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Article 463. Griggs A (1998) Tracheostomy: suctioning and humidification. Nursing Standard. 13, 2, 49-56.

This article relates to UKCC Professional Development categories:

Tracheostomy: suctioning and humidification

This article explains tracheostomy suctioning and humidification. It outlines how nurses can assess the need for tracheostomy suctioning to be performed and possible complications that may occur as a result of the procedure.
AIM AND INTENDED LEARNING OUTCOMES
The aim of this article is to improve the nurses knowledge and understanding of adult tracheostomy suctioning and humidification. After reading this article, you should be able to: I Describe the reasons for tracheostomy suctioning and humidification. I Discuss the complications associated with tracheostomy suctioning. I Demonstrate the recommended suction pressure. I Discuss the different types, sizes and effects of suction catheters. I Illustrate the importance, and types, of humidification. I Describe a research-based tracheostomy suction technique. a choking sensation, stinging, pressure and the need to cough while suctioning is carried out. It has been suggested that these sensations are dependent on the method used by the practitioner carrying out the procedure (Oermann et al 1983). NOW DO TIME OUT 1 Think of a patient you have cared for with a tracheostomy. How did you feel about carrying out tracheostomy suctioning? What sort of problems did you encounter? Think about the information and skills that are necessary to feel confident in performing this procedure.

Angela Griggs RGN, is Senior Staff Nurse, Royal National Throat, Nose and Ear Hospital, London.

THE IMPORTANCE OF SUCTION AND HUMIDIFICATION

The upper airway of a patient with a tracheostomy has been bypassed. This means that both the warming and humidification of air, and the normal defence mechanisms coughing and mucociliary transport are adversely affected. During quiet respiration, inspired air, the water content of which is usually less than 25 per cent, is warmed and humidified through the nose. By the time it reaches the nasopharynx, it has been warmed to approximately 37oC and is fully saturated. The trachea, however, is ill-equipped to warm and humidify inspired air, so the presence of a tracheostomy causes cold, dry air to reach the bronchi and lungs (Jackson 1996). This lack of nasal warming and humidification will cause drying of tracheobronchial secretions and mucosa, which slows mucociliary transport the sweeping of secretions up the trachea by the action of tracheal cilia (Van Oostdam et al 1986). The effect of this is that patients with a tracheostomy become prone to atelectasis and pulmonary infection, due to: I The drying of secretions. I The loss of the normal filtering mechanism of the nose. I Reduced mucociliary transport. I Reduced airway pressure.

INTRODUCTION

Continuing Education articles are run in conjunction with the Royal College of Nursing Institute to help you to maintain and develop your practice and can be used to meet your UKCC requirements for PREP. All you have to do is read through the article, follow the instructions in the Time Out boxes, then answer the assessment questions that follow. Fill in the answer sheet and return it to the Freepost address with your fee or free assessment voucher.

The aim of tracheostomy suctioning is to maintain a clear airway and normal breathing sounds and pattern, without exaggerated effort or awareness of the sensation of breathing, and without causing trauma or hypoxia. Suctioning is carried out on all adults with a tracheostomy, and has been identified as both a routine procedure (Regan 1988) and one that many nurses find worrying due to a lack of relevant skills and experience (Grossenbach-Landis and McLane 1979, DeCarle 1985). It can, if not carried out correctly, cause complications, including tracheal mucosal damage, hypoxia and even death (Regan 1988). Studies examining the way in which nurses carry out tracheostomy suctioning have suggested that two main areas assessing respiratory insufficiency and following written procedures were poor. It was found that techniques used were more dependent on ward policy, or an individuals chosen technique, than on research (Grossenbach-Landis and McLane 1979, Harris and Hyman 1983, DeCarle 1985). Tracheostomy suctioning obviously affects the person receiving suction. Many people report

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Fig. 1. A closed system, multiple use suction unit

Box 1. Assessment of a patients breathing sounds

Assessment should include observation for: I Abnormal breathing sounds whistling, crepitus (creps) or diminished sounds (Knipper 1984) I Irregular respiration pattern I Changes in secretions alterations in the amount or consistency of tracheal secretions would indicate either retention or drying and thickening of secretions I Increase in coughing incidents I Change in the patients appearance an anxious appearance could indicate respiratory distress. Change in skin colour, and the ability to talk without blocking the end of a noncuffed tracheostomy tube, could indicate a partly or completely blocked tracheostomy tube

The cough is an important and powerful mechanism used to expel material from the trachea. However, it is affected by the presence of a tracheostomy because the larynx cannot be closed by the glottis to produce high air flow velocity on expiration of the cough. People with a tracheostomy use cough-like manoeuvres; although unable to close the larynx, they are still able to produce compression in the lower trachea and bronchi. This ability can, however, be compromised by muscle weakness, pain and reduced mucociliary transport. In these people, alternative means of airway clearance in the form of tracheostomy suctioning is, therefore, required.

