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
 

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

Tracheostomy Suctioning

The trach tube bypasses these mechanisms, so that the air moving through the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. Suctioning clears mucus from the tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop. Avoid suctioning too frequently as this could lead to more secretion buildup.

Removing mucus from trach tube without suctioning

1. Bend forward and cough. Catch the mucus from the tube, not from the nose and mouth.
2. Squirt sterile normal saline solutions (approximately 5cc) into the trach tube to help clear the mucus and cough again.
3. Remove the inner tube (cannula).
4. Suction.
5. Call 911 if breathing is still not normal after doing all of the above steps.
6. Remove the entire trach tube and try to place the spare tube.
7. Continue trying to cough, instill saline, and suction until breathing is normal or help arrives.

When to suction

Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. Suctioning should be considered

• Any time the patient feels or hears mucus rattling in the tube or airway
• In the morning when the patient first wakes up
• When there is an increased respiratory rate (working hard to breathe)
• Before meals
• Before going outdoors
• Before going to sleep

The secretions should be white or clear. If they start to change color, (e.g. yellow, brown or green) this may be a sign of infection. If the changed color persists for more than three days or if it is difficult to keep the tracheostomy tube intact, call your surgeon's office. If there is blood in the secretions (it may look more pink than red), you should initially increase humidity and suction more gently. A Swedish or artificial nose (HME), which is a cap that can be attached to the tracheostomy tube, may help to maintain humidity. The cap contains a filter to prevent particles from entering the airway and maintains the patient's own humidity. Putting the patient in the bathroom with the door closed and shower on will increase the humidity immediately. If the patient coughs up or has bright red blood mucus suctioned, or if the patient develops a fever, call your surgeon's office immediately.

How to suction

Equipment
Clean suction catheter (Make sure you have the correct size)
Distilled or sterile water
Normal saline
Suction machine in working order
Suction connection tubing
Jar to soak inner cannula (if applicable)
Tracheostomy brushes (to clean tracheostomy tube)
Extra tracheostomy tube

1. Wash your hands.
2. Turn on the suction machine and connect the suction connection tubing to the machine.
3. Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is to be reused, place the catheter in a container of distilled/sterile water and apply suction for approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with running water for a few minutes then soak in a solution of one part vinegar and one part distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they become stiff or cracked.
4. Connect the catheter to the suction connection tubing.
5. Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders. Some patients may prefer a sitting position which can also be tried.
6. Wet the catheter with sterile/distilled water for lubrication and to test the suction machine and circuit.
7. Remove the inner cannula from the tracheostomy tube (if applicable). The patient may not have an inner cannula. If that is the case, skip this step and go to number 8.
   
   a. There are different types of inner cannulas, so caregivers will need to learn the specific manner to remove their patient's. Usually rotating the inner cannula in a specific direction will remove it.
   
   b. Be careful not to accidentally remove the entire tracheostomy tube while removing the inner cannula. Often by securing one hand on the tracheostomy tube?s flange (neck plate) one can/ will prevent?accidental removal.
   
   c. Place the inner cannula in a jar for soaking (if it is disposable, then throw it out).
8. Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the natural curvature of the tracheostomy tube. The distance to the location of catheter becomes easier to determine with experience. The least traumatic technique is to pre-measure the length of the tracheostomy tube then introduce the catheter only to that length. For example if the patient?s tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there will be instances when this technique of suctioning (called tip suctioning) will not clear the patient?s secretions. For those situations, the catheter may need to be inserted several mm beyond the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be able to judge the distance to insert the tracheostomy tube without measuring.
9. Place your thumb over the suction vent (side of the catheter) intermittently while you remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10 seconds since the patient will not be able to breathe well with the catheter in place.
10. Allow the patient to recover from the suctioning and to catch his/her breath. Wait for at least 10 seconds.
11. Suction a small amount of distilled/sterile water with the suction catheter to clear any residual debris/secretions.
12. Insert the inner cannula from extra tracheostomy tube (if applicable).
13. Turn off suction machine and discard catheter (clean according to step 3 if to be reused).
14. Clean inner cannula (if applicable).

