source of bacterial contamination.
3. CUFF MANAGEMENT – essential for prevention of necrosis and aspiration. Two different cuff-inflation techniques are currently used:
4. Minimal leak technique (ML) – inject air into cuff until no leak is heard and then withdrawing the air until a small leak is heard on inspiration. (Problems are related to maintaining PEEP, aspiration around the cuff, and increased movement of the tube.)
5. Minimal occlusive volume technique (MOV) – inject air into cuff until no leak is heard, then withdrawing the air until a small leak is heard on inspiration, and then adding more air until no leak is heard on inspiration. (Problems are related to higher cuff pressures than ML technique.) Use only if patient needs a seal to provide adequate ventilation and/or is at high risk for aspiration.
6. Monitor cuff pressures at least q. 8 h. Maintain pressure 18 to 22 mm Hg (25 to 30 cm H2O. Greater pressures decrease capillary blood flow in tracheal wall and lesser pressures increase risk of aspiration. Do not routinely deflate cuff.
7. POSTURAL DRAINAGE & POSITIONING (see respiratory references).
8. Key Point: Pneumonia = "Good lung down position"
9. ARDS = prone positioning for improved oxygenation
10. SUCTIONING – perform as sterile procedure only when patient needs it and not on a routine schedule. Observe for hypoxemia, atelectasis, bronchospasms, cardiac dysrhythmias, hemodynamic alterations, increased intracranial pressure, and airway trauma.

 

ENDOTRACHEAL/ TRACHEAL SUCTIONING PROCEDURE

OBJECTIVES:

The nurse performs endotracheal and tracheostomy suctioning to:

1. Maintain a patent airway.
2. To improve oxygenation and reduce the work of breathing.
3. To remove accumulated tracheobronchial secretions using sterile technique.
4. Stimulate the cough reflex.
5. Prevent pulmonary aspiration of blood and gastric fluids.
6. Prevent infection and atelectasis.

EQUIPMENT:

Sterile normal saline
Suction source
Ambu bag connected to 100% O2
Clear protective goggles/mask or face shield                   
Sterile gloves for open suction        
Clean gloves for (in-line) closed suction
Sterile catheter with intermittent suction control port or In-line suction catheter

PROCEDURE:

1. Wash hands. Reduces transmission of microorganisms.
2. Assess patient’s need for suctioning. Since endotracheal suctioning can be hazardous and causes discomfort, it is not recommended in the absence of apparent need.

Coarse breath sounds
Coughing; increased respirations
Increased PIP on ventilator