COMPLICATIONS OF TRACHEOSTOMY SUCTIONING

Tracheostomy suctioning can cause many complications if not carried out correctly. The three main complications are: I Trauma. I Hypoxia. I Infection. Tracheal trauma This is one of the main complications of tracheostomy suctioning. Plum and Dunning (1956) identified that tracheal trauma was caused by a combination of high suction pressure, often up to 500mmHg, and the application of suction pressure on insertion of the catheter, causing the catheter to adhere to the tracheal wall. They recommended applying suction pressure only when removing the catheter, using a Y-connector, and not

pinching the catheter to obstruct suction pressure. Pinching the catheter to prevent suction pressure on insertion only increased the pressure when the pinch was released. More recent studies have found that the type of suction catheter used also has an effect on the amount of trauma caused. These studies suggest that multi-eyed catheters cause less trauma than single-eyed catheters. This is because the small side holes in the multi-eyed catheter suck in the secretions, while the single-eyed catheter pulls the mucosa as well as secretions into its single side hole (Sackner et al 1973, Jung and Gottlieb 1976, Fiorentini 1992). It was found that all suction catheters will cause trauma when pushed against the tracheal wall, but the extent of the trauma depends on the individual practitioners technique (Demers and Saklad 1973, Landa et al 1980, Kleibar et al 1988). Research studies focusing on suction pressure have found that no more secretions are removed at 200mmHg (28Kpa) than at 100mmHg (14Kpa), and that the amount of trauma is increased at higher pressure. The higher the pressure, the more likely it is that the suction catheter will collapse (Demers and Saklad 1973, Kuzenski 1978, Czornik et al 1991). Hypoxia This is a diminished amount of oxygen in the bodys tissues and occurs during tracheal suction because oxygen, as well as secretions, is removed. It has been found that the lower the initial oxygen saturation level, the greater the decrease in oxygen saturation will be during suctioning (Skelley et al 1980). This means that patients with decreased lung function, due to airway disease or in the initial post-operative stage, are at risk of developing suction-induced hypoxia. One solution is to ask the patient to breathe deeply before and after suctioning; but in patients who are at risk of hypoxia, oxygen saturation monitoring should be used to assess the level of hypoxia (Barnes and Kirchhoff 1986). Infection This can occur at the site of tracheal trauma. Bacteria can be introduced during tracheostomy suctioning if a contaminated suction catheter is used. This can lead to tracheitis, pneumonia and fistula formation (Brown 1982, Gibson 1983). Suction catheters should, therefore, remain sterile until used, only be used once and not be used to suction oral secretions first. Additional complications are as follows: I Vagus nerve stimulation the vagus nerve that supplies the trachea also supplies the heart; this can be stimulated by the catheter touching the tracheal mucosa which can lead to cardiac arrhythmias or to a vaso-vagal attack (Fiorentini 1992).

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I Atelectasis alveoli collapse, caused by the reabsorption of air from the alveoli, can be instigated by high suction pressure and drying of secretions. I Paroxysmal coughing a sudden attack of coughing can be caused by irritating the tracheal mucosa with a suction catheter.

ASSESSMENT
NOW DO TIME OUT 2 Based on what you have read so far, make short notes on your understanding of the complications of tracheostomy suctioning. Using these notes, reflect on your past practice and identify areas where improvements should be made. Tracheostomy suctioning should not be carried out routinely or at set times, and should only be practised following assessment of the patients breathing sounds (see Box 1). Suction needs to be carried out when the patient is unable to clear his or her own secretions, or is only able to clear them into the tracheostomy tube with cough-like mechanisms. However, having a tracheostomy does not necessarily result in the retention of secretions or difficulty in clearing the airway. Many patients are able to cough any secretions out via the tracheostomy, or into the tracheostomy tube which can then be removed and cleared with minimal use of suctioning.