Red Cross Suctioning Fact Sheet, Click Here to View....

What is a Tracheostomy?........

A tracheotomy or a tracheostomy is an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth. The term “tracheotomy” refers to the incision into the trachea (windpipe) that forms a temporary or permanent opening, which is called a “tracheostomy,” however; the terms are sometimes used interchangeably.

Reasons for a tracheostomy

A tracheotomy is usually done for one of three reasons:

1. to bypass an obstructed upper airway;
2. to clean and remove secretions from the airway;
3. to more easily, and usually more safely, deliver oxygen to the lungs.

All tracheostomies are performed due to a lack of air getting to the lungs. There are many reasons why sufficient air cannot get to the lungs.
Airway Problems That May Require a Tracheotomy

• Tumors, such as cystic hygroma
• Laryngectomy
• Infection, such as epiglottitis or croup
• Subglottic Stenosis
• Subglottic Web
• Tracheomalacia
• Vocal cord paralysis (VCP)
• Laryngeal injury or spasms
• Congenital abnormalities of the airway
• Large tongue or small jaw that blocks airway
• Treacher Collins and Pierre Robin Syndromes
• Severe neck or mouth injuries
• Airway burns from inhalation of corrosive material, smoke or steam
• Obstructive sleep apnea
• Foreign body obstruction

Lung Problems That May Require a Tracheostomy

• Need for prolonged respiratory support, such as Bronchopulmonary Dysplasia (BPD)
• Chronic pulmonary disease to reduce anatomic dead space
• Chest wall injury
• Diaphragm dysfunction

Other Reasons for a Tracheostomy

• Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm
• Aspiration related to muscle or sensory problems in the throat
• Fracture of cervical vertebrae with spinal cord injury
• Long-term unconsciousness or coma
• Disorders of respiratory control such as congenital central hypoventilation or central apnea
• Facial surgery and facial burns
• Anaphylaxis (severe allergic reaction)

How a tracheostomy is performed

Surgical Anatomy

The superior thyroid notch, cricoid and suprasternal notch usually can be easily palpated through the skin. The cricothyroid space can be identified by palpating a slight indentation immediately below the inferior edge of the thyroid cartilage. Cricothyroid arteries traverse the superior aspect of this space on each side and anastomose near the midline.
The innominate artery crosses from left to right anterior to the trachea at the superior thoracic inlet. Its pulsations can be palpated and occasionally seen in the suprasternal notch especially in case of a high riding vessel, representing a contraindication for a bedside percutaneous or open tracheostomy.
The isthmus of the thyroid gland lies across the 2nd to 4th tracheal rings and must be dealt with in any procedure at or around the upper trachea.

Indications for PDT

They are the same as a routine open operative tracheostomy with particular attention to contraindications.¹

Contraindications for PDT

Absolute:
Emergent tracheostomy ( i.e., securing emergent airway) in any patient population, infants and children (<15 years)
Relative Surgical Contraindications: Poor neck landmarks, neck mass (e.g. goiter), high innominate or pulsating vessels, previous neck surgery, limited neck extension, severe coagulation (uncorrected)
Relative Anesthetic Contraindications:
High PEEP (>18 cm), high airway pressure (>45 cm), high FiO2 (80%), retrognathic mandible with a limited view of the larynx on laryngoscopy

Preparation for Tracheostomy

Once the decision to perform a tracheostomy has been made, the surgeon must determine if the patient is a good candidate for the surgery and obtain written informed consent. In addition, the range of motion of the neck needs to be assessed. The tracheostomy team, including the surgeons and anesthesiologists need to discuss the entire sequence and alternatives to the procedure. All equipment must be available and functioning properly.

Equipment

A regimented approach to preparation and performance of the procedure has been shown to significantly reduce the incidence of procedural complications⁴.
Our approach includes the following equipment and protocols:

• We routinely use Cook Blue Rhino single dilator kit and videobronchoscopy to perform the procedure.
• The following must be available:
  • An attending anesthesiologist must be present for maintenance of airway, provision of intravenous sedation and performance of bronchoscopy.
  • An intubation roll and a cricoid hook.
  • Open tracheostomy set.

