Ian Kirby D.

Magsumbol BSN-IVA Definition

Oropharyngeal, tracheal, and endotracheal suction are methods of clearing secretions by the application of negative pressure via either a yankauer sucker (oropharyngeal) or an appropriately sized tracheal suction catheter (tracheal/endotracheal). This procedure may be required in an emergency situation or as part of a patients planned care.

It is important to remember that:

The purpose of performing oral suction is to maintain oral hygiene and comfort for the patient or to remove blood and vomit in an emergency situation. The purpose of tracheal/endotracheal suction is to remove pulmonary secretions in patients who are unable to cough and clear their own secretions effectively. The patient may be fully conscious or have an impaired conscious level. Secretions are cleared from these patients airways in order to maintain airway patency and to ensure that adequate gas exchange (particularly oxygenation) occurs.

Tracheal suction can be performed via a variety of routes:

Orally, using an oropharyngeal airway (unlikely to be tolerated by a conscious patient). Nasally, using a nasopharyngeal airway (contraindicated if the patient has clotting Abnormalities) Via a tracheostomy tube. Via an endotracheal tube. When suction is performed, an assessment should be made of the type of secretions obtained and any changes noted. Secretions may be: Copious Minimal Mucopurulent (green or yellow) if infection is present Frothy (possibly seen if the patient has pulmonary edema) Bloodstained (possibly from trauma to the tracheal mucosa) Thick Watery A sputum sample may be requested for microbiological investigation.

Open or Closed System Suctioning

Open endotracheal suctioning (OES)- the patient is temporarily removed from the ventilator to breathe freely, or manually ventilated, while ETS is performed. Some studies have shown that there is more secretion removal with OES. Closed system suctioning (CSS)- the patient remains attached to the ventilator, or their supplemental breathing device, and a reusable inline (enclosed) catheter is used for ETS.

While tracheal/endotracheal suctioning may be a necessary procedure, it can be associated with some potentially harmful effects. These may include:
Hypoxaemia as oxygen as well as secretions may be removed from the lungs when Vasovagal response causing arrhythmias and hypotension Mucosal trauma -suction should only be applied when withdrawing the catheter, never when inserting it. Cross-infection Suction procedures should therefore be as brief as possible, lasting approximately 15 seconds

Choosing the right sized suction catheter

The suction catheter diameter should be half the diameter (or less) of the tracheal tube. This prevents occlusion of the airway and avoids the generation of large negative intra-thoracic pressures A method of calculating the correct size of suction catheter: Sizing a suction catheter (Fg French gauge) Diameter of endotracheal tube (mm)x3/2 Example: For a size 8.0 ETT: 8.0 x3=24 24/2=12 (Fg) suction catheter. Age Preterm Term 6 Months 12-18 Months 3 Years 5 Years 6 Years 8 Years 12 Years 16 Years Adult Female Adult Male Size of ETT 2.5-3.0 uncuffed 3.0-3.5 uncuffed 3.5 uncuffed 4.0 uncuffed 4.5 uncuffed 5.0 uncuffed 5.5 uncuffed 6.0 uncuffed 6.5 cuffed 7.0-8.0 cuffed 7.5-8.0 cuffed 8.0-8.5 cuffed Suction Catheter 4-5 6-8 8 8 8 10 10 10 10 12 12 14

When to perform suction and in whom? Potential indications for tracheal or endotracheal suctioning include: Raised respiratory rate. Inability to clear secretions effectively. Reduced air entry on auscultation. Audible secretions. Spontaneous but ineffective cough. Reduced oxygen saturation levels.

However, the need for suction should be assessed on an individual basis rather than as a ritualized activity, meaning that patients should only receive suctioning when they need it, not because a certain length of time has elapsed since it was last performed When not to perform suction Oral suctioning can cause trauma if the oral mucosa is damaged; it should also be undertaken with extreme caution in patients with clotting disorders. Suction should never be applied during insertion of the suction catheter.

Procedure
Preparation Prepare yourself Ensure that you understand how the equipment works, how to assemble it, and the reason you need to perform suction. Wash your hands. Prepare the patient The procedure should be fully explained to the patient Prepare the equipment Assemble the correctly sized catheter, gloves (sterile or non-sterile depending on your employers infection control policy), and other equipment. Ensure that the suction machine works. Discussing the procedure with the patient and family Explain what you are going to do and why it is necessary/important. Explain that the procedure is likely to be uncomfortable, but will be brief. Explain that the procedure may need to be done more than once. Depending on the conscious level of the patient, explain that the patient may cough for a short while after the procedure.

Equipment
y y y y y y Suction machine Suction connecting tubing Suction catheters Sterile or clean cup with NSS or sterile water Tissues Gloves (optional for home care, use powder-free gloves)

Sizes and Color

6- Green 8- Blue 10- Black 12- White 14- Green 16- Orange 18- Red 24- Yellow

Step-by-step guide to performing tracheal suction

Step
1. Introduce yourself, confirm the patients identity, explain the procedure, and obtain consent. 2. Assess the patient to ensure that suction is necessary (including the effectiveness of their cough). 3. Assist the patient into an upright position (if possible). 4. Apply an oxygen saturation (SpO2) probe.

Rationale
To identify the patient correctly and gain informed consent.

To reduce potential complications from endotracheal suction and avoid unnecessary interventions.