Box 2. How to calculate suction catheter size

I Divide the tracheostomy tubes internal diameter by two this gives the external diameter of the suction catheter I Multiply this result by three to obtain the French gauge (Fg) For example, for a tracheostomy tube with an internal diameter of 8mm: 8 2 = 4mm 4 x 3 = 12mm The suction catheter size is 12Fg. In addition, the diameter of the suction catheter should be half the diameter of the tracheostomy tube (DeCarle 1985)

mucosa damage and hypoxia. Kuzenski (1978) suggests that tracheal damage is directly related to incorrect suction pressure: if suction pressure is too low, the patients airway will not be cleared; if it is too high, the suction catheter can adhere to the tracheal wall, damaging the tracheal mucosa. High pressure can cause (Serra 1982, Shekelton and Neild 1987): I Atelectasis (alveoli collapse). I Mucosal damage. I Catheter collapse. Suction pressure units vary according to different scales of measurement used and can be calibrated by the following indicators: I The European pressure measurement, the kiloPascal (kPa). I Millimetres of mercury (mmHg). I Low, medium and high. Before suctioning, the scale of measurement and the setting must be checked. In general, the lowest amount of suction pressure needed to remove secretions should be used. A great deal of research into the correct levels of suction pressure has been carried out, and the recommended pressure for adults has been suggested to be (Demers and Saklad 1973, Kuzenski 1978, Regan 1988, Martin 1989): I 14 to 16kPa. I 100 to 120mmHg. I Low.

THE SUCTION CATHETER SUCTION PRESSURE

NOW DO TIME OUT 3 Before reading the next section, consider the suction procedure that you are familiar with and add this to your notes for Time Out 2. Suction is the drawing of air out of a space to create a vacuum that will then suck in surrounding liquids secretions in tracheostomy suctioning. The suction pressure used can affect the amount of secretions removed, and cause tracheal A suction catheter should allow secretions to flow easily without damaging the mucosa. Suction catheters have a tendency to suck tracheal mucosa into the catheter side holes, especially while the catheter is stationary. This can cause mucosal haemorrhage (Sackner et al 1973). It has been shown that all suction catheters produce some degree of trauma, although it is often negligible, during a single suction procedure and that poor or repeated suctioning techniques can cause increased mucosal damage (Jung 1976, Regan 1988, Kleiber et al 1988). Multiple-eyed catheters have been shown to cause less damage than single-eyed catheters (Sackner et al 1973, Landa et al 1980, Sigler and Wills 1985). This is because the multi-eyed type dissipate the focus of suction pressure, making it less likely that the mucosa will be sucked into the side holes. Many of the multi-eyed catheters have been designed to produce a cushion of air at the tip of the catheter in order to prevent the catheter coming into contact with the tracheal mucosa, again causing less trauma (Sackner et al 1973, Serra 1982, Gibson 1983). Closed systems The closed system, multiple use suction unit is designed to reduce the risk of cross

Box 3. Tracheostomy tube and suction catheter sizes

TRACHEOSTOMY TUBE IDmm 10 9 8 7 6 5 4 3 Fg (30) (27) (24) (21) (18) (15) (12) (9) SUCTION CATHETER Fg (14) (14) (12) (10) (10) (8) (6) (5) ODmm 4.5 4.5 4.0 3.3 3.3 2.6 2.0 1.6