Technique

Watch a tracheostomy (24 MB Windows Media file)

The technique described here is based on Seldinger’s principle ². The technique we use was first described and later modified by Ciaglia ³. The use of bronchoscopy was first introduced by Marelli et al and has subsequently been adopted by many centers ^{4, 5}.
Positioning

1. The patient’s neck is extended over a shoulder roll (unless there is a contraindication).
2. The anesthesiologist stands at the head end of the bed and under direct laryngoscopy positions the endotracheal tube (ETT) so that the cuff is midway at the vocal cord level.

Incision

1. We routinely inject the skin with 1% lidocaine with 1:100,000 epinephrine solution.
2. A horizontal or vertical incision centered on the inferior border of the cricoid cartilage may be used. We routinely use a 3-4 cm vertical incision.

Placement of Introducer Needle

1. A minimal dissection is performed onto the pretracheal tissue in order to push the thyroid isthmus downward.
2. The larynx is stabilized and pulled cephalad with the operator’s left hand.
3. A bronchoscopy is then performed and the light reflex is used to select the best site for the introducer needle.
4. Placing the needle at the inferior edge of the light reflex, the tip of the needle is directed caudad into the tracheal lumen avoiding the posterior tracheal wall at all cost.

Introduction of Guide Wire, Stylet and Initial Tract Dilatation The needle is withdrawn while keeping the cannula in the tracheal lumen. A J-tipped guide wire is then place under vision. The stylet is then placed with the safety ridge directed towards the tip of the wire. The tract is then dilated with the 8 FR dilator.
Dilatation with the Blue Rhino Dilator The Blue Rhino dilator is loaded on the stylet with the tip resting on the safety ridge. The dilator is moved in and out to optimally dilate the tissue between the skin and the tracheal lumen. The Blue Rhino dilator is never advanced beyond the point where 40 FR mark disappears below the skin level.
Placement of the Tracheostomy Tube

1. A tracheostomy tube is loaded onto the dilator
   - Females: a size 6 cuffed Shiley tracheostomy tube is loaded on to the 26 FR dilator
   - Males: a size 8 cuffed Shiley tracheostomy tube is loaded on to the 28 FR dilator
2. The dilator is then loaded on the safety ridge of the stylet and placed into the tracheal lumen under direct visualization.

Confirmation of Placement
The bronchoscope is withdrawn from the ETT and introduced via the tracheostomy tube. The placement is confirmed by visualizing the carina.
Securing the Tube
We routinely secure the tube with 2 sutures of 2-0 nylon on each side of the flange. In addition, a tracheostomy tape is used to hold the tube in place. A flexible extension tube is used to connect the tube to the ventilator circuit to avoid undue movement of the tube in the immediate postoperative period.

Postoperative Consideration

A chest X-ray is not routinely required as long as the entire procedure was done under direct visualization and there were no adverse events intraoperatively⁶. The postoperative care is same as for the open procedure.
The tract between the skin and the tracheal lumen takes a little longer (10-14 days) to mature as there is no formal layer by layer dissection involved. We, therefore, perform the first tube change on Day 10-12 postoperatively.

Bedside Percutaneous Dilational Tracheostomy (PDT)

Overview

Watch video of procedure

Percutaneous dilational tracheostomy (PDT), also referred to as bedside tracheostomy, is the placement of a tracheostomy tube without direct surgical visualization of the trachea. This is considered a minimally invasive, bedside procedure that may be easily performed in the intensive care unit or at the patient’s bedside – with continuous monitoring of the patient’s vital signs.
Two critically important preoperative criteria for PDT are:

• The ability to hyperextend the neck
• Presence of at least 1 cm distance between cricoid cartilage and suprasternal notch ensuring that the patient will be able to be reintubated in case of accidental extubation

Patients should not be considered for this procedure if they are:

• Children (younger than 12 years of age)
• Obese
• Patients with severe coagulopathies

Techniques

There are several different systems and approaches for PDT. Following are brief descriptions:

Ciaglia (method used at Hopkins)
With this technique, there is no sharp dissection involved beyond the skin incision. The patient is positioned and prepped in the same way as for the standard operative tracheostomy. General anesthesia is administered and all steps are done under bronchoscopic vision.