3. Don goggles and mask or face shield. Potential for contamination
4. Turn on suction apparatus and set vacuum regulator to appropriate negative pressure. Recommend 80-120 mmHg; adjust lower for children and the elderly. Significant hypoxia and damage to tracheal mucosa can result from excessive negative pressure.
5. Prepares suction apparatus. Secure one end of connecting tube to suction machine, and place other end in a convenient location within reach.
6. Use in-line suction catheter or open sterile package (catheter size not exceeding one-half the inner diameter of the airway) on a clean surface, using the inside of the wrapping as a sterile field.
7. Prepares catheter and prevents transmission of microorganisms. Catheter exceeding one-half the diameter increases possibility of suction-induced hypoxia and atelectasis.
8. Prepare catheter flush solution.With in-line catheter use sterile saline bullets to flush catheter. With regular suctioning set up sterile solution container and being careful not to touch the inside of the container, fill with enough sterile saline or water to flush catheter.
9. With in-line suction catheter use clean gloves. With regular suctioning, done sterile gloves. Maintain sterility. Universal precautions. In regular suctioning the dominant hand must remain sterile throughout the procedure.
10. Pick up suction catheter, being careful to avoid touching nonsterile surfaces. With nondominant hand, pick up connecting tubing. Secure suction catheter to connecting tubing. Maintains catheter sterility. Connects suction catheter and connecting tubing
11. Ensures equipment function. Check equipment for proper functioning by suctioning a small amount of sterile saline from the container. (skip this step in in-line suctioning)
12. Remove or open oxygen or humidity device to the patient with nondominant hand. (skip this step with in-line suctioning). Opens artificial airway for catheter entrance. Have second person assist when indicated to avoid unintentional extubation.
13. Replace O2 delivery device or reconnect patient to the ventilator. Hyperoxygenate and hyperventilate via 3 breaths by giving patient additional manual breaths on the ventilator before suctioning. Hyperoxygenation with 100% O2 is used to offset hypoxemia during interrupted oxygenation and ventilation. Preoxygenation offsets volume and O2 loss with suctioning. Patients with PEEP should be suctioned through an adapter on the closed suction system.
14. Without applying suction, gently but quickly insert catheter with dominant hand during inspiration until resistance is met; then pull back 1-2 cm. Catheter is now in tracheobronchial tree. Application of suction pressure upon insertion increases hypoxia and results in damage to the tracheal mucosa.
15. Apply intermittent suction by placing and releasing dominant thumb over the control vent of the catheter. Rotate the catheter between the dominant thumb and forefinger as you slowly withdraw the catheter. With in-line suction, apply continuous suction by depressing suction valve and pull catheter straight back. Time should not exceed 10-15 seconds. Intermittent suction and catheter rotation prevent tracheal mucosa when using regular suctioning methods. Unable to rotate with closed- suction method.
16. Replace oxygen delivery device. Hyperoxygenate between passes of catheter and following suctioning procedure. Replenishes O2. Recovery to base PaO2 takes 1 to 5 minutes. Reduces incidence of hypoxemia and atelectasis.
17. Rinse catheter and connecting tubing with normal saline until clear. Removes catheter secretions.
18. Monitor patient’s cardiopulmonary status during and between suction passes. Observe for signs of hypoxemia, e.g. dysrhythmias, cyanosis, anxiety, bronchospasms, and changes in mental status.
19. Once the lower airway has been adequately cleared of secretions, perform nasal and oral pharyngeal or upper airway suctioning. Removes upper airway secretions. The catheter is contaminated after nasal and oral pharyngeal suctioning and should not be reinserted into the endotracheal or tracheostomy tube.
20. Upon completion of upper airway suctioning, wrap catheter around dominant hand. Pull glove off inside out. Catheter will remain in glove. Pull off other glove in same fashion and discard. Turn off suction device. Reduces transmission of microorganisms.
21. Reposition patient. Supports ventilatory effort; promotes comfort; communicates caring attitude.
22. Reassess patient’s respiratory status. Indicates patient’s response to suctioning
23. Dispose of suction liners and connecting tubing, sterile saline solution every 24 hours and set up new system. Decreases incidence of organism colonization and subsequent pulmonary contamination. Universal precautions.

PRECAUTIONS:

1. Minimize suctioned-induced atelectasis and hypoxemia:

a. Avoid using catheters larger than one-half the diameter of the airway.
b. Administer one or more postsuctioning hyperinflations, using manual or sigh breaths on the ventilator or ambu bag if not ventilated.

2. Maintain rigorous sterile technique when suctioning the intubated patient. Impaired pulmonary defense systems and invasive instrumentation of the pulmonary tract predisposes these patients to colonization and infection. Never use same catheter to suction the trachea after it has been used in the nose or the mouth.
3. Limit the frequency of suctioning and avoid, as much as possible, catheter impaction in the bronchial tree when the patient is anticoagulated or when hemorrhage from suction-induced trauma is evident.
4. Minimize the frequency and duration of suctioning when patient is on positive end-expiratory pressure (PEEP) greater than 5 cm or continuous positive airway pressure (CPAP). Small suctioning-induced changes may have profound effects on these marginally oxygenated patients.
5. Maintain awareness of the limitations of ET/tracheal suctioning. Maneuvers and catheter design have been proposed to increase the likelihood of passage into the left bronchus; however, these have been shown to be of limited success. Because the left main stem bronchus emerges from the trachea at the 45-degree angle from the vertical, suction catheters are almost inevitable passed into the right bronchus (when they pass the carina) despite head-turning, etc.
6. The use of saline installations for loosening secretions has been controversial and recent research shows that in fact it is detrimental and poses a greater risk of pneumonia for the patient.