ID = Internal diameter; OD = Outer diameter; Fg = French gauge

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REFERENCES Ackerman MH (1985) The use of bolus normal saline installation in artificial airways: is it useful or necessary? Heart and Lung. 14, 5, 505-506. Barnes C, Kirchhoff K (1986) Minimizing hypoxia due to endotracheal suctioning: a review of the literature. Heart and Lung. 15, 2, 164176. Brown I (1982) Trach care? Take care infections on the prowl. Nursing. 6, 70-71. Czornik R et al (1991) Differential effects of continuous versus intermittent suction on tracheal tissue. Heart and Lung. 20, 2, 141151. DeCarle B (1985) Tracheostomy care. Nursing Times. 81, 40, 50-54. Demers R, Saklad M (1973) Minimizing the harmful effects of mechanical aspiration. Heart and Lung. 2, 4, 542-545. Doyle HJ et al (1984) Different humidification systems for high frequency jet ventilation. Critical Care Medicine. 12, 3, 815. Fiorentini A (1992) Potential hazards of tracheobronchial suctioning. Intensive Critical Care Nursing. 8, 4, 217-226. Gibson IM (1983) Tracheostomy management. Nursing. 2, 18, 538. Grossenbach-Landis I, McLane AM (1979) Tracheal suctioning: a tool for evaluation and learning needs assessment. Nursing Research. 28, 4, 237-242. Harris RB, Hyman RB (1983) Clean v sterile trachy care and level of pulmonary infection. Nursing Research. 33, 2, 80-85. Jackson c (1996) Humidification in the upper respiratory tract: a physiological overview. Intensive and Critical Care Nursing. 12, 1, 27-32. Jung RC, Gottlieb LS (1976) Comparison of tracheobronchial suction catheters in human chests. Chest. 69, 2, 179-181. Khan RC (1983) Humidification of the airways, adequate for function and integrity. Chest. 84, 4, 510. Kleiber C et al (1988) Acute histological changes in the tracheobronchial tree associated with different suction catheter insertion techniques. Heart and Lung. 17, 1, 10-14. Knipper J (1984) Evaluation of a adventitious sounds as an indicator of the need for tracheal suctioning. Heart and Lung. 13, 3, 292-293. Kuzenski B (1978) Effect of negative pressure on tracheobronchial trauma. Nursing Research. 27, 4, 260-263. Landa JF et al (1980) Effects of suctioning on mucociliary transport. Chest. 77, 2, 202207. Martin LK (1989) Management of the altered airway in the head and neck cancer patient. Seminars in Oncology Nursing. 5, 3, 182190. Oermann MH et al (1983) After a tracheostomy: patients describe their sensations. Cancer Nursing. 16, 361-366. Plum F, Dunning M (1956) Techniques for minimizing trauma to the tracheobronchial tree after tracheostomy. The New England Journal of Medicine. 254, 193-200. Regan H (1988) Tracheal mucosal injury: the nurses role. Nursing. 3, 29, 1064-1066. Sackner MA et al (1973) Pathogenesis and prevention of tracheobronchial damage with suction procedures. Chest. 63, 3, 284-290. Serra A (1982) Tracheostomy. Nursing Mirror. 155, 2, i-xvi.

infection while suctioning (Fig. 1). It can also be used for patients who are ventilated, as ventilator pressures can be maintained during suctioning of the critically ill patient. Calculating the size of the catheter To calculate the correct size of suction catheter use the formula in Box 2. The diameter of the suction catheter should be half the diameter of the tracheostomy tube (DeCarle 1985). There is no standardisation of tracheostomy tube and suction catheter sizes. It can be confusing, therefore, trying to work out what size of catheter to use for each size of tube. However, the majority of tracheostomy tubes are numbered by internal diameter size and suction catheters are numbered by Charriere (French gauge), although they often include the outer diameter on the packaging (see Box 3).

are at the tip of the tracheostomy tube and at the carina. This practice is no longer recommended (Kuzenski 1978, Serra 1982, DeCarle 1985, Sigler and Wills 1985, Kleibar et al 1988, Fiorentini 1992).

Should the suction catheter be rotated on removal?

Catheters are rotated in the belief that this will pick up more secretions and prevent adherence to the tracheal wall. Although this was the practice when single-eyed catheters were used, multi-eyed catheters have holes around their diameter and can, therefore, draw secretions without rotation. When should suction pressure be applied? Suction pressure should only be applied when removing the catheter. If pressure is on during insertion, the catheter will adhere to the mucosa (Plum and Dunning 1956). What about humidification? Breathing dry, cold air causes the tracheal cilia to beat more slowly and secretions to dry. It is important, therefore, to maintain systemic hydration. If the patient becomes dehydrated, the mucous membrane will be drier, mucociliary transport will reduce and there will be a retention of secretions. Immediately following a tracheostomy, the patient requires humidification to warm and moisten inspired air. This should almost eliminate dried or tenacious secretions (Khan 1983, Doyle et al 1984, Ackerman 1985). After a few days, the trachea adapts to the tracheostomy and secretion production is reduced (Sackner et al 1973, Landa et al 1980). This means that alternative humidification methods can be used.

COMMON QUESTIONS
NOW DO TIME OUT 4 Consider your healthcare environment. Do you know what scale your suction pressure gauges are and what type of suction catheters are available? Suction technique should ensure the maximum removal of secretions, while causing no tissue damage or hypoxia (Shekelton et al 1987). How long should suction last? Suction should be applied for no longer than ten seconds (Brown 1982, Serra 1982, DeCarle 1985, Martin 1989, Fiorentini 1992). Many older textbooks recommend that suctioning should be carried out for as long as you can hold your breath; however, this does not allow for the possibility that the patients lungs are not healthy. The patient should be encouraged to breathe deeply before suctioning commences and allowed time to recover between episodes. The length of recovery depends on the individual patient and his or her susceptibility to hypoxia. How far should the suction catheter be inserted? Again, this depends on the person being suctioned. A few days after tracheostomy formation, most people, unless ventilated, are able to cough secretions to the end of the tracheostomy tube and the suction catheter need only be inserted to just beyond the end of the tube (approximately 15cm). Some textbooks state that the suction catheter should be inserted until resistance is felt. This area of resistance is called the carina, and is where the trachea splits into the two bronchi. It is a sensitive area of the trachea and causes coughing and distress when touched. Research studies have shown that the two main areas of tracheal trauma