Procedure:

• Skin incision is made and the pretracheal tissue is cleared with blunt dissection.
• Endotracheal tube is withdrawn enough to place the cuff at the level of the glottis.
• Endoscopist places the tip of the bronchoscope such that the light from its tip shines through the surgical wound.
• Operator enters the tracheal lumen below the second tracheal ring with an introducer needle.
• The tract between the skin and the tracheal lumen is then serially dilated over a guidewire and stylet.
• A tracheostomy tube is placed under direct bronchoscopic vision over a dilator.
• Placement of the tube is confirmed again by visualizing the tracheobroncial tree through the tube.
• Tube is secured to the skin with sutures and the tracheostomy tape.
• We routinely use Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer Tray.

Shachner (Rapitrac) systemAfter making a small skin incision, the surgeon passes a dilator tracheotome over the guidewire into the trachea to dilate the tract fully in one step. The tracheotome has a beveled metal core with a hole through its center that accommodates a guidewire. Once inside the trachea, the tracheotome is dilated. A conventional tracheostomy cannula, fitted with a special obturator, is passed through the tracheal opening. The dilator and obturator are then removed.

Translaryngeal tracheostomy (Fantoni’s technique)
Unlike the other techniques, the initial puncture of the trachea is carried out with the needle directed cranially and the tracheal cannula inserted with a pull-through technique along the orotracheal route in a retrograde fashion. The cannula is then rotated downward using a plastic obturator. The main advantage of Fantoni’s tracheostomy is the minimal amount of skin incision required, with practically no bleeding observed. It should be noted that the procedure can only be carried out under endoscopic guidance, and rotating the tracheal cannula downward may pose a problem – demanding that the surgeon have more experience.

Advantages of PDT

Although there is a learning curve to the technique of PDT, it is relatively easy to learn. The learning curve may be overcome by performing a number of supervised procedures. Other advantages include:

• Time required for performing bedside PDT is considerably shorter than that for an open tracheostomy
• Elimination of scheduling difficulty associated with operating room and anesthesiology teams for critical care patients
• PDT expedites the performance of the procedure because critically ill patients who would require intensive monitoring to and from the operating room need not be transported
• Cost of performing PDT is roughly half that of performing open surgical tracheostomy due to the savings in operating room charges and anesthesia fees
• 
  

Complications and Risks of Tracheostomy

As with any surgery, there are some risks associated with tracheotomies. However, serious infections are rare.
Early Complications that may arise during the tracheostomy procedure or soon thereafter include:

• Bleeding
• Air trapped around the lungs (pneumothorax)
• Air trapped in the deeper layers of the chest(pneumomediastinum)
• Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema)
• Damage to the swallowing tube (esophagus)
• Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)
• Tracheostomy tube can be blocked by blood clots, mucus or pressure of the airway walls. Blockages can be prevented by suctioning, humidifying the air, and selecting the appropriate tracheostomy tube.

Many of these early complications can be avoided or dealt with appropriately with our experienced surgeons in a hospital setting.
Over time, other complications may arise from the surgery.
Later Complications that may occur while the tracheostomy tube is in place include:

• Accidental removal of the tracheostomy tube (accidental decannulation)
• Infection in the trachea and around the tracheostomy tube
• Windpipe itself may become damaged for a number of reasons, including pressure from the tube; bacteria that cause infections and form scar tissue; or friction from a tube that moves too much

These complications can usually be prevented or quickly dealt with if the caregiver has proper knowledge of how to care for the tracheostomy site.
Delayed Complications that may result after longer-term presence of a tracheostomy include:

• Thinning (erosion) of the trachea from the tube rubbing against it (tracheomalacia)
• Development of a small connection from the trachea (windpipe) to the esophagus (swallowing tube) which is called a tracheo-esophageal fistula
• Development of bumps (granulation tissue) that may need to be surgically removed before decannulation (removal of trach tube) can occur
• Narrowing or collapse of the airway above the site of the tracheostomy, possibly requiring an additional surgical procedure to repair it
• Once the tracheostomy tube is removed, the opening may not close on its own. Tubes remaining in place for 16 weeks or longer are more at risk for needing surgical closure

A clean tracheostomy site, good tracheostomy tube care and regular examination of the airway by an otolaryngologist should minimize the occurrence of any of these complications.