RELATED CARE:

1. Include strategies to move secretions through peripheral airways. These measures are: appropriate hydration and adequate humidification of inspired gases (to keep secretions thin); coughing and deep breathing; frequent position changes (may need rotation bed); chest physiotherapy; and bronchodilating agents as ordered.
2. Monitor the patient carefully during ET/tracheal suctioning for ectopic dysrhythmias aggravated by suction-induced hypoxemia and other dysrhythmias, particularly conduction disturbances, related to catheter irritation of vagal receptors within the respiratory tract (requires immediate cessation of suctioning and hyperoxygenation).

POTENTIAL COMPLICATIONS

Hypoxemia
Atelectasis
Dysrhythmias
Nosocomial pulmonary tract infection
Sepsis
Mucosal trauma with increase secretions

Cardiac Arrest

 

Additional Reading......Below

 

 

 

1.0. DESCRIPTION
1.1 Definitions:
1.1.1 Deep tracheal suctioning is a sterile procedure which is performed to mobilize secretions from the patient's airway. By aspiration through a suction catheter placed proximal to the secretions. Airway suctioning removes excess secretions and promotes the cough reflex to help in maintaining a clear airway.
1.1.2 The Ballard Closed Tracheal Suction System is a multiple use tracheal suction catheter which is incorporated into the ventilator circuit via a standard T-piece elbow or double swivel elbow (DSE) allowing for the continuation of mechanical ventilation during suctioning and reducing the potential for contamination.
1.2 Indications
1.2.1 Suctioning is indicated for:
1.2.1.1 Patients with artificial airways
1.2.1.2 Patients with copious, retained secretions who cannot cough well due to loss of muscle tone, loss of an adequate cough reflex, or severe pain
1.2.1.3 The presence of adventitious breath sounds, i.e. Rhonchi
1.2.1.4 A requirement for a sputum specimen for laboratory analysis from a patient who is unable to produce a specimen via his own cough mechanism or who has an artificial airway

 

The use of the closed tracheal suction system is indicated for intubated/tracheal patients who:
1.2.1.5 Are placed in Respiratory Isolation
1.2.1.6 Require frequent suctioning, ie, greater than three times per 12-hour shift
1.2.1.7 Require greater than 10 cm H2O positive end expiratory pressure (PEEP) and/or an FiO2 greater than 0.50
1.2.1.8 Have documented desaturations demonstrated on pulse oximetry during suctioning
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1.3 Contraindications
1.3.1 Patients with known hypersensitivity or vasovagal response to suctioning
1.3.2 Nasotracheal suctioning of patients who are thrombocytopenic, on systemic anticoagulant therapy, or have recently sustained surgery or trauma to the pharynx
1.3.3 Patients with epiglottitis
1.3.4 The closed tracheal suction system is contraindicated for use with endotracheal or tracheostomy tube sizes less than 5.0 mm ID.

 

1.4 Complications
1.4.1 Hypoxemia
1.4.2 Dysrhythmias
1.4.3 Hypotension
1.4.4 Atelectasis
1.4.5 Infection
1.4.6 Tracheal mucosal damage
1.4.7 Vomiting and aspiration of stomach contents

 

