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To remove excess secretions from the upper respiratory tract in patients who are unable to do so independently.

Tracheal suction is the passing of a catheter into the upper airway through which a negative pressure is applied as the catheter is withdrawn in order to aspirate secretions.

Indications for suction

There are two groups of patients who will require tracheal suction.

  • patients unable to effectively remove secretions independently by coughing due to conditions such as a reduced level of consciousness, fatigue, and muscle weakness

  • to maintain a patent endotracheal tube or tracheostomy.

The frequency with which suction is required will vary widely between patients. Each must be individually assessed. Factors which should be considered are:

  • patients ability to cough and clear own secretions

  • amount and consistency of secretions

  • oxygen saturation/arterial blood gases

  • presence of infection

Routes for suction

Mouth - if the mouth is used an oropharyngeal airway must be used. Most conscious patients cannot tolerate the placement of this type of airway. A size 2, 3 or 4 is used in adults.

Nose - catheters may be inserted directly into the nose or via a nasopharyngeal airway. This method is only used in patients who have a very weak cough, or to collect virology specimens.

Endotracheal and tracheostomy tubes - these will be used for patients requiring artificial ventilation or long term airway protection.

Tracheal suction must be carried out regularly on these patients as it is vital to clear secretions from the chest to maintain a patent airway and prevent lung collapse due to small airways blocked by secretions.

Patients with a tracheostomy or endotracheal tubes also have an increased risk of pneumonia as the natural defence mechanisms of the upper airway are bypassed. See the guidelines for caring for a patient with tracheostomy for further details.

 

Potential Problems

Patient Distress. Suction may be very uncomfortable for the patient. Nasal or oral suction should only take place if absolutely necessary. Careful explanation and reassurance are essential.

Hypoxia. Caused by obstructing the airway with the catheter and by reducing the patients oxygen supply during the procedure. This may be prevented by giving extra oxygen prior to the procedure, using an appropriate sized catheter, and not prolonging the suction procedure.

Care is needed when considering preoxygenation of patients with type II respiratory failure (i.e. normal oxygen, high CO2) as they become dependant on oxygen levels to initiate respiration. If they are given additional oxygen this may reduce their respiratory drive. However patients with both type I and type II respiratory failure (i.e. low oxygen, high CO2 may benefit from additional oxygen - they should be monitored closely.

Soft Tissue Damage such as epistaxis, mucosal damage, ulceration and ischemia of trachea. This may be prevented by using appropriate vacuum pressures and careful selection of the catheter size.

Atelectasis due to a fall in pulmonary compliance and tidal volume. This may be prevented by lung inflation with positive pressure or by deep breathing following the procedure.

Laryngospasm, Stridor, Bronchospasm or Bronchoconstriction. The catheter may irritate the larynx or bronchus causing spasm. Careful technique and appropriate vacuum pressure will reduce this occurring.

Gagging/Vomiting. This is caused mainly when using nasal or oral suction. Careful technique will reduce the risks.

Vasovagal Stimulation causing Bradycardia and Hypotension. This is most common in unstable patients. Introducing the catheter gently and to the correct depth will prevent this.

Infection. Infection may be introduced during tracheal suction. A clean technique must be used and catheters are for single use only. Infection may also be spread from the patient unless universal precautions are used to protect the staff and other patients.

Hypertension. This is usually due to patient distress and will settle quickly after the procedure is complete.

Raised Intracranial Pressure (ICP). If the patient’s blood pressure is raised this will also increase ICP. ICP will also rise if the patient coughs, vomits or becomes hypoxic. If any of these conditions persist in a neurologically unstable patient it may cause further instability.
 

 

Contraindications

General:

  • tracheo/esophageal fistulae

  • severe bronchospasm.

  • stridor

Nasal suction:

  • basal skull fractures - as the catheter may pass into the brain instead of down the trachea

  • severe epistaxis

  • leakage of cerebral spinal fluid - suggests skull fracture so suction may cause further damage

  • occluded nasal passage

  • deranged clotting

Oral suction: 

  • jaw fractures

 

Precautions

  • recent esophageal or tracheal surgery

  • coagulopathy and bleeding disorders

  • upper airway lesions

  • irritable airways

  • pulmonary oedema

  • loose teeth

 

Signs that suction has been effective

  • reduced work of breathing

  • reduced respiratory rate

  • increased oxygen saturation

  • visible evidence of removal of secretions

  • absence of audible secretions in large airways

  • patient’s colour improves.