To allow optimum lung expansion and effective cough.

To enable evaluation of patients oxygenation prior to and following the suction procedure To reduce the risk of cross-infection.

5. Wash hands.

6. Put on disposable apron and protective visor/ eye wear, according to local policy. 7. Connect suction catheter to suction tubing and turn suction machine on. 8. Use sterile/clean non-sterile glove* on the hand manipulating the catheter and clean non-sterile glove on other hand. 9. Withdraw suction catheter from sleeve with clean gloved hand and grasp catheter with sterile/clean non-sterile gloved* hand away from catheter tip. 10. Advance catheter gently until a cough is stimulated or resistance is felt. Do not apply suction during catheter insertion. 11. When a cough is initiated or resistance is felt, withdraw the catheter approximately 1 cm and apply suction by occluding suction control port on catheter with thumb. Withdraw gently. 12. Procedure should last no more than 15 seconds. Dispose of suction catheter and gloves in clinical waste disposal bin. 13. Rinse suction tubing with sterile/non-sterile* water. 14. Clear patients oral secretions if required. 15. Dry the container used for rinsing and wash hands. 16. Repeat procedure if required, having checked the patients SpO2. Allow the patient to rest/recover between each suction procedure.

To reduce risk of cross-infection and to protect yourself from droplets/sputum contamination. To allow suction to begin.

To reduce risk of cross-infection to the patient and to yourself.

To reduce risk of cross-infection.

To minimize risk of mucosal trauma.

To reduce potential complications from suctioning.

To reduce risk of cross-infection and ensure clinical waste is correctly disposed of.

To ensure sputum is removed from suction tubing.

To maintain patient comfort. To reduce risk of cross-infection to the patient and to yourself. If the patient has a sustained lower SpO2 compared to before the procedure, they may require oxygen for a period of time.

Reminders Dont forget to: Use the correct size of suction catheter. Explain the procedure to the patient. Only apply suction when withdrawing the catheter. Reflection and evaluation After you have performed tracheal suction on a patient, think about the following questions: 1. What made you decide that the patient required suction? 2. Did you explain the procedure so that the patient understood what was going to happen? 3. Was there an improvement in the patients respiratory condition after the procedure had been performed? 4. Did you observe and record the volume, colour, and consistency of the patients secretions?

Nursing Responsibilities Before:

1. Review the patients chart for physicians order, and note any indications, contraindications, or potential side effects of therapy ordered. Review the patients history, physical diagnosis, progress notes, CXR, lab reports (including ABGs) and medications before performing the procedure. 2. Identify patient to those on the physicians orders for therapy 3. Examine and auscultate the patient. 4. Assemble Equipment: Attach connective tubing to suction regulator/equipment and inlet of suction container. Connect suction machine to vacuum wall outlet. Turn vacuum on, and occlude tip of connective tubing. If no suction is demonstrated on gauge, tighten all connections. If still no suction occurs increase vacuum. If still no suction occurs, label machine "defective" obtain another suction machine, reassemble and retest. 5. Identify patient by verification of name by verbal questioning. 6. Identify yourself. 7. Inform the patient/family of the procedure and its purpose. Be prepared to answer any questions about the procedure that the patient may have.

During:
Using a catheter 1. Wash hands and apply personal protective equipment as indicated (gloves and sub-micron masks mandated). (gowns, eye protection if splashing is likely to occur.) 2. Adjust vacuum between -80 to -120mmHg for adults or -60 to -80mmHq for pediatrics.

3. Position the patient by extending the neck slightly to facilitate entrance into the trachea (especially for nasotracheal auctioning). 4. Open suction catheter exposing only the connector, attach to connective tubing and maintain sterility of catheter. 5. Fill sterile box with sterile water, and place a dab of water-soluble lubricant on sterile envelope if nasotracheal auctioning is to be performed. 6. Check heart rate before, during and after procedure. If tachycardia or bradycardia occurs discontinue the procedure until it resolves. 7. Place sterile gloves on both hands. 8. Remove suction catheter from envelope maintaining sterile technique. NOTE: coat tip of catheter with lubricant only if nasotracheal suctioning is to be performed. 9. If patient has an artificial airway in place, hyperoxygenate with a resuscitation bag or mechanical ventilator. If patient is receiving oxygen therapy, request several deep breaths before suctioning. 10. Insert the catheter through the nose or endotracheal tube to the point of restriction without applying suction. NOTE: do not aggressively force the tip of the catheter through any obstructions in the nose. Withdraw the catheter and reposition the patient's head and try again. 11. After the restriction has been passed, slowly advance catheter. Ask patient to take deep breaths or watch for inspiration. Pass catheter into trachea. 12. Once catheter has been placed in trachea, slowly withdraw while applying intermittent suction and rotating catheter. Remember: Suction should not be applied for more than 10-15 seconds. 13. Hyperoxygenate the intubated patient or request the non-intubated patient to take several deep breaths. 14. 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.

After:
1. Discard gloves and catheters in an aseptic manner, clear connective tubing with remaining sterile H20 and turn off suction. 2. Return the patient to comfortable position. 3. Discard personal protective equipment and wash hands. 4. Document procedure as per department guidelines. 5. Inform nurse and/or physician of any pertinent request, complaints or reactions to the therapy.