1.5 Precautions
1.5.1 Acute hypoxemia during the suctioning process may precipitate heart rate abnormalities in the critically ill. Dysrhythmias resulting from myocardial hypoxia may compromise hemodynamic stability. Vagal stimulation secondary to tracheal irritation may lead to profound bradycardia.
1.5.2 Hypotension may occur from either prolonged bradycardia or prolonged coughing during suctioning.
1.5.3 Atelectasis may result from insertion of a large suction catheter into the small diameter of an artificial airway. The catheter should not occupy more than one-half of the internal diameter of the tube being suctioned. (See Section 2.1)
1.5.4 Sterile technique must always be followed to avoid contamination of the airway. The catheter must never be reused.
1.5.5 Airway mucosal trauma may occur when improper suctioning techniques are employed. Suction should only be applied while withdrawing the catheter, and excessive vacuum pressure and lengthy suction maneuvers should be avoided. It is advisable to pay particular attention to the depth of insertion in patients who may be particularly vulnerable to mucosal damage, i.e., very young patients. In these cases, follow the procedure for determining the proper insertion
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depth of the suction catheter through an artificial airway as outlined in 3.8. Procedure.
1.5.6 The decision to suction patients on high levels of positive end expiratory pressure (PEEP) and/or in fulminant pulmonary edema must be weighed against the cardiopulmonary effects of the loss of PEEP to these patients.
1.5.7 Patients with artificial airways who are sedated should have gastric tubes in place with vacuum applied for the evacuation of stomach contents.
1.5.8 Patients with thrombocytopenia and/or on systemic anticoagulant therapy must be suctioned with care to avoid mucosal trauma and bleeding.
1.5.9 When using the closed tracheal suction system, the catheter must be withdrawn to the full extent, ie, the black line must be visible within the bag, to prevent obstruction of the airway.
1.6 Adverse Reactions and Interventions
1.6.1 If dysrhythmias occur or significantly increase during suctioning, abort the procedure and hyperoxygenate the patient. If a further attempt at suctioning promotes a dysrhythmia, notify the physician for further instruction.
1.6.2 If the patient fails to return to his/her baseline clinical status after suctioning, notify the physician.
1.6.3 Patients receiving PEEP levels of five cm H2O and above should have the same level of PEEP maintained between suctioning passes. PEEP levels of 10 cm H2O or greater warrant the use of bronchoscopy adapters, or, alternatively, the closed tracheal suction system (See 1.3. Indications). Suctioning through these systems eliminates the interruption in the mechanical ventilatory process, therefore PEEP may be maintained.
1.6.4 If vomiting occurs, maintain suction to the hypopharnyx and oropharynx until the vomiting has stopped.

 

2.0 EQUIPMENT AND MATERIALS
2.1 Appropriately sized sterile suction catheter: ID Tube (Size)/patient Catheter size 8.0-9.5/avg. adult 14 French 5.0-7.5/child, sm. adult 10 French 4.0-4.5/ infant, sm. child 8 French 2.5-3.5/infant 6 French
OR
Appropriately sized in-line suction catheter (closed tracheal suction system): ID Tube (Size)/patient Catheter size
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6.0-6.5/lg. child 12 French
7.0-9.5/adult 14 French
2.2 Suction source that is capable of generating up to 300-600 mm Hg vacuum
pressure with connecting tubing:
Vacuum pressure for: adults = 120-150 mm Hg children = 100-120 mm Hg infants = 60 -100 mm Hg
2.3 Sterile/nonsterile gloves, as appropriate
2.4 Manual resuscitator and mask (with PEEP valve, if appropriate) and oxygen
source for intubated patients; supplemental blowby oxygen for nonintubated
patients
2.5 Soluble lubricant for nasotracheal suctioning of the nonintubated patient
2.6 Sterile water for clearing clogged catheter
2.7 Universal precautions attire
2.8 Sterile specimen trap (if indicated)
2.9 0.9% NaCl for lavage, if indicated by inspissated secretions

 