HUMIDIFICATION Moist gauze veil This is simply a piece of moist

gauze held in front of the tracheostomy by tape tied loosely around the neck. It provides both moist air and protection from inhalation of foreign bodies. It is useful in the initial period following a tracheostomy, but in the long term it is not cosmetically the best solution. Many patients, however, continue to use it at night when at home. Tracheostomy covers There are many tracheostomy covers available, based on the use of foam. Some adhere to the skin above the tracheostomy tube, others tie around the neck. Moisture and warmth from expired air are trapped in the foam, and inspired air is warmed and humidified through the foam. Heat and moisture exchangers These are cylindrical devices that attach to the tracheostomy tube. They trap the warmth and moisture of expired air in a vast surface area created by rolled, often corrugated, paper at either end of the cylinder. Inspired air is warmed and humidified through the rolled paper. Saline nebulisers These provide fully saturated air with a fine mist of moisture for patients with a

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tracheostomy who either have dried secretions or feel that their secretions are drying. Providing humidification via a vapour or an aerosol has been shown to thin secretions and promote clearance (Demers and Saklad 1973, Sharpiro et al 1979).

Box 4. A tracheostomy suctioning procedure

I Assess for the need to suction I Explain the procedure to the patient, and what he or she might feel I Turn on the suction pressure gauge, checking that the pressure is set between 14 and 16kPa I Put on gloves I Attach the suction catheter to suction tubing. Ensure the catheter is half the diameter of the tracheostomy tube I Ask the patient to take a couple of deep breaths I Observe the patient at all times during the procedure I With the Y-connector open (therefore no suction pressure), insert the suction catheter into the tracheostomy tube until it is just beyond the end of the tube I Apply suction pressure by covering the Y-connector I Slowly withdraw the catheter, without rotation, within ten seconds I Dispose of the suction catheter, following infection control procedures I Repeat as necessary

CONCLUSION
This article has discussed appropriate methods NOW DO TIME OUT 5 Reflect on patients with a tracheostomy you have nursed: I How do you explain what is about to happen? I Do you use terminology that they do not understand? I Do they ever appear anxious or irritated when suctioning is being carried out? I For those who are going home with a tracheostomy, how are they, or their relatives, taught to manage their own suctioning? You may find it helpful to discuss these questions with a respiratory nurse specialist. Look back over the section that discussed common questions that are often asked regarding tracheostomy suction and think of how you would respond to a patient asking you the same questions. for suction and humidification in patients who have a tracheostomy and, like any other procedure, an aseptic technique is of paramount importance. Time Out 5 reminds us that there is, of course, a patient involved in this procedure and that we must not lose sight of that. Most nurses will, from time to time, manage a patient who has a tracheostomy, but the healthcare environments will vary enormously, for example in intensive care units, on specialist ENT units, on general wards and in the community. The needs of patients will, therefore, vary depending on whether the tracheostomy is to be temporary or permanent, whether the patient is conscious or unconscious, and whether the patient will be expected to manage the suctioning him- or herself, or if a relative may need to take on this responsibility. Having studied this article, you will be better informed and more confident when advising patients, Box 4 provides a summary of suctioning procedures I

Shekelton ME, Neild M (1987) Ineffective airway clearance related to artificial airway. Nursing Clinics of North America. 22, 1, 167-178. Sharpiro B et al (1979) Humidity and aerosol therapy. Clinical application of respiratory therapy. Chicago Year Book. Chicago, Medical Publishers. Sigler BA, Wills JM (1985) Nursing care of a patient with a tracheostomy. Tracheostomy. New York, Churchill Livingstone. Skelley BFH et al (1980) The effectiveness of two preoxygenation methods to prevent endotrachial suctioning hypoxia. Heart and Lung. 9, 2, 316. Van Oostdam JC et al (1986) Effect of breathing dry air on structure and function of airways. In: Fishman AP (Ed) Handbook of Physiology. Bethesda, Maryland, American Physiological Society. 312-317.

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