High-risk groups

The risks associated with tracheostomies are higher in the following groups of patients:

• children, especially newborns and infants
• smokers
• alcohol abusers
• diabetics
• immunocompromised patients
• persons with chronic diseases or respiratory infections
• persons taking steroids or cortisone

Types of Tracheostomy Tubes

A tracheotomy (trach) tube is a curved tube that is inserted into a tracheostomy stoma (the hole made in the neck and windpipe (Trachea)). There are different types of tracheostomy tubes that vary in certain features for different purposes. These are manufactured by different companies. However, a specific type of tracheostomy tube will be the same no matter which company manufactures them.
A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck plate), inner cannula, and an obturator. The outer cannula is the outer tube that holds the tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach cloth ties or velcro strap around the neck. The inner cannula fits inside the outer cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning. The obturator is used to insert a tracheostomy tube. It fits inside the tube to provide a smooth surface that guides the tracheostomy tube when it is being inserted.
There are different types of tracheostomy tubes available and the patient should be given the tube that best suits his/her needs. The frequency of these tube changes will depend on the type of tube and may possibly alter during the winter or summer months. Practitioners should refer to specialist practitioners and/or the manufacturers for advice.

Tube	Indication	Recommendations
CuffedTube with Disposable Inner Cannula
	Used to obtain a closed circuit for ventilation	Cuff should be inflated when using with ventilators. Cuff should be inflated just enough to allow minimal airleak. Cuff should be deflated if patient uses a speaking valve. Cuff pressure should be checked twice a day. Inner cannula is disposable.
Cuffed Tube with Reusable Inner Cannula
	Used to obtain a closed circuit for ventilation	Cuff should be inflated when using with ventilators. Cuff should be inflated just enough to allow minimal airleak. Cuff should be deflated if patient uses a speaking valve. Cuff pressure should be checked twice a day. Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Cuffless Tube with Disposable Inner Cannula
	Used for patients with tracheal problems Used for patients who are ready for decannulation	Save the decannulation plug if the patient is close to getting decannulated. Patient may be able to eat and may be able to talk without a speaking valve. Inner cannula is disposable
Cuffed Tube with Reusable Inner Cannula
	Used for patients with tracheal problems Used for patients who are ready for decannulation	Save the decannulation plug if the patient is close to getting decannulated. Patient may be able to eat and may be able to speak without a speaking valve. Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Fenestrated Cuffed Tracheostomy Tube
	Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak	There is a high risk for granuloma formation at the site of the fenestration (hole). There is a higher risk for aspirating secretions. It may be difficult to ventilate the patient adequately.
Fenestrated Cuffless Tracheostomy Tube
	Used for patients who have difficulty using a speaking valve	There is a high risk for granuloma formation at the site of the fenestration (hole).
Metal Tracheostomy Tube
	Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes.	Patients cannot get a MRI. One needs to notify the security personnel at the airport prior to metal detection screening.

Living with a Tracheostomy

Troubleshooting a tracheostomy change
Tracheostomy care/suctioning
Stoma care
Tracheostomy equipment
Tracheostomy equipment cleaning and care
Eating with a tracheostomy
Speech with a tracheostomy
Tracheostomy as a Passey Muir Valve
Suctioning a tracheostomy
Traveling with a tracheostomy
Swimming with a tracheostomy
Tracheostomy Humidification
Decannulation

Professional Organizations
American Academy of Otolaryngology - Head and Neck Surgery
American Association for Respiratory Care
Resources for Nurses Caring for Patients with a Tracheostomy Society of Otorhinolaryngology and Head-Neck Nurses, Inc. (SOHN)
AAOHNS Conferences and Events
Support Group