3.0 PROCEDURE
3.1 Check order, gather equipment, and wash hands.
3.2 Assess the patient by inspection and auscultation.
3.3 Inform the patient of the procedure.
3.4 Don universal precautions attire.
3.5 Turn on the vacuum regulator and adjust the pressure as appropriate.
3.6 Preoxygenate the patient.
Routine nasotracheal suctioning or suctioning of artificial airways:
3.7 Open the catheter kit and don the gloves while maintaining sterility. Lubricate
the catheter at this time, if appropriate. A nasopharyngeal airway may be used
to facilitate passage of the catheter through the nasopharynx and thereby
minimize trauma to the area. Connect the catheter to the vacuum tubing.
3.8 Suctioning the airway
3.8.1 For intubated patients, insert the catheter into the airway until an
obstruction is met, then withdraw about one cm. For very young
patients, the catheter need only be withdrawn approximately 1/2 cm
at this point.
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3.8.2 For nasotracheal suctioning of nonintubated patients, blowing of the nose and use of an antiseptic mouthwash prior to the procedure may minimize the risk of tracheal infection. Position the head so that the neck is mildly hyperextended, and insert the lubricated catheter into one of the nares. Advance the catheter slowly during inspiration. Except in the most obtunded patient, vigorous coughing will result when the catheter passes into the trachea. Pass the catheter until resistance is met, and then pull back about one cm, or 1/2 cm in very young patients.
***Alternatively, measure the depth of insertion by summing the length of the airway adaptor and the distance to the tip of the endotracheal or tracheostomy tube. Insert the suction catheter only to this depth.
3.9 Suction should not be applied for more than fifteen seconds, and ventilation and oxygenation should not be interrupted for more than twenty seconds in adults. For pediatric patients, suction should be applied for no more than five seconds, and the total interruption to ventilation and oxygenation should not exceed ten seconds.
3.10 Reoxygenate and hyperventilate the patient prior to performing another suction maneuver. Ensure stable vital signs prior to reinsertion of the catheter.
3.11 Repeat the suctioning procedure until secretions are cleared from the airway and breath sounds are improved. For nasotracheal suctioning, it may be helpful to withdraw the catheter into the airway above the epiglottis, without completely removing it, between suction passes.
3.12 If the patient has tenacious secretions, sterile 0.9% NaCl may be instilled prior to suctioning to facilitate loosening and removal of the secretions. Ventilation of the patient with a manual resuscitator immediately following instillation, and prior to suctioning, may aid in distribution of the diluent.
Use of the closed tracheal suction system:
3.13 Place the 24 hour change out sticker over the suction valve on the in-line suction catheter. NOTE: Catheters must be changed every 24 hours or more frequently PRN.
3.14 Attach wall suction tubing to the control valve.
3.15 Insert the T-piece between the endotracheal/tracheostomy tube and the ventilator circuit.
3.16 Open the irrigation port, and attach a 0.9% NaCl vial.
3.17 For sputum collection, connect specimen trap inline between the suction control valve and the suction tubing. Suction patient as described below. Note: Collection of sputum through closed catheters is only completely free of contaminants when first used.
3.18 Preoxygenate the patient.
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3.19 Grasp the T-piece with one hand and advance the catheter using the thumb and forefinger of the opposite hand.
3.20 If opting to lavage: Advance the catheter approximately four inches for an endotracheal tube and two inches for a tracheostomy tube. Instill 3-5 ml of 0.9% NaCl from the vial during inspiration and immediately advance the catheter down the tube to the desired depth.
3.21 Withdraw the catheter slowly while depressing the suction control valve. Do not remove the catheter until the valve is fully depressed. Stabilize the T-piece with your non-dominant hand while withdrawing the catheter.
3.22 Withdraw the catheter to its full extent (black line must be visible within bag).
3.23 Reoxygenate the patient prior to performing another suction maneuver. Ensure stable vital signs prior to reinsertion of the catheter.
3.24 Repeat the suctioning procedure until secretions are cleared from the airway and breath sounds are improved.
3.25 When transferring the patient, disconnect the suction catheter from the suction tubing, and rotate and lock the suction control valve.
4.0 POST PROCEDURE
4.1 Rinse the suction tubing in water after the procedure to prevent clogging of the vacuum apparatus.
4.2 Assure that the patient is comfortable, and that vital signs are stable before leaving the bedside.
4.3 Immediately discard the dirty catheter and gloves.
For use of the closed tracheal suction system:
4.4 Instill at least 5 ml of 0.9% NaCl while applying continuous suction via the suction control valve to clean the catheter. Do not allow secretions to remain in the catheter or suction line after suctioning, since these may dry and harden, reducing line suction efficiency.
4.5 Cap the lavage port after removing the normal saline vial. Discard the empty vial.
4.6 Rotate and lock the suction control valve.
5.0