 

Vacuum pressure

The higher the level of vacuum pressure applied to a suction catheter the greater the degree of mucosal damage.  70-100 mmHg is ideal but clinically this level is often insufficient to evacuate thick mucoid secretions therefore may require pressure up to 200 mmHg. 

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Suction catheter selection

Catheter Sizes

Type of suction

Suction Catheter

 

FG

mm

Nasal

10 or 12

 

Minitrach

10

 

Oropharyngeal airway

12

 

Nasopharyngeal airway

10 or 12

 

ET or tracheostomy - size of inner diameter

 

 

10 mm

14

4.7

9 mm

12

4

8 mm

12

4

7 mm

12*

4

6 mm

10

3.3

5 mm

8

2.6

* It is more appropriate to use a size 12 catheter here as although it is slightly larger than 1/2 the diameter it provides more effective removal of secretions.

Tracheal damage may be caused during tracheal suction. This can be minimised by using the appropriate sized suction catheter. If the catheter is too large the suction it creates will cause damage Catheters larger than a 12 French Gauge (FG) should only be used for patients who are intubated or have a tracheostomy, following consultation with the physiotherapist. A large catheter will also occlude the airway which may cause hypoxia - it is recommended that the diameter of the catheter should be no more than half the internal diameter of the airway.  If the catheter is too small it will not be adequate to remove secretions so repeated attempts will be necessary which have also been shown to damage the trachea.

Instillation of Sodium Chloride 0.9%

Instilling sodium chloride 0.9% via a tracheal tube is an intervention described in nursing texts. The literature providing evidence for this practice is controversial and inconsistent.

Some studies suggest instillation of sodium chloride 0.9% thins, mobilises and therefore aids the removal of dried secretions. This maintains the patency of the tracheal tube. However other studies show that it has little or no effect.

Evidence confirms that sodium chloride 0.9 % in the form of an aerosol contributes to the thinning of secretions, but mucous and sodium chloride 0.9 % in bulk form and do not mix , even after vigorous shaking. However the mucous will be suspended in the sodium chloride 0.9 % and will be easily removed through a suction catheter.

Another proposed benefit of sodium chloride 0.9 % is the vigorous cough which is sometimes elicited, and one study has shown that a significantly greater amount of material is removed on suction using sodium chloride 0.9% instillation, than suction without.

The instillation of sodium chloride 0.9 % is not recommended as a routine part of the suctioning procedure. If a patient has very thick secretions sodium chloride 0.9 % nebulisers should be prescribed and administered as this is known to thin secretions. Following discussion with the physiotherapist a maximum of 5 ml's of sodium chloride 0.9 % may be instilled during suction for patients who continue to have thick secretions.


 

Equipment required for suction

Functioning suction unit

Suction catheters of correct size

Yankeur sucker

Oral/nasal pharyngeal airway

Lubricant i.e. KY jelly

Disposable latex gloves

Sterile polythene gloves (disposable gloves)

Protective eyewear

Mask

Disposable apron

Oxygen supply

0.9% sodium chloride and syringes if required

Receptacle and chlorhexidine for flushing

Functional resuscitation equipment in the area

 

 

Procedure 

Intervention

Rationale

Check the emergency equipment

To maintain a safe environment

Explain the procedure to the patient and any visitors

To obtain patients co-operation.  This procedure is unpleasant & can be frightening. 

Choose route and insert artificial airway if required

 

Position the patient - if the patient is not intubated, position lying on side (or turning the head to one side)

Prevent aspiration of gastric contents

If the patient is oxygen dependent or cardiovascularly unstable, it may be necessary to give the patient some extra oxygen for a short while before and after suctioning This procedure must not be carried out for patients who are CO2 retainers.

Introducing a suction catheter into the airway may cause hypoxia

Observe the patient throughout the procedure to ensure their general condition is not affected.

Tracheal suction may cause vagal stimulation leading to bradycardia, hypoxia and may stimulate bronchospasm.

Put on disposable apron, protective eye wear & mask. Wash & dry hands

To reduce the risk of cross infection and protect nurse through universal precautions.  Most patients cough directly onto the nurses clothes after suction; standing to one side should minimise the risk.

Switch suction unit on and check that the suction machine is set appropriately.

To ensure the machine is working correctly.  Too great a suction pressure can cause tracheal mucosal injury Greater suction pressure does not equal increased secretion removal.

Put on latex gloves

To protect hands from secretions

Connect the most appropriate sized suction catheter to the suction tubing, ensuring the catheter remains in the sterile packet.

