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Why may suctioning be required?
to remove saliva, pulmonary secretions, blood, or vomitus
When does suctioning occur?
when subatmospheric pressure is applied to a flexible catheter or rigid tube
What are the various types of suctioning?
- - Open system catheter for Suctioning lower airway
- - Closed system catheter For ventilator patients
- - Closed system catheter For ventilator patients
- - Open system catheter for Suctioning lower airway
What therapies can suctioning be performed in conjunction with?
bronchial drainage, percussion, hyperinflation, aerosol therapy, and assisted coughing
What are the areas/settings in which suctioning can be used?
hospital, extended care facility, home, outpatient clinic, physicians office, and even the transport vehicle
What are the routes for suctioning?
- - Mouth: Oropharyngeal
- - Nose: Nasopharyngeal
- - Endotracheal, Tracheostomy tube, and Nasotracheal
What is the equipment required for suctioning?
- - Functioning suction regulator attached to the wall or a portable suction unit
- - Suction supply tubing
- - Suction catheters of correct size
- - Lubricant, K-Y jelly
- - Sterile saline for instillation
- - Sterile bulk water or saline
- - Basin for irrigating catheter
- - Disposable latex gloves
- - Sterile polythene gloves (disposable gloves)
- - Protective eyewear, gown, and mask
- - Oxygen supply
- - Functional resuscitation equipment in the area
- - Suction regulator/Portable unit
How do you determine the appropriate size of suction catheter for the tube size used?
- - multiply the tube�s inner diameter by 2. Then use the next smallest size catheter.
- - Ex. 6-mm endotracheal tube: 2 x 6 = 12 ; next smallest catheter is a 10 French
- - Ex. 8-mm endotracheal tube: 2 x 8 = 16 ; next smallest catheter is a 14 French
What are the various types of suction catheters?
- - Suction Catheter tip designs
- - Ballard closed suction system
What are the indications for suctioning?
- - performed whenever it is clinically indicated, or on an as needed basis
- 1. The need to remove accumulated secretions
- 2. The need to obtain a sputum specimen to rule out or identify microbiological organism (pneumonia or other pulmonary infection) or for cytological examination
- 3. The need to maintain the patency and integrity of the artificial airway
- 4. The need to stimulate a cough in patients unable to cough effectively secondary to changes in mental status or the influence of medication
- 5. Presence of pulmonary atelectasis or consolidation, presumed to be associated with secretion retention
What are the hazards and complications of suctioning?
- 1. Hypoxemia/Hypoxia
- 2. Cardiac dysrhythmias
- 3. Hypotension and Hypertension
- 4. Pulmonary atelectasis
- 5. Mucosal trauma
- 6. Contamination/Infection
- 7. Increased intracranial pressure
- 8. Bronchoconstriction/Bronchospasm
- 9. Laryngospasm, gagging/vomiting, and uncontrolled coughing
- 10. Cardiac arrest and death
How can Hypoxemia/Hypoxia complications occur?
when the PaO2 decreases below 65 mmHg or a pulse oximetry reading decreases below 90%
What are the potential causes of hypoxemia during suctioning?
- suctioning duration
- time interval between suctioning
- suction flow/pressure (vacuum) level
- suction catheter OD verses tube ID
- duration of pre and post oxygenation
- number and volume of hyperinflations
- concentration of oxygen supplied
- closed or open suction system
- use of double lumen suction catheter
How can Cardiac Dysrhythmia complications occur?
- - This may occur mainly as a result of hypoxemia.
- - Mechanical stimulation of the airway, particularly the area around the larynx, will also cause arrhythmias.
- - Bradycardia may result from vagal stimulation as the catheter enters the larynx or touched the carina.
- - Tachycardia may result from patient agitation and/or hypoxemia
How can Hypotension and Hypertension complications occur?
- - Can occur secondary to cardiac arrhythmias that can cause a decrease in cardiac output
- - It also can potentially be caused by severe coughing episodes that can decrease venous return
- - Some hemodynamically unstable patients may experience decreased cardiac output and hypotension due to hyperinflation pre and post suctioning
- - may also occur, caused by hypoxemia
How can Pulmonary Atelectasis complications occur?
- - can occur secondary to removing air from the lungs as secretions are removed. This can add to the patients hypoxemia.
- - Excessively negative pressure and a suction catheter that is too large for the ID of the airway, are considered the main cause of this problem
How can Mucosal trauma complications occur?
- Trauma can occur to the turbinates, pharynx, larynx, nasal mucosa, tracheal mucosa, and bronchial mucosa depending on the type of suctioning, nasotracheal or tracheal tube.
- Excessive trauma can cause pulmonary or mucosal hemorrhage or tracheitis
What are the potential causes of Mucosal trauma?
- Negative pressures used for suctioning
- Excessive force when inserting the catheter
- Design of the suction catheter
- Adherence of catheter to tracheal wall
- Suctioning in absence of secretions
How can Contamination/Infection complications occur?
- as a catheter is passed through the upper airway.
- Airway contamination and nosocomial pneumonia can be linked to suctioning procedures primarily from transmission by workers� hands.
How can Increased Intracranial pressure complications occur?
secondary increase in the mean arterial pressure or coughing. These changes are only transient, with values normally returning to baseline within one minute
How can Bronchoconstriction/Bronchospasm complications occur?
- stimulation of the bronchial smooth muscle via the catheter.
- This could occur mainly with a person with reactive airway disease
How can Laryngospasm, gagging/vomiting, and uncontrolled coughing complications occur?
How can Cardiac Arrest and Death complications occur?
- The exact mechanism is not known and it may vary depending on the patients� stability at the time of suctioning.
- It is probably caused by one or more of the previously mentioned complications occurring at the same time
How do you potentially avoid or minimize the complications with hypoxemia/hypoxia during suctioning?
- - recommended that patients always be pre-oxygenated prior to suctioning with 100% oxygen and, where indicated, hyperinflated with a manual resuscitator or ventilator at one and a half times the tidal volume (Vt).
- - Closed system suction catheters and double lumen (one lumen for suction, the other for oxygen delivery) catheter help prevent hypoxemia during suctioning
- - Post suction oxygenation and hyperinflation should be accomplished with the same method as before the treatment. Post oxygenation should be done for at least 1 minute.
- - Allow only 15 seconds as maximum suctioning time
- - The OD (outer diameter) of the suction catheter should not exceed more than one half the ID (inner diameter) of the artificial airway to prevent atelectasis and hypoxemia
How do you potentially avoid or minimize the complications with Mucosal Trauma during suctioning?
- - Limiting suction pressures may minimize damage. It is recommended that the lowest suction pressures that will accomplish the task should be used
- - Lubrication of the catheter with a water soluble gel prior to suctioning
- - avoid suctioning as the catheter is advanced and when withdrawing the catheter rotate the catheter, with intermittent suctioning (to avoid tearing mucosal tissue due to cather adherence to airway)
- - check for indications prior to suctioning and stop suctioning once all secretions have been removed
How do you potentially avoid or minimize the complications with Contamination/Infection during suctioning?
- Sterile (aseptic) technique and gentile advancement of the catheter, when suctioning, should help minimize the problems. Gloves must be worn on both hands to prevent direct contact transmission with infected tracheal secretions.
- Closed suction systems also minimize organism transfer.
- Caregivers should use the CDC�s guidelines for Standard Precautions
What are commonly used suction pressures?
- -100 to -120 mmHg for adults
- -80 to �100 mmHg for children
- -60 to -80 mmHg for infants
What should be done if hypotension or hypertension are noted?
the suctioning procedure should be stopped and oxygenation and ventilation restored
It is recommended that the external diameter of the catheter should never exceed ________ the internal diameter of the airway.
What are the potential contraindications for suctioning?
- - Most contraindications are relative to the patients risk of developing adverse reactionsor worsening clinical conditions as the result of the procedure
- 1. Patient doesn�t need airway suctioning
- 2. Untrained personnel or improper equipment should not be used for airway suctioning on a patient
- 3. An unstable cardiovascular status, especially with severe hypotension can cause the patient to go into cardiac arrest
- 4. Excessively high intercranial pressure should be lowered, if possible, before suctioning
What are the upper airway complications/contraindications for nasotrachel suctioning?
- Epiglottitis or Croup (this is an absolute contraindication)
- Occluded nasal passages
- Nasal bleeding
- Acute head, facial, or neck injury
- Coagulopathy or bleeding disorder
- Irritable airway
- Upper respiratory tract infection
How do you assess whether tracheal suctioning was effective or not?
- 1. Pulmonary secretions are removed
- 2. Breath sounds are improved
- 3. Work of breathing decreases
- 4. Oxygen saturation or arterial blood gases improve
- 5. If peak inspiratory pressure and measured airway resistance decreased for a patient on a volume cycled ventilator, or an increased tidal volume for a patient on pressure-limited ventilation.
What is the procedure of suctioning for artificial airway?
- 1. Assess the patient for indications
- 2. Assemble and Check Equipment
- 3. Preoxygenate and Hyperinflate the patient
- 4. Insert the Catheter
- - Insert the catheter carefully, until it can go no further.
- - Then withdraw the catheter a few centimeters before applying suction.
- 5. Apply Suction/Clear Catheter
- - Apply suction while withdrawing the catheter using a rotating motion.
- - Keep total suction time less than 10 to 15 seconds.
- - After removing the catheter, clear it using the sterile basin and bulk water/saline while applying suction.
- - If any untoward response occurs during suctioning, immediately remove the catheter and oxygenate the patient.
- 6. Reoxygenate and Hyperinflate the Patient
- 7. Monitor the Patient and Assess Outcomes
What parameters should be monitored during suctioning procedure?
Patient's vital signs
What are the CDC infection control guidelines that should be followed during suctioning?
- - wash hands
- - use sterile procedure
Crit Thinking 1.Identify at least three hazards and complications of suctioning that are unique to the nasotracheal route?
Epistaxis, laryngospasm.insertion of the catheter into the esophagus, vomiting
Crit Thinking 2.Contrast the dysrhythmias one would expect as a result of vagal stimulation during the suctioning procedure versus those that would result from hypoxemia.
- Vagal stimulation would result in bradycardia or cardiac arrest.
- Hypoxemia is more likely to cause tachycardia and ectopy, such as premature ventricular contractions.
Crit Thinking 3.Differentiate between mucus, sputum and phlegm.
- Mucus: viscous secretions containing mucin, white blood cells water and inorganic salts.
- Sputum: material coughed up from the lungs and expectorated through the mouth.
- Phlegm: thick mucus secreted by the goblet cells in the respiratory tract.
Crit Thinking 4.Is sputum normally considered a high risk fluid for the transmission of bloodborne pathogens?
No, not unless it contains blood. More of a hazard for airborne transmission.
Crit Thinking 5.What is the rationale for personal protective equipment use while performing suctioning?
Besides the fact that sputum is �yucky� and who wants it on themselves, there is always the possibility of bleeding during the procedure. Other pathogens, such as MRSA and VRE, can betransmitted via contact.
Crit Thinking 6.Given the following scenarios, identify all possible causes of the problem and offer at least two alternative solutions to correct each problem.
- A.You turn on an electrical suction machine and it does not work.
- Check to see if it is plugged in, and if not, do so.
- Double check to see if you turned it on, and if not, do so.
- Change outlets and see if another one works.
- Check cord for frays or tears and replace machine if needed.
- B.In the middle of suctioning a patient, the suction is lost.
- Discontinue suction, reoxygenate and ventilate.
- Check to see if the catheter is obstructed, if so, rinse or replace.
- Check all connections to make sure they are tight fitting.
- Check suction collection container. If it is full, a safety valve will turn it off automatically.If so, change the container.
- Check another suction outlet. The main suction compressor may have malfunctions.
- C.You cannot get suction from a wall suction regulator.
- Make sure the quick connect is secured.
- Check that the suction control is turned on.
- Check another outlet to see if it works or if the entire system has malfunctioned.
- D.While attempting to suction a patient with an endotracheal tube, you cannot advance the catheter more than 5 inches.
- The tube may be obstructed, kinked, or the patient may be biting down.
- Make sure the patient is not biting, or use a bite block.
- Make sure you can ventilate the patient.
- Rotate the catheter gently, attempt to lavage.
- Attempt gently to reposition the endotracheal tube slightly.
- E.After suctioning a patient, you hear a honking or high pitched sound coming from the endotracheal tube.
- The tube may be obstructed or has been accidentally dislodged. Ensure you can ventilate the patient, verify tube position, and attempt to pass a catheter. You may need to extubate and manually ventilate if all of these actions fail.
Crit Thinking 7.Calculate the maximum catheter sizes that can be used: Show your work!
- ID 4.0 mm trach tube: 8 Fr (1/2 4 = 2 x 3 = 6 +2)
- ID 6.0 mm ET tube: 10 Fr (1/2 6 = 3 x 3 = 9 +2)
- ID 7.5 mm ET tube: 12 Fr (1/2 7.5= 3.75 x 3 = 10.5 +2), no odd sizes available, round to the smaller size.
- ID 10 mm trach tube : 16 Fr (1/2 10 = 5 x 3 = 15 +2), no odd sizes available
Crit Thinking 8.A patient is suffering from hypoxemia and dysrhythmias andbronchospasm during suctioning. Identify what methods you used to assess the patient's status during suctioning and describe what precautions should be taken to prevent each of the hazards mentioned.
- Patient assessment should include observation of color and comfort level, ECG monitoring, pulse oximetry, and auscultation.
- Hypoxemia and dysrhythmias can be prevented by adequate preoxygenation and hyperinflation. Correct suction pressures and catheter size will reduce hypoxemia. Gentle suctioning will prevent dysrhythmias and bronchospasm from vagal stimulation. Bronchodilator therapy may also be indicated.
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