 

DOCUMENTATION
5.1 Chart the procedure by initialing the proper column on the patient's bedside flowsheet.
5.2 Chart any adverse reactions that may have occurred and the interventions required to correct these on the Notes side of the Continuous Ventilation Record. Report these to the patient’s nurse and the responsible physician.

6.0
REFERENCES
6.1 AARC Clinical Practice Guideline “Nasotracheal Suctioning”
6.2 AARC Clinical Practice Guideline “Endotracheal Suctioning of
Mechanically-Ventilated Adults and Children with Artificial Airways”.
6.3 Barnhart SL, Czervinske MP, eds. Perinatal and pediatric respiratory care.
Philadelphia: WB Saunders Co., 1995.
6.4 Ballard Medical Products: Quality Assurance Manual
6.5 Whitaker K. Comprehensive perinatal and pediatric respiratory care. Delmar
Publishers, Inc.: 1992; ppg. 209-214.

 

 

 

More Reading......

So, you have read about suctioning  dozens of times already. You have listened to your Clinical Instructors discuss it in lectures and classes, but would you actually remember those lectures  when you get to perform the procedure for the first time when you’re all nervous and feeling fidgety?
Here are some of the things you should take into consideration  when you perform suctioning... whether for the first or nth time already.

• Have the equipment needed ready at bedside: suction machine, irrigating suction, suction catheter, suction bottles. Of course, you wouldn’t want to cram and say “Hey, where is the irrigating solution?” when the time comes that it is urgently needed to perform the procedure.
• Wash your hands before the procedure. As always, aseptic technique. Also, wear protective gear such as gloves, facial mask, etc as needed.
• You can repeat this procedure. This is not a one-time procedure. You can actually repeat suctioning if necessary, but when you do so, allow your patient to catch their breath first.
• The patient should be in a sitting position for suctioning.
• Coughing is normal. Don’t panic and call for the doctor when your patient coughs when you suction. The patient will cough as the throat is entered and you will feel resistance at some point.

• Hyperoxygenate patient before and after the procedure. Or you may advise your patient to take several deep breaths before suctioning.
• Check heart rate before, during and after procedure. If tachycardia or bradycardia occurs discontinue the procedure until it resolves
• If nasotracheal suctioning is to be performed, you may coat tip of catheter with lubricant.
• When removing the catheter, apply intermittent suction and do it in a circular motion. Suction should not be applied for more than 10-15 seconds.
• Throw out catheters after use, unless you have been instructed by your nurse to clean and re-use them. Most of the suction catheters are on a single use basis only.
• Auscultate the patient’s chest; if secretions can still be heard repeat the suctioning procedure (5-10ml of normal saline may be used to loosen tenacious secretions). Before re-suctioning, clear catheter with sterile water.

Everyone, no matter how experienced and skilful they might be, always has their first time. We may feel a bit panicky and nervous on our first time to do a procedure, we may forget some concepts we have learned in that moment, but what’s imperative is that we remember certain things especially the main points when it comes to performing suctioning. That way, we won’t only know what to do, but we may also save our patients from potential harm as well.

Sources:

• http://www.stannhospice.com/HomeCareBooklet.htm#Suctioning
• http://www.sh.lsuhsc.edu/cps/pandp/7.16.pdf