The diameter of the suction catheter should be less than half the inner diameter of the inner tracheostomy tube, to prevent hypoxia.

To reduce the risk of transferring infection from the hands to the suction tubing.

Insert lubricated oro/nasal pharyngeal airway if required

 

Put a disposable sterile glove on dominant hand & use it to withdraw the catheter from the pack without touching the outside of the pack

To keep the catheter clean.
 

If via the nose

Dip the tip of the catheter in the lubrication gel.

To aid smooth passage and limit trauma.

 

Introduce catheter into the nostril pushing it gently towards the back of the nose with an upward inclination until a slight resistance is felt.

Rotate the catheter gently between thumb and index finger until this resistance is overcome

 

 

Continue to advance the catheter - it is best to do this as the patient takes a deep breath It will pass into the pharynx and then into the trachea.

The patient should cough.

This will help guide the catheter.

 

 

When the trachea has been entered a cough reflex will be stimulated

Do not apply suction while introducing the catheter

Suctioning while introducing the catheter  causes mucosal irritation, damage & hypoxia

Apply suction & smoothly withdraw the catheter from the tube. Do not suction for longer than 15 seconds at a time

 

It is not necessary to rotate the catheter whilst applying suction as catheters have circumferential holes.  Prolonged suctioning will result in hypoxia and trauma
 

If via an oro or nasal pharyngeal tube

Introduce catheter until a slight resistance is felt. 

Rotate the catheter gently between thumb and index finger until this resistance is overcome

 

 

Continue to advance the catheter - it is best to do this as the patient takes a deep breath

It will pass into the pharynx and then into the trachea.

The patient will cough.

This will help guide the catheter.

 

 

When the trachea has been entered a cough reflex will be stimulated

Do not apply suction whilst introducing the catheter

Suctioning while introducing the catheter  causes mucosal irritation, damage & hypoxia

Apply suction & smoothly withdraw the catheter from the tube. Do not suction for longer than 15 seconds at a time

Move to **** for all patients below

It is not necessary to rotate the catheter whilst applying suction as catheters have circumferential holes.  Prolonged suctioning will result in hypoxia and trauma
 

If endotracheal tube or tracheostomy -

Gently introduce the catheter until it stops. Withdraw approximately 2 cm. Do not push against resistance at any time.

The catheter should go no further than the carina to minimise risk of trauma to tracheal wall

Do not apply suction whilst introducing the catheter

Suctioning while introducing the catheter  causes mucosal irritation, damage & hypoxia

Apply suction & smoothly withdraw the catheter from the tube. Do not suction for longer than 15 seconds at a time

Move to **** for all patients below

It is not necessary to rotate the catheter whilst applying suction as catheters have circumferential holes.  Prolonged suctioning will result in hypoxia and trauma

If via a minitracheostomy

Gently introduce the catheter until it stops. Withdraw approximately 2 cm. Do not push against resistance at any time.

The catheter should go no further than the carina to minimise risk of trauma to tracheal wall

Do not apply suction whilst introducing the catheter

Suctioning while introducing the catheter  causes mucosal irritation, damage & hypoxia

Apply suction. Slowly and smoothly withdraw the catheter from the tube

Prolonged suctioning will not effect the patient as they continue to breath through the mouth and nose.
 

 ***** For all patients

Note the color, tenacity and quantity of the secretions. If secretions look infected consider sending a sample if this has not recently occurred.

Monitor changes and anticipate potential infection at an early stage.

Remove the glove from the dominant hand by inverting it over the used catheter & dispose in yellow polythene bag

To minimise the risk of infection

Assess the patient’s respiratory rate, skin colour and/or oxygen saturation to ensure they have not been compromised by the procedure and if they need further suction.

Suction should be performed only when needed and not as part of a routine

If the patient needs further suction, repeat the above actions using new gloves & a new catheter

Flush through the connection tubing with the chlorhexidine 0.5%

To minimise the risk of infection

Turn the suction off.  Leave the patient end of the tubing attached to the yankeur sucker (which should remain in the packaging) and supported well off the floor.

Ensures that in an emergency equipment is ready for immediate use.

Remove latex gloves and wash hands

Prevent cross infection

Ensure that the patient is comfortable.

 

Record the color, quantity & tenacity of secretions, and any other relevant details,  in nursing notes

To facilitate on-going evaluation.

 

There is debate in the literature regarding the effectiveness of using clean versus sterile techniques for suctioning. Practices vary. We recommend a sterile technique should be used for patients in hospital but this may differ for patients with long term tracheostomies or those who are self